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 CONTENTS 
 
 Acute Traumatic Peritonitis ; Nature and 
 Treatment of. 
 
 Disease of Knee Joint — A case of, in which 
 Amputation was performed with success, 
 under the most unfavorable circumstances. 
 
 Erysipelas, its Clinical History, Pathology, 
 and Treatment. 
 
 Fracture of the Spine. 
 
 Morbus Cox-E, or the Chronic Scrofulous 
 Disease of the Hip Joint, its Diagnosis, 
 Pathology, and Treatment. 
 
 Attempted Suicide, by Hanging. 
 
 Laceration of the Urethra,
 
 7 
 
 CLINICAL OBSERVATIONS 
 
 gfata aifir toted 
 
 ACUTE TRAUMATIC PERITONITIS, 
 
 TRE RESULT OF A RUPTURE OR PERFORATION OF ONI 
 OF THE HOLLOW VISCERA. 
 
 JAMES STAKNUS HUGHES, M.D., E.R.C.S.T. 
 
 REPRINTED FROM " THE DUBLIN" HOSPITAL GAZETTE. 
 
 DUBLIN : 
 PRINTED BY J. If. O'TOOLE. 
 
 13, HAAVKIXS'-STREET. 
 1856.
 
 i vv> 
 
 S V l»"
 
 ACUTE TRAUMATIC PERITONITIS. 
 
 Of all the inflammations to which the human 
 frame is liable, there is not one of a more formi- 
 dable character than that of the acute traumatic 
 peritonitis, whether the result of perforation of 
 an intestine from previous disease, or of rupture 
 of one of the hollow viscera from external vio- 
 lence. In such a case the patient generally vomits 
 immediately after the accident; the abdomen 
 becomes rapidly tympanitic, and exquisitely ten- 
 der to the touch ; the patient is seized with a 
 rigor, he lies in the supine position, with 
 the knees drawn up, the thighs being semi- 
 flexed, the pulse, although usually rapid, small, 
 and compressible, is very variable, occasion- 
 ally it is slow at the commencement, but, 
 generally speaking, it sooner or later becomes 
 small, weak, and faltering, gradually declin- 
 ing in strength ; the respiration becomes 
 hurried and thoracic ; the extremities cold ; the 
 countenance pale and anxious. If at this stage 
 you interrogate the patient as to his suffering?, 
 he will point with agony to the abdominal region. 
 In traumatic peritonitis, accompanied by a rup-
 
 4 ACUTE TRAUMATIC TEltlTOXITIS. 
 
 ture of a hollow viscera, percussion, which is at 
 first attended by a diffused tympanitic resonance 
 over the entire area of the abdomen, is sooner or 
 later followed, should the patient live suffi- 
 ciently long, by more or less dulness in depend- 
 ing- positions, as for instance, the iliac and 
 lumbar regions, from the effusion of lymph 
 serum, or pus, or of all combined. 
 
 Although the tympanitis, which is so instan- 
 taneous, and therefore so important a symptom in 
 traumatic peritonitis, whether from perforation 
 from within, or rupture of an intestine from vio- 
 lence from without, is generally uniformly diffused 
 over the entire of the abdominal cavity ; yet it 
 may be irregular in outline from previous effusion 
 of lymph ; thus, in a remarkable case laid before 
 the Pathological Society, by Dr. Stokes, in the 
 Session of 1843, an irregularity in the abdominal 
 tympanitis accompanying a perforation of the 
 intestine, which was detected during life, was 
 found, on dissection, to be " caused by a chronic 
 adhesion, almost ligamentous, of omentum, form- 
 ing a dissepiment, between which and the dia- 
 phragm were included the stomach and liver, 
 with fluid intermixed with some of the ingesta, 
 and a quantity of gaseous fluid." 
 
 The frottement* so audible on auscultation, 
 and the friction vibrations so sensibly communi- 
 cated to the touch in other forms of peritonitis, 
 
 * The presence of frottement in peritonitis was first no- 
 ticed by M. Piorry, in his work " De la Percussion ;" Laennec, 
 however, as Piorry remark*, was of opinion that in perito- 
 nitis a sound as of crumpling parchment could be heard. 
 Dr. Beatty published the first observations on the subject 
 in this country, and was followed by Drs. Corrigan, Bright.
 
 ACUTE TEAEMATIC PEEITOXITIS. O 
 
 produced by the rubbing together of the sur- 
 faces of the peritoneum, altered by inflammation, 
 either during the respiratory movements, the 
 motion exercised by pressure of the hand on the 
 abdomen, or by the peristaltic motion of the in- 
 testines, are, as far as my experience goes, alto- 
 gether absent in traumatic peritonitis accompanied 
 by rupture of one of the hollow viscera, a fact 
 easily, in my mind, accounted for, by the inflation 
 of the peritoneal cavity, and consequent separation 
 of its parietal and visceral layers. 
 
 In almost all the instances of traumatic peri- 
 tonitis from rupture of an intestine, which have 
 fallen under my observation, there was not only 
 an approach to suppression of urine, but so great 
 a difficulty in passing water, in consequence of 
 the excessive pain which every effort to do so 
 was attended by, that inexperienced persons 
 were, in many of the cases, led erroneously to 
 conclude that a rupture of the bladder had posi- 
 tively taken place. In describing peritonitis, 
 Abercrombie says — " According to the seat of 
 the inflammation various organs become affected : 
 when it is in the lower part of the abdomen, 
 there is often a frequent painful desire to pass 
 urine, and an acute pain extending along the 
 urethra ; when in the neighbourhood of the kid- 
 neys, the secretion of urine is often greatly di- 
 minished, or nearly suspended."* 
 
 In the vast majority of cases of traumatic 
 
 Stokes, and Spittal ; the latter gentleman has published an 
 excellent paper on the subject in " The London and Edin- 
 burgh Monthly Journal of Medical Science," Mar, 1845, 
 p. 345. 
 
 * Abercrombie on the Stomach.
 
 6 ACUTE TRAUMATIC PERITONITIS. 
 
 peritonitis, whether the result of perforation of 
 an intestine from previous disease, or rupture of 
 one of the viscera from external violence, the 
 progress to a fatal termination is very rapid 
 indeed — death not unfrequently taking place 
 within thirty-six or forty-eight hours after the 
 occurrence — sometimes even sooner ; at other 
 times the patient survives seven or eight days ; 
 in more fortunate cases the patient recovers. 
 
 If a case of traumatic peritonitis is to end fa- 
 tally, we shall find that the abdominal pain, 
 which has diffused itself over the entire of that 
 cavity, becomes more and more acute, the slight- 
 est pressure on the abdomen being insupportable ; 
 the pulse becomes extremely rapid and feeble, 
 frequently it intermits ; the extremities assume 
 an icy coldness ; the vomiting becomes more in- 
 cessant, acquiring a gulping or regurgitating 
 character ; the countenance becomes hippocratic ; 
 hiccough now sets in, and death soon follows, 
 being not uncommonly ushered in either by coma 
 or convulsions. 
 
 Sometimes towards the fatal termination the 
 pain, vomiting, and many of the other prominent 
 symptoms become mitigated, and occasionally, 
 just prior to death, an almost complete immunity 
 from suffering takes place, a fact well exempli- 
 fied in the person of a man who died some time 
 since in the male accident ward of this hospital, 
 having been placed under my care for traumatic 
 peritonitis, the consequence of a suicidal stab of 
 a butcher's knife in the abdomen, whilst the 
 patient was labouring under an attack of delirium 
 tremens. 
 
 If, on the other hand, a case of traumatic
 
 ACUTE TRAUMATIC PERITONITIS. 7 
 
 peritonitis is to recover, the abdomen gradually 
 becomes less painful and tympanitic, and at the 
 same time more tolerant of pressure, the pulse 
 becomes less frequent, and compressible, assuming 
 a more healthy character, the countenance gra- 
 dually improves, keeping pace with the amend- 
 ment in the other symptoms, and thus the case 
 proceeds until a perfect convalescence is esta- 
 blished. 
 
 It is generally supposed that the length of 
 time a person may survive with perforation of 
 one of the hollow viscera will depend on the 
 following circumstances, namely : — the pre- 
 vious state of health of the patient, the period 
 at which the accident has occurred after a 
 meal, and the quantity of faecal matter effused ; 
 but although the foregoing observations hold good 
 in a general sense, still the disease has, in some 
 cases, proved fatal in which the quantity of 
 faecal matter was so small that it could hardly 
 be detected either by its presence or odour ;** for 
 in cases of perforated ulcers of the stomach, 
 as in those of the other hollow viscera, effusion 
 is occasionally prevented by the formation of 
 " salutary adhesions" with neighbouring struc- 
 tures ; thus I recollect a case of perforating ulcer 
 of the stomach which was brought before the 
 Pathological Society in March, 1843, by Professor 
 E. W. Smith, in which the floor of the ulcer was 
 formed by the pancreas. 
 
 Sometimes in rupture of an intestine from ex- 
 ternal violence, as in perforation from internal 
 
 * See Cyclopaedia of Practical Medicine, Art. Perforation 
 of the Hollow Viscera, by Dr. Carswell.
 
 8 ACUTE TRAUMATIC PERITONITIS. 
 
 causes, the fatal results are referrible to the shock 
 to the constitution, and subsequent peritoneal in- 
 flammation, and not to extravasation, as the fol- 
 lowing case, which was laid before the Surgical 
 Society of Ireland on the 6th March, 1841, will 
 show : — 
 
 " Mr. Hargrave detailed a case of rupture of 
 the intestine, from external violence. The pa- 
 tient, a fisherman, named Philip Loughlin, about 
 1 8 years of age, while engaged in the duties of 
 his occupation, was struck by the boom and jam- 
 med in. He felt an intense pain in the lower 
 part of the abdomen (the seat of the injury), fell 
 on the deck, was carried below, and remained 
 in his berth that day and the following night, 
 suffering intensely from pain of the abdomen, 
 accompanied by occasional vomiting, and relieved 
 only by lying in a prone position. When brought 
 to hospital on the following morning, his face 
 and lips were pale, his pulse small and weak, and 
 he complained of pain in the abdomen, increased 
 by pressure over the epigastric and hypogastric 
 regions. His respiration was of a peculiar cha- 
 racter. He endeavoured to inspire and expire 
 by the muscles of the chest alone, without throw- 
 ing into action those of the abdomen. He was 
 put to bed, had warm fomentations to the ab- 
 domen, and dry cupping to the chest, and was 
 ordered to take a grain of opium every third hour. 
 He vomited occasionally during the day, but ap- 
 peared to be greatly relieved by the opium ; so 
 much so, that on the following night he was 
 able to get out of bed, and walk to the night 
 chair. On the next morning he was found to be 
 free from pain; but about 11 o'clock in the fore-
 
 ACUTE TRAUMATIC PEEITOKLTIS. 9 
 
 noon he became suddenly worse, and died about 
 thirty-six hours after the occurrence of the in- 
 jury. From the state in which he entered, Mr. 
 Hargrave was induced to think that there was 
 some important lesion of the abdominal viscera, 
 and the post-mortem examination proved that his 
 suspicions were correct. On opening the abdo- 
 men a quantity of air escaped from the cavity of 
 the peritoneum. There was also a considerable 
 quantity of bloody serum, together with fluid 
 and coagulated blood. The latter was found 
 chiefly in the pelvic cavity, and arose from injury 
 inflicted on the sigmoid flexure of the colon. The 
 patient stated that his bowels had been confined 
 for some days before the accident, but they had 
 been opened shortly after admission. The sig- 
 moid flexure of the colon was found on examina- 
 tion to be the part ruptured ; but in consequence 
 of a quantity of small hard scybala, which were 
 impacted in the intestine, both above and below 
 the seat of the injury, there was no extravasa- 
 tion. 
 
 Perforation of the stomach, the result of ulce- 
 ration,** often takes place in a most unexpected 
 manner. The following case, recorded by Dr. 
 Samuel Gordon, under the head of " Reports of 
 the Hardwicke Hospital," in the Dublin Medical 
 Press, vol. iii. p. 79, shows the insidious way 
 in which perforation of an intestine may set in: — 
 " The second case was a man whom I was called 
 to see at nine o'clock one evening. The nurse 
 
 * For an admirable paper on Chronic Ulcer of the 
 Stomach, by my friend, Dr. Lees, see Dublin Journal of 
 Medical Science, No. XIX. New Series.
 
 10 ACUTE TRAUMATIC PERITONITIS. 
 
 said he had got a ' weak fit,' and that there was 
 something very odd about him : on inquiry I 
 found he had been nineteen days ill ; he had had 
 diarrhoea, which had now ceased ; his pulse was 
 small and quick ; he was covered with cold per- 
 spiration ; the nurse said he had passed water, 
 and had a motion from his bowels not long be- 
 fore ; he himself was now raving, and trying to 
 get out of bed ; the abdomen was tumid ; pres- 
 sure did not seem to pain him. He died the 
 next day. 
 
 " On examination I found he had died of peri- 
 tonitis, caused by extravasation of the contents 
 of the intestines into the peritoneal cavity through 
 a perforating ulcer of the ileum. There were 
 several other ulcers close to the perforation, and 
 the mucous coat of the intestines was most ex- 
 tensively diseased. 
 
 " [Mr. Adams, Mr. Brabazon, Mr. Kennedy, 
 and several others witnessed the post-mortem 
 appearances.] 
 
 "In Dr. Cheyne's Report of the Harkwicke 
 Hopital, in the first volume of the Dublin Hos- 
 pital Reports, will be found a case closely assi- 
 milating this : he saw the patient day after day 
 for six days ; he was admitted on the 22nd day 
 of fever, and died on the 28th. At the close of 
 the report he says : — ' It is worthy of remark that 
 although a mortal disease was forming in the 
 intestines, there was nothing in this man's case, 
 previous to the 27th, which led me to suppose 
 that his bowels were much diseased.' See case 
 of Dromgoole, Dublin Hospital Reports, vol. i. 
 p. 43." 
 
 Post-mortem examinations of persons who have
 
 ACUTE TBATJMATIC PERITONITIS. 11 
 
 fallen victims to peritonitis, from rupture of one 
 of the hollow viscera, the result of external vio- 
 lence, have proved, that although the breach of 
 continuity in such cases may involve any of the 
 viscera, yet, that it is usually situated in either 
 the jejunum, or ccecum intestines. For a true 
 explanation of the mechanism by which such 
 ruptures are occasioned, we are indebted to Dr. 
 John Hart of Dublin, who says — "The late 
 Professor Todd conceived that it (the rupture 
 of the intestine from external violence) was 
 owing to the portion of the intestine which suf- 
 fered happening to be in a distended state at 
 the time when the contusing force impinged 
 on the surface of the abdomen. According to this 
 hypothesis, no one part of the intestinal tube 
 should be more liable to this species of lesion 
 than another, except in proportion as it was sub- 
 ject to be more frequently in a distended state. 
 But what is the result of experience on this 
 point ? It is that this particular kind of injury 
 almost invariably happens to the jejunum, where 
 it is continuous with the duodenum, or at some 
 short distance from that point ; now, although 
 my experience has convinced me that the state- 
 ment so carefully transcribed from one system 
 of anatomy to another, as to the jejunum being 
 generally empty, is erroneous, more especially 
 as regards the state in which it is found in per- 
 sons who have met with a violent death while in 
 full health and vigour, yet as it is not usually 
 found more distended than any other portion of 
 the small intestines, it appears obvious that its 
 distention cannot be the reason why it is the 
 part invariably ruptured by external violence."
 
 12 ACUTE TRAUMATIC PERITONITIS. 
 
 " Some otlier cause than the simple distention 
 must therefore operate in predisposing a certain 
 portion of intestine to suffer the injury in ques- 
 tion. It occurs to me that this may more justly 
 be attributed to the circumstance of the intestine 
 being to a certain degree fixed on some resisting 
 surface at the moment when it receives the im- 
 pulse of the contusing force. Such is the condi- 
 tion of the upper portion of the jejunum, which, 
 at its commencement, is fixed to the spine, and 
 which, for some inches lower down, is confined 
 to the vicinity of that part by the shortness of its 
 mesentery. The absence of such contiguous resist- 
 ing surface would explain why it was that the 
 arch of the colon, in the case here cited, escaped 
 being torn, although the violence had acted on 
 it with a degree of force suificient to rupture the 
 blood-vessels between its coats so as to produce 
 extensive ecchymosis. Every part of the large 
 intestine, however, is not so exempt from rup- 
 ture produced from external violence, as are the 
 arch of the colon and the more moveable part of 
 the small intestines ; the coecura,* for instance, 
 which is usually bound down by the peritoneum 
 to the surface of the right iliac fossa, is occa- 
 sionally burst by external violence." 
 
 Perforation of an intestine from within may, 
 as is well known, occur in any part of the ali- 
 mentary canal from the stomach to the rectum, 
 but the ilium is the portion of the intestinal 
 track most liable to perforation. On opening the 
 
 * For interesting cases of rupture of the ccecum from ex- 
 ternal violence, see Mr. Spear's paper, Dublin Hospital 
 Reports, vol. iv. ; and Mr. Ellis's Clinical Surgery, p. 192.
 
 ACUTE TRAUMATIC PERITONITIS. 13 
 
 abdomen in such cases after death, a quantity of 
 most offensive gas escapes the moment the knife 
 enters the walls of the cavity ; the peritoneum 
 is in general found highly injected, presenting 
 shades of colour from a bright red to that of dark 
 mahogany ; the sac frequently contains sero-pu- 
 rulent matter mixed with flakes of lymph, and 
 more or less of the contents of the ruptured or- 
 gan. If the stomach is the part injured, par- 
 tially digested food will probably be detected ; 
 if the gall bladder bile ; if the small intestines, 
 thin faecal matter ; and so on, the character of the 
 liquid pointing out, to a certain extent, the seat 
 of the disease ; sometimes the intestines are all 
 found glued together by means of organized 
 lymph. Not unfrequently several perforations 
 in the bowel are detected. I have seen as many 
 as three ; in one instance, which Dr. Stokes 
 dissected, " the small intestines were glued toge- 
 ther by flakes of unorganized lymph, and on 
 separating their folds we discovered four perfo- 
 rations, each sufficiently large to admit a quill ; 
 these corresponded to recent ulcers in the muci- 
 parous glands, which had perforated all the 
 coats of the intestine, and in fact rested on the 
 serous membrane of the opposite folds : no fte- 
 cal matter was discovered in the cavity of the 
 abdomen. "* 
 
 Although there are several diseases which 
 may, and have been mistaken for the other forms 
 of peritonitis, amongst which we may enumerate 
 colic, gastritis, enteritis, hepatitis, nephritis, 
 neuralgia, hysteria, and lastly, either contusion 
 
 * Cyclopaedia of Practical Medicine, Art. Peritonitis.
 
 14 ACUTE TRAUMATIC PERITONITIS. 
 
 or rheumatism of the abdomnal muscles, yet 
 traumatic peritonitis, when accompanied by a 
 perforation or rupture of one of the hollow vis- 
 cera, is in general easily distinguished from all 
 other affections by the following group of symp- 
 toms, viz.: the rapid supervention of peritonitis, 
 accompanied by great distention and exquisite 
 tenderness of the abdomen ; sudden prostration 
 of the powers of life ; prompt occurrence of 
 vomiting ; an absence of frottement ; and lastly, 
 by a peculiarly painful and sunken expression of 
 the face. Whilst pointing to the diagnostic 
 symptoms of peritonitis from perforation of an 
 intestine, Louis says, "At a certain period of the 
 disease, on account of which the patients had 
 entered hospital, they experienced suddenly an 
 exquisite and tearing pain of the abdomen, rapid- 
 ly followed by alteration of the features, nausea, 
 and vomiting, &c. These symptoms continued 
 with greater or less violence from twenty to fifty- 
 four hours, presenting remissions which were 
 more or less well marked, and indicating a most 
 intense peritonitis produced by a violent cause, 
 acting in a sudden manner, just as occurs when 
 an irritating substance is applied to the surface 
 of the peritoneum. It is by the re-union of 
 these signs that the lesion that now occupies us 
 has been recognized by MM. Lerminier, Cho- 
 mel, and Martin Solon, under whose care the 
 patients were. From these circumstances it ap- 
 pears that we may regard the following as cha- 
 racteristic signs of perforation of the intestine : 
 If in an acute disease, and in an unexpected man- 
 ner, a violent pain of the abdomen suddenly super- 
 venes, if this pain is exasperated by pressure,
 
 ACUTE TRAUMATIC PERITONITIS. 15 
 
 accompanied by a rapid alteration of the features, 
 and more or less promptly followed by nausea and, 
 vomiting, we may believe and announce that there 
 is a perforation of the intestine."* 
 
 On the same subject Dr. Stokes remarks : " 7Ve 
 have now witnessed a considerable number of 
 these cases, which occurred under our obser- 
 vation in the wards of the Meath Hospital ; in 
 nine of these cases the diagnosis was made, and 
 proved to be accurate by dissection. It is scarcely 
 necessary to remark that the general features 
 were the same, namely, the sudden supervention 
 of the symptoms of peritonitis, and the rapid 
 sinking of the vital powers" 
 
 The prognosis in any case of traumatic perito- 
 nitis, whether the consequence of perforation, or 
 rupture of an intestine, must, for the reasons al- 
 ready mentioned, be always unfavourable, but as 
 a general rule, the greater the danger the nearer 
 the injury is to the solar plexus. However, inas- 
 much as modern treatment, based on scientific 
 principles, has in a few instances succeeded in 
 saving life in both of the foregoing forms of 
 traumatic peritonitis, we should in no case of 
 the disease abandon all hopes of recovery, but 
 should afford the patient the only chance of 
 recovery, by having immediate recourse to those 
 curative measures which have been in a few 
 instances crowned with success, and which I 
 shall, in my next lecture, endeavour to put you 
 in possession of. 
 
 The following are the principal indications 
 which demand attention in the treatment of a case 
 of traumatic peritonitis, accompanied by evidences 
 
 * Recherckes Anatomico-pathologiques. Paris, 1826.
 
 16 ACUTE TRAUMATIC PERITONITIS. 
 
 of a rupture of one of the hollow viscera, viz. : 
 Firstly. The arrest of the peristaltic motion of 
 the intestines, with a view of favouring adhesions 
 and preventing foecal effusion into the peritoneal 
 cavity. Secondly. The adoption of measures for 
 the purpose of subduing or circumscribing the 
 rapidly progressive peritoneal inflammation. 
 Thirdly. The withdrawal or cautious exhibition 
 of fluid nourishment until the period of danger 
 of its extravasation into the abdominal cavity shall 
 have passed by. 
 
 The attainment of the first object, in the treat- 
 ment of traumatic peritonitis, can best be 
 effected by the administration of opium, or some 
 of its preparations, in full and repeated doses. 
 Some years since, Mr. Bates, of Sudbury, di- 
 rected the attention of the profession to the great 
 value of opium, both by the mouth and rectum, 
 in severe peritonitis, where blood-letting was 
 obviously inadmissible; and Dr. Graves, some 
 thirty years ago, " treated successfully two 
 cases of peritonitis after tapping, and occurring 
 in patients of bad habit, by opium, without 
 withdrawing a drop of blood ; and, more lately, 
 the same remedy in a case of peritonitis from 
 effusion of purulent matter into the serous sac:"* 
 but to Dr. William Stokes, on the one hand, 
 is the merit due of having been the first to prove 
 that opium, when administered with boldness, 
 has the power to save life in peritonitis from 
 perforation of an intestine from previous disease ; 
 and to Dr. John Hart, late Professor of Anatomy 
 
 * See Dr. Stokes' Clinical Observations on Opium, 
 Dublin Journal of Medical Science, vol. i. p. 128. 1832.
 
 ACUTE TEATJMATIC PERITONITIS. 17 
 
 in the Royal College of Surgeons in Ireland, are 
 we, on the other hand, indebted for the proposal 
 of administering opium in large doses, in cases 
 of faecal effusion into the peritoneum from rup- 
 ture of an intestine, the result of external 
 violence, icitha view of controlling the peristaltic 
 action of the intestines* The following are the 
 details of the first case of peritonitis from per- 
 foration, treated successfully by Dr. Stokes, a 
 case which is in every way interesting, but 
 especially so to the practical physician, as 
 being the first reported case of the kind, as far 
 as I know, to be found in the annals of medi- 
 cine. " A middle-aged man was admitted on 
 the 27th of June, 1830, apparently in the last 
 stage of peritoneal inflammation ; the disease 
 was of three days' standing ; had supervened 
 suddenly, in a few days after hypercatharsis 
 induced by a large dose of glauber salts, and 
 followed by long-continued exposure to cold. It 
 was attended by several of the usual symptoms 
 of peritonitis from ulcerative perforation of the 
 intestine ; the belly was swollen, and so exqui- 
 sitely tender, that the slightest pressure made 
 the patient utter screams. The countenance 
 was Hippocratic, and the patient tormented 
 with constant hiccup. Coldness of the extre- 
 mities had commenced, and the pulse was weak 
 and slow. Before the hour of visit, leeches had 
 been applied to the belly, without relief ; the 
 patient was then ordered one grain of opium 
 every hour. The next day it was found that 
 the symptoms were improved. The patient had 
 
 * Dublin Hospital Reports, voL v. p. 306. 
 
 B
 
 18 ACUTE TKAUMATIC PEKITONTTIS. 
 
 not experienced the slightest coma, head-ache, or 
 delirium. The same plan of treatment was 
 persevered in, the daily dose of opium being 
 gradually diminished, until the 7th of July, 
 when the convalescence having been completely 
 established, the remedy was omitted. During 
 this time diarrhoea set in for three or four days 
 severely ; this was treated by the application of 
 a few leeches to the anus, and the use of ano- 
 dyne enemata. 
 
 " The patient took in all one hundred and 
 five grains of opium (exclusive of that in the 
 injections), without ever experiencing any of 
 the usual effects of this substance, when exhi- 
 bited in large doses." 
 
 Dr. "Wood, Professor of Medicine in the Uni- 
 versity of Pensylvania, has, in the following ob- 
 servations, whilst pointing out the treatment to 
 be adopted in enteric fever, added his valuable 
 testimony in favour of opium in cases of perito- 
 nitis from intestinal perforation : — " A case has 
 recently come under the notice of the author, in 
 which during apparent convalescence from an 
 attack of fever, when the pulse had become 
 natural in frequency, and all the symptoms 
 were favourable, the patient was suddenly at- 
 tacked with violent pain in the right iliac 
 region, extending over the right side of the 
 abdomen, with great distention, exquisite ten- 
 derness on pressure, and extreme frequency of 
 the pulse. It was the opinion of Dr. Gerhard, 
 who was the attending physician, and myself, 
 that perforation had taken place. We put the 
 patient under the powerful influence of morphia, 
 applied a blister to the abdomen, and had the
 
 ACUTE TEATIMATIC PEEITOKETIS. 19 
 
 satisfaction to see our patient ultimately re- 
 
 cover. 
 
 '• 
 
 Drs. Cusack, Patterson, Gooch, Churchill, and 
 others, have spoken highly of the utility of 
 opium in low puerperal peritonitis, and Dr. 
 Stokes has suggested a trial of the same remedy 
 in peritonitis from rupture of the bladder or 
 uterus, traumatic rupture of the intestines, or 
 after the operation for strangulated hernia. 
 
 The following is a case of acute peritonitis, 
 with supposed rupture of the urinary bladder, 
 successfully treated with opium, according to 
 Dr. Stokes' suggestion, by one of our most emi- 
 nent provincial practitioners, Dr. Mackesy, of 
 Waterford; for the notes of the case, and the re- 
 marks thereon by Dr. lEackesy, I have to thank 
 Dr. Stokes. 
 
 " January 25th, 1831. — Kobert Bennett, a 
 blacksmith, set. 28, of great muscular strength, 
 employed at Knockmahon Copper Mines, had 
 drank freely yesterday evening in the public 
 house of the village. From time to time he ne- 
 glected the urgent call to pass water, but at last 
 was going out for that purpose with a distended 
 bladder, when one of his companions caught 
 him, challenged him to wrestle, threw him down, 
 and fell heavily upon him. Immediately he 
 was unable to raise himself from the floor, com- 
 plained of most acute pain in the belly, and 
 said something had burst within him. He was 
 visited at once by Dr. Baker of Bonmahon, who 
 passed a catheter into the bladder and drew off 
 
 * Wood's Practice of Medicine, vol. i. p. 345, 3rd Edi- 
 tion.
 
 20 ACUTE TRAUMATIC PERITONITIS. 
 
 about an ounce of bloody urine ; no urine was 
 found on his clothes, he was in profound col- 
 lapse, and all his distress was referred to his 
 desire and inability to pass urine ; he had vo- 
 miting, which distressed him greatly, and had a 
 peculiar pinched expression of face, indicative of 
 great anxiety. 
 
 " He was put in a warm bath, warm diffusible 
 stimulants given him, and after some time an 
 enema was administered. 
 
 " The injury occurred about seven o'clock in 
 the evening. In about two hours, when re- 
 action had set in, he was bled from the arm 
 nearly ad deliquium, but without any decided 
 relief. 
 
 " I was summoned from "Waterford, and after 
 hearing the foregoing details from Dr. Baker, I 
 proceeded with him to visit Bennett, about 
 twenty-four hours after the receipt of the injury. 
 He was lying on his back, his knees drawn up, 
 with hoops extended across the bed to bear off 
 the weight of the bedclothes, so exquisitely ten- 
 der was the abdomen. The greatest anguish 
 and distress were depicted in his face ; refers all 
 his distress to his inability to pass urine ; belly 
 prominent and tense, but he would scarcely 
 allow a hand to be put near him; pulse 130, 
 small ; breathing hurried. I passed a full sized 
 gum-elastic catheter into his bladder; a small 
 quantity of bloody urine came off; thirty leeches 
 were applied over the pubic and iliac regions; 
 warm fomentations over the whole abdomen as 
 hot as could be tolerated, under oiled silk. A 
 drain of blood to be kept up as long as the pulse 
 and strength would admit, by leeches over the
 
 ACUTE TRAUMATIC PERITOXITIS. 21 
 
 pubis. A draught of sixty drops tinct. opii 
 was giveu him at once, and in two hours after 
 a grain of opium in pill every hour to the eighth 
 dose, unless sleep supervened. The catheter to 
 remain in the bladder; a stop being adjusted, 
 so as to prevent the instrument entering the 
 bladder further than the eye of it. 
 
 " January 26th. — Heard by letter from Dr. 
 Baker that there was some mitigation of symp- 
 toms. He had taken a grain of opium every 
 hour for six hours, when he was disposed to sleep ; 
 in an hour had another grain, and then slept for 
 three hours, in a profuse perspiration, and ex- 
 pressed himself relieved on awaking. Takes 
 gr. i. of opium eveiy three hours ; fomentations, 
 &c, as before. 
 
 "January 27th. — Yisited Bennett. Counte- 
 nance much improved ; abdomen still tense and 
 painful on pressure, but in a less degree. Has 
 had a grain of opium every three or four hours ; 
 pulse 112, more developed ; water passes through 
 the catheter freely ; not tinged with blood. 
 
 ""Withdrew the catheter, and passed a new 
 one. To persevere in all respects as before. 
 
 " Bonmahon is fifteen miles from Waterford. 
 I did not again visit the case. Dr. Baker con- 
 tinued the catheter to the seventh day. He then 
 passed it every four hours for a few days, when 
 Bennett was able to relieve himself naturally. 
 He gradually recovered, and in seven weeks re- 
 turned to his work. 
 
 " This man had every symptom of rupture of 
 the urinary bladder, with the exception of his 
 having recovered from the injury. Had he died, 
 and no post-)nortem examination made, no doubt
 
 22 ACUTE TBATTMATIC PERITONITIS. 
 
 could have existed as to the nature of the 
 lesion. 
 
 " The intensity of the collapse, setting in im- 
 mediately on receipt of the injury, the rapidity 
 with whicli acute peritonitis supervened, the 
 sensation of something having given way inter- 
 nally, followed by the small quantity of bloody 
 urine, drawn off by the catheter, are all quite 
 characteristic of the injury. 
 
 " The practical part has reference to the effi- 
 cacy of opium freely administered, up to the 
 point of producing narcotism. That the happy 
 issue of this most formidable lesion was to be 
 attributed to its use, as far as human agency 
 goes, I have not the slightest doubt. 
 
 " In conversation with Bennett, I ascertained 
 that in the early part of the evening he had 
 drank freely of punch, and had been out several 
 times to pass water. For more than an hour pre- 
 vious to the injury, finding (to use his own 
 term) his head going, he had only drank warm 
 water and sugar, so that in all probability the 
 urine contained in his bladder, when ruptured, 
 was of a less irritating quality than usual." 
 
 Dr. Churchill has furnished me with notes of 
 the following case which occurred in his practice 
 many years ago. " A woman had hysteritis 
 after delivery, from which she did not perfectly 
 recover, and two or three months after, in mak- 
 ing some exertion, she felt something give way, 
 and was immediately attacked by acute peri- 
 tonitis. Dr. Haughton saw her first, and adopted 
 the usual treatment, but without any apparent 
 relief; we then put her on opium, gr. i. ter qua- 
 terve in die, which was followed by an amend-
 
 ACUTE TRAUMATIC PEEITOEITIS. 23 
 
 ment of all the symptoms, and ultimate recovery 
 I fear to state how much opium she took, but I 
 ought to state, that the debilitated condition in 
 which she was, when I first saw her, precluded 
 any more active measures." Dr. Churchill adds 
 that he took the hint as to the treatment that 
 should be adopted in the foregoing case from 
 Drs. Graves and Stokes. 
 
 Opium is, therefore, to be given in full and 
 repeated doses, in cases of traumatic peritonitis, 
 where grounds exist for believing that a rupture 
 of a hollow viscus has taken place, and for the 
 reasons stated the patient must be held steadily 
 under its influence until the period of danger 
 shall have elapsed. The usual manner of giving 
 opium in these cases is to administer it in doses 
 of from half a grain to one grain every hour in 
 the form of pill, watching, of course, its effects 
 with the greatest anxiety, the patient being fre- 
 quently visited whilst under the opiate treat- 
 ment, for although the generality of persons 
 labouring under this disease tolerate opium won- 
 derfully well, all do not do so. Should inces- 
 sant vomiting be present in a case of the kind, 
 we must then order the opium in the form of 
 enemata in suitable doses, and at proper intervals. 
 
 The second indication in the treatment of 
 traumatic peritonitis, accompanied by symptoms 
 of rupture of one of the intestines when the re- 
 sult of external violence, can, according to my 
 experience, be best accomplished by the full but 
 judicious administration of mercury, by local de- 
 pletions, and lastly, by extensive counter-irrita- 
 tion. 
 
 I may possibly here be asked, If opium, un-
 
 24 ACUTE TRAUMATIC PERITONITIS. 
 
 combined with any other remedy, has proved 
 itself capable of curing peritonitis from perfora- 
 tion of an intestine, the consequence of previous 
 disease, why not trust to it alone in peritonitis 
 following on rupture of an intestine from exter- 
 nal violence? A moment's reflection will, how- 
 ever, satisfy any impartial person that the fore- 
 going cases are essentially different in character, 
 inasmuch as in the former constitutional com- 
 plications of a debilitating character are neces- 
 sarily present, none in the latter, and that con- 
 sequently our remedies must, to be successful, 
 be pushed with much more vigour in the latter 
 than in the former. 
 
 In stating my conviction that mercury, pushed 
 to salivation, is indispensable for the purpose of 
 arresting or circumscribing acute traumatic peri- 
 tonitis, the consequence of rupture of an intes- 
 tine from external violence, I am well aware 
 that the opiate and mercurial plans of treatment 
 are considered incompatible in such cases by 
 some, who assume that mercury will, if given 
 early, prevent the effusion of lymph necessary 
 for the union of the injured intestine, or its ad- 
 hesion to a neighbouring viscus, and that if ad- 
 ministered late it will cause premature absorption 
 of the " salutary adhesions," should such already 
 have been established. I trust, however, that 
 I shall be able to show, by a reference to the 
 following facts, that the prejudices entertained 
 against the administration of mercury in trau- 
 matic peritonitis, accompanied by a rupture of 
 an intestine, are purely hypothetical : — 
 
 lstly. Innumerable pathological investigations 
 have proved, beyond doubt, that in rupture
 
 ACUTE TKATOIATIC PERITONITIS. 25 
 
 of the intestines lymph is effused long before 
 the system can be brought under the influence 
 of mercury, which cannot, according to my ex- 
 perience, be effected, even under the most favour- 
 able circumstances, much before the third day. 
 
 The following case, reported by Dr. Croker 
 King, now Professor of Anatomy in the Queen's 
 College, Galway, shows how very soon lymph 
 may be poured out after a rupture of one of the 
 hollow viscera : — 
 
 "Rupture of the Small Intestine.* — Julia 
 M'Donnell, aged 30, admitted June 12.- Half 
 an hour before admission she had been buried 
 beneath the fallen roof of her cabin, from whence 
 she was dug out with as much expedition as pos- 
 sible ; but even in that short time, she had fallen 
 into a state of collapse. Her limbs were cold, and 
 her pulse imperceptible at the wrist. The only 
 complaint she uttered was of pain in the left 
 hip. 
 
 "The patient was put to bed — external 
 warmth applied, and a warm stimulant adminis- 
 tered. There were no outward marks of injury, 
 except some slight contusions about the face. 
 In the evening she became extremely restless ; 
 the pulse, although perceptible, was so small and 
 rapid, as to be countless ; the respiration very 
 hurried ; the bowels not moved since the acci- 
 dent ; the urine freely voided ; complains of pain 
 in the right iliac region and back, but nowhere 
 else ; no tenderness of abdomen on pressure. 
 "Habeat tinct. opii gutt. xxx. instanter. 
 
 "13th. — Passed a very restless night; con- 
 tinually tossing about in bed ; no sleep. 
 
 * Quoted from the Dublin Medical Press.
 
 26 ACUTE TEATTHATIC PERITONITIS. 
 
 " Eight o'clock, a.m. — Pulse scarcely distin- 
 guishable ; respiration panting ; countenance 
 sunken ; complains not of pain, but of general 
 distress and oppression ; abdomen tympanitic, 
 and tender on pressure in the right iliac region ; 
 tongue white and dry ; stomach undisturbed ; 
 mental faculties unimpaired. 
 
 " Ordered continuous warm stupes to the ab- 
 domen ; an enema, containing 30 drops of lau- 
 danum, immediately, and a glass of wine, with 
 30 further drops, every second hour. 
 
 " Twelve o'clock, morning. — Enema rejected, 
 but wine and opium retained on the stomach ; 
 temperature of limbs sinking fast ; cold, clammy 
 perspiration on face and trunk; pulse gone at 
 wrists ; intellect still perfect ; craved more wine, 
 which, on being given, rallied her for a moment, 
 but she rapidly sank again, and after one or two 
 convulsive gasps, expired — the event being only 
 twenty-six hours from the receipt of the injury. 
 
 " It was in virtue of an early diagnosis, made 
 by Dr. Houston, of rupture of an intestine, and 
 of the sinking state of the patient, that the plan 
 of treatment by opium and wine was adopted. 
 No treatment, however, could have saved life. 
 
 " Examination, twenty hours after death. — The 
 ilium was ruptured within four feet of its termi- 
 nation. Two small openings existed close to 
 each other, from which the contents of the in- 
 testine had escaped into the peritoneal cavity. 
 The more fluid parts of these contents had gra- 
 vitated into the pelvis ; the more consistent parts 
 were spread over the coils of the ilium in the 
 right iliac fossa. The peritoneum, at this place, 
 was highly vascular, and the intestines were
 
 ACUTE TBAUMATIC PEEITOXITIS. 27 
 
 glued ly soft lymph. The inflammation in the 
 more remote parts of the peritoneum had made 
 comparatively little progress." 
 
 2ndly. Mercury, when pushed to salivation in 
 the analogous cases of wounds of the other vital 
 organs and their serous membranes, as, for in- 
 stance, the brain and arachnoid, the lungs and 
 pleurae, possesses an unquestionable power of ar- 
 resting the inflammation of the injured viscera 
 and their investing membranes, without either 
 averting the effusion of lymph necessaiy for the 
 union of the wounded organ, or of causing its 
 untimely absorption ; thus you recollect that 
 within the last month I pushed mercury to sali- 
 vation in Keegan in Xo. 3 "Ward, who was ad- 
 mitted with a wound and subsequent inflamma- 
 tion of the right lung and pleura, consequent on 
 a severe fracture of three of the true ribs, the 
 result of a violent kick of a horse, under which 
 treatment the man rapidly and perfectly re- 
 covered. 
 
 3rdly. The great majority of hospital surgeons 
 of the present day, encouraged by experience, 
 very properly prescribe mercury after all severe 
 operations involving the peritoneum, as, for ex- 
 ample, in cases of large strangulated hernias, as 
 a prophylactic agent against the supervention of 
 inflammation, without the slightest apprehension 
 of either preventing or delaying thereby the 
 union of the wound unavoidably inflicted for 
 the preservation of the patient's life. Thus, for 
 instance, Mr. Robert Adams, of the Eichmond 
 Hospital, has published a case, which he treated 
 in conjunction with Sir Philip Cramp ton and Mr. 
 Elliot, strikingly illustrative of the value of mer-
 
 28 ACTTTE TEAT7MATIC PEEITONITIS. 
 
 cury as a prophylactic against inflammation in- 
 volving the peritoneum. The case alluded to was 
 one of strangulated congenital hernia of extraordi- 
 nary size, in which, from the extent of the wound 
 (necessarily six inches in length), and from the 
 exposure of three feet of intestine, subjected of 
 course to handling in their reduction, mercury 
 was freely administered with a view of meeting 
 the inflammation so likely to attack the peri- 
 toneum after such an operation, under which 
 treatment the case proceeded to a favourable 
 termination. One of the aphorisms laid down 
 by Mr. Adams at the conclusion of the foregoing 
 case runs thus : — " That in the subsequent 
 treatment of the case, it is well to anticipate the 
 symptoms of acute peritonitis by the treatment 
 which is usually found serviceable, when it has 
 actually appeared, namely, by the active exhibi- 
 tion of mercury.* 
 
 In another case of strangulated femoral her- 
 nia which I visited, in consultation with Dr. 
 Symes, of Kingstown, we pushed mercury to 
 salivation, after the reduction of the hernia 
 had been accomplished by operation, whilst the 
 patient was under the influence of chloroform, 
 and the woman made an unusually rapid reco- 
 very, although the hernia had been in a state of 
 strangulation for six days before Dr. Symes was 
 called in. The particulars of the foregoing case 
 were brought by me before the meeting of the 
 Surgical Society of Ireland, December 18th, 
 
 * Transactions Pathological Society of Dublin, 27th 
 Jan., 1844.
 
 ACUTE TBALilATIC PEEITOSTITIS. 29 
 
 1847, and published in the Dublin Medical Press, 
 January 5th, 1848. 
 
 4thly, and lastly. The rapid and permanent 
 union of a wound, when taking place in a per- 
 son in a state of salivation, is, in my opinion, a 
 conclusive proof that the administration of mer- 
 cury neither interferes with nature in the repair 
 of this class of injury, nor causes its subsequent 
 disunion. 
 
 "Whilst strenuously advocating the employ- 
 ment of mercury in the treatment of acute trau- 
 matic peritonitis, accompanied by symptoms of 
 rupture of an intestine, the result of external 
 violence, it is my duty to inform you, that 
 unless its administration is carried out with 
 the greatest judgment, instead of benefiting 
 the patient, the mercury may destroy all chance 
 of his recovery by exciting diarrhoea, the oc- 
 currence of which would obviously neutralize 
 the beneficial effects of the opium, by rous- 
 ing the peristaltic action of the. intestines, and 
 favouring thereby extravasation of their con- 
 tents into the peritoneal cavity. For these rea- 
 sons the mercury should, as we shall presently 
 see, be introduced into the system chiefly by 
 means of inunction. 
 
 I shall now relate two examples (reported by 
 Mir. Allan Douglas, late Resident Pupil to the 
 Hospital), of the successful combination of the 
 opiate and mercurial plans of treatment in severe 
 traumatic peritonitis, accompanied by all the 
 symptoms of rupture of one of the hollow viscera 
 from external violence. Tou all have been 
 afforded an opportunity of witnessing the first 
 case ; several of you saw the second.
 
 30 ACUTE TRAUMATIC PERITONITIS. 
 
 Case I. — Mary Browne, aged 32, a dressmaker, 
 of good constitution, was admitted into Jervis- 
 street hospital on the 13th November, 1855, 
 under the following circumstances: — The pa- 
 tient, whilst driving, having suddenly jumped 
 off the car, under influence of fright, in conse- 
 quence of the horse having become restive, fell 
 on the ground, and whilst down received a most 
 violent kick from the horse in the right side of 
 the abdomen, corresponding to the ileo-ccecal 
 region ; the patient was insensible after the ac- 
 cident,, and vomited a large quantity of blood. 
 She was conveyed into a neighbouring shop, and 
 remained there for about three-quarters of an hour, 
 being in a state of insensibility for more than 
 half of that time. On examination, some hours 
 after the accident, Mr. Hughes found th& abdo- 
 men extremely tympanitic, being apparently 
 distended to the highest possible degree, and ex- 
 quisitely tender to the touch ; there was a large 
 ecchymosis at the seat of injury, the extremities 
 were cold, the pulse weak' and compressible. 
 Urine secreted in small quantities, and expelled 
 with great difficulty and pain. Ordered twenty- 
 four leeches to the abdomen, and pills of calomel 
 and opium, the former to lay a foundation for 
 mercurialization, the latter to maintain the 
 bowels in a state of rest. After a few of the 
 foregoing pills had been given, the calomel was 
 withdrawn, and opium, in one grain doses, was 
 administered every hour, mercurial ointment 
 being at the same time freely rubbed into the 
 axillae and inside of the thighs. Thirst to be 
 quenched by placing a small piece of Wenham 
 lake ice in the mouth from time to time. On 
 the evening of the second day of treatment
 
 ACUTE TEATTMATIC PERITONITIS. 31 
 
 the patient had taken ten grains of solid 
 opium without any of the unpleasant effects of 
 that remedy having evinced themselves, when 
 vomiting of a very obstinate character having 
 re-appeared, nothing being retained on the sto- 
 mach, forty drops of the tincture of opium were 
 administered in two ounces of the mucilage of 
 starch in the form of enema, and repeated at 
 suitable intervals, so as to keep the patient 
 steadily under the opiate influence. On the third 
 day the patient was alarmingly ill, and gave up 
 all hope of her recovery, the vomiting having 
 persisted, assuming a gulping or regurgitating 
 character ; the stomach continued intolerant of 
 pressure, and the tympanitis remained un- 
 changed. On this day the patient was seized by 
 loose evacuations from the bowels containing a 
 quantity of coagulated blood, which, however, 
 were soon controlled by the opiate enemata 
 given at shorter intervals. Ordered three ounces 
 of port wine, to be given in spoonful doses, occa- 
 sionally ; continue the ice. On the morning of 
 the fourth day an amendment in all the symp- 
 toms became, for the first time, apparent; the 
 vomiting ceased, the abdomen became less tym- 
 panitic and less painful, and the pulse improved 
 in character. On the same day the patient came 
 fully under the influence of mercury, as evinced 
 by mercurial fcetor and slight insalivation. 
 
 On the sixth day the pulse rose in frequency, 
 and abdominal pain increased, in consequence 
 of which mercurial ointment was again freely 
 rubbed into the axilla?, and a large blister was 
 applied to the abdomen. 
 
 From this date the patient gradually but
 
 32 ACUTE TRAUMATIC PERITONITIS. 
 
 steadily recovered, having for seven days been 
 kept under the full influence of opium, duriiig 
 which period she took ten grains of solid opium, 
 and 840 drops of laudanum. There was a per- 
 fect absence of abdominal frottement, all through, 
 in Mrs. Brown's case. For several days after her 
 recovery, a circumscribed hardness, corresponding 
 to the seat of injury, could be detected, at which 
 part percussion elicited a dull sound, symptoms 
 obviously the result of the effusion of organized 
 lymph. 
 
 Case II. — J. J. Gibbs, set. 35, a recruit, 
 was carried into Jervis-street Hospital, on the 
 23rd December, 1854. History of the Case. — 
 The patient having become intoxicated whilst 
 spending his bounty money, staggered off the 
 footway, and fell under a heavily loaded float, 
 the wheel of which passed obliquely over his 
 abdomen. Mr. Hughes having been imme- 
 diately sent for, found the man in a state of 
 collapse, lying partly on his left side, with his 
 knees drawn up, his thighs being flexed ; the 
 abdomen was extremely tympanitic and sensi- 
 tive of pressure ; pulse 105, weak ; features 
 pinched, and expressive of great suffering ; the 
 pain, which at first was referrible to the left side 
 of the abdomen, rapidly extended over the entire 
 of that cavity ; soon after admission, the patient 
 was seized by an intense and prolonged rigor. 
 Leeches were applied to the abdomen, and the 
 patient was ordered calomel guarded by opium. 
 In the course of this evening, the patient was 
 seized with distressing vomitings, and the urine, 
 which was scanty and high-coloured, was voided 
 with extreme difficulty and pain. Ice to be
 
 ACUTE TRAUMATIC PERITONITIS. 33 
 
 given in small quantities to slake thirst, which 
 is excessive. On the second day, the pain and 
 other symptoms having remained unmitigated, 
 additional leeches were applied to the abdomen ; 
 the calomel was now withdrawn, but the opium 
 was continued in half grain doses, mercurial 
 ointment being at the same time freely rubbed 
 into the thighs and axillae. 
 
 The foregoing treatment was continued till 
 the fourth day, when the abdominal pain became 
 loss severe, and the vomiting altogether ceased. 
 On this day, slight mercurial fcetor and insa- 
 livationwere detected. Before the hour of visit, 
 the patient was seized with loose evacuations 
 from the bowels, which proved, on examination, 
 to consist of pure liquid blood, in consequence of 
 which two grains of the acetate of lead were 
 added to each of the opiate pills, and a large 
 blister was applied to the abdomen. Under 
 which combined treatment the haemorrhage soon 
 ceased. 
 
 Fifth day. — Patient considerably improved; 
 abdomen much less tympanitic and more tole- 
 rant of pressure ; mouth now fully salivated ; 
 continue the opiate pills. From this date the 
 patient progressed to a recovery, and left the 
 hospital on the 16th of January, to join his 
 regiment. 
 
 At no period of Gibbs's illness was abdominal 
 irottcment detected. 
 
 It is quite possible that some persons may 
 argue, that in assuming that the foregoing speci- 
 mens of traumatic peritonitis were accompanied 
 by a rupture of one of the hollow viscera, that 
 such a conclusion has been gratuitously arrived
 
 34 ACUTE TRAUMATIC PERITONITIS. 
 
 at, and although it is difficult to pronounce with 
 certainty upon the exact nature of the injury in 
 either case, yet few practical surgeons, who have 
 paid attention to injuries of the abdomen, will, 
 I am convinced, doubt the probability of the ex- 
 istence of a rupture of one or other of the hollow 
 intestines, in either of the foregoing cases, when 
 they take into consideration the group of symptoms 
 Avhich were present in each of them, namely : 
 the sudden depression of the vital powers ; the 
 rapid supervention of peritonitis ; the highly tym- 
 panitic state of the abdomen ; the exquisite tender- 
 ness of every portion of that cavity ; the absence of 
 frottement ; and lastly, the occurrence of intestinal 
 hemorrhage. 
 
 You all must recollect how different were the 
 symptoms in Mrs. Brown's case, as compared with 
 those which were present in that of Cullen, lately 
 in this hospital, under the care of my colleague, 
 Dr. Power. Cullen was admitted, you know, 
 labouring under traumatic peritonitis, having 
 been crushed in the abdomen between the shafts 
 of two drays which were passing rapidly in 
 contrary directions, but there were no symptoms 
 of rupture of an intestine present in Cullen ; 
 thus in his case there was no sudden prostration 
 of the vital powers, no vomiting or difficulty 
 of passing water ; no ha3morrhage from the sto- 
 mach or bowels ; and finally, in his case, the abdo- 
 men, instead of being suddenly distended and 
 tympanitic, was, on the contrary, at first re- 
 tracted. Browne's and Cullen' s cases, which 
 occurred about the same time, proved highly 
 valuable to us, as they served to point out most 
 forcibly the differential diagnosis of the two.
 
 ACUTE TRAUMATIC rUMTOXITIS. 35 
 
 forms of traumatic peritonitis. There can but 
 little doubt be entertained that the opiate treat- 
 ment proved highly advantageous in Browne's 
 and Gibbs' cases, not only by lessening the 
 shock to the system and controlling the peristal- 
 tic action of the intestines, but likewise by 
 gaining time for the carrying out of other cura- 
 tive measures. 
 
 It is, however, extremely worthy of your recol- 
 lection, that in neither Browne's nor Gibbs' cases 
 did any marked amendment take place, notwith- 
 standing the liberal administration of opium, 
 until mercurial action had set in, as proved by the 
 presence of mercurial fcetor and insalivation, 
 which became established in both cases on the 
 fourth day. 
 
 In both Gibbs' and Browne's cases, we com- 
 menced the mercurial treatment by the adminis- 
 tration of calomel combined with opium, so as to 
 lay a foundation, as it were, for rapid mercu- 
 rialLzation, after which the calomel was with- 
 drawn, . when we had recourse to inunction, 
 mercurial ointment being rubbed in freely, until 
 salivation was fully established, opium being of 
 course at the same time administered in sufficient 
 doses, and at proper intervals, so as to maintain 
 the system steadily under its influence, till the 
 period of danger had elapsed. 
 
 It may not be out of place here to mention, 
 for the information of the junior portion of the 
 class, that the conjoint exhibition of opium and 
 mercury, as antiphlogistic remedies, was first 
 introduced into practice by Dr. Robert Hamilton,* 
 
 * Medical Commentaries, vol. ix, p. 191. 1785.
 
 36 ACUTE TRAUMATIC PEKITOXITIS. 
 
 of Lynn Regis, and subsequently adopted and 
 recommended by Dr. Armstrong of London, in 
 his " Practical Illustrations of Typhus Fever;" 
 since which period they have been almost uni- 
 versally, at least in Great Britain and Ireland, 
 resorted to in a combined state, in various in- 
 flammations of a serious character, but more 
 especially in those involving the organs contained 
 within the cavities of the chest and abdomen. 
 
 In both Gibbs' and Browne's cases, as well as 
 in that recorded by Dr. Stokes, looseness of the 
 bowels set in on the fourth day ; in both of the 
 former patients, blood was passed on the same 
 day by the rectum ; in Gibbs' case, the blood 
 was liquid, in Browne's coagulated. Some per- 
 sons are of opinion, that when the evacuated 
 blood is liquid in ruptured intestines, it is 
 a proof of the injury to the alimentary canal 
 being low down, and that, on the contrary, a 
 discharge of coagulated blood is evidence of an 
 injury having its seat higher up, near the sto- 
 mach ; but I agree with Lisfranc, who says, that 
 this distinction cannot be relied on. 
 
 Although, owing to the great depression of the 
 vital powers, which invariably occurs in trau- 
 matic peritonitis, the consequence of a rupture 
 of an intestine from external violence, depletion 
 to the same extent as would be requisite in sorr. 2 
 of the other forms of peritonitis is contra-indi- 
 cated, yet the application of leeches to the abdo- 
 men, in both Browne's and Gibbs' cases, was 
 attended with apparent benefit. I have often 
 thought that there appeared to be some truth in 
 an opinion which had some weight with the an- 
 cients, viz., that local depletions exercise more
 
 ACUTE TRAUMATIC PERITONITIS. 37 
 
 salutary influences over membranous inflamma- 
 tions, than general blood-letting by either arte- 
 riotomy, or venesection, inasmuch as the former 
 act more energetically on the capillaries of the 
 parts implicated, than the latter. 
 
 The applications of blisters to the abdomen, in 
 the cases already cited, were thought to be of 
 service. 
 
 As the recoveries in Gibbs' and Browne's cases 
 were, in my opinion, attributable to a proper 
 combination of the opiate and mercurial plans 
 of treatment, 'assisted by local depletions and 
 counter-irritation, I strongly recommend the 
 adoption of these measures in similar cases. 
 
 I would, in conclusion, observe, that in all 
 cases of traumatic peritonitis, in which a rupture 
 of an intestine is believed to exist, the patient 
 should be enjoined absolute rest in the horizontal 
 posture, and that drinks should be denied the 
 sufferer for the first few days, or at least ad- 
 mitted only, as suggested by Dr. Wood, " in 
 such quantities as may insure them against 
 passing through the pylorus, "f thirst being, as 
 in Browne's and Gibbs' cases, slaked by means 
 of small pieces of Wenham lake ice placed on 
 the tongue from time to time. 
 
 THE END. 
 
 Trinted by J. li. O'Toole, 13, Hawkins'-street, Dublin.
 
 A CASE 
 
 DISEASE OF THE KNEE JOINT 
 
 ADVANCED STAGE. 
 
 AMPUTATION PERFORMED UNDER UNFAVOURABLE 
 CIRCUMSTANCES, WITH THE BEST RESULTS. 
 
 WITH OBSERVATIONS. 
 
 JAMES S. HUGHES, M.D., F.R.C.S.L, 
 
 SURGEON TO JERVIS-STREET HOSPITAL, SURGEON IN ORDINARY TC 
 HIS EXCELLENCY THE LORD LIEUTENANT. 
 
 DUBLIN : 
 
 PRINTED BY J. M. O'TOOLE, 13, HAWKINS'-STREET, 
 
 1856.
 
 A CASE 
 
 DISEASE OF THE KNEE JOINT. 
 
 History of the Case. — The patient, Joseph 
 Kelly, set. 19, a house carpenter by trade, was 
 admitted in June last into Jervis- street Hos- 
 pital, under the following circumstances. The 
 right knee was enormously enlarged, being at 
 least four times the size of the opposite one ; the 
 integuments were pale, tense, and shining, with 
 several enlarged veins ramifying through them, 
 five fistulous openings existed in connexion with 
 the diseased joint, two of which were situated 
 on the outside of the knee, one about the central 
 portion of the anterior surface of the thigh, and 
 two below the joint at the inner side of the tibia. 
 The leg was bent at an obtuse angle with the 
 femur, the limb above and below the joint was 
 wasted, indeed the patient was in the greatest 
 state of general emaciation conceivable, pulse 
 120, very feeble, complete loss of appetite, night 
 perspirations, alternating with attacks of diar- 
 rhoea. The patient slept but little, being con- 
 stantly disturbed, especially during the night 
 time, with startings of the limb, and* referred 
 the pain in the joint, which was excruciating
 
 i CASE OF DISEASE OF THE KNEE JOINT. 
 
 on the slightest movement of the limb, to the 
 external condyle of the femur. 
 
 The patient had but little cough, but he was 
 troubled with profuse expectoration ; there was 
 comparative dulness under the left clavicle, with a 
 corresponding feebleness of respiration. 
 
 As to the anterior history of this case, the 
 patient stated, that about two years and a half 
 previously he was seized with a pain in his right 
 knee, followed by swelling of the joint, which 
 he attributed to a fall from a horse some time be- 
 fore ; that although the pain was tolerably se- 
 vere from time to time, it never prevented him 
 from following his occupation for a year and a 
 half, notwithstanding the swelling used to in- 
 crease after walking any distance. In this way 
 matters proceeded for about one year and a half, 
 when the swelling having increased, and the pain 
 having become more acute, he was no longer 
 able to follow his occupation, and applied to 
 Dr. Banon, who opened an abscess in connexion 
 with the joint, and recommended him to come 
 into hospital, which he refused to do. The 
 patient received considerable relief after the ab- 
 scess was opened, but subsequently the five 
 fistulous openings, already referred to, became 
 established, through which a quantity of whey- 
 like fluid was constantly oozing. The severe 
 spasms of the limb, particularly at night-time, 
 now became most painful, and almost incessant; 
 his appetite failed him, his strength declined, 
 perspirations, alternating with diarrhoea, then 
 set in, and in this state he sought admission 
 into hospital, where he was, in the unavoidable 
 absence of Dr. Banon, placed under my care.
 
 CASE OF DISEASE OF THE KNEE JOINT. 5 
 
 A question now arose in consultation -with my 
 colleagues on this case, as to how far, with the 
 evidences of Kelly's pulmonary delicacy before 
 us, amputation — re-section of the joint being, 
 for obvious reasons, not even thought of — was 
 likely to benefit the patient. It was apparent 
 that without operative interference the patient 
 could not live many weeks, and his sufferings 
 were of the most aggravated nature. It was 
 therefore, after much deliberation, agreed on to 
 propose to the patient the only chance of a pro- 
 longation of his life, namely, amputation of the 
 thigh, to which, after some hesitation, he con- 
 sented. The operation was accordingly per- 
 formed by me on the 1 8th of last June, by the 
 double circular method, whilst the patient was 
 under the full influence of chloroform. The 
 stump healed in tolerably quickly, considering 
 the low vitality of the patient at the time. 
 
 The following were the appearances which 
 the joint exhibited on being opened after ampu- 
 tation. The synovial membrane had almost dis- 
 appeared ; here and there were seen vascular 
 fringes of organized lymph. The cartilages of 
 incrustation had been almost completely re- 
 moved from the extremities of the femur and 
 tibia, the ends of the bones being exposed. The 
 vascular fringes, already noticed, were found in 
 contact with the only patches of cartilage left on 
 the tibia. Scarcely any vestige of the crucial 
 ligaments could be detected. The patella, de- 
 nuded of cartilage, was in a highly vascular 
 condition, and lay on the external condyle of 
 the femur, which was likewise preternaturally 
 red and vascular, and it was to this part of the
 
 b CASE OF DISEASE OF THE KNEE JOINT. 
 
 joint, as already mentioned, that the patient re- 
 ferred all his sufferings. Every texture entering 
 into the formation of the joint was implicated in 
 the disease; a considerable quantity of un- 
 healthy-looking fatty deposit was found in the 
 areolar tissue external to the articulation.* 
 
 As soon as the stump was healed the patient 
 was sent to Clontarf ; he was ordered a mixture 
 containing the citrate of iron and quinine, toge- 
 ther with cod-liver oil, and light, nutritious 
 diet. The compound tincture of iodine was, 
 from time to time, applied to the left subclavi- 
 cular region. 
 
 Observations. — Nearly eleven months have 
 now elapsed since the operation was performed 
 in Kelly's case ; the patient has regained his 
 flesh and strength, being now enabled to walk, 
 with the assistance of a crutch, from Clon- 
 tarf to the hospital to see me occasionally ; but 
 what is of more consequence, the expectoration 
 has completely disappeared, and, when I last 
 examined his chest, in presence of the class at 
 Jervis- street Hospital, about a fortnight since, 
 the dulness, on percussion under the left cla- 
 vicle, had become sensibly diminished, and the 
 respiration in that region had assumed a more 
 natural character. 
 
 * I have kept the joint in Dr. Stapleton's preservative 
 fluid [see Dublin Quarterly Journal of Medical Sciences, 
 Feb. 1848, p. 280], by which means the pathological ap- 
 pearances have been admirably preserved, and with but 
 little change of colour, as proved by comparing the wet 
 preparation with a negative photographic sketch of the 
 joint in my possession, which was taken by my friend. 
 Mr. Frederick Sanders, immediately after the operation, 
 and afterwards coloured by him from the recent specimen.
 
 CASE 01' DISEASE OF THE KXEE J0I2fT. / 
 
 Kelly's case must be looked on by every 
 practical surgeon as one of more than ordinary 
 interest, affording, as it does, incontestable proof 
 of the correctness of a statement made by Sir 
 Benjamin Brodie, in the last edition of his work 
 on Diseases of the Joints, where he says, and 
 adduces a case in point to prove his position, 
 that in certain cases of diseased joints visceral 
 disease, which was previously in a state of in- 
 activity, may assume a new form, and begin to 
 make rapid progress under the depressing in- 
 fluence of the disease of the joint, and that am- 
 putation, under these circumstances, may be the 
 means of preserving the patient, if not alto- 
 gether, at least for a considerable time — perhaps, 
 for years. 
 
 THE E>'D.
 
 CLINICAL LECTURES 
 
 ERYSIPELAS 
 
 DELIVEBED AT 
 
 JERVIS-STREET HOSPITAL, SESSION 1853. 
 
 BY 
 
 JAMES S. HUGHES, M.D., F.R.C.S.I.. 
 
 EXAMINEE IN SUEGERY rN THE QUEEN" 's UNIVERSE! V 
 ES' IRELAND. 
 
 From the "Duelix Hospital Gazette." 
 
 DUBLIN: 
 
 PRINTED BY J. M. O'TOOLE, 13, HAWKINS' STREET. 
 
 1854.
 
 ERYSIPELAS; 
 
 Its Clinical History; Patliology ; and Treatment. 
 Being the Substance of tu:o Lectures on the 
 Sahjeet, delivered at Jer vis- street Hospital, 
 Session 18-53. 
 
 Erysipelas has been very prevalent in parts of 
 Dublin and its environs for some months past, 
 but more especially in hospital practice, super- 
 vening not only on every species of wound, but 
 likeYYise attacking persons apparently in health 
 and free from local injury, thus approaching to, 
 if not positively assuming, the character of an 
 epidemic. 
 
 We have at present several cases of erysipelas 
 in the hospital ; vre may, therefore, avail our- 
 selves of this favourable opportunity of making 
 some observations on the nature and treatment 
 of that disease. 
 
 Erysipelas has usually been described as an 
 unhealthy inflammation of the skin alone, or of 
 the skin and subcutaneous areolar or cellular 
 tissue ; but this is too limited a description of the 
 disease, for erysipelas is not invariably confined to
 
 4 LECTURES ON ERYSIPELAS. 
 
 the surface of the body, but may, as in the case of 
 William Austin, spread from the face to the throat, 
 and from thence extend to the larynx and bron- 
 chial tubes ; it may migrate from the fauces to 
 the pharynx and lining membrane of the gastro- 
 intestinal canal ; or it may, on the other hand, 
 suddenly leave the surface of the body and at- 
 tack the brain or its membranes, leading thereby 
 to special, and not infrequently, fatal forms of 
 internal inflammation. 
 
 Erysipelas presents itself under a great variety 
 of phases ; but for practical purposes we are in 
 the habit of classifying it under either of the 
 following forms, viz., the simple, superficial, or 
 true erysipelas, the phlegmonous erysipelas, 
 and the cedematous erysipelas. Since the month 
 of October last we have, in this hospital, chiefly 
 met with the first and second varieties of erysi- 
 pelas ; the regions most frequently attacked by 
 the former were these of the face and head, 
 whilst the latter was principally, if not alto- 
 gether, confined to the lower extremities. 
 
 In true erysipelas the skin of the part af- 
 fected usually assumes a peculiar red or rose 
 tint, pervaded by a yellowish hue ; but al- 
 though this is the ordinary colour of the 
 disease, yet erysipelas may, as we have lately 
 seen, vary in tint from a bright scarlet to a 
 dark red or dusky hue ; when erysipelas spreads 
 from a central point to both sides of the body, 
 it frequently does so in a perfectly symmetrical 
 manner, a feature of the disease which has 
 been much dwelt on by Dr. Graves, and which 
 was extremely well-marked in some of the cases 
 lately under our notice, but more especially in
 
 LECTTJEES OX ERYSIPELAS. 5 
 
 those of Kelly and Austin, in the male Accident 
 "Ward. The redness in true erysipelas is defined 
 by an abrupt festooned border ; if the inflamed 
 surface is subjected to pressure, the redness will 
 disappear, but will rapidly return as soon as the 
 pressure is withdrawn. There is no tangible 
 amount of swelling in true erysipelas. Erysi- 
 pelas has a great tendency to spread, the inflam- 
 mation usually declining at the part first at- 
 tacked ; the disease may thus extend over a con- 
 siderable portion of the body before it finally 
 leaves the patient. "When erysipelas is about to 
 spread, the colour of its festooned border changes 
 from its ordinary colour to a deeper red or more 
 florid hue ; by this change of colour, when con- 
 joined with other symptoms, to which we shall 
 presently refer, we have often been enabled to 
 anticipate a renewed disposition to spread, where 
 the inflammation had previously been in an ap- 
 parently declining state. Informing our prognosis 
 in erysipelas, we should, therefore, attentively 
 examine the border of demarcation between the 
 sound and inflamed skin. M. Chomel has di- 
 rected the attention of the profession to a fea- 
 ture in erysipelas which he considers a most 
 valuable one, as proving a tendency in the dis- 
 ease to extend itself from one point to another, 
 viz., a red elevation at the line of limitation - of 
 the disease, which is, as he states, easily recog- 
 nized, being about one line and a half in thick- 
 ness. By its presence, M. Chomel thinks the 
 physician can positively predict the periods of 
 shifting of erysipelas, and that its absence, on 
 the other hand, indicates the period of limitation 
 of the disease. Vesications not infrequently
 
 b LECTUEES OX ERYSIPELAS. 
 
 make their appearance in erysipelas, which in- 
 duced some writers on cutaneous diseases to group 
 it with the class Bulla); but true erysipelas fre- 
 quently terminates in resolution, as it did in the 
 case of Gaynor, in No. 6 Ward, under which cir- 
 cumstance the inflammation gradually subsides, 
 the skin regaining its healthy condition, either 
 with or without desquamation of the cuticle. 
 When the cuticle becomes detached in the form 
 of vescicles or bulla?, it gives way sooner or 
 later, leaving, in general, the cutis beneath in a 
 healthy state. Sometimes, however, especially 
 in constitutions already enfeebled by want or 
 intemperance, these vesicles run rapidly into 
 troublesome, unhealthy ulceration. 
 
 True erysipelas is divided into idiopathic and 
 traumatic ; there are two instances of the former 
 in the hospital, and of the latter four or five. The 
 true idiopathic erysipelas, which has by some 
 nosologists been classed amongst the acute ex- 
 anthematous diseases, is usually ushered in by 
 a well-marked feverish attack : thus, two or three 
 days before the local inflammation exhibits itself, 
 the patient is attacked with rigors, followed by 
 nausea, and often by vomiting ; he feels drowsy, 
 suffers from headach, and perhaps delirium ; 
 his pulse becomes quick and hard, sometimes 
 there is tenderness in the hepatic and epigastric 
 regions, an intensely bitter taste on the mouth, 
 a tongue thickly coated with yellow fur, together 
 with a semi-jaundiced appearance of the eyes and 
 surface of the body, under which circumstances 
 the disease is properly termed bilious erysipelas. 
 
 In erysipelas the fever and local inflammation 
 hold relative proportions to each other ; thus,
 
 LECTXEES OX EEYSIPELAS. / 
 
 when the eruption appears, the fever, instead of 
 subsiding, as in the true exanthematous diseases, 
 generally in erysipelas becomes aggravated. The 
 delirium in erysipelas usually assumes a low, 
 muttering form, but sometimes it acquires an 
 active character ; thus at several of our visits we 
 found that the patient Austin could be kept in 
 his bed with difficulty, as he exhibited a con- 
 stant desire to wander about the ward, and 
 otherwise prove unmanageable. The delirium 
 of erysipelas often sets in suddenly, a fact well 
 exemplified in the case of Eobertson, now con- 
 valescent in the Accident Ward ; he was suddenly 
 seized with delirium immediately after one of 
 our visits, as evinced by a rambling, talkative 
 state, which persisted for several days. If erysi- 
 pelas is to terminate in death, we shall find that 
 at each of our visits a greater amount of the in- 
 flammation has been superadded at one extremity 
 of the diseased surface than has disappeared at the 
 other; the colour of the erysipelas at the same time 
 assumes a darker hue ; the fever, which perhaps 
 at first bore somewhat of the inflammatory form, 
 now acquires a low, asthenic or typhoid character, 
 delirium evinces itself, involuntary discharges 
 of faeces and urine now frequently take place ; 
 coma next often ensues ; under which circum- 
 stances, death generally soon follows. In the 
 fever of erysipelas, however, as in other forms 
 of low fever, the patient may be reduced to a 
 very low condition, and yet, as we have seen 
 more than once lately, he may recover : we 
 should, therefore, in erysipelas, persist in our 
 remedial measures to the last moment of life. 
 In the latter stages of erysipelas the patient
 
 8 LECTTJEES ON - ERYSIPELAS. 
 
 may, as in the other forms of fever, be seized 
 with retention instead of incontinence of urine, 
 a practical fact which the surgeon should always 
 hold in recollection. 
 
 "We possess no means by which we can pre- 
 dict the period over which erysipelas will ex- 
 tend itself, but, as a general rule, the disease 
 may last from five to about twenty days, or 
 more : thus, in Robertson's case, the erysipelas 
 took about sixteen days to run its course, when 
 it terminated in suppuration of both eyelids, 
 and extensive desquamation of the cuticle of the 
 face and forehead ; whilst Austin's case, in the 
 same ward, spread itself over a longer period 
 Although erysipelas seldom disappears under 
 five days, yet we lately had an opportunity 
 of witnessing a case in this hospital which 
 terminated in resolution within four days; 
 I allude to the case of Gaynor, in No. 6 
 Ward. In the recovery of a patient from ery- 
 sipelas we are not to expect a marked crisis, for 
 the amendment usually takes place in a very 
 gradual manner, as it did, for instance, in the 
 persons of Kelly and Austin : in their cases 
 the delirium slowly but steadily subsided ; the 
 tongue, from being dark brown, dry, and re- 
 tracted, gradually became moist at its edges, and 
 cleaner in appearance ; the pulse became softer 
 and less frequent ; the local inflammation gra- 
 dually disappearing ; and in this manner all the 
 symptoms slowly but steadily improved, until a 
 complete recovery was effected. 
 
 The danger in erysipelas is not to be reckoned 
 so much by the extent of the local inflammation, 
 as by the amount and type of the accompanying
 
 LECTURES OX EKYSIPEIAS. 9 
 
 fever : thus, if the local disease, although spread 
 oyer an extensive surface, should not be ac- 
 companied by much constitutional disturbance, 
 then our prognosis may, so far, be a compara- 
 tively favourable one ; whereas, on the other 
 hand, the existence of a high degree of delirium, 
 a tongue brown, dry, and retracted, and a pulse 
 quick, weak, and compressible, indicate consider- 
 able danger. Erysipelas has such a tendency to 
 spread, that, as long as the smallest amount of 
 the disease exists, so long the patient cannot be 
 pronounced out of danger. 
 
 Sometimes, in erysipelas, a sudden and unex- 
 pected formation of matter is established in a 
 distant part of the body ; thus, in a case of trau- 
 matic erysipelas of the upper portions of the 
 body, which I am at present attending, in con- 
 junction with Mir. McCarthy of Capel-street, a 
 remarkably sudden and extensive collection of 
 matter has taken place over the right ankle 
 joint. 
 
 A patient labouring under true erysipelas 
 may, apparently, be going favourably through 
 the disease, when the inflammation may sud- 
 denly disappear, under which circumstance the 
 patient may perish from a rapid translation of 
 the external inflammation to some internal vital 
 organ, an additional reason for the formation of 
 a cautious prognosis in any case of erysipelas. 
 
 Occasionally patients labouring under ery- 
 sipelas will gradually sink from extreme ex- 
 haustion, although strenuous and well directed 
 efforts have been made to support their strength 
 from the very commencement of the attack. 
 
 Some pathologists assert that the areolar tis-
 
 10 LECTUEES ON EETSIPELAS. 
 
 sue is the primary seat of erysipelas, and that 
 when erysipelatous inflammation attacks the 
 skin, the serous, or the mucous membranes, that 
 it is the areolar tissues entering into their forma- 
 tion that first become involved in the diseased ac- 
 tion; however, erysipelas is now very gene- 
 rally, and, in my opinion, properly regarded as 
 a true blood poison ; it is subject to the same 
 general laws, and requires the same methods of 
 treatment which other true blood diseases de- 
 mand, and it is now generally affirmed that the 
 inflammation of the areolar and other tissues is 
 secondary to, and dependent on, a previously 
 vitiated condition of the blood. 
 
 Erysipelas has been considered by some au- 
 thorities as essentially a contagious disease, 
 whilst others refer its origin altogether to atmo- 
 spheric causes. It can now be scarcely doubted, 
 that to epidemic sources, whatever they may be, 
 the great majority of cases of erysipelas are due ; 
 but it would be going too far, in the present state 
 of our information on the subject, to assert, that 
 erysipelas may not, at times, assume a conta- 
 gious character, for which reason it is always 
 advisable, especially in hospital practice, to take 
 the precaution of isolating patients labouring 
 under erysipelas. 
 
 Erysipelas sometimes prevails at particular 
 seasons of the year, at which periods it not in- 
 frequently attacks several hospitals in the same 
 city, defeating, for a longer or shorter time, the 
 most energetic measures to arrest it.* When 
 
 * Thus, this city has, within our own recollection, been 
 visited by several attacks of epidemic erysipelas. The par- 
 ticulars of two such epidemics have been ably and faith-
 
 LECTURES OX ERYSIPELAS. 11 
 
 erysipelas prevails in an hospital, it materially 
 interferes with the success of operations ; thus I 
 have been obliged, in the present epidemic, to 
 postpone an amputation of the breast, and some 
 minor operations, until the erysipelas shall have 
 left our wards. 
 
 Erysipelas frequently attacks over-crowded 
 and badly ventilated hospitals, and other public 
 institutions ; owing, however, to the remarkable 
 cleanliness, and improved modes of ventilation 
 of the hospitals of this city, we have for years 
 past been comparatively free from erysipelas, 
 except at such periods as the present, when the 
 disease is apparently dependent for its existence 
 on some peculiar conditions of the atmosphere. 
 
 I would now direct your attention to the 
 cases of erysipelas of the face and head, at pre- 
 sent in hospital. As the structure of the scalp 
 renders it liable to certain forms of erysipelas, 
 and likewise to peculiar terminations, we are in 
 the habit of dividing erysipelas of that region 
 into the idiopathic and traumatic, as well as into 
 the superficial and deep-seated. 
 
 Idiopathic erysipelas of the face and head is 
 most usually preceded by symptoms of ppexia : 
 the feverish symptoms having existed for two or 
 three days 'twenty-four hours only in Gaynor's 
 case) ; the erysipelas will make its appearance on 
 the face and forehead, or, as in Austin's case, in 
 the neighbourhood of the ear, in the shape of a 
 
 fully recorded by the late Drs. M'Dowell and Graves ; the 
 papers of these distinguished physicians are most valuable 
 as pointing out the peculiarities of the epidemics referred to, 
 and the treatment that was found most applicable to each 
 form of the then prevailing disease.
 
 12 LECTURES ON ERYSLTELAS. 
 
 small red patch, which evinces a great tendency 
 to spread. At first the patient does not complain 
 of much pain in the part, but, as the disease 
 advances, he generally suffers from a disagree- 
 able prickling, or smarting sensation ; the fever 
 at this period increases. As the inflammation 
 proceeds, it attacks the scalp ; when it extends to 
 the face, the e3 r elids often become enormously 
 swollen and cedematous, the nose likewise 
 swells, especially about the alse ; in extreme 
 cases, the lips also become swollen and bloated- 
 looking. "When the inflammation of the face is 
 at its height, the features of the patient become 
 completely altered. AVe often find that the ears 
 also become swollen, and matter, not infre- 
 quently, forms either in the eyelids or behind 
 the ears ; in these cases, vesicles often make their 
 appearance on the forehead and nose. It has 
 been remarked by some French writers, that 
 erysipelas of the scalp is occasionally preceded 
 by swelling of the glands of the neck, or in the 
 neighbourhood of the jaw.* Although erysipelas 
 of the face and forehead is usually ushered in by 
 a considerable amount of constitutional disturb- 
 ance, yet, in some cases, the local inflammation 
 first manifests itself. Erysipelas of the face not 
 infrequently extends from the lips to the inte- 
 rior of the mouth, and, sometimes, in this way 
 it reaches the larynx and bronchial tubes, as it 
 did in Austin's case, thus producing a form of 
 
 * In corroboration of Avhich, I here may state, that I 
 lately saw a case of extensive erysipelas of the face and fore- 
 head, which, being preceded by tumefaction in both parotid 
 regions, was, in the commencement, looked on as a case of 
 mumps.
 
 LECTURES OX ERYSIPELAS. 13 
 
 bronchitis which may prove fatal. In erysipelas 
 of the head the patient may suddenly die in a 
 comatose condition, death being the result of 
 inflammation of the brain or its membranes, 
 as proved by post mortem examination ; tumes- 
 cence of the vessels of the cerebrum, or its mem- 
 branes, together with serous or purulent effu- 
 sion, either on the surface of the brain or in its 
 ventricles, being the usual appearances which 
 are, in such cases, discovered. 
 
 The following is a well-marked case of idio- 
 pathic erysipelas of the face and head, compli- 
 cated with bronchitis : — 
 
 Reported by He. Wil. Chaeles Ryajt. 
 
 Case I. — Idiopathic Erysipelas of the Head and 
 Face ; Supervention of Bronchitis ; Mercurial In- 
 unction; Recovery. — ¥m. Austin, set. 36, a smith 
 by trade, admitted January 12, 1853, under Mr. 
 Hughes. The patient had been in Jervis-street 
 Hospital for some time, labouring under syphilitic 
 ulceration of the throat, and was discharged on 
 Monday, the 3rd instant, in consequence of 
 erysipelas prevailing in the institution. On 
 Friday, the 7th instant, four days after his dis- 
 missal from hospital, he was seized with rigors, 
 nausea, and insatiable thirst ; soon after which 
 he experienced a burning sensation in his left 
 ear, which became red and swollen ; the inflam- 
 mation gradually extended to his face. On ad- 
 mission this day the left ear was greatly swollen, 
 and of a dusky red hue, its borders being sur- 
 rounded by a very large semi-transparent vesicle. 
 The erysipelas has spread to the left cheek, in-
 
 14 LECTURES ON ERYSIPELAS. 
 
 volving the eyelids, which are nearly closed up. 
 The erysipelas, which is intensely red at its 
 borders, is denned on the upper lip and chin by 
 the situation of the beard. Pulse 100, hard, 
 and somewhat full ; headach ; tongue covered 
 by a thick, yellowish fur ; bowels confined. 
 
 Be Antimonii tartarizati, gr. ij. 
 
 Aq. distillatee, § viij . 
 
 Sulphatis magnesia?, $iv. M. 
 Capiat unciam tertiis horis. 
 
 The affected parts to be dusted over with finely 
 levigated flour. 
 
 13th. — The medicine kept up a nauseated 
 condition for a time ; bowels opened during 
 the night. The erysipelas has extended itself, 
 the right ear being now involved, the in- 
 flammation being perfectly symmetrical on 
 either side, and of an intensely red colour at 
 its border, which, through a magnifying glass, 
 appears slightly raised above the surrounding 
 healthy integuments. Pulse 120, less full ; 
 tongue brown, dry, and retracted. 
 
 Omit the antimonial mixture. The inflamed 
 parts to be smeared over with half a drachm of 
 mercurial ointment. 
 
 R Ammoniae bicarbonatis, 9j. 
 
 Sue. limonum ad sat. plen. 
 
 Mist, camphorse, §vjss. 
 
 Syrupi simplicis, § ss. M. 
 Capiat coch. mag. duo tertia quaq. hora. 
 
 14th. — Very delirious throughout the night. 
 The nurse found great difficulty in keeping him 
 in bed, as he was constantly getting up and en-
 
 LECTURES OX ERYSIPELAS, 15 
 
 deavouring to ramble about the wards. The 
 erysipelas has extended itself to the lips, interior 
 of the month, and fauces ; on the back of the 
 pharynx there is a very unhealthy-looking ulcer ; 
 the patient complains of a sense of suffocation, 
 and has a frequent cough. On examination of 
 the chest there is evidence of bronchitis over 
 the entire region of both lungs. Pulse 130; 
 very weak ; tongue black and dry, protruded 
 ■with difficulty. 
 
 One drachm and a half of mercurial ointment 
 to be applied over the inflamed surface on the 
 face and forehead. 
 
 Eight ounces of red wine. 
 
 Beef-tea as a drink. 
 
 A large sinapism to be applied to the anterior 
 surface of the chest for twenty minutes. 
 
 15th. — Mercurial fcetor and tenderness of 
 gums ; erysipelas declining ; coughed less ; still 
 evidence of bronchitis, but of a less intense cha- 
 racter; he raved some during the night, but 
 was not so unmanageable as at last report. 
 Tongue not so dry or dark; pulse 120. 
 
 Omit the mercurial ointment. 
 
 Continue the wine and beef-tea. 
 
 17th. — Slept well; no delirium; cough less 
 troublesome ; sonorous rales still to be heard 
 over both sides of the chest. The erysipelas of 
 the face is rapidly disappearing ; the cuticle is 
 beginning to desquamate on the forehead and 
 nose ; the patient is much annoyed by the ulcer 
 of the pharynx. Pulse 130; weak. Ordered — 
 
 Mist, ammoniae sat. ut antea. 
 Vini rubri, §x. Arrow-root.
 
 16 LECTURES ON ERYSIPELAS. 
 
 The ulcer in throat to be brushed over with a 
 strong solution of nitrate of silver. 
 
 19th. — Coughed more during the night; has 
 some difficulty of breathing ; evidences of bron- 
 chitis more marked ; cuticle on face desquama- 
 ting rapidly. 
 
 Yesicat. mag. inter scapulas. 
 
 Mist, expect. 
 
 Eepeat the wine and arrow-root. 
 
 20th. — Much relieved by the blister, which 
 rose well. Coughs less frequently. 
 
 Repeat the wine, beef-tea, and arrow-root. 
 
 24th. — Patient is now rapidly advancing to 
 convalescence. 
 
 This patient was dismissed cured on the 5th 
 of February, 1853. 
 
 Traumatic erysipelas of the scalp divides itself 
 into the superficial and deep-seated. The for- 
 mer generally supervenes on contused wounds, 
 as exemplified in the cases of Byrne, Robertson, 
 and Kelly, and the supervention of erysipelas 
 becomes a serious addition to the danger of 
 the original injury, occasionally causing the 
 death of the patient. 
 
 When a person suffering under a wound of 
 the scalp is to be attacked by erysipelas, he will, 
 about the third or fourth day after the infliction 
 of the injury, be seized with a rigor ; in rare 
 cases, however, the erysipelas may supervene 
 in twenty-four hours after the receipt of the 
 wound ; the rigor in these cases is soon followed 
 by nausea, and sometimes by vomiting ; the 
 patient complains of thirst, his pulse becomes 
 quick and hard. If, at this period, we examine
 
 LECTEEES ON EEYSEPELAS. 17 
 
 the wound of the scalp, we shall find that it has 
 assumed an unhealthy appearance, the dressings 
 are found to adhere to its edges, the scalp in the 
 immediate neighbourhood of the injury pits 
 on pressure. This form of erysipelas, like the 
 idiopathic, possesses a great tendency to spread, 
 frequently, as in Kobertson's case, extending to 
 the face, ears, and nose, and a formation of pu- 
 rulent matter may take place in both eyelids. 
 If a case of traumatic erysipelas of the scalp ia 
 arrested, we will observe that the inflammation 
 having spread to a particular point, begins to 
 fade at its festooned border, and no longer extends 
 itself; the fever, at the same time, will gradu- 
 ally subside ; in this way the amendment will 
 be more visible at each of our visits. In some 
 of these cases the urine may, about this period, 
 be secreted in greater quantity, and deposit, on 
 cooling, as it did in Robertson's case, a copious 
 sediment. If, on the other hand, the attack is 
 to terminate fatally, the inflammation will con- 
 tinue to spread, the fever will increase, the 
 tongue, at first moist and furred, will become 
 shrivelled, brown, dry, and retracted ; low de- 
 lirium now sets in, and the patient not infre- 
 quently dies comatose. In this, as in the simple 
 idiopathic form of erysipelas, we are guided in 
 our prognosis more by the increase of the fever 
 and delirium, than by the extent of the local 
 inflammation.
 
 18 LECTURES ON ERYSIPELAS. 
 
 Reported by Me. "W. E. Lynch. "& 
 
 Case II. — Traumatic Erysipelas of the Face and 
 Forehead, illustrative of the Advantages resulting 
 from the early Exhibition of an Emetic, followed 
 by Diaphoretics. — John Byrne, get. 2 7, a labourer, 
 admitted January 4th, 1853, under Mr. Hughes. 
 On the evening of the 27th December last the 
 patient, whilst drinking in a tavern, had a dis- 
 pute with a companion, from whom he received 
 a severe blow of a poker over the right eye, by 
 which a deep wound was inflicted, which bled 
 profusely ; he suffered no further inconvenience 
 until last night, when he was seized with a 
 severe rigor, followed by nausea. On ad- 
 mission into hospital this morning, the upper 
 parts of the face and forehead were covered 
 by erysipelatous inflammation of an intensely 
 scarlet colour at the festooned borders ; both eyes 
 were closed up, the eyelids being considerably 
 swollen and cedematous ; the edges of the wound 
 were dry and unhealthy looking ; the dressing 
 adhered to them ; he complains of severe head- 
 ach and pain in his loins; skin hot and dry ; 
 tongue white and moist ; no epigastric tender- 
 ness ; pulse quick and full. 
 
 R Antimonii tartarizat. gr. i. 
 
 Pulv. ipecac, gr. xv. 
 
 Aq. tepida3, §vi. M. 
 Fiat haust. statim sumendus. 
 
 A light poultice to be applied to the wound ; 
 the patient to be placed on low diet. 
 
 oth. — The emetic acted immediately after it 
 was taken ; the patient is greatly relieved ; the
 
 LECTURES OX EEYSIPELAS. 19 
 
 redness of the face and forehead and swelling of 
 the eyelids have all greatly diminished; the 
 border of the erysipelatous surface has greatly 
 faded in colour ; the patient slept quietly during 
 the greater part of the night ; his headach is 
 nearly gone ; bowels still confined ; pulse softer. 
 
 ft Hydrarg. submuriatis, gr. iij. 
 Pulv. jalapae, 9i. 
 Mel. q. s. ut flat bolus. 
 Statim sumend. 
 
 R Aq. citratis ammonia), §ij. 
 Aq. distillatae, §vss. 
 Syrupi simplicis, § ss. M. 
 Fiat mistura, cujus capiat coch. mag. duo 
 tertiis horis. 
 
 7th. — The erysipelas has quite disappeared ; 
 tongue clean ; bowels freely opened ; pulse soft . 
 
 Eepetatur mistura ut antea. 
 
 8th. — Discharged cured. 
 
 Reported by Me. Chaeles AV^r. Ryax. 
 
 Case III. — Traumatic Erysipelas of the Head 
 and Face ushered in by low Fever, complicated with 
 Epistaxis and Diarrhcea, successfully treated by 
 Wine and light Nourishment from the Onset. — 
 Greville Robertson, set. 40, a tax collector, of 
 intemperate habits, admitted January 1st, 1853, 
 under the care of Mr. Hughes. 
 
 Seven days since the patient accidentally fell 
 against one of the posts of his bedstead, by 
 which he sustained a few trifling scratches on the 
 back part of his head, which bled but little ; be- 
 tween the second and third day after the accident
 
 20 LECTURES ON ERYSIPELAS. 
 
 he was attacked with erysipelas at the seat of 
 injury, which rapidly extended to the right side 
 of the face. On the fourth day he was seized by 
 repeated and violent attacks of bleeding from 
 his nose, and by diarrhoea, which weakened him 
 very much. On admission this day (seven days 
 after the fall), the back part of the head, the fore- 
 head, right side of the face, and a portion of the 
 left were covered with erysipelatous inflam- 
 mation of a dusky livid hue ; pulse rapid and 
 compressible ; tongue dark brown and dry ; the 
 diarrhoea has returned. Ordered — 
 
 R Misturse cretce, §viij. 
 Confectionis aromat. 3i- 
 Tinct. kino, 5ij. M. 
 
 Capiat cochlearea magna duo post sing, liquidas 
 sedes. Yini rubri, § vi. Arrow root. The in- 
 flamed parts to be dusted over with finely levi- 
 gated flour. 
 
 2nd Jan. — The patient was suddenly seized 
 with delirium after our morning visit on yes- 
 terday, and raved much during last night ; he 
 is now constantly muttering to himself ; is lying 
 low in the bed on his back, and picking the bed- 
 clothes. The erysipelas has extended over the 
 entire of the right side of the face, having kept 
 stationary on the left side and back of the head. 
 Pulse very weak and compressible ; tongue dry 
 and brown, and protruded imperfectly and with 
 great difficulty ; diarrhoea gone. 
 
 Increase the wine to §xii. in the twenty- 
 four hours. Ordered bark mixture with ammo- 
 nia. 
 
 3rd Jan. — Patient extremely restless and de-
 
 LECTURES OX ERYSIPELAS. 21 
 
 lirious during the night; the erysipelas has 
 spread ; eyelids closed up and cedematous ; a 
 large vesication occupies the top of the nose ; 
 pulse extremely quick, small, and compressible ; 
 tongue black, dry, and more retracted ; lips 
 covered with dark sordes ; still lying on his back 
 low in the bed. 
 
 Ordered a pint of wine. Beef-tea as a drink. 
 Eepeat the bark mixture. 
 
 4th Jan. — Considerably improved. The ery- 
 sipelas has not extended ; raved less ; slept a 
 little ; pulse less compressible, not so rapid. 
 
 Eepeat the wine and mixture. 
 
 5th Jan. — A further amendment ; raved but 
 little ; slept better ; inflammation of head and 
 face greatly reduced ; tongue becoming clean and 
 moist at its edges ; the urine, on cooling, depo- 
 sits a copious sediment ; pulse less frequent and 
 stronger. 
 
 Ordered six ounces of brandy, beef-tea, and 
 arrow-root. 
 
 The patient from this date gradually improved, 
 and was pronounced convalescent on the 20th of 
 January, suppuration having in the meantime 
 been established in both eyelids, and the matter 
 having been let out by suitable incisions, which 
 healed in without leaving any deformity. 
 
 The deep-seated form of traumatic erysipelas of 
 the scalp is most frequently the result of a 
 punctured wound, involving the tendon of the 
 occipito-frontalis muscle and the areolar mem- 
 brane beneath it. But, although in these cases 
 the inflammation originates in these structures, 
 it ultimately extends itself to the adjoining tex- 
 tures. Sometimes, as in Bateson's case (under
 
 22 LECTURES ON ERYSIPELAS. 
 
 Mr. Banon's care in "No. 3 Ward), this deep- 
 seated erysipelas is not the result of a punc- 
 tured wound of the scalp, but may be caused 
 by erysipelas spreading from a wound of the face 
 to the head. In this disease we find, from about 
 the second to the third or fourth day, a circum- 
 scribed tumour, which is hard, painful, and 
 accompanied by a high degree of fever, and not 
 infrequently by delirium. If a case such as the 
 foregoing is not met with both promptness and 
 judgment, the inflammation will spread along 
 the areolar tissue, beneath the occipito-frontalis 
 muscle, and irreparable mischief may be the 
 result ; thus even the bones of the cranium may 
 become carious, and the patient eventually die 
 of inflammation of the brain. In these cases 
 the scalj) resists the destructive process to almost 
 the latest period of the disease, owing to its 
 peculiar vascular supply. In this deep-seated 
 form of erysipelas of the scalp, the swelling is 
 usually limited by the insertion of the occipito- 
 frontalis muscle, the eyelids and ears not usually 
 being involved in the disease ; however, the 
 superficial and deep-seated forms may co-exist, 
 as in the case of Bateson, already referred to, 
 under which circumstances you will, of course, 
 be prepared for both the eyelids and ears becom- 
 ing affected by the inflammation. In this deep- 
 seated erysipelas of the scalp, the local symptoms 
 almost invariably manifest themselves before the 
 constitutional disturbance sets in. 
 
 The next form of erysipelas is the phleg- 
 monous ; two interesting cases of which are 
 at present under my care in the hospital. 
 This affection, which received the name of dif-
 
 LECTEEES OX EEYSITELAS. Td 
 
 fuse phlegmon from Dupuytren, is distinguished 
 from true erysipelas by its involving the subcu- 
 taneous areolar membrane, as well as the skin; by 
 its disposition to terminate in suppuration, and 
 lastly, by its frequently inducing destruction of 
 the skin in a secondary manner. In plilegmo- 
 nous erysipelas, the colour of the skin assumes a 
 deeper hue than in true erysipelas, as you had 
 an opportunity of observing in the girl "Walsh's 
 case, who was admitted into ±so. 6 Ward, three 
 days since, with phlegmonous erysipelas of the 
 leg ; in her case the colour of the affected part 
 was of a dark livid hue, and had a peculiar 
 mottled appearance. Phlegmonous inflamma- 
 tion may attack the skin and areolar membrane 
 of any part of the body ; but the extremities, 
 especially the lower, are most frequently the 
 seat of this severe disease. Soon after phlegmo- 
 nous erysipelas sets in, the limb becomes con- 
 siderably swollen and tense ; the areolar tissue 
 being at first loaded with serum, the integu- 
 ments pit on the slightest pressure ; in the very 
 onset of the attack the patient does not, in ge- 
 neral, complain much of heat or pain in the part, 
 but after a lapse of a day or two, if the case is 
 neglected, the pain becomes acute, and in the 
 advanced stage is accompanied by a distressing 
 throbbing sensation. As the disease proceeds, 
 the limb becomes more tense, and no longer pits 
 on pressure. In this stage the cuticle often be- 
 comes detached from the true skin, as occurred 
 in M'Xamara's case, in Ko. 1 Ward, forming 
 bullae or vesicles, filled with a dark turbid fluid. 
 Inflammation of the absorbents and lymphatics, as 
 we lately had opportunities of witnessing, often
 
 24 LECTURES ON ERYSIPELAS. 
 
 accompanies phlegmonous inflammation; how- 
 ever, such an occurrence is, by no means, a neces- 
 sary feature of the disease. As the diseased action 
 progresses in phlegmonous erysipelas, the limb 
 acquires a soft and boggy feel, the fluid first 
 effused into the areolar membrane is of a light 
 serous nature and consistence, but as the disease 
 advances this fluid assumesmoreof a purulentcha- 
 racter ; in this form of inflammation the matter is 
 not circumscribed, as in ordinary phlegmon, but 
 becomes diffused throughout the areolar tissue of 
 the limb. Phlegmonous, like true erysipelas, has 
 consequently a great tendency to spread. The areo- 
 lar membrane in phlegmonous erysipelas becomes 
 destroyed, being converted, in the course of ten 
 or twelve days, into a slough of a greyish white 
 colour. In a still more advanced stage, the inte- 
 guments, having lost their vitality, are now, in 
 different parts, converted into small dark patches. 
 In extreme cases, the greater portion of the are- 
 olar tissue of the limb may be lost ; the muscles 
 being dissected and laid bare, the tendons may, 
 in the same way, become detached ; and in some 
 extremely neglected or improperly treated cases 
 (more especially when the result of a compound 
 fracture), the joints may be opened, and their 
 texture completely destroyed. Phlegmonous ery- 
 sipelas is always accompanied by a considerable 
 amount of fever; in the early stage the pulse 
 may, as in simple erysipelas, be hard and full ; 
 afterwards, however, as the disease advances, it 
 usually becomes quick and feeble; delirium 
 and subsultusmay set in, vomiting and diarrhoea 
 not infrequently ensue, the delirium may, at 
 this stage, increase, and under such circum-
 
 LECTURES OX ERYSIPELAS. 25 
 
 stances, the patient soon becomes comatose, in 
 which, condition he dies. In some of these cases 
 death is preceded by inflammation of the organs 
 within either the head, chest, or abdomen, or, as 
 occnrred in the case of M'Geogh, lately nnder 
 the care of Hr. Stapleton, pns may be formed in 
 many of the joints, and, as in his case, within 
 the pericardium. 
 
 In peculiar conditions of the constitution, phleg- 
 monous erysipelas may be accompanied by trau- 
 matic delirium, or, as in M'jSaniara's case at pre- 
 sent, in No. lAYard, by well-marked delhium tre- 
 mens ; such complications, of course, add consi- 
 derably to the danger of the patient. 
 
 If a case of phlegmonous erysipelas is to re- 
 cover, the sloughs are thrown off, granulations 
 spring up, and the ulcers heal; but in the 
 extreme cases, which I have endeavoured to de- 
 scribe to you, where the limb has suffered ex- 
 tensively, the joints being disorganized, nothing 
 short of amputation will save the patient's life, 
 for otherwise he will sink under the profuse 
 discharge, and constitutional disturbance. 
 
 Phlegmonous erysipelas is generally the result 
 of an injury such as a severe contused, lacerated, 
 or punctured wound, or it may follow a compound 
 fracture. In lE'Xamara's case, the disease super- 
 vened on a contused and lacerated wound ; in 
 Walsh's case, in Xo. 6 Ward, the exciting cause 
 of the inflammation was a severe kick on the 
 shin. At other times, phlegmonous erysipelas 
 makes its appearance without any very assign- 
 able cause. There is a disease which bears con- 
 siderable resemblance to phlegmonous erysipelas ; 
 I allude to diffuse inflammation of the areolar
 
 26 LECTURES ON ERYSIPELAS. 
 
 membrane. In true diffuse inflammation the 
 skin does not, at first, in the great majority of 
 cases, partake of the inflammation, and when it 
 does become involved, it is but in a secondary 
 manner. Diffuse inflammation resembles phleg- 
 monous erysipelas in its great tendency to spread, 
 and to terminate in suppuration. Diffuse in- 
 flammation not infrequently engages the areolar 
 membrane of an entire limb, and often rapidly 
 extends from one part of the body to another. 
 On post mortem examinations of patients who 
 have died of diffuse inflammation, purulent de- 
 posits are frequently found in the interior of the 
 pericardium, large joints, &c, &c. Diffuse in- 
 flammation sometimes is the result of a wound 
 in dissection; at other times, it is the consequence 
 of the bite of a venomous animal ; occasionally it 
 follows on fever. 
 
 Reported by Mr. "W. E. Lynch. 
 
 Case IY. — Severe Phlegmonous Erysipelas of 
 the Leg, complicated with Delirium Tremens ; Re- 
 covery. — Patrick M'Namara, set. 35, an omnibus- 
 driver, of intemperate habits, admitted into Jer- 
 vis-street Hospital, 25th December, 1852, under 
 Mr. Harrison. 
 
 As the patient was ascending the box of his 
 omnibus his foot slipped, and he fell with vio- 
 lence to the ground; two deep lacerated and 
 contused wounds were inflicted on the leg below 
 the knee by some projecting part of the wheel, 
 whilst he was falling. 
 
 On examination, after admission, the leg from 
 the knee downwards was swollen, and the 
 patient was suffering from intense agonizing
 
 LECTURES OX EEYSIPELAS. 'J, i 
 
 pain in the seat of injury. Warm lead fomenta- 
 tions were applied to the limb, and the patient 
 was ordered the antimonial mixture. 
 
 28th. — The inflammation has greatly extend- 
 ed, the surface of which is cedematous, and pits 
 on pressure ; the patient was very delirious 
 during the night, and complains of much pain 
 in the limb. Mr. Harrison made two deep in- 
 cisions into the leg, by which a quantity of 
 purulent matter was let out ; poultices were then 
 applied to the limb, and the patient was or- 
 dered — 
 
 R Mist. Camphorse, §viss. 
 Aceti opii, 3i- 
 Liq. tart, antimonii, §i. 
 Spaipi simplicis, § ss. M. 
 Capiat cochleare magnum omni hora. 
 One quart of porter. 
 
 29th. — Much relieved by the incisions and 
 treatment. Repeat the mixture and porter. 
 
 30th. — Patient less delirious; inflammation 
 extending towards the knee. Mr. Harrison 
 made another incision above the former ones, 
 through which much matter escaped. Ordered — 
 
 R Mist, camphorae, §iv. 
 
 Spirit, ammonias arom. 3ij- 
 Tinctures opii, gtts. xl. 
 Syrupi, 3ij. M. 
 Sumat § ss. omni hora. 
 
 January 1st. — Mr. Harrison's period of duty 
 at the hospital having expired, Mr. Hughes took 
 up the case. The patient has been very rest- 
 less for the last twenty-four hours ; he is watch- 
 ful and suspicious ; has been attacked with hal-
 
 28 LECTURES Otf ERYSIPELAS. 
 
 lucinations, fancying that all sorts of demons 
 are torturing his injured leg; at other times the 
 associations of his calling are aroused, at which 
 periods he starts up, asks for his whip, and gives 
 directions to imaginary grooms concerning his 
 horses. Pulse weak and quick ; tongue very 
 tremulous. Ordered — 
 
 R Pulv. opii, gr. i. 
 
 Ext. humuli, gr. ij. 
 Fiat pil. 4ta quaq. hora sumend. 
 Be Decoct, cinchonas, oviij. 
 
 Ammonias bicarb. 3i- M. 
 Capiat unciam tertia quaq. hora. 
 Brandy, 6 oz. Beef-tea as a drink. 
 
 2nd. — Still suffering under hallucinations; 
 profuse discharge from the incisions in the leg ; 
 had slight snatches of sleep. 
 
 Repeat the medicines, brandy and beef-tea. 
 
 4th. — Spent a very restless night ; still fan- 
 cying that he is driving the omnibus ; pulse 
 weak and quick ; tongue very tremulous, and 
 covered with a white fur. 
 
 Be Acet. morphias, gr. J. 
 
 Aq. distillatas, 3vi. 
 
 Aceti et syrupi aa Si- 
 Fiat haust. 3tiis horis sumend. (si op. sit). 
 
 The resident pupils to watch the effects of 
 the draughts, and to omit them if necessary. 
 Brandy and beef- tea as before. 
 
 5th. — Much improved ; less restlessness ; slept 
 for short intervals ; hallucinations not so marked. 
 The left instep attacked during the night with 
 swelling, redness, and pain. Ordered —
 
 LECTURES OX ERYSIPELAS. 29 
 
 R Acet. morphiae, gr. i. 
 Aq. distillatee, 3 v i- 
 Aceti et syrupi, aa 3j- ^- 
 
 Fiat haust. statim sumend. et repetatur 
 hora somni (si op. sit). 
 
 6th. — Slept soundly throughout the night; 
 the hallucinations are nearly gone ; less tremor 
 in the tongue ; discharge from leg health}' and 
 less profuse ; pulse stronger and less frequent. 
 
 Ordered bark mixture in effervescence; brandy 
 and beef-tea. 
 
 7th. — Complaining a good deal of pain in the 
 left leg, where a sense of fluctuation can be de- 
 tected over left ankle, into which an incision was 
 made and a quantity of matter let out. The right 
 leg is also causing him much pain ; he is very 
 weak and was bathed in profuse perspiration all 
 night. 
 
 Omit the bark mixture. 
 
 Ordered 12 drops of black drop immediately, 
 and to be repeated, if necessary, at night. 
 
 R Sulph. quininaa, 9i. 
 Infus. rosae comp. § viii. 
 St. §i. ter in die. 
 
 One pint of porter ; continue the brandy, and 
 give a chicken for dinner. 
 
 8th. — Delirium quite gone, but he is suffering 
 much from pain in the right leg, where gra- 
 nulations are forming extensively; discharge 
 healthy and less profuse. 
 
 Ordered six drops of black drop, night and 
 morning ; repeat brandy, porter, and chicken. 
 
 10th. — Is much improved; pulse stronger:
 
 30 LECTUEES ON ERYSIPELAS. 
 
 tongue steady, and cleaning ; pain in leg abated, 
 but not quite gone. 
 
 Repeat the quinine mixture, and give half a 
 grain of the sulphate of morphia three times in 
 the day ; lay aside the poultices ; dress the 
 leg with lint spread with ung. calaminae, and 
 apply the many-tailed bandage, so as to gently 
 approximate the edges of the ulcers. 
 
 18th. — On this day the limb was placed on 
 Listen' s splint, and the use of many-tailed band- 
 age continued. From this date the patient ra- 
 pidly improved, and was discharged cured on 
 the 1st of March, 1853. 
 
 In the third form of erysipelas, or that which 
 has received the name of cedematous, or white 
 erysipelas, the affection is best marked when met 
 with in persons whose state of health has been 
 impaired by organic disease, causing obstruc- 
 tion to the circulation ; here the skin is smooth, 
 tense, and glassy, the integuments pit on pres- 
 sure, and but slowly regain their level when the 
 pressure is withdrawn. Bullae sometimes form 
 in this variety of erysipelas. The scrotum, 
 labiee pudendi, and extremities of dropsical 
 persons are the portions of the body in which 
 cedematous erysipelas is most frequently met 
 with; in this disease the patient is seized 
 with pain in the part, the skin assumes a red, 
 tense, shining appearance, after a time the inte- 
 guments acquire, in different places, a dark, livid, 
 or leaden hue, in which spots sloughs are formed, 
 the pulse becomes quick, wiry, and intermit- 
 ting ; vomiting, and perhaps diarrhoea, now 
 make their appearance, low muttering delirium 
 ensues, and death is the result. This commonly
 
 LECTUEES ON EEYSIPELAS. 31 
 
 fatal form of erysipelas has often supervened on 
 the operation of acupiincturation of the legs of 
 dropsical persons. 
 
 TREATMENT OF ERYSIPELAS. 
 
 A great diversity of opinion has existed as to 
 the mode of treatment that should be adopted in 
 true erysipelas, and many who have written on 
 the subject have, by lauding some particular 
 curative plan of their own, as applicable to 
 almost every form and variety of the disease, 
 led, but too frequently, to embarrassment of the 
 student, and to erroneous treatment on the part 
 of the practitioner. In the management of true 
 erysipelas, however, you must not permit your- 
 selves to be carried away by any uniform or 
 exclusive line of treatment, but must, in each 
 case of the disease entrusted to your care, be 
 guided in the selection of your remedies by the 
 age, constitution, and habits of life of the patient, 
 and by the type of the accompanying fever. 
 
 The treatment of true erysipelas is conve- 
 niently divided into local, and constitutional, 
 and, as the latter is of the greatest importance, 
 we shall take it first into consideration. 
 
 General bloodletting has been advocated by 
 some authors, in the early stage of true erysipe- 
 las, and, although venesection may, perhaps, in 
 some rare cases, especially in provincial prac- 
 tice, be justifiable in the very onset of the 
 disease, if the patient be young and plethoric, 
 and if the local inflammation and constitutional 
 disturbance should run very high, yet in the 
 varieties of erysipelas now prevalent in this 
 city, in which the high degree of feverish ex-
 
 32 LECTUEES ON EETSIPELAS. 
 
 citement, which usually ushers them in, is soon 
 followed by an asthenic or typhoid state, blood- 
 letting is obviously contra-indicated; and, in- 
 deed, these remarks are equally applicable to 
 the forms of erysipelas which, for years past, 
 we have met in this metropolis, whether in the 
 wards of our hospital or in private practice. 
 
 In the commencement of true erysipelas, when 
 the pulse is hard and full, and when there is 
 much heat of surface, but an absence of gastro- 
 intestinal irritation or inflammation, the early 
 exhibition of an emetic generally constitutes the 
 first step in our treatment, and it almost invari- 
 ably proves beneficial ; for, we find, that when 
 the stomach is, in this way, unloaded, the pulse 
 becomes softer and less frequent, the heat of the 
 surface, at the same time, being sensibly dimi- 
 nished. It is, however, only at the very onset of 
 erysipelas that emetics can be administered with 
 safety ; but, when so given, they have, in many 
 cases lately under our observation, as, for in- 
 stance, in that of Byrne, assisted in arresting 
 the disease. The medicine which we generally 
 use to produce emesis is the tartarized antimony, 
 either alone or combined with ipecacuanha ; as 
 soon as the emetic action is over, we usually 
 employ the tartarized antimony in solution, in 
 minute doses, at long intervals, as recommended 
 by Desault, with a view of determining to the 
 surface ; for we find the greatest advantage, in 
 this incipient stage of the disease, in maintain- 
 ing a steadily increased action of the skin. At 
 other times, after the emetic action has subsided, 
 -and where we apprehend that the depressing 
 influence of the antimony may, perhaps, prove
 
 LECTURES ON ERYSIPELAS . 33 
 
 injurious, we order diaphoretic mixtures, con- 
 taining either the citrate or acetate of ammonia. 
 I may here mention that some authorities con- 
 sider aconite and belladonna important reme- 
 dies in erysipelas. Thus, Mr. Erasmus "Wilson, 
 in his work on Skin Diseases, says : " Both of 
 these remedies act by reducing the excitement 
 of the arterial system, and procuring rest ; the 
 extract of aconite is especially useful in checking 
 the heart's action and promoting cutaneous 
 transpiration ; and, for this purpose, should be 
 administered in half-grain doses, eveiy four 
 hours." !Mr. Liston remarks, " that after the 
 aconite has performed its office, the extract of 
 belladonna, in doses of one-sixteenth of a grain, 
 is productive of the most beneficial effects." 
 
 When, in erysipelas, the bowels are in a torpid 
 condition, a suitable aperient should be given. In 
 cases in which the biliary organs are deranged, 
 the exhibition of calomel or some other mercu- 
 rial preparation, followed by a mild purgative, 
 always proves useful; when the erysipelatous 
 inflammation and fever subside, and the tongue 
 becomes clean, we usually place the patient on 
 the bark mixture in effervescence, and order 
 him light, nutritious diet; if, on the other 
 hand, the fever assumes a low asthenic or 
 typhoid form, which it did, for instance, in 
 Robertson's case, from the very onset of the 
 attack, we have early recourse, and, in general, 
 with marked benefit, to the administration of 
 wine, brandy, ammonia, and other stimulants, 
 together with light and suitable diet ; in these 
 cases, when, by the tongue becoming moist and 
 clean, an approach to health is indicated, we
 
 34 LECTURES ON ERYSIPELAS, 
 
 find great advantage in the exhibition of bark 
 and quinine. 
 
 There is no question of greater practical im- 
 portance than the period at which the adminis- 
 tration of stimulants should be commenced in 
 erysipelas. Some physicians give wine, in all 
 cases of the disease, from the very outset. Thus, 
 Dr. Eobert Williams, of London, says : — " The 
 mode, then, in which I am in the habit of 
 treating idiopathic erysipelas, whatever may be 
 the part affected, or with whatever symptoms it 
 may be accompanied, is as follows : The patient 
 is put on a milk diet, the bowels gently opened, 
 and from four to six ounces of port wine, together 
 with sago, allowed daily. This mode of treat- 
 ment it is seldom necessary to vary throughout 
 the whole course of the disease ; for the deli- 
 rium, if present, is generally tranquillized ; if 
 absent, prevented ; the tongue more rarely be- 
 comes brown, or only continues so for a few 
 hours; while the local disease seldom passes 
 into suppuration or gangrene ; in a word, all the 
 symptoms are mitigated, and the course of the 
 disease shortened. I have pursued this system 
 for several years, and I hardly remember a case 
 in which it has not been successful."* 
 
 In the administration of wine in any given 
 case of erysipelas, you ought, however, in my 
 mind, to be guided, both as to the period of 
 giving it and the quantity required, by the age, 
 constitution, and habits of life of the patient, 
 and by the type of the fever ; thus, if you are 
 called in the early stage of the disease, and if a 
 
 * " Williams on Morbid Poisons," vol. i. page 284.
 
 LECTURES ON EEYSIPF~^8. 35 
 
 high degree of fever exists, instead of pouring in 
 wine at once, you should first unload the sto- 
 mach and bowels by suitable medicines, and 
 exhibit diaphoretics, after which wine may, ac- 
 cording to my experience, be given, with greater 
 safety and advantage ; if, on the contrary, this 
 first stage should have lapsed, or that the 
 attack has been ushered in by a low form of 
 fever, the sooner you order wine the better. 
 
 In some cases, lately under our observation, 
 we found six or eight ounces of wine during the 
 twenty-four hours, sufficient ; whereas, in others, 
 as you are aware, it became necessary to order 
 more than double that quantity within the same 
 period. In hospital practice, where the patients 
 have been more or less accustomed to the use of 
 ardent spirits, we have found brandy, or malt 
 whiskey, in suitable quantities, to be better 
 stimulants than wine. In cases of erysipelas in 
 which the patient loses his power of swallow- 
 ing, liquid food should be introduced into the 
 stomach by means of the oesophagus tube ; or, 
 nutritious and stimulating enemata should be 
 administered to him at proper intervals ; for, we 
 should ever hold in recollection, the possibility 
 of persons recovering from this disease under the 
 most unpromising circumstances. And here, let 
 me impress on you the vital importance of sedu- 
 lously watching, in all these cases, the state of 
 the patient's bladder. In my first lecture I told 
 you, that although patients in the advanced 
 stages of erysipelas frequently labour under in- 
 continence of urine, yet, that retention of urine 
 sometimes occurs in the latter stages of the 
 disease; therefore, examine the condition of
 
 36 LECTURES ON ERYSIPELAS. 
 
 the patient's bladder, at each of your visits, 
 not trusting to the nurse's report, who may, 
 possibly, mistake stillicidium uringe for incon- 
 tinence of urine; and should retention have 
 taken place, you will, of course, introduce a 
 catheter to unload the bladder, and have the 
 operation repeated at proper intervals. 
 
 Bronchitis was, as you are aware, a promi- 
 nent symptom in Austin's case, and in him we 
 found support of the system by wine and light 
 nourishment, in judicious quantities, as neces- 
 sary as in the low forms of external erysipelas. 
 In this variety of bronchitis, the application of 
 sinapisms and blisters proved highly beneficial. 
 
 In the local treatment of the lighter forms of 
 true erysipelas, the application of finely levigated 
 flour, or hair powder, affords much comfort to 
 the patient; in some instances, especially, when 
 the disease is situated in the lower extremities, 
 the use of the nitrate of silver, as recommended 
 by Mr. Higginbotham, appears to limit the dis- 
 ease ; in more severe cases, where the vessels of 
 the skin are in a highly congested state, punc- 
 turing the surface freely with the lancet, as 
 proposed by Sir Eichard Dobson, affords relief ; 
 in a few instances, we have found the solution 
 of sulphate of iron, as recommended by M. 
 Velpeau, apparently of some advantage; and 
 both Dr. Snow, of London, and Mr. Busk, of the 
 Dreadnought, speak favourably of the employ- 
 ment of collodion to the surface of true erysi- 
 pelas. 
 
 The topical remedy, however, which proved 
 especially useful in the most unpromising cases 
 of the prevailing erysipelas, was the employment
 
 LECTURES ON ERYSIPELAS. 37 
 
 of mercurial ointment to the inflamed surface ; 
 in proof of which, I need only refer you to the 
 cases of erysipelas of the face and head, which 
 you have seen successfully treated, on this prin- 
 ciple, within the last month, by Dr. Power, my 
 colleague on duty, and myself. The mercurial 
 inunction requires to be used in these cases with 
 considerable caution ; the diseased surface should 
 be covered with the ointment, and the applica- 
 tion renewed at proper intervals ; but, if we do 
 not watch the effects of the inunction with care, 
 the patient may, to our great annoyance and his 
 discomfort, become suddenly hyper- salivated : 
 in Robertson's case, three drachms of mercurial 
 ointment had scarcely been used to the face and 
 forehead, in divided portions, and at short inter- 
 vals, when salivation set in, but from that mo- 
 ment all his symptoms improved, although we 
 had previously looked on his case as one of the 
 most unlikely to recover that we had met with 
 during the session. Whilst using the mercurial 
 ointment, externally, in erysipelas, we must not 
 lose sight of the constitutional treatment ; thus, 
 in Austin's case, already alluded to, whilst we 
 were carrying out the treatment by mercurial 
 inunction, wine, and bark in effervescence, to- 
 gether with beef tea, were freely given, to sup- 
 port his strength, which, at the time, was 
 rapidly sinking. The merit of havirg first 
 recommended mercurial inunction in erysipelas, 
 although attributed by some to the French sur- 
 geons, is, we believe, due to Messrs. Dean and 
 Little, of New York. Dr. Dean published a 
 paper on the subject in the American Recorder. 
 as early as July, 1820; but to some of our
 
 38 LECTURES ON ERYSIPELAS. 
 
 French brethren we are chiefly indebted for the 
 general introduction of this valuable mode of 
 treatment. In Dublin, the mercurial ointment 
 was used soon after its advantages had been 
 tested in the Parisian hospitals, by the late Dr. 
 M 'Dowel, Mr. Reid, and others. It is right to 
 state, that pure creasote has been extolled as a 
 local application in erysipelas, by Dr. Fahne- 
 stock, of Pittsburg, and that it has been tried by 
 others, and, as it has been asserted, with the best 
 results. We cannot at present speak, from our 
 own experience, as to the value of creasote in 
 erysipelas, but we purpose to give it an impar- 
 tial trial, and to note carefully its effects. 
 
 In the management of phlegmonous erysipelas, 
 your chief reliance must be placed in local treat- 
 ment. This form of the disease almost invariably 
 terminates in the formation of matter, and de- 
 struction of the subcutaneous areolar tissue to a 
 greater or less extent; and here nature unas- 
 sisted is not equal to form a timely outlet for 
 the matter; instead, therefore, of having recourse 
 to temporising measures, such as cold lotions, 
 leechings, &c, you must endeavour, by early 
 and efficient openings, to afford a free exit for the 
 suppuration and dead areolar tissue. By this 
 mode of treatment we often are enabled, as in 
 Walsh's case still under observation, to com- 
 pletely arrest the destructive process soon after 
 it has commenced. In phlegmonous erysipelas 
 the incisions should, as a general rule, be made 
 in those parts of the limbs where the tension 
 appears to be greatest. In the instances lately 
 under our care, however, we did not, as you 
 observed, carry our incisions to the unlimited
 
 LECTURES ON ERYSIPELAS. 39 
 
 extent formerly recommended by some authori- 
 ties. In ordinary cases we found one or two 
 openings of between two and three inches in 
 length, and of a suitable depth, quite sufficient 
 to afford the necessary relief. In no case did we 
 leave our patient's side, after having made deep 
 and long incisions in phlegmonous erysipelas, 
 until the bleeding from them had been com- 
 pletely arrested ; for fatal terminations have 
 occasionally followed the loss of blood from such 
 incisions. Should the bleeding in such cases 
 prove troublesome, you must have the limb 
 placed in an elevated position, and dress the 
 wound from the bottom, either with dry lint, as 
 in AValsh's case, or with lint steeped in spirits 
 of turpentine, Euspini' s styptic, or a strong so- 
 lution of gallic acid, by which means, together 
 with the light pressure of a well-adjusted band- 
 age, the haemorrhage will, in general, soon 
 cease. In some few cases of bleeding from the 
 incisions made in phlegmonous erysipelas, it has 
 been found necessary to apply a ligature or 
 torsion to one or two bleeding vessels ; in the 
 generality of such cases, however, the blood 
 comes from innumerable small vessels, consti- 
 tuting, in fact, an oozing from the cut surfaces. 
 After having made suitable incisions in phleg- 
 monous erysipelas, fomentations and poultices 
 should be assiduously applied to favour the de- 
 tachment of the dead cellular tissue ; when, in 
 the process of time, the sloughs are thrown oif, 
 the poultices should be laid aside, and the ulcers 
 should be dressed with suitable applications ; 
 the many-tailed bandage may then be lightly 
 applied to the entire limb, so as gently to ap-
 
 40 LECTUEES ON ERYSIPELRS. 
 
 proximate the edges of the ulcers, and thus 
 expedite the patient's recovery. This plan of 
 treatment has been carried out in M'J^amara's 
 case with considerable advantage. In some 
 cases of erysipelas you may be called on to make 
 incisions into collections of matter in or about 
 the face ; as, however, incisions into the eyelids 
 are sometimes followed by permanent deformity, 
 you should, if possible, avoid them. We have 
 in more than one case lately succeeded in stimu- 
 lating the absorbents to remove collections of 
 matter in the eyelids, by repeated applications 
 of the compound tincture of iodine, applied care- 
 fully, by means of a camel's hair pencil, to the 
 superincumbent integuments ; we can, there- 
 fore, strongly recommend the adoption of this 
 practice. 
 
 When suppuration is established in phlegmo- 
 nous erysipelas, the patient's strength must be 
 supported by light diet, wine, &c. Should 
 delirium tremens evince itself, as it did in 
 M Samara, it then requires to be combated by 
 suitable treatment. In M Samara's case you 
 recollect that we succeeded in tranquillizing 
 his nervous system by the administration of 
 full opiates, at proper intervals, together with 
 brandy, to the free use of which he was accus- 
 tomed. 
 
 When, in extremely neglected phlegmonous 
 erysipelas, the destructive process has com- 
 mitted great ravages, the bones being laid bare 
 and the joints opened, the patient's strength 
 will gradually decline under the drain and con- 
 stitutional disturbance, unless we come to his 
 relief. In such cases it therefore becomes an
 
 LECTUEES ON EEYSIPELAS. 41 
 
 imperative duty to propose amputation of the 
 limb, as the only chance of saving life. 
 
 In the treatment of superficial erysipelas of 
 the head, whether of the idiopathic or traumatic 
 forms, we must be guided, as in true erysipelas 
 elsewhere, in the selection of our remedies, by 
 the age, constitution, and habits of life of the 
 patient, and by the type of the accompanying 
 fever. In not a single case of the disease 
 lately presented to our notice, did we con- 
 sider we were justified in having recourse 
 to either general or local blood-letting. Here, 
 when the pulse was hard and full, and that 
 there was much heat of surface, we found, as in 
 Byrne's case, the early exhibition of an emetic 
 (unless contra-indicated by the state of the sto- 
 mach and bowels) highly advantageous. Here, 
 as in true erysipelas of other regions, when the 
 biliary system was deranged, we found the ex- 
 hibition of calomel, followed by saline medicines, 
 beneficial. In many of the cases of erysipelas 
 of the head lately in hospital, when the fever 
 assumed a low typhoid character from the onset, 
 we gave wine or brandy from the very beginning 
 of the attack, and with the best results. It 
 was in these severe and dangerous forms of ery- 
 sipelas of the face and head that we found the 
 employment of mercurial inunction of the great- 
 est service. 
 
 When, in erysipelas of the head, symptoms of 
 inflammation of the parts within the cranium 
 evince themselves, no time should be lost in 
 bringing the system as rapidly as possible under 
 the full influence of mercury ; the further treat- 
 ment of such a case must, of course, be con-
 
 42 LECTURES ON ERYSIPELAS. 
 
 ducted in accordance with the age and consti- 
 tution of the patient. Thus, if he is young, 
 vigorous, and plethoric, which seldom is the 
 case, general blood-letting may be called for ; 
 in some cases leechings to the temples or behind 
 the ears may be requisite ; but as in the majo- 
 rity of the cases met with in metropolitan prac- 
 tice, whether in or out of hospital, the patient 
 cannot afford to lose blood, our local treatment 
 must chiefly consist in the application of blisters 
 to the vertex or nape of the neck, and sinapisms 
 to the calves of the legs, &c. 
 
 In the deep-seated form of erysipelas of the 
 scalp, recourse must be had to early and efficient 
 incisions, by which, as in Bateson's case, for 
 instance, almost instantaneous relief will be 
 afforded both to the local and constitutional 
 disturbance. In these cases the incisions should 
 be made in the transverse direction, at right 
 angles with the fibres of the occipito-frontalis 
 muscle, by which means the lips of the wound 
 will be kept apart, and a free outlet for the mat- 
 ter thus secured. 
 
 THE END. 
 
 Printed by J. M. O'Toole, 13, Hawkins' -street, Dublin.
 
 CLIXICAL OBSEEYATIONS 
 
 morbus coxj;, 
 
 C|rmuc Scrofulous $mm of ilje f ip-jomi 
 
 BY JAMES S. HUGHES, M.D.,F.R.C.S.I., 
 
 SURGEON TO JERVIS-STREET HOSPITAL, EXAMINER IX SURGERY IN THE 
 QUEEN'S UNIVERSITY IN IRELAND, ETC. 
 
 (Reprinted from the " Dublin Medical Press.") 
 
 DUBLIN: 
 
 PRINTED BY J. M. O'TOOLE, 13, HAWEINS'-STREET. 
 
 1854.
 
 CLINICAL LECTURE. 
 
 Morbus Coxa, or the Chronic scrofulous Disease of the 
 Hip- joint ; its Diagnosis, Pathology, and Treatment. 
 
 Tee chronic disease of the hip-joint demands your 
 most serious attention, not only from the frequency 
 of its occurrence, but likewise from the importance 
 of its results. Repeated opportunities have lately been 
 afforded you, of studying the disease in its different 
 stages in the wards of this hospital, and as I have a 
 case at present in the house under treatment, I am 
 anxious to bring the subject fully before your notice in 
 this morning's lecture. 
 
 The hip, like the knee aud other joints, may become 
 the seat of acute, sub-acute, and chronic inflammation: 
 and disease of the hip-joint has its varieties, being 
 sometimes connected with a scrofulous diathesis, whilst 
 at other times it is referrible to the effects of injuries, 
 exposure to cold, or specific inflammation; however, at 
 present, I wish to confine your attention to what has 
 been familiarly called " disease of the hip," and which 
 has been termed coxalgia, morbus coxce infantilis, 
 morbus coxarius, coxarthrocace ; but being most fre- 
 quently connected with a scrofulous diathesis, it is now 
 generally known by British surgeons under the name of 
 " the chronic scrofulous disease of the hip-joint/' 
 
 Chronic disease of the hip-joint chiefly attacks chil-
 
 4 CLINICAL LECTURE 
 
 dren from about seven to fourteen years of age, but it 
 may be met with at a later or earlier period of life. It 
 has been divided by some authors into two stages, and 
 by others into three. In this hospital we are in the 
 habit, as you are aware, of adopting the latter division, 
 as being in our opinion the most practical. 
 
 In the first or incipient stage of hip disease, the 
 symptoms are generally at first so trifling that they are 
 unfortunately often either overlooked or neglected. In 
 the very commencement, the patient usually experiences 
 a sensation of stiffness in the joint, especially in the 
 morning, together with a slight pain in the hip, which 
 frequently extends down the thigh to the knee. This 
 pain is not continuous, but often increases at night, 
 sometimes depriving the patient of sleep, and is not 
 infrequently confounded with what are popularly called 
 "growing pains.' 1 Jt is generally believed that the 
 pain in this disease is conveyed down the thigh by 
 branches of the anterior crural nerve; but Sir Charles 
 Bell is of opinion that the pain is communicated by the 
 6bturator nerve. However, before attention is directed 
 to the joint, a marked change in the health and strength 
 of the child is sometimes first observed by those about 
 him. The weakness and stiffness of the hip are then 
 soon succeeded by a limping and awkward gait, but as 
 the pain is referred in a great measure to the knee of 
 the affected side, the seat of the disease often escapes 
 observation, and it so happens that the affection may 
 exist for some time, even in adults, without its existence 
 being even suspected. In this first stage no outward 
 appearance of disease is discoverable, but if you apply 
 pressure on, or immediately behind the great trochanter, 
 or over the front of the joint, where the femoral vessels 
 pass under Poupart's ligament, if you percuss the heel 
 of the affected side, or if you suddenly flex the thigh on
 
 ON MOREL'S COX^E. 5 
 
 the pelvis, the patient will complain of pain in the hip- 
 joint, and he cannot stand so well or so long on the 
 diseased, as on the healthy side. The glands in the 
 groin now sometimes enlarge, and may even run on to 
 suppuration, taking on in fact a scrofulous action. In 
 this stage the general health is occasionally unaffected; 
 but on the other hand, a derangement of health may not 
 only be observed previous to the detection of the joint 
 disease, but the incipient stage may, in certain cases, be 
 ushered in by, or accompanied with a smart degree of 
 fever, which fever may, and has been mistaken for, and 
 treated as the ordinary infantile or gastric fever, the 
 joint disease being completely overlooked till irreparable 
 mischief had been established. In order to put you on 
 your guard, and impress this practical point on you, I 
 need only mention the outline of the following case, 
 as entered in my note- book, which was very lately 
 presented to our notice in the dispensary of this hospi- 
 tal : — 
 
 "John Macdonnell, agtat. 5, affected with morbus 
 coxae of five months 1 standing; the disease is in the 
 third stage; limb considerably shortened; suppuration 
 has set in; the mother states that the child was first 
 seized with feverish symptoms, which were treated as 
 those of worm fever, the disease of the hip not having 
 been detected until it had made considerable progress.'" 
 I also know of a similar case which occurred some time 
 since in private practice, in which the hip disease had 
 ran on through the three stages before attention was 
 directed to it. I therefore, gentlemen, beg that you will 
 bold the possibility of such an occurrence in mind, in 
 order that you may avoid making so very unfortunate 
 a mistake. As it is only in the incipient stage of hip 
 disease that treatment can have the effect of restoring 
 the patient to the full power over his limb, and conse-
 
 O CLINICAL LECTURE 
 
 quently obviating deformity, it behoves you to endeavour 
 to detect it at its very onset. 
 
 The period that hip disease may remain in the first 
 stage, if uninterfered with, will depend to a great extent 
 on the age and constitution of the patient, together 
 with a variety of other circumstances, but the usual 
 time is about from one to three months. 
 
 When the disease runs into the second stage, there 
 is an apparent lengthening of the extremity of the 
 affected side, the motion of the limb now becomes con- 
 siderably impaired, its bulk decreasing almost from the 
 very onset, extension of the thigh is now performed 
 with great difficulty, and flexion of the limb, as well as 
 rotation of the joint, especially inwards, is productive 
 of excruciating agony. If you now make the patient 
 stand opposite to you, you will find that he does not 
 bring the sole of the affected limb to the floor, but 
 throwing the weight of his body on the limb of the 
 sound side, he brings the diseased limb forwards, resting 
 its toe ou the ground, with the heel elevated, merely to 
 balance himself. It is this position which gives an obli- 
 quity to the pelvis, and thereby causes an apparent 
 lengthening of the limb in this stage of the disease. 
 You can easily satisfy yourselves that the lengthening 
 is here only apparent, by measuring both extremities 
 accurately. If you now come to examine the patient 
 with his back to you, you will observe that the buttock 
 of the diseased side is flattened, wasted, and hangs 
 lower down than that of the opposite side; the pain is 
 now referred not so much to the affected hip as to the 
 knee of that side ; however, pain is elicited from the 
 hip-joint by striking the trochanter or heel of the affect- 
 ed side. If you now make the patient sit down, and 
 ask him to pick up something off the floor, you will 
 observe that in attempting to do so he does not flex
 
 ON MORBUS COX£. 7 
 
 his diseased thigh, but carries his heel behind the seat, 
 and he can neither raise his foot so as to place it on a 
 chair, nor tie his shoe-string, without considerable pain. 
 In this stage, if you examine the spine, you will find a 
 degree of lateral curvature present, owing to the obli- 
 quity of the pelvis. When instituting these examina- 
 tions, you should make the patient stand as erect as he 
 can, and when all the foregoing symptoms are present, 
 you can scarcely mistake the disease. Generally speak- 
 ing, in this stage, when the affection has advanced, the 
 pain becoming acute, the pulse is accelerated, the tongue 
 becomes loaded, the patient is liable to chills, followed 
 by flushings, the strength declines, and in this stage the 
 patient is frequently disturbed at uight by involuntary 
 startiugs of the limb. 
 
 If the disease should still proceed unchecked, it will 
 gradually run into the third stage, in which the diseased 
 limb becomes really shortened, as a consequence either 
 of the diminished head of the femur being drawn up 
 into the acetabulum, deepened and widened by disease, 
 or from dislocation of the femur. It is now, however, 
 well established, that dislocation in these cases is by no 
 means so common as it was formerly supposed to be; it 
 is, in fact, a very rare occurrence, for in the great bulk 
 of cases, a mound or ridge of bone is thrown up on the 
 dorsum of the ilium, constituting a beautiful provision 
 of nature against dislocation. When dislocation does 
 take place, the head of the bone is usually displaced 
 upwards on the dorsum of the ilium, but the displace- 
 ment may take place backwards towards the ischiatic 
 notch, and in rare cases either downwards and inwards 
 towards the foramen ovale, or on the horizontal ramus 
 of the pubis. In this stage the pain is very severe in 
 the hip-joint, and the destructive process rapidly extends 
 to all the structures entering into the formation of the
 
 8 CLINICAL LECTURE 
 
 articulation. The third stage of hip-joint disease is 
 frequently accompanied by the formation of matter: 
 rigors, and other symptoms of fever, throbbing pain, 
 swelling of the joint, painful enlargement of the -glands 
 in the groin, together with startings of the affected 
 limb, may usher in or accompany the suppuration. In 
 other cases, the constitutional disturbance preceding the 
 formation of matter is not so great, and sometimes 
 matter is formed without any appreciable accession of pain 
 or fever. Hip disease, however, may go through its dif- 
 ferent stages without suppuration, as I lately had an 
 opportunity of proving to you in the person of James 
 Sharkey of Malahide, who was brought into this hospi- 
 tal for a recent injury of the back. This man first 
 came under my observation some years since, when I 
 was Mr. Colles's resident apprentice in Steevens' Hospi- 
 tal, where Sharkey was twice under treatment for 
 chronic disease of the hip-joint, and the disease was 
 apparently arrested each time, but as the patient had 
 not the means of caring himself when out of hospital, 
 the disease progressed, and there is now considerable 
 shortening of the extremity, and consequent lameness; 
 but the man's general health is good, and he is able to 
 go through the laborious employment of a farmer's 
 labourer. Disease of the hip may, however, terminate 
 fatally without the formation of one drop of matter. 
 When suppuration is established, the matter may 
 remain for months without undergoing any apparent 
 change, it may almost suddenly disappear, being re- 
 moved by absorption, or it may gradually approach the 
 surface and open of itself. It is very uncertain where 
 such an abscess will present itself : thus it may open on 
 the hip, thigh, in the groin, rectum, or in the female, as 
 I have known, into the vagina. Mr. Colles used to 
 mention a case of hip disease, in which the abscess opened
 
 ON MORBUS COX.E. 9 
 
 both externally and internally into the rectum, in which 
 case, whenever the patient had a liquid stool, the fseces 
 used to appear through the external opening; but 
 examples of these abscesses opening both externally and 
 internally are very rare. A case is recorded by Mr. 
 Coulson, in which the matter made its escape from the 
 affected joint into the pelvis, so as to cause retention 
 of urine by its pressure on the neck of the bladder. 
 Sir Astley Cooper was in the habit of relating a case, 
 in which the abscess, in making its way from the hip, 
 had ulcerated a small hole in the femoral artery as that 
 vessel passed over the front of the joint; and a case is 
 recorded by Scott, in which the disease affected both 
 hip-joints, and abscesses communicated with the cavity 
 of the pelvis through the acetabulum of each side. In 
 abscesses of the hip-joint the first opening may heal up, 
 and another may form at a different part of the joint, 
 and in this way six or eight openings may be established 
 in the hip, groin, and buttock, as was the case in the 
 person of James Eustace, who was admitted some time 
 since into No. 4 Ward under my care. I mention all 
 these facts in order to prepare you to expect abscesses 
 connected with the hip-joint taking extraordinary routes 
 to the surface. The external orifices of these abscesses 
 often degenerate into fistulous openings, through which 
 exfoliations of bone may take place: these exfoliations 
 may be either large or small, and may be considered as 
 favourable indications. Sometimes, in the advanced 
 stage of hip disease, the head of the femur becomes 
 detached at its epiphysis, and either remains in the 
 joint, acting as a foreign body, or it makes its way to 
 the surface through an outlet in the integuments, estab- 
 lished either by nature or art. The following is a short 
 outline of a case of the former description, which is 
 still under observation as an out case at Jervis-street
 
 1 CLINICAL LECTURE 
 
 Hospital, for the notes of which I am indebted to Mr. 
 Edward M. Sheehy, one of our resident pupils, and for 
 the possession of the detached head of the femur I have 
 to thank my colleague, Dr. John Hatch Power, under 
 whose care the little patient is at present: — " Sarah 
 Robinson, aged five years, of very delicate appearance, 
 received a severe fall on the affected hip about one year 
 and a-half ago; the accident was followed by pain and 
 swelling of the hip-joint, finally an opening formed of 
 itself behind the trochanter major, through which a 
 quantity of unhealthy purulent matter has ever siuce 
 been escaping. The opening has now degenerated into 
 a fistulous canal, at the orifice of which the detached 
 head of the femur lately presented itself, when the 
 mother of the child caught hold of it with her fingers 
 and withdrew it, believing it, as she said, to have been 
 a bit of sinew." 
 
 On examination, the detached head of the femur is 
 seen denuded of its cartilage of incrustation, and ex- 
 hibits all the appearance of having lain within the joint 
 in a state of maceration for a considerable time. Mr. 
 Adams states that he has known two examples of the 
 head of the femur thus separated from their epiphysis 
 from the neck of the bones, in which cases the patients 
 recovered with the usual deformity. 
 
 Hectic fever very often ensues after the abscess con- 
 nected with the hip-joint has opened; thus the pulse 
 becomes rapid and weak, the patient is seized with 
 rigors, followed by night sweats, colliquative diarrhoea, 
 and great prostration of strength, under which these 
 patients often sink. 
 
 Having thus described the symptoms of the chronic 
 disease of hip-joint, I shall now proceed to [investigate 
 its pathology. Some eminent modern writers on the 
 subject have attempted to divide the chronic disease of
 
 ON MORBUS COXjE. 1 1 
 
 the hip-joint into varieties, according to the particular 
 structure first implicated ; thus they have described the 
 symptoms and characters of synovitis, chondritis, and 
 ostitis, but, as I shall presently show you, this arrange- 
 ment is seldom available in practice ; for admitting, 
 as I do, that the disease may commence in one or other 
 of the structures of the joint, it generally has extended 
 to the parts entering into the general formation of the 
 articulation before the surgeon is consulted. 
 
 Sir Benjamin Brodie, whose opinions on this, as on 
 all other pathological subjects, are deserving of the 
 greatest attention, conceives that ulceration of the car- 
 tilages is the primary affection in the majority of those 
 cases of disease of the hip-joint which occur in adult 
 persons; whereas in children the hip-joint is principally 
 affected by scrofulous disease of the cancellous structure 
 of the bones; and Sir Benjamin believes that these two 
 affections exhibit many circumstances in common, but 
 have certain points of difference, which admit of their 
 being, in the early stage, distinguished from each other 
 by a careful and minute observation; and he states that 
 on these points of difference our diagnosis, so far as it 
 can be made, must mainly depend; in proof of which he 
 says, that when the cartilages of the hip are ulcerated, 
 the only symptoms met with for some time are pain and 
 a slight degree of lameness in the limb — the pain resem- 
 bling a good deal that of rheumatism, being referred to 
 different parts of the limb in different individuals, and 
 even in the same individual at different periods. As the 
 disease advances, the pain, according to Brodie, becomes 
 exceedingly severe, especially at night, and as it in- 
 creases in intensity it becomes more localized ; but 
 wherever situated it is greatly aggravated by motion of 
 the hip-joint. On the other hand, Brodie says, that 
 whilst the disease is going on in the cancellous structure
 
 1 2 CLINICAL LECTURE 
 
 of the bone, before it has extended to the other parts of 
 the joint, the patient experiences some degree of pain, 
 which, however, is never so severe as to occasion serious 
 distress, and often is so slight, and takes place so gra- 
 dually, that it is scarcely noticed ; but Brodie admits 
 that the progress of the disease, whether commencing 
 in the bone or cartilage, is nearly alike. In both there 
 is the same reference of pain to the knee rather than to 
 the affected joint, the same alteration in the appearance 
 of the nates, the same shortening of the limb from 
 destruction of the head of the femur and acetabulum, or 
 more rarely from dislocation, and the same production 
 of abscesses; but the principal difference consists in the 
 less degree of pain which accompanies the scrofulous 
 disease of the bone, except in a very few instances, and 
 in the most advanced stage of the disease, where a por- 
 tion of the bone has died, and having exfoliated so as 
 to remain loose in the cavity of the joint, thus becomes 
 a perpetual source of irritation. 
 
 Mr. Key, on the other hand, is of opinion, from cases 
 of hip-joint disease which he has had opportunities of 
 examining in the incipient stage after death, that ulce- 
 ration of the cartilage is preceded by inflammation of 
 the ligamentum teres; whilst Mr. Coulson says, that 
 from post mortem appearances which he has observed, 
 he has been led to infer that the disease commences 
 most frequently, if not invariably, in the synovial mem- 
 brane, that the round ligament is nearly destroyed, and 
 that disease of the cartilage usually follows that of the 
 synovial membrane. Finally, Liston, Syme, and a host of 
 other authors, suspect that the disease begins in the bones. 
 Opportunities of examining the joint in the incipient 
 stage of hip disease are very rare, but my own opinion 
 is that the disease would appear sometimes to commence 
 in one structure and sometimes in another, and that it
 
 ON MORBUS COX;E. 1 3 
 
 is a very difficult matter to say positively, during the 
 lifetime of a patient, whether the disease resides in the 
 synovial membrane, cartilage, or bone ; for by the time 
 our assistance is sought for, all the textures entering 
 into the formation of the joint are most probably impli- 
 cated. 
 
 When opportunities are afforded of making post 
 mortem examinations of patients who have died of 
 hip-joint disease, the following are the appearances 
 which usually present themselves : — The synovial mem- 
 brane is generally found inflamed, thickened, and 
 occasionally perforated by small openings; patches of 
 coagulable lymph have been found adhering to it in 
 different degrees of thickness; the articular cartilages 
 have been found abraded in some parts, or completely 
 removed in others ; the cartilage of the acetabulum 
 would appear in some cases to be the first affected, 
 whilst in others that of the femur apparently first suf- 
 fered; the bones have been found in a preternaturally 
 red and vascular state, with a deficient supply of earthy 
 matter, being easily cut with a knife, and yielding to 
 slight pressure: these bones generally float in water. 
 Together with these morbid appearances, adventitious 
 growths are found both on the ilium and femur; but, as 
 Mr. Robert Adams says, these growths are only met 
 with in the post mortem examinations of such cases 
 as have manifested in their course alternations of 
 improvement and reverses; they are almost invariably 
 found where the caries of the bone had been arrested, 
 and an imperfect attempt at anchylosis had been made. 
 In persons who have died of the very advanced stage 
 of the disease, you will generally find the cartilages 
 removed, together with a scrofulous deposit in the 
 cancellated structure of the bones, or a yellowish 
 cheese-like matter in their cells, and the bones of the
 
 14 CLINICAL LECTURE 
 
 pelvis entering into the formation of the hip-joint 
 as well as the head of the femur, are in the great ma- 
 jority of cases extensively diseased, which we shall find 
 to be a matter of practical importance when we come 
 presently to speak of the proposal of excising the head 
 of the femur in these cases. In this last stage, the 
 ligamentum teres is frequently destroyed, the capsular 
 ligament is sometimes perforated by fistulous openings, 
 and in the very advanced stage, little if any appearance 
 of the capsule can be traced. In addition to these 
 morbid changes, the lungs in these cases are frequently 
 found extensively tuberculated, and the glands of the 
 neck, mesentery, &c, are often found enlarged. 
 
 In forming your prognosis in hip-joint disease, you 
 must never forget, as a general rule, that diseases of the 
 articulations of the lower extremities are more severe in 
 their characters and consequences, and usually more 
 tedious in their progress, than diseases of the corres- 
 ponding joints in the upper extremities. These facts 
 can, to a certain extent, be accounted for by holding in 
 recollection that the joints of the former are more 
 extensive than those of the latter, and likewise the 
 difficulty of maintaining the lower extremities in a qui- 
 escent state. This latter reason applies peculiarly to 
 the hip-joint, the slightest movement of the body 
 communicating motion to that joint by its action on the 
 pelvis. Adults recover less frequently from hip disease 
 than young children, especially when the case has run 
 on to suppuration, for, under such circumstances, adults 
 seldom recover, whilst children sometimes do. 
 
 When hip disease terminates favourably, the cure is 
 occasionally accomplished by the process of true bony 
 anchylosis ; but this result must be looked upon as a 
 very rare occurrence, for although there are now four 
 well-marked specimens of true anchylosis of the hip-
 
 ON MORBUS COXJE. 15 
 
 joint in the pathological collection of the Dublin College 
 of Surgeons, and some also in the Richmond Hospital 
 Museum, I have a distinct recollection of the late Mr. 
 Colles stating to his surgical class some years since, 
 that he had only seen one example of it. 
 
 It here, gentlemen, becomes my duty to direct your 
 attention to certain diseases in and about the hip, 
 which might, and have been, confounded with disease 
 of the hip-joint, amongst which the following may be 
 enumerated: — viz., sciatica, morbus coxae senilis, or the 
 chronic rheumatic arthritis of the hip-joint, congenital 
 or original luxation of the hip-joint from malformation, 
 psoas abscess presenting at the hip, fungus haematodes 
 of the acetabulum, disease of the superior extremity 
 of the shaft of the femur, inflammation and swelling of 
 the gluteal burs*, a peculiar affection of the lower ex- 
 tremities in children, depending on spinal irritation from 
 either dentition or the presence of worms in the intestinal 
 canal; and finally, as I before mentioned, disease of 
 the hip may be mistaken for, and treated as disease of 
 the knee. 
 
 In sciatica there is pain in the hip and thigh, follow- 
 ing the course of the great sciatic nerve. In that 
 disease the patient is able to point out accurately the 
 seat of pain ; in the advanced stages of sciatica the but- 
 tock of the affected side is flattened, falling down lower 
 than the opposite one, and the knee may even be flexed, 
 as in the disease of the hip; but in sciatica the pain 
 comes on suddenly, and pressure over the nerve, as it 
 escapes from the pelvis, is productive of excruciating 
 agony; but in it neither pressure nor percussion over the 
 hip-joint elicits pain. Another and very important 
 diagnostic difference is, that in sciatica, pressure over 
 the front of the joint does not produce pain, which 
 you now know it does in hip disease; finally, in
 
 16 
 
 CLINICAL LECTURE 
 
 sciatica, there is no difference in the length of the 
 extremities. 
 
 The next disease of importance, which resembles the 
 chronic hip-joint disease, is that known for many years 
 by the Dublin surgeons as the morbus coxse senilis, but 
 more recently named by our distinguished fellow-citizen, 
 Mr. Robert Adams of the Richmond Hospital, "the 
 chronic rheumatic arthritis of the hip-joint/' the symp- 
 toms and pathology of which you must thoroughly un- 
 derstand, to prevent your confounding it with the chronic 
 scrofulous disease of the hip. This peculiar affection is, 
 with rare exceptions, confined altogether to the down- 
 hill of life, and it is, generally speaking, the male sex 
 that it attacks at or about fifty years of age; but I have seen 
 it in a patient under forty; and Mr. Liston and others 
 mention cases of affection at so early a period as twenty 
 years of age. This disease sets in with pain, more or 
 less acute, in the hip-joint, and is often described as 
 commencing in the groin and running back to the 'but- 
 tock. This paiu is greatly influenced by the state of 
 the weather, being peculiarly severe during rain and 
 frost; this pain is not continuous, and is frequently 
 referred to rheumatism; it is aggravated by over-exer- 
 cise of the limb as well as by exposure to wet and cold ; 
 but neither pressure on the great trochanter, nor percus- 
 sion of the heel, so as to push the head of the bone 
 rudely against the acetabulum, is productive of uneasi- 
 ness, which is the case in the chronic hip-joint disease. 
 The limb, after a time, in these cases, becomes gradually 
 shortened, the patient is rendered lame, and in walking 
 applies the sole of the foot on the affected side flat to 
 the ground; the toes are turned outwards, the lumbar 
 vertebrae appear to acquire an unusual degree of mobility, 
 the muscles of the thigh become flabby and wasted, 
 however, although the muscles are wasted, they ne /er
 
 ON MORBUS COXJE. 1 7 
 
 become so flabby as in the hip disease. If you now 
 examine such a patient from behind, you will at once 
 observe that the buttocks do not correspond, that of the 
 affected side having lost its plumpness, whilst that of 
 the opposite side seems to have increased in its bulk and 
 firmness from being called into increased action. As 
 the disease advances, the spine assumes a degree of 
 lateral curvature; these patients generally, in walking, 
 carry a stick, but they usually carry it in the hand 
 opposite to the affected side. It is said that the 
 hip disease more frequently attacks the right than the 
 left hip, but occasionally it is met with in both hips at 
 the same time, as was the case in the person of the late 
 lamented Dr. Percival of this city. 
 
 On inquiring into the pathology of the chronic rheu- 
 matic arthritis of the hip-joint, we shall find that the 
 affection was described by Mr. Benjamin Bell under the 
 name of " interstitial absorption of the neck of the 
 thigh-bone," but to some of the Dublin hospital surgeons 
 we are principally indebted for our present extensive 
 information as to the pathology of the disease: amongst 
 these, the names of Colles, Robert Adams, and R. W. 
 Smith staud foremost. When opportunities have been 
 afforded of making post mortem examinations of per- 
 sons who have long suffered under this painful affec- 
 tion, the head of the bone has been found completely 
 altered in shape and size; sometimes the neck of the 
 femur is altogether obliterated, undergoing a total 
 absorption, in which case the head of the bone sinks to 
 a right angle with the shaft, the cartilage is removed 
 from the head of the bone, and is replaced by an ivory- 
 like deposit, the acetabulum is generally found larger 
 than natural, and in some cases it likewise is covered 
 by a porcelain or ivory-like deposit. In most cases the 
 round ligament is destroyed (Mr. Smith says that "it is 
 
 B
 
 18 CLINICAL LECTURE 
 
 invariably destroyed, even in the early stages of the 
 disease") ; according to others, it is converted into 
 a hard substance. The head of the bone may be 
 found flattened and spread out over the brim of the 
 acetabulum ; the neck of the femur is sometimes sur- 
 rounded with a number of vascular, villous-like produc- 
 tions of the synovial membrane; ossific deposits, or 
 spiculse of bone, are often met with about the trochanters, 
 which give the limb an altered form; the capsular 
 ligament and synovial membrane are thickened; the 
 synovial fluid is rendered more viscid. When the head 
 and neck of the femur have become altered in shape and 
 size, as I have described to you, Mr. Smith says that 
 " a vertical section of the bone in this state bears a close 
 resemblance to the fracture of the cervix external to the 
 capsule which has become united, and I have no doubt 
 has often been mistaken for it." Indeed this would 
 appear to have been the case in the person of the late 
 celebrated comedian, Matthews, a cast of whose hip- 
 joint is to be found in the Museum of the Dublin College 
 of Surgeons. Mr. Matthews was lame for some years 
 before his death, and having suffered from a fall was 
 supposed to have laboured under a fracture of the neck 
 of the femur, but, as Mr. Adams says, a careful exami- 
 nation of the joint will satisfy any one who is well 
 acquainted with the disease I am speaking of, that the 
 deformity was the result of chronic rheumatic arthritis 
 of the hip-joint. 
 
 This peculiar affection of the hip-joint never goes on 
 to suppuration, or entangles the constitution in a marked 
 manner; and although it is both a distressing and painful 
 affection, causing great irritability of temper, I never 
 knew of a patient dying of it. On the contrary, I have 
 seen men labouring under it live to a very advanced 
 age, and of these facts you may assure your patients. I
 
 ON MORBUS cox.i:. 19 
 
 lately exhibited to you a man of the name of Toole, who 
 was approaching his seventieth year, and yet, although 
 he was the subject of this disease for eleven years and 
 a half, his constitution was wonderfully good. 
 
 As to the exciting cause of this affection, it no doubt 
 is frequently referrible to exposure to wet, cold, and 
 what is called hardship in the lower classes; in the 
 upper ranks, where such causes do not often exist, it has 
 by some been considered to be the result of gouty inflam- 
 mation. It would appear in some cases to follow the 
 infliction of a direct injury to the joint at an advanced 
 period of life, and in a certain state of constitution; the 
 possibility of which should make you cautious in your 
 prognosis in injuries of the hip occurring at an advanced 
 period of life; for such a patient may receive a fall, and 
 apparently only bruise his hip, yet after a time shorten- 
 ing of the limb and permanent lameness may possibly 
 take place as a consequence of the disease before us; and 
 if, under these circumstances, the surgeon has not given 
 a guarded opinion, I need scarcely say that blame will 
 certainly be attached to him. 
 
 Congenital or original luxation of the hip-joint is 
 liable to be mistaken for disease of the hip, and it be- 
 comes a matter of great importance for you to discriminate 
 between these affections, as the treatment of each is 
 just as different as that of lateral curvature and Potts' 
 curvature of the spine, hip-joint disease requiring abso- 
 lute rest, &c, whilst congenital malformation calls for 
 tonics, good air, and moderate exercise; the last of 
 which, can, perhaps, be best carried out by means of a 
 moveable chair, by which the patient can enjoy exercise, 
 the principal weight of the body being at the same time 
 taken off the hip-joints. 
 
 The attention of the Profession was long since directed 
 by Baron Dupuytren and others to the subject of con-
 
 20 CLINICAL LECTURE 
 
 genital or original luxation of the hip-joint. More 
 recently, Messrs. Adams, Hutton, Harrison, and Smith, 
 of this city, have brought forward cases in which they 
 have pointed out the anatomical relations of the hip in 
 this malformation. 
 
 In a clinical lecture on this subject, delivered by Baron 
 Dupuytren, at the Hotel Dieu, in the year 1833, he 
 says: — " This luxation is not only of importance in it- 
 self, but it is still more so when considered with reference 
 to diagnosis; in fact, presenting all the signs of that 
 which is dependent on morbid changes in the ilio-femoral 
 articulation, it may be, and long has been, confounded 
 with it, and by an inevitable consequence has been always 
 subjected to the same treatment, although it is nothing 
 more than an infirmity — a vice of conformation. Several 
 individuals affected with original luxation have been 
 constrained by this error of diagnosis to keep their bed 
 for many years; I have seen others compelled to support 
 innumerable applications of leeches, blisters, and caute- 
 ries, especially moxas. I recollect a young lady who 
 underwent the application of twenty-one moxas to her 
 hips, without experiencing the least change of situation 
 from this useless — this barbarous treatment. I may 
 mention to you the curious case of a nurse whom the 
 distracted parents accused unjustly of having caused, by 
 neglect or brutality, the accidental luxation in a child 
 born with this conformation. Another was that of 
 Dauton, the victim of an atrocious assassination. His 
 body, mutilated, disfigured, and thrust into a sack, con- 
 tinued unrecognized, despite the most active researches, 
 wheu the vice of conformation, which I pointed out to 
 the legal authorities, set justice in the right path, and 
 aided her in the desired identification. We may readily 
 succeed in distinguishing these two affections, so analo- 
 gous in their signs, but so different in their origin,
 
 ON MORBUS COX.E. 21 
 
 nature, and treatment, by the following negative symp- 
 toms: — Absence of pain, engorgement, abscess, fistula, 
 cicatrix, &c. ; in the majority of cases there is a simul- 
 taneous dislocation of both sides — I say in the majority, 
 as in some it is only on one side. Of the twenty-six 
 facts of this kind, 1 have observed that two or three 
 only w r ere of one side; one of these was a child whose 
 sister, curious to relate, displayed the same derangement, 
 and also at one and the same side." For the anatomi- 
 cal character of this malformation I beg to refer you to 
 Mr. Adams' paper on the subject, in Todd's Cyclopaedia 
 of Practical Anatomy — a paper which reflects great 
 credit on its author. 
 
 There is an affection of children accompanying denti- 
 tion, or irritation of the bowels, in which the limbs be- 
 come perfectly useless, and which might, by a superficial 
 observer, be taken for disease of the hip; but here the 
 difference will be at once seen by finding that in the 
 former both limbs are affected, whereas in morbus coxae 
 the disease is in general confined to one; moreover, the 
 affection I am now alluding to soon yields to the use of 
 the warm bath, and close attention to the bowels. There 
 is also a curious affection which occasionally occurs in 
 children after sleeping, and which, at the moment, very 
 m uch resembles hip-joint disease in some of its symptoms : 
 they are liable to it up to about ten years of age. The 
 child goes to bed quite well and gets up lame in the 
 morning; but there is no complaint of pain: it yields to 
 rest, the warm bath, and Dover's powder.^ Here the 
 suddenness of the attack, the absence of pain, and the 
 rapid disappearance of the affection under suitable treat- 
 ment, distinguish it from hip-joint disease. 
 
 Hysterical affections of the hip might be taken for 
 
 * See Colles's Lectures on Surgery.
 
 22 CLINICAL LECTURE 
 
 hip-joint disease, and I have seen periostitis of the su- 
 perior portion of the femur, as also chronic enlargement 
 of the gluteal bursas, mistaken for, and treated as, dis- 
 ease of the hip-joint. 
 
 Having thus, gentlemen, dwelt on the affections which 
 are liable to be confounded with disease of the hip, I 
 shall pass on to the treatment of the chronic scrofulous 
 disease of the hip-joint. 
 
 The remedial measures to be adopted in the chronic 
 disease of the hip-joint will greatly depend on the stage 
 in which you are called on to treat the affection. If 
 consulted in the first or incipient stage of the disease, 
 your object should be to subdue the inflammation, which 
 pathological investigations have satisfactorily proved to 
 exist in the commencement of the affection, and you 
 should endeavour to attain this object by absolute rest, 
 local depletions, and the exhibition of mercury. The 
 advantage of rapidly placing a patient labouring under 
 chronic disease of the hip under the influence of mercury, 
 was first pointed out to the Profession by Dr. O'Beirne 
 of Dublin, formerly surgeon to this and the Richmond 
 Hospitals, in an able paper on the subject, contained in 
 the May Number of the Dublin MedicalJournal of 1 834, 
 in which Dr. O'Beirne adduced numerous cases to prove 
 that the rapid insalivation of patients labouring under 
 ulceration of the cartilages of the hip-joint, even in 
 scrofulous persons, if met with in the early stage, will, 
 in general, restore the patient to the full use of the ex- 
 tremity. In none of the cases brought forward then 
 by Dr. O'Beirne, and which were seen by Mr. Carmichael, 
 and other eminent surgeons, were any injurious effects 
 observed to follow the practice. Dr. O'Beirne has the 
 merit of having been the first to recommend mercury 
 pushed on to rapid salivation in the early stage of syno- 
 vitis, as well as in ulceration of the cartilages, whether 
 
 . , » y l '* 
 
 2rxx&e.~ -
 
 ON MORBUS COX.E. 23 
 
 the result of synovial inflammation, or existing as a pri- 
 mary or independent affection. Dr. O'Beirne was led 
 to the trial of mercury in these cases from its decided 
 and happy effects in all kinds of membranous inflamma- 
 tions, and he follows up the mercurial treatment by the 
 administration of sarsaparilla in lime water, with the 
 view of anticipating, he says, and preventing the super- 
 vention of injurious effects of mercury in scrofulous 
 persons. 
 
 I have had considerable experience in the iuternal 
 exhibition of mercury in the incipient stage of hip disease, 
 both in this hospital and elsewhere, and I wish to record 
 my decided opinion in favour of its efficacy in the great 
 majority of these cases, when administered at the very 
 onset of the disease; but like other remedies, it is not 
 infallible. If I were asked in what cases it apparently 
 exerted most influence, I should say those in which, 
 from the symptoms present, the synovial membrane of 
 the joint was apparently the texture of the articulation 
 primarily affected. At the same time, I admit that I 
 have seen the mercurial treatment followed with advan- 
 tage iu cases where the symptoms of ulceration of the 
 cartilages, as laid down by the best authorities on the 
 subject, predominated. The success of the mercurial 
 plan of treatment will, however, to a great extent, 
 depend on its being brought into operation in the vwy 
 commencement or incipient stage of the disease. I have 
 already mentioned that the incipient stage of hip dis- 
 ease, if uninterfered with, extends itself, as a general 
 rule, over a period varying from one to three months ; 
 it is, however, important to know that, under favorable 
 circumstances, the disease may remaiu in the first stage 
 for a longer period; thus, not long since, I was afforded, 
 in conjunction with Sir Philip Crampton, an opportunity 
 of testing the value of the mercurial treatment in a case
 
 24 CLINICAL LECTURE 
 
 of hip disease, which had persisted in the incipient stage 
 for fully four months. The patient was a young lady 
 of fifteen years of age, who was brought from the country 
 to seek advice for pain in her left hip and knee, and a 
 limping gait, which her friends attributed to growing 
 pains, but which we, on examination, found to depend 
 on hip disease in its incipient stage; we accordingly 
 placed the patient under the influence of mercury as 
 rapidly as possible, having first enjoined perfect rest in 
 the recumbent position, and the result was, that the 
 pain and other symptoms soon subsided, and the young 
 lady is now as active as any person of her age, and is 
 able to walk a considerable distance without the slight- 
 est inconvenience. In the selection of the mercurial 
 preparation for this class of patients, you must exert 
 your own judgment. In some cases we give calomel, 
 in others blue pill. When the patient is very young, 
 I generally, as you have seen, order it in the form of 
 gray powder in suitable doses. 
 
 The best way of enforcing absolute rest, which is of 
 primary importance in the treatment of hip disease, is 
 to confine the patient to the horizontal position, with 
 the limb of the affected side in the extended state, and 
 the best apparatus for keeping the limb in this position 
 as free as possible from motion, is that which you have 
 often seen adopted in this hospital — I allude to the long 
 splint applied to the outside of the limb, and extending 
 from the foot to the axilla. 
 
 When directing leechings or cuppings in cases of hip 
 disease, be careful not to carry your depletion too far, 
 holding in mind that these patients are generally of a 
 scrofulous diathesis, and consequently do not well bear 
 the loss of blood. 
 
 Where there is an objection to the use of the long 
 splint, I generally secure the joint as perfectly as I can
 
 ON MORBUS COX.E. 25 
 
 from motion, by applying a sheet of gutta percha of 
 sufficient thickness, previously softened in warm water 
 to the pelvis and affected thigh, and of such a size as to 
 take an accurate mould of the parts. When this mould 
 is dry, I remove it, pare the edges, and perforate it 
 here and there with holes, so as to prevent the retention 
 of perspiration. Having done so, I line it with wash 
 leather or oiled silk, and then reapply it, by which 
 means the joint is kept in a quiescent state. Motion in 
 these cases has a tendency not only to promote ulceration 
 of the cartilages, but likewise to increase the chances of 
 suppuration. 
 
 If you should be so fortunate as by these meausto arrest 
 the disease in its onset, you must hold in recollection 
 that the affection, in the generality of cases, is intimately 
 connected with a scrofulous diathesis, and consequently 
 depends to a great extent on a diseased condition of the 
 system at large: therefore, in such cases, whilst you 
 bring your local measures into effect, you must in every 
 stage of it direct your most anxious attention to the 
 improvement of the general health. 
 
 If, as often happens, you are not consulted until the 
 disease has made considerable progress, absolute rest, 
 with counter-irritation, sea-air, nourishing diet, together 
 with the exhibition of cod-liver oil, iodine, or iron, are 
 indicated. When the patient is very young, I prefer 
 the application of small blisters constantly repeated, 
 and placed round and about the joint. Mr. Ford, 
 however, strongly recommended the counter irrita- 
 tion to be carried out in these cases by means of 
 issues, and he appeared to be of opinion that few patients 
 died of hip disease who had issues applied in time, and 
 it certainly is true that in many cases they exert a most 
 beneficial influence. The application of setons in front 
 of the joint has been recommended by Sir B. Brodie.
 
 26 CLINICAL LECTURE 
 
 The actual cautery was used by the ancients, and has 
 since been reintroduced by some modern surgeons in 
 preference to the employment of issues, setons, or 
 blisters. Stimulating frictions, as recommended by 
 some, are altogether contraindicated, as interfering with 
 one of our chief objeets in the treatment of hip disease — 
 viz., that of maintaining the joint in a state of perfect 
 quietude. 
 
 If, unfortunately, you are not consulted till the 
 disease has proceeded to the third stage, your best 
 endeavours can only have the effect of arresting the 
 disease, but a degree of lameness, in proportion to the 
 amount of destruction, must necessarily be left behind. 
 
 The position of the limb in the advanced stage of the 
 disease is a matter of great consequence. The one 
 which the patient generally selects himself is that of 
 lying on the affected side; but as Sir B. Brodie very 
 justly remarks, it leads to bad consequences — viz., it 
 naturally distorts the pelvis, induces lateral curvature 
 of the spine, and in cases in which the round ligament 
 of the joint is destroyed, it facilitates the escape of the 
 head of the femur from the acetabulum, and the produc- 
 tion of luxation. However, when the patient has 
 accustomed himself to the position, it is difficult to alter 
 it. In such cases we can, to a certain extent, counter- 
 act this tendency to luxation by interposing a cushion 
 between the patient's knees. 
 
 In the third stage, two positions have been recom- 
 mended with the intention of favouring true anchylosis ; 
 one is that in which the patient lies in the horizontal 
 position, with both extremities on a double inclined plane 
 furnished with foot boards; and the other is that in 
 which the patient lies in the horizontal position, with 
 the limb fully extended, and kept so with the long splint 
 before described: both plans have their advocates. But
 
 ON MORBUS COX^. 27 
 
 beyond a doubt, the most useful position for an an- 
 chylosed hip-joint is that in which the limb approaches as 
 near as possible to the fully extended state. Mr. Key, who 
 is a warm advocate for the straight position, says, that 
 when suppuration is established, it is somewhat modi- 
 fied by that position, the matter being inclined to the 
 forepart of the joint; but he says that no inconvenience 
 in his cases followed this peculiar course of the abscess. 
 When anchylosis takes place with the thigh flexed 
 to a great degree on the pelvis, the deformity is very 
 great indeed. 
 
 When matter is formed in conjunction with disease of 
 the hip, you should endeavour in the commencement to 
 promote its absorption by the application of iodine, for 
 which purpose you will find the alcoholic solution of iodine 
 and hydriodate of potash sometimes of service. Here 
 the cod-liver oil internally, in doses suited to the age of 
 the patient, has proved in some cases of the greatest 
 possible value. In this stage the syrup of the iodine of 
 iron is a valuable medicine, as also are the different 
 other preparations of iron, iodine, bark, quinine, &c. 
 
 If, notwithstanding this mode of treatment, that the 
 formation of matter should proceed, and that the 
 integuments should become inflamed, you had better 
 discontinue the application of iodine: and here a ques- 
 tion of great importance suggests itself — viz. : What 
 now will you do with the abscess? Will you open it, 
 or let nature make an outlet for it ? Authors are 
 divided on this point of practice. Here I should be 
 guided altogether by the accompanying symptoms. If 
 the sufferings of the patient were not great, and that 
 the integuments covering the abscess were very thick, 
 I should be content with the application of emollient 
 poultices and the exhibition of morphia to allay irri- 
 tation, and when the integuments became thinned, I
 
 28 CLINICAL LECTURE 
 
 would anticipate nature in discharging the matter. If, 
 on the other hand, the pain from the distention caused 
 by the contained matter was very acute, and the suffer- 
 ings of the patient very great, I would not hesitate to 
 open the abscess and treat the case according to circum- 
 stances. If you should open the abscess, what kind of 
 opening will you make? Formerly small valvular 
 openings were made, but of late Sir B. Brodie has given 
 good reasons for opening large abscesses connected with 
 disease of the knee-joint by a very free incision, so that 
 the pus may flow out without squeezing, or any other 
 kind of rough manipulation. Brodie says that he knows 
 that mischief sometimes arises from opening a large 
 abscess, but that he also knows that it is generally from 
 the fault of the surgeon; for if a small opening be made, 
 it is only by squeezing and pressure that the abscess 
 can be emptied of its coutents, and this rough treatment 
 induces inflammation of its parietes. Some time since 
 I carried out the method of opening a large abscess, 
 connected with disease of the hip-joint, in a case in the 
 upper male ward of this hospital, by a free incision ; 
 the practice was followed by relief, and no bad con- 
 sequences ensued; and when another case of the kind 
 offers itself, I shall adopt the same line of practice. 
 When suppuration has taken place, and that the matter 
 has got exit, the patient will require your most anxious 
 attention. Here well marked hectic symptoms, with 
 great prostration of strength, very often rapidly set 
 in, and here you must endeavour to support the con- 
 stitution by generous light diet, together with bark, 
 wine, or porter, and anodynes must be administered, 
 when called for. 
 
 If, fortunately, the abscess should heal in, and that 
 the disease apparently becomes arrested, the patient 
 must be very cautious indeed before he places the weight
 
 ON MORBUS COXJ2. 29 
 
 of his body on the diseased limb, and when he does go 
 about, he ought to do so by means of crutches, to the 
 use of which these patients adapt themselves wonder- 
 fully soon. 
 
 Before concluding, I shall just allude to the subject 
 of excision of the head of the carious thigh-bone, which 
 has been recommended in the cases of hip-joint disease, 
 practised by White, Hewson, and others, and lately 
 reintroduced by Messrs. Ferguson and Henry Smith 
 of London. 
 
 In Mr. H. Smith's case, lately operated on in London, 
 the patient lived but a few months, and although his 
 kidneys were reported to have been diseased, yet it was 
 very candidly admitted that the whole extent of the 
 cotyloid cavity was bare and rough, and also that the 
 lumbar vertebrae were found to be carious in a portion 
 of their bodies. Mr. Hewson's patient is reported by 
 Mr. Hargrave, in his " Operative Surgery," to have 
 survived the operation but a few months, when he 
 declined, owing to excessive and large purulent collec- 
 tions which were found to extend into the pelvis through 
 an opening in the cotyloid cavity. It is but justice 
 to Mr. Ferguson to give his opinion on this important 
 subject in his own words : — 
 
 " I am anxious that you should not misunderstand 
 me about this operation. Do not for an instant sup- 
 pose that 1 bring it forward as the treatment for hip 
 disease. I advocate the practice as applicable to certain 
 cases only, and these cases seem to me so few in number, 
 that years may be passed in active practice ere such an 
 instance may come under the surgeon's notice; but when 
 such are met with, I conceive that the principles on 
 which we treat caries, where there seems no disposition 
 to a spontaneous cure, are as eligibly applicable here 
 as in all other parts of the body where we are in
 
 30 CLINICAL LECTURE. 
 
 the habit of cutting away carious bone." — Lancet, 
 April, 1849. 
 
 The pathological fact of the bones entering into the 
 formation of the acetabulum being, in the great majo- 
 rity of these cases extensively diseased, as well as the 
 head of the femur, will at once point out to you the 
 impracticability of removing, as a general rule, the 
 entire disease by excision of the head of the femur, 
 and consequently renders the operation unjustifiable in 
 the ordinary state of things; and as the operation is 
 not likely to be attempted except in cases in which 
 dislocation of the carious head of the femur has taken 
 place, and as this is a very uncommon occurrence, the 
 cases in which the operation is justifiable must neces- 
 sarily be very few indeed. 
 
 THE END. 
 
 J. M. O 'Toole, Printer, 13, Hawkins'-street, Dublin.
 
 A CASE 
 
 FRACTURE OF THE SPINE 
 
 (Mori lUgimt; 
 
 WITH OBSERVATIONS. 
 
 BY 
 
 JAMES STANNUS HUGHES, M.D., F.R.C.S.I., 
 
 SURGEON TO THE JERVIS-STREET HOSPITAL, EXAMINER IN SURGERY 
 IN THE QUEEN'S UNIVERSITY IN IRELAND. 
 
 DUBLIN: 
 PRINTED BY J. M. O'TOOLE, 
 
 13, HAWKINS'- STREET. 
 1855.
 
 A CASE 
 
 OF 
 
 FRACTURE OF THE SPINE 
 
 IN THE 
 
 The subject of the accident, J. I)., was a 
 strong, healthy man, of 35 years of age, who, 
 whilst working in the hold of the " Albatross" 
 steamship, then lying in the River Liffey, was 
 struck by a large sack of oatmeal, which, having 
 slipped from the slings, struck him on the back 
 of the neck near the shoulders ; the patient was 
 felled by the blow, and soon after the accident 
 was carried to Jervis-street Hospital, labouring 
 under all the symptoms of fracture of the spine 
 in the cervical region, below the origin of the 
 phrenic nerve, viz., there was complete loss of 
 motion and sensation of the lower extremities, 
 with partial loss of motion and sensation of the 
 upper limbs; the respiration was extremely 
 laboured, being principally carried on by the 
 diaphragm, the abdominal and intercostal mus- 
 cles being paralysed ; the pulse was unusually 
 slow, being only 36 in the minute ; the ex- 
 tremities were cold ; there was a total loss of 
 power over the bladder; the penis was in a
 
 4 FEACTURE OF THE SPINE 
 
 semi-erect state; the abdomen became tympa- 
 nitic immediately after the accident. On ex- 
 amination after admission a fracture of the spi- 
 nous process of the fifth cervical vertebra was 
 detected. The patient lived for four days, and 
 up to within a few minutes of his death he 
 could not be persuaded of his danger, being, as 
 he expressed himself, " so free from pain and 
 suffering of any description." 
 
 The apparent immediate cause of death was 
 apncea, from effusion into the bronchial tubes. 
 It is to be added, that the urine, which was 
 drawn off two or three times daily by means of 
 a catheter, remained acid to the last moment of 
 life. 
 
 Autopsy. — On removing the superincumbent 
 parts from the posterior aspect of the cervical 
 vertebrae, a fracture of the spinous process of the 
 fifth cervical vertebra, involving the left lateral 
 lamina, was revealed ; in addition to which a 
 fracture was ascertained running through the 
 bodies of the fifth and sixth cervical vertebra?. A 
 considerable effusion of blood had taken place both 
 internal and external to the theca vertebralis at 
 the seat of injury ; the spinal chord was in a 
 softened and highly vascular condition, not only 
 where the displaced body of the sixth cervical 
 vertebra and the effused blood had exercised a 
 considerable amount of pressure, but likewise 
 for some distance both above and below that 
 point. 
 
 The accompanying woodcut, executed by 
 Oldham, after a drawing by Connolly, which 
 was reduced by my friend, Mr. Frederick San- 
 ders, to its present dimensions, through means
 
 IN THE CERVICAL EEGION. O 
 
 of the photographic process, beautifully and 
 faithfully exhibits the morbid appearance? just 
 referred to. 
 
 Observations. — The foregoing case exemplifies 
 the train of symptoms which usually follow on 
 fractures of the spine in the cervical region, 
 when occurring below the origin of the phrenic- 
 nerve, whilst the post mortem appearances, the 
 chief points of interest, not only exhibit the 
 ordinary results of these formidable accidents, 
 but account for the failure of the operations. 
 which have been proposed, and practised for 
 their relief. 
 
 There are two questions which naturally sug- 
 gest themselves in connexion with the treat- 
 ment of fractures of the spine, with displacement, 
 namely — 1st, Should a reduction of the fracture- 
 be attempted ? 2nd, Should the surgeon, in a
 
 b FRACTURE OF THE SPINE 
 
 case of fracture of the vertebrae, followed by 
 displacement and paralysis, proceed to cut 
 through the superincumbent parts at the seat of 
 injury, and endeavour to remove, as has been 
 proposed, any portion of bone which he may find 
 compressing the spinal chord, and thus treat the 
 case on the same principle as he would a de- 
 pressed fracture of the skull accompanied by 
 symptoms of compression of the brain ? To the 
 solution of these questions we shall now briefly 
 address ourselves in connexion with J. D.'s case, 
 leaving out of view, for the present, the general 
 treatment that should be adopted in fractures 
 of the spine. 
 
 With regard to the first question, all authori- 
 ties of weight are, with very few exceptions, 
 agreed on the danger and impropriety of at- 
 tempting reduction, when the fracture is si- 
 tuated in the cervical region. Boyer has 
 described a case in which a child suddenly 
 expired under such an attempt. When the 
 fracture has its seat in the lower portion of the 
 spine, Sir Benjamin Brodie says, "that the 
 attempt to effect reduction may not only be made 
 with impunity, but that it may be successful ;"* 
 and he has recorded two cases in support of this 
 assertion. As however the paralysis persisted in 
 both cases, and as they appear to have ran the 
 same course as many such cases have taken 
 where no such treatment had been adopted, they 
 have not been generally received by the pro- 
 fession as evidences in favour of the point 
 now under consideration. Although some are 
 
 * Med. Chiruvg. Trans., vol. xx. p. 159.
 
 IN THE CERVICAL REGION. 7 
 
 still of opinion that, in every case of fracture of 
 the spine with displacement, a reduction of the 
 displaced parts should he attempted, yet the great 
 majority of modern surgeons are, on the contrary, 
 strenuously opposed to the employment of forcible 
 extension in fractures of the bodies of the 
 vertebrae, wherever situated; not only inas- 
 much as such attempts have hitherto failed in 
 saving life, but moreover as such treatment 
 would obviously have a tendency, as it had in 
 Boyer's case, for instance, to inflict additional 
 injury on the spinal chord, which, in nearly all 
 these cases, has been found to have suffered 
 from severe concussion or laceration, as well as 
 from compression of blood or bone, or from the 
 conjoint effects of both, as in J. D.'s case. 
 
 In respect of the second question, Heister,* a 
 century since, laid it down as a rule of practice, 
 that in the worst cases of fractures of the spine, 
 "the surgeon must lay bare the fractured 
 vertebra with a scalpel, or else remove such 
 fragments as injured the spinal marrow." But 
 it does not appear that either Heister or any of 
 his cotemporaries, as far as we have been able to 
 make out, had recourse to such a proceeding. 
 
 More recently (in the year 1814) 3Ir. H. 
 Cline, Jun., proposed the operation of trephin- 
 ing or sawing away the vertebral arch, with a 
 view of relieving the compressed spinal chord in 
 fractures of the spine with displacement, and 
 such an operation was not only performed by 
 Mr. Cline with the utmost hopes of success, 
 but his example was followed by Tyrrell, South, 
 
 * Heister's Surgery, vol. I p. 140, 1757.
 
 8 FEACTTJRE OF THE SPINE 
 
 Wickham, Attenburrow, Holscheir, Smith, and 
 Rogers. The operation, however, unfortunately 
 proved unsuccessful in every case in which it 
 was attempted.* Experience has, therefore, de- 
 clared against Cline's operation, whilst patho- 
 logy is opposed to it, inasmuch as innumerable 
 post mortem examinations, conducted by impartial 
 observers, have not only proved that in the gene- 
 rality of cases of fractures of the spine, as in J.D.'s, 
 the chord is violently concussed or lacerated, as 
 well as compressed, the usual consequences of 
 which are rapid ramollissement, and subsequent 
 disorganization ; but they have likewise made it 
 manifest that the chief pressure is, in the majo- 
 rity of these cases, not exercised by the vertebral 
 arch, but, as in J. D.'s case, by the broken body 
 of the lower vertebra projecting backwards, a 
 part obviously, as Mr. Liston has properly re- 
 marked, " completely out of the reach of any 
 operation whatever."! 
 
 In answer to the objections against Cline's 
 operation, Mr. South, one of its most strenuous 
 and distinguished supporters of the present day, 
 says, "The only objection to the operation of 
 
 * Sir Astley Cooper's name is intentionally excluded 
 from the list of those who performed Cline's operation, for 
 although Sir Astley commenced such an operation in a case 
 in which there was supposed to he a fracture of the spine 
 with displacement, the arch was not meddled with, as the 
 case turned out to be merely a fracture of the spinous process 
 of a dorsal vertebra at its root. Mr. South when refer- 
 ring to Cooper's case, says, " I saw the operation performed, 
 but I do not recollect how the case terminated."— Chelius 1 
 Surgery, vol. i. p. 540. 
 
 f Liston's Practical Surgery.
 
 IN THE CEBVICAL REGION. 9 
 
 trephining the spine is, that we cannot, previous to 
 the operation, ascertain whether the spinal chord 
 be simply compressed, or whether it be partially 
 or entirely torn through, or whether the symp- 
 toms of compression result from the effusion of 
 blood in the different situations above men- 
 tioned, neither of which, indeed, can be ascer- 
 tained after the vertebral canal has been opened, 
 unless the sheath be rent. If, however, this 
 objection hold in regard to the fracture of 
 the skull with symptoms of compression, for 
 no one can certainly determine what mischief 
 may be beneath the fractured bone, and even if 
 it be seen, as occasionally it may be, that the 
 membranes of the brain are torn, and a portion 
 of the brain itself squeezed out, yet if the bone 
 be depressed, and the brain labours under pres- 
 sure, no one would hesitate to remove the bone in 
 whatever condition the brain beneath might be 
 expected to be found. This treatment of a com- 
 pressed brain, with symptoms of compression, 
 being that which is thought necessary by all 
 surgeons of experience, it seems to me that the 
 analogy is so close as regards compressed spinal 
 chord, that the operation is not merely per- 
 missible, but is called for imperatively ; and I 
 fully agree with Jaeger, that the earlier it is 
 performed the better. The much dreaded sub- 
 sequent inflammation I do not think is much to 
 be feared ; at any rate, it is never taken as an 
 objection to trephining the skull. The great 
 difficulty in the after treatment is the great 
 irritability of the bladder from the highly alka- 
 line state of the urine, which depends on the
 
 10 FKACTT7KE OF THE SPINE 
 
 irritation of the chord, but which, I doubt not, 
 might be counteracted."* 
 
 Mr. Liston, on the other hand, when discuss- 
 ing the different proposals for the removal of 
 the pressure of the chord in fractures of the 
 spine by surgical operations, says, "By these 
 means, now generally and very properly looked 
 upon as unwarrantable, effused blood could not 
 be removed, nor lacerations repaired, while the 
 chance of inflammatory action would be much 
 increased." 
 
 Sir Benjamin Brodie, speaking of Cline's 
 operation, says, "The question respecting such 
 an operation seems to me to lie in a very small 
 compass; if the whole, or nearly the Whole, of a 
 vertebra be driven forwards, the depression of 
 the posterior part of it will, of course, occasion 
 a diminution of the size of the spinal canal; but 
 the removal of any portion of the vertebrce, 
 which is accessible to an operation, will be of 
 little avail, as the irregularity in the anterior 
 part of the canal, made by the displacement of 
 the body of the vertebra, must be the same 
 after, as it was before the operation." 
 
 " If there be simply a fracture on each side 
 of the spinous process, with a depression of the 
 loose or intermediate portion of bone, of course 
 there must be a corresponding diminution of 
 the size of the vertebral canal ; but as that 
 canal is much larger than the spinal chord, 
 which it contains, it does not follow that the 
 spinal chord is really compressed, or that any 
 
 * See Chelius' Surgery, by South, vol. i. p. 541.
 
 IN THE CEEVICAL EEGION. 11 
 
 material diminution of the symptoms would 
 follow the elevation of the depression." 
 
 " But let it be supposed that the spinal chord 
 is really suffering from pressure, it has been 
 already shewn that a much less degree of vio- 
 lence than that which is necessary to occasion a 
 fracture of the spine may produce concussion, 
 softening, and ultimately dissolution of the 
 spinal chord, with a train of symptoms much 
 worse than those which arise from simple 
 pressure. Now, no operation can be of the 
 smallest advantage in this respect ; but on the 
 contrary, if it be necessary to apply the saw in 
 the performance of it, the jar and disturbance of 
 the parts which this must occasion is even 
 likely to aggravate the mischief." 
 
 " If these views be correct, it is evident that 
 the cases in which there are any reasonable 
 grounds for the performance of the operation 
 must be of very rare occurrence, and that even 
 under the most auspicious circumstances it must 
 be doubtful whether it may not be productive 
 of harm rather than of good to the patient. 
 Nor, as far as I am acquainted with the results, 
 do the experiments which have been hitherto 
 made on the subject lead to any more satisfac- 
 tory conclusions. I am not aware that in any 
 of the cases in which it had been performed, the 
 operation has proved the means of preserving 
 the patient's life, or even of relieving any of the 
 more important symptoms."* 
 
 Med. Chirurg. Trans. Vol. xx. p. 160.
 
 ATTEMPTED SUICIDE 
 
 gj facing, 
 
 WITH OBSERVATIONS. 
 
 JAMES S. HUGHES, M. D., F.R.C.S.I., 
 
 EXAMINER IH SURGERY IN THE QUEEN 8 UMIVKKSITY IX IRELAND. 
 
 (From the "Dublin Hospital Gazette. 
 
 DUBLIN : 
 PRINTED BY J. M. O'TOOLE, 13, HAWKINS'-STBEET. 
 
 1854.
 
 CASE OF ATTEMPTED SUICIDE 
 
 WITH OBSERVATIONS. 
 
 J -J , a coach trimmer, set. 63, of small 
 
 stature and light weight, was found by a fellow- 
 workman suspended, by means of a rope round 
 his neck, from the rafter of a coach factory loft, 
 at a quarter before 12 o'clock, on the 2nd of 
 February, having been observed ascending the 
 loft about ten minutes previously ; he was cut 
 down as soon as assistance could be procured, 
 and brought on a door to Jervis-street Hospital, in 
 a state of complete insensibility, at five minutes 
 past 12 o'clock. On admission his respiration 
 was slow, laboured, and stertorous, with puffing 
 of the cheeks during expiration ; heart's action 
 laboured ; pulse at wrist 40 in the minute ; 
 face livid and somewhat swollen ; a few frothy 
 bubbles were seen between the lips, which latter 
 were of a dark purple colour ; eyes glassy, not 
 prominent; pupils rather contracted than dilated, 
 but perfectly insensible to light ; tongue not 
 protruded ; temporal vessels extremely turgid, 
 and ropy to the touch ; extremities cold ; ab-
 
 4 ATTEMPTED SUICIDE 
 
 sence of hgeniorrhage from the eyes, ears, and 
 nose ; a dark circular ring, with a depression in 
 the centre, encircled the neck, taking a course 
 from below and before, upwards and backwards, 
 crossing the larynx. 
 
 It being obvious from the existence of the 
 foregoing symptoms, that the patient was labour- 
 ing under congestion of the brain or apoplexy, 
 the result of compression of the large blood- 
 vessels of the neck, Mr. Hughes, who was 
 visiting the hospital at the time, ordered the left 
 temporal artery to be instantly opened : as the 
 blood, however, issued from it but slowly, Mr. 
 Hughes thought it advisable to have the right 
 temporal artery likewise opened, from which the 
 blood poured out freely ; as the blood flowed the 
 pulse rose, and improved in character; the 
 bleeding was encouraged till about twelve ounces 
 had been abstracted, at which period the re- 
 spiration had become less laboured, the stertor 
 had subsided, and the pupils exhibited evidence 
 of sensibility to light. A turpentine enema was 
 now administered ; heaters were applied to the 
 feet, and sinapisms to the calves of the legs. 
 Ten grains of calomel were subsequently shaken 
 on the tongue. 
 
 At a quarter past one o'clock (one hour and 
 ten minutes after admission into hospital), the 
 patient was gradually regaining consciousness ; 
 at two o'clock he spoke coherently, and had 
 perfect power over his limbs, but he neither 
 knew where he was, nor did he appear to have 
 the most remote recollection of having attempted 
 self-destruction. 
 
 Six o'clock. — Slightly delirious; is very rest-
 
 BY HANGING. O 
 
 less; answers questions in a very incoherent man- 
 ner ; is constantly endeavouring to tear the dress- 
 ings from the temples. As the first enema produced 
 no effect, a second was administered, which was 
 followed by copious vitiated evacuations, after 
 which he appeared to be more tranquil, and fell 
 into a tolerably calm sleep ; but, whilst he slept, 
 an occasional puffing of the cheeks was observed 
 during the act of expiration. 
 
 February 3rd. — Passed the night in a tole- 
 rably easy manner, being occasionally restless ; 
 pulse 104, hard and somewhat irregular; com- 
 plains now much of his head ; is constantly an- 
 noyed by a stridulous laryngeal cough; act of 
 swallowing accompanied with pain ; power ot 
 motion perfect ; sensation good everywhere but 
 in his ears and jaws, where the sense of feeling- 
 is considerably diminished. 
 
 Ordered — 
 
 R' Hydrarg. submuriatis, gr. xii. 
 Pulv. Jacobi veri gr. vi. 
 Sacch. alb. 9i. M. 
 
 Divide in chart, aeq. vi. Capiat unam tertia 
 quaq. hora. Apply cold lotion to head. 
 
 4th. — Much improved ; pulse regular ; head 
 relieved, still, however, suffers at intervals from 
 slight uneasiness in it, increased by the act of 
 coughing, which is still annoying, and of a la- 
 ryngeal character. Ordered to take one grain of 
 calomel every sixth hour. 
 
 5th. — All uneasiness in the head removed ; 
 cough less troublesome ; slight salivation, and 
 mercurial fcetor present. Omit the calomel. 
 
 1 5th. — He is now so far recovered that the
 
 b ATTEMPTED SUICIDE 
 
 only obstacle to his immediate removal from the 
 hospital is the possibility of his repeating the 
 attempt at suicide, as he is suffering under great 
 depression of spirits, and speaks despondingly of 
 his circumstances and prospects. 
 
 20th. — The patient's spirits have much im- 
 proved, but he received a great shock since last 
 report, on having been told, in a very unguarded 
 way, by a fellow-patient, of his having made an 
 attempt on his life, of which he had not the most 
 remote recollection. 
 
 April 30th. — Dismissed quite well. 
 
 Observations. — The modes of death by hanging- 
 may be thus summed up, not in the order of 
 their frequency, but of their fatality : — First, 
 Luxation of the odontoid process of the second 
 cervical vertebra, or fracture of the spine, and 
 consequent injury to the medulla spinalis ; 
 Second, Suffocation from pressure on the wind- 
 pipe, producing complete obstruction to respira- 
 tion ; TJiird, Congestion of the brain, or apo- 
 plexy from arrest of the return of blood from 
 the head to the heart, the result of compression 
 of the great bloodvessels of the neck ; Fourth, 
 Injury inflicted by violent and prolonged pres- 
 sure on the important nerves of the neck. 
 
 The first cause of death by hanging, or that by 
 luxation or fracture of the cervical vertebras, is 
 rarely met with, even in those who have been 
 criminally executed ; thus, in four cases of this 
 description, the late Dr. Houston found the 
 " cervical vertebras uninjured, and also the spi- 
 nal marrow and the brain ;"* and in the case of 
 
 * Quoted by Dr. Beatty.
 
 BY HANGING. I 
 
 Hurley, who was hanged in August, 1853, for 
 the murder of a young- girl at Dunsandle Wood, 
 although the body had fallen from the drop, 
 " with a tremendous jerk, and oscillated for a 
 few minutes," yet we are informed by Dr. Cro- 
 ker King, who made a minute examination of 
 the culprit's body eighteen hours after the exe- 
 cution, that " there was no dislocation or frac- 
 ture of the vertebral column or injury of the 
 ligaments or spinal cord."* Sir Benjamin Bro- 
 die states, that he has examined the bodies of 
 several persons who had been hanged, and never 
 found the spine to have been injured in a single 
 instance. 
 
 It is now generally admitted that the most fre- 
 quent immediate cause of death by hanging is 
 that by suffocation, or exclusion of air from the 
 lungs, the result of pressure of the rope or liga- 
 ture on the windpipe, but in many cases death 
 would appear to be produced by the combined in- 
 fluences of suffocation and apoplexy ; indeed, ac- 
 cording to Reiner and Caspar, asphyxia and apo- 
 plexy operate in the greater number of cases of 
 hanging as mixed causes of death. The rapidity 
 of death by suffocation will depend on a variety 
 of circumstances, which may be thus enume- 
 rated, viz. : the exact position of the rope or li- 
 gature round the neck, the weight of the body, 
 the height of the fall, the age of the patient, and 
 the quantity of air in the lungs at the moment 
 the ligature was applied to the neck. The fol- 
 lowing are the physiological results which en- 
 sue soon after the respiration has been completely 
 
 * Dublin Journal of Medical Science, New Series, No. 
 XXXV., p. 89.
 
 8 ATTEMPTED SUICIDE 
 
 stopped. The heart, after a few beats, propels 
 impure blood, that is, blood no longer oxygen- 
 ated, to the brain, and, as the action of the heart 
 and diaphragm depend on nervous energy, and 
 as nervous energy requires a supply of pure 
 or oxygenated blood, it follows that when the 
 supply of pure arterial blood is cut off, the 
 heart and diaphragm soon cease to act.* 
 
 The heart continues to act for a brief period 
 after respiration has completely ceased. When 
 speaking of the rapidity of death in these cases, 
 Dr. Taylor says : " Supposing the hanging to be 
 unattended with violence to the parts about the 
 neck, it is possible that some individuals might 
 be resuscitated after five minutes' suspension, or 
 longer ; others again may not be recovered when 
 cut down immediately after suspension, a fact 
 which depends probably on the different degrees 
 to which asphyxia or apoplexy have extended."! 
 Sir B. Brodie is of opinion that under ordinary 
 circumstances it rarely happens that the heart 
 continues to act for more than four minutes after 
 the trachea has been completely obstructed ; 
 and he thinks in weak and exhausted animals 
 the period to be shorter than in the strong and 
 vigorous. 
 
 The great majority of physiologists are of opi- 
 nion that once the heart's action has positively 
 ceased, in consequence of the suspension of respi- 
 ration, it cannot be renewed. Dr. Carpenter, 
 however, says : " The cessation of the heart's 
 action is due to two distinct causes, acting on the 
 two sides, for on the right side it is the result of 
 
 * See Brodie' s Lectures on Physiology and Surgery, 
 f Taylor's Medical Jurisprudence, p. 634.
 
 BY HAXGI.NO. 9 
 
 over- distention of the walls of the ventricle, 
 owing to the accumnlation of venons blood, and 
 on the left to deficiency of the stimulus necessary 
 to excite the movement. The property of con- 
 tractility is not finally lost nearly as soon as the 
 movements cease, for the action of the right 
 ventricle may be renewed for some time after it 
 has ceased, by withdrawing a portion of its con- 
 tents, either through the pulmonary artery, their 
 natural channel, or more directly by an opening 
 made in its own parietes, in the auricle, or in the 
 jugular vein; or, on the other hand, the left 
 ventricle may be again set in action by renewing 
 its appropriate stimulus of arterial blood; hence, 
 if the stoppage of the circulation has not been of 
 too long a continuance, it may be renewed by 
 artificial respiration, for the replacement of car- 
 bonic acid by oxygen in the air cells of the 
 lungs restores the circulation through the ca- 
 pillaries, and thus, at the same time, relieves the 
 distention of the right ventricle, and conveys to 
 the left the due stimulus to its action."'* 
 
 Although in the third mode of death by hang- 
 ing, or that by apoplexy, the sudden compression 
 of the great bloodvessels of the neck cannot com- 
 pletely arrest the circulation of blood, inasmuch 
 as it cannot reach the vertebral vessels, yet, if 
 the pressure be sufficiently long and forcibly sus- 
 tained, it can, by delaying the return of blood 
 from the head to the heart, produce extreme 
 congestion of the cerebral vascular system, 
 which, as proved by post-mortem investigations, 
 may or may not be accompanied by extravasa- 
 
 * Carpenter's Physiology, page 545.
 
 10 ATTEMPTED SUICIDE 
 
 tion. As, however, in a considerable number of 
 the cases of attempted suicide by hanging, which 
 have recovered, no paralysis ensued, we have 
 some reason to conclude that in many cases the 
 apoplexy which results from compression of the 
 great bloodvessels of the neck is of the con- 
 gestive form, a point of considerable practical 
 importance, inasmuch as it is in that par- 
 ticular form of apoplexy that the voice of the 
 profession is in favour of bloodletting. 
 
 Compression of the important nerves of the 
 neck must necessarily be followed by injurious 
 results, although it may not act as a proximate 
 cause of death in these cases. Thus, J. J. 
 suffered from considerable distress from laryn- 
 geal cough for several days after the attempt at 
 suicide ; he likewise complained of a loss of sen- 
 sation in his jaws and ears, which was obvi- 
 ously ascribable to the forcible compression to 
 which the nerves of the neck were subjected 
 whilst the patient was in the siite of suspen- 
 sion. 
 
 Much of the success of the treatment of a case 
 of attempted suicide by hanging will depend on 
 the nature of the injuries inflicted, the period at 
 which assistance is procured, and a proper discri- 
 mination in the selection of remedial measures. 
 Thus, if the surgeon is summoned to a person 
 within a few minutes after he has suspended 
 himself, although the breathing may have com- 
 pletely stopped, yet, provided there is neither 
 dislocation nor fracture of the vertebrae, and conse- 
 quent injury of the medulla spinalis, animation 
 may, in many cases, be restored by an immediate 
 recourse to artificial respiration. Electricity, or
 
 BY HAXGIXG. 11 
 
 electro -galvanism, if within reach, ought at the 
 same time to be applied to the cardiac and spinal 
 regions; if, on the other hand, the patient is cut 
 down before respiration has ceased, and that 
 symptoms of congestion of the brain or apoplexy 
 should, as in J. J.'s case, present themselves, blood- 
 letting ought at once to be resorted to. Although, 
 as already stated, there is reason to believe that 
 the apoplexy which results from compression 
 of the great bloodvessels of the neck is fre- 
 quently of the congestive form, yet, as we 
 possess no infallible rule by which we can 
 positively pronounce, in these cases, whether 
 cerebral haemorrhage has taken place or not, 
 we should in every such case exercise as much 
 caution in the abstraction of blood as we would 
 in apoplexy from other causes ; here, as else- 
 where, we should, whilst endeavouring to re- 
 move congestion, or arrest haemorrhage, ever bear 
 in mind that the brain has suffered from a vio- 
 lent shock, for the repair of which the system 
 will require its best resources. 
 
 Much difference of opinion has existed both 
 as to the quantity of blood to be taken away 
 in cases of apoplexy, in which bleeding is in- 
 dicated, and as to the precise situation from 
 which the blood should be abstracted. The con- 
 dition of the pulse, and the effects of the with- 
 drawal of blood on it, will be the safest guides 
 as to the former ; with regard to the latter, we 
 generally select the temporal arteries, agreeing, 
 as we do, with Abercrombie, who, whilst treat- 
 ing on the subject, says : — " Much importance 
 has been attached to bleeding from the jugular 
 vein, as more likely to give immediate relief to
 
 1 2 ' ATTEMPTED SUICIDE BY HANGING. 
 
 the head ; but we must remember, that the only 
 jugular vein that can be opened is the external 
 jugular, which has little communication with 
 the brain, and, consequently, bleeding from it 
 is much inferior to bleeding from the temporal 
 artery."* The rapidity of relief from bleeding 
 was remarkable in the case of J. J., who, in all 
 human probability, is indebted for a prolongation 
 of his life to the lightness of his weight ; to the 
 shortness of his fall ; to the rope having been 
 adjusted round his larynx instead of his trachea, 
 whereby suffocation was delayed ; to his having 
 been detected soon after the act of suspension ; 
 and, finally, to timely bloodletting, by which 
 the congestion of the brain, under which he was 
 obviously sinking on admission to the hospital, 
 was speedily removed. 
 
 * Abercrombie on the Brain, page 289. 
 
 THE END. 
 
 Printed by J. M. O'Toole, 13, Hawkins'-street, Dublin.
 
 LACERATION OF THE UEETHEA 
 
 THE PERINEAL REGION: 
 
 CLINICAL OBSERVATIONS. 
 
 JAMES S. HUGHES, M.D., F.B.C.S.I. 
 
 DUBLIN : 
 
 PRINTED BY J. M. O'TOOLE, 13, HAWKINS'-STBEET. 
 
 1854.
 
 LACERATION OF THE URETHRA 
 
 THE PERINEAL REGION 
 
 D. ^XTI , aet. 36, a dairyman, of delicate 
 
 appearance, and very intemperate habits, was 
 admitted into Jervis-street Hospital, on the 19th 
 September. 
 
 The patient, on the previous evening, whilst 
 in a state of intoxication, ascended a ladder for 
 the purpose of mending a breakage in the roof 
 of his house, when, having lost his hold, he fell 
 from a considerable height to the ground on his 
 feet ; but having then staggered, he again fell 
 with his legs astride on the edge of a large mash 
 tub. On becoming somewhat sober, towards 
 morning, he found that he was bleeding pro- 
 fusely from the orifice of his urethra, and that his 
 scrotum and perineum were hot and swollen, 
 and of a dark, purplish colour. On endeavouring 
 then to pass water, he found that he was incapa- 
 ble of doing so ; in consequence of which, he con- 
 sulted a medical gentleman in his neighbourhood,
 
 4 LACEKATION OF THE URETHRA. 
 
 who tried to pass a catheter into the bladder, 
 but without success ; as the day advanced, the 
 desire to pass water became more and more 
 urgent, and, at three o'clock, he sought relief at 
 the hospital. The bladder was then felt distended, 
 reaching nearly to the umbilicus; there was a pro- 
 fuse flow of florid blood from the orifice of the 
 urethra, which had completely saturated the pa- 
 tient's clothes; the perineum felt hot, tense, and 
 full; there was a general ecchjmiosed appear- 
 ance of the scrotal and perineal regions ; the 
 patient appeared blanched from the loss of blood, 
 his extremities were cold, his pulse quick, weak, 
 and wiry ; he was in excruciating agony from the 
 constant and almost involuntary straining to 
 make water. 
 
 An ineffectual attempt having been made to 
 introduce an instrument into the bladder, owing 
 to the point of the catheter becoming arrested at 
 the seat of injury, I immediately had the patient 
 placed on the edge of a firm table, in the position 
 for the lateral operation for lithotomy, and having 
 introduced a full- sized catheter down to the lace- 
 rated portion of the canal, I then made a free 
 incision in the line of the raphe, through the in- 
 teguments and fasciae of the perineum, on the 
 point of the instrument. On turning out a quan- 
 tity of coagulated blood the lacerated urethra 
 Avas exposed to view, the canal being torn across 
 transversel} 7 ; a catheter was now introduced into 
 the bladder, when over a quart of stale ammonia- 
 cal urine was drawn off. The patient lost but 
 little blood during the operation. The catheter 
 having been secured in the bladder, the man was 
 placed in bed, and ordered a full opiate.
 
 LACERATION OF THE URETHRA. 
 
 On inquiring into the previous history of the 
 patient, it was ascertained that he had been in 
 hospital on a former occasion, labouring under a 
 diseased condition of the prostate gland, with 
 chronic inflammation of the lining membrane of 
 the bladder. 
 
 The instrument was retained in the bladder 
 for some days after the operation ; but irritability 
 of that organ, accompanied by constitutional dis- 
 turbance, having set in, the instrument was 
 immediately withdrawn, and the patient was 
 ordered hip baths, opiates, and mucilaginous 
 drinks. 
 
 On the sixth day after the operation, the pa- 
 tient was suddenly seized with profuse and re- 
 peated attacks of bleeding from the wound in 
 the perineum, which were, at once, in my una- 
 voidable absence, controlled by my colleague 
 on duty, Mr. Stapleton, by properly directed 
 pressure, and other suitable means. On the 
 seventh daj'-, the haemorrhage recurred, and as the 
 bleeding then appeared to proceed partly from 
 the bladder, and partly from the urethra, at the 
 seat of laceration, the pressure was reapplied, 
 and the patient was ordered large and frequently 
 repeated doses of gallic acid, which soon com- 
 pletely arrested the haemorrhage. 
 
 The patient is now rapidly improving in health 
 and appearance, the wound in the perineum is 
 nearly healed, and the irritability of the bladder 
 has so completely subsided, that the man has been 
 able to wear the instrument in the bladder for 
 several days past, without any inconvenience, 
 either local or general.
 
 6 LACEEATIOX OF THE URETHBA. 
 
 Observations. — Laceration of the urethra in 
 the perineal region is worthy of most serious 
 attention ; for, if the accident is not promptly 
 and judiciously treated immediately after its oc- 
 currence, it may and frequently has terminated 
 in the death of the patient. At a more distant 
 period, it may, if neglected, lay the foundation 
 of a most intractable form of stricture of the 
 urethra, which may, or may not, be accompa- 
 nied by a fistula in perineo. 
 
 Laceration of the urethra may be the result 
 of violence inflicted on that canal, either from 
 within, or from without. Rupture from within 
 is occasionally met with as a consequence of the 
 forcible and injudicious use of instruments, or, 
 as more rarely happens, it may be the result of 
 the impaction of a sharp urinary calculus in 
 the urethra; an opportunity of seeing such a 
 case, I was lately afforded by Dr. Symes, of 
 Kingstown. Laceration of the urethra from 
 external violence is, fortunately, not a very 
 common accident, even in hospital practice. It 
 is occasionally met with, as the result of a violent 
 kick in the perineum, a sudden tilting forward 
 of a horseman on the pommel of his saddle, or, 
 as in the case before us, by a fall from a height 
 on the perineum, against some resisting sub- 
 stance ; by any of which accidents, the iu*e- 
 thra may be either completely or partially di- 
 vided. The rupture may take place either in 
 the transverse or longitudinal direction; the 
 latter being the least common. 
 
 The urethra may be lacerated from within by 
 the abuse of instruments, in any part of its 
 course, from its orifice to the neck of the blad-
 
 LACERATION OF THE URETHRA. 7 
 
 der ; but when the laceration is the result of in- 
 jury inflicted from without on the perineum, 
 the rupture is usually situated in front of the 
 triangular ligament. Sometimes the bulb of the 
 urethra is completely cut across. 
 
 Laceration of the urethra in the perineal re- 
 gion, from external violence, may be met with 
 under two very different circumstances; thus, 
 the canal may be ruptured without a division of 
 the integuments or fascise of the perineum, as ex- 
 emplified in D. M'l 's case ; or, on the other 
 
 hand, the laceration of the urethra may be ac- 
 companied by a more or less extensive division 
 of the superficial parts. 
 
 Sometimes laceration of the urethra is the 
 result of fracture of the bones of the pelvis, 
 which, of course, adds considerably to the dan- 
 ger of the patient. At other times the bladder, 
 as well as the urethra, is ruptured, which is 
 usually a fatal accident. 
 
 The immediate danger to be apprehended in 
 laceration of the urethra is, infiltration of urine 
 into the surrounding structures. When a 
 wound of the perineum communicates freely 
 with a rupture of the urethra, then no lodg- 
 ment of urine is likely to take place, but if the 
 laceration of the urethra be unaccompanied by 
 an external opening, or should an opening 
 exist, which is narrow and valvular, then the 
 occurrence of extravasation of urine must be 
 anticipated. The following symptoms usually 
 denote the occurrence of laceration of the ure- 
 thra. "When the patient recovers from the first 
 shock of the accident, his attention is generally 
 first directed to a flow of blood from the orifice
 
 8 LACERATION OF THE URETHRA. 
 
 of the urethra. The loss of blood in these 
 cases varies from a few drops to several ounces ; 
 
 thus, in D. M'l 's case, the haemorrhage 
 
 was so profuse, as not only to saturate the pa- 
 tient's clothes, but likewise to give him quite 
 an anaemic appearance. The patient next, not 
 infrequently, observes a fulness in the perineum, 
 and experiences a sense of weight in that re- 
 gion, owing to effusion of blood into the cellu- 
 lar membrane of the part. A dark, purplish 
 discoloration of the scrotum is now often no- 
 ticed: all the foregoing symptoms were well 
 marked in the present case. If a patient should, 
 under the foregoing circumstances, have had 
 time to try to pass water before surgical assist- 
 ance shall have been procured, he will either 
 state that he was totally unable to empty his 
 bladder, or that, although he thought he had 
 succeeded, to his great alarm he only ob- 
 served a few drops, if any, to escape from the 
 orifice of his urethra ; and he will, probably, 
 further state, that immediately afterwards he 
 was seized with an intolerable scalding pain in 
 the perineum. 
 
 When a case of extensive laceration of the 
 urethra is unaccompanied by a wound of the in- 
 teguments, and that the patient has propelled 
 the contents of the bladder into the cellular mem- 
 brane at the seat of rupture, the urine will 
 first make its way into the cellular tissue in the 
 perineum ; but as the superficial fascia binds this 
 region posteriorly, the urine can only pass for- 
 wards and upwards, it consequently makes its 
 way into the cellular membrane of the scrotum 
 and penis, causing great distention of these parts;
 
 LACERATION OF THE URETHRA. 9 
 
 not infrequently, if the case goes oh uninter- 
 fered with, the mine ultimately makes its way 
 into the cellular membrane over the pubes and 
 in the groins : if such a case should continue 
 unrelieved by prompt surgical treatment, the in- 
 filtrated urine, acting as a deadly stimulant, will 
 excite unhealthy inflammation of the cellular 
 membrane, and mortification to the extent to 
 which the extravasated urine has reached. This 
 destructive process is accompanied by well- 
 marked local and constitutional symptoms, thus 
 the patient is seized with heat, throbbing, and 
 weight in the perineum and surrounding parts ; 
 the integuments of the scrotum become swollen, 
 the rugae being obliterated in a short time, the 
 skin of the affected part assumes a glassy hue, 
 and is pervaded by an erysipelatous blush, a 
 group of appearances which have unfortunately, 
 on more than one occasion, to my knowledge, 
 led inexperienced practitioners into the fatal 
 mistake of treating the patients for cedematous 
 erysipelas. If a case of the foregoing descrip- 
 tion should be still further neglected, the penis 
 will become enormously swollen, and twisted 
 near its extremity, the prepuce acquiring a semi- 
 transparent appearance; ultimately patches of 
 dark livid spots will form here and there on the 
 integuments of the penis and scrotum, nature 
 endeavouring, through the media of these sloughs, 
 to relieve herself from the infiltrated urine and 
 deadened cellular membrane. The destruction of 
 the tissues with which the urine comes in con- 
 tact is generally so extremely rapid, that unless 
 the surgeon is called in early, and conducts the 
 treatment of the case promptly and efficiently,
 
 10 LACERATION" OF THE URETHRA. 
 
 both in affording a free outlet for the urine al- 
 ready diffused, and at the same time takes the 
 necessary precautions to prevent its further ex- 
 travasation, the life of the patient maybe forfeited. 
 
 The constitutional symptoms, in cases of ex- 
 travasation of urine, are as well marked as the 
 local ; thus very soon after the accident the pa- 
 tient is seized with repeated and prolonged rigors, 
 ushering in a form of fever which soon assumes 
 the low typhoid character ; the pulse becomes 
 quick and wiry, the countenance wears a pecu- 
 liarly sunken aspect, the eyes become suffused, 
 and, if the case be unrelieved, the tongue will 
 become brown and dry, the pulse falters ; hiccup, 
 followed by low delirium, now sets in, and the 
 patient dies, either in a comatose condition, or 
 is carried off in a convulsion. 
 
 Although, as I have already stated, extensive 
 destruction and sloughing of the cellular mem- 
 brane, as a general rule, follow extravasation of 
 urine, cases have been recorded by Messrs. 
 Bellingham, Hargrave, Wilmot, and others, in 
 which, although extensive extravasation of 
 urine had existed for some time, only a trifling 
 amount of sloughing of the cellular membrane 
 took place; and in the case of rupture of the 
 urethra from impaction of a calculus which I, 
 not long since, saw with Dr. Symes, and to 
 which I have already alluded, although extrava- 
 sation had existed for nearly twenty-four hours 
 before the patient was first visited by Dr. Symes, 
 and although the urine had forced its way into 
 the cellular membrane of the scrotum, penis, and 
 groins, yet little sloughing of the cellular tissue 
 ensued. Whether in the latter case the youth
 
 LACEEATIOX OF THE rEETHEA. 11 
 
 of the patient, the previously healthy state of 
 the urinary organs, the less acrid condition of the 
 mine, and its freedom from alcohol, can account 
 for this comparative exemption from destruction 
 and subsequent sloughing of the cellular mem- 
 brane, are questions which here suggest them- 
 selves. 
 
 If, in extravasation of urine, the patient seeks 
 timely and proper assistance, his life may be pre- 
 served, and the destructive process may be ar- 
 rested ; thus I have seen, in more than one ap- 
 parently hopeless case, the patient rescued from 
 impending death by prompt and suitable treat- 
 ment. 
 
 In forming a prognosis in a case of laceration 
 of the urethra, we must not only take into con- 
 sideration the extent of the injury, the presence 
 or absence of extravasation of urine, the age, 
 constitution, and habits of life of the patient, but 
 likewise the condition of the urinary organs pre- 
 vious to the infliction of the injury ; thus in D. 
 
 31 'I 's case, we were very guarded in our 
 
 prognosis, in consequence of the patient having 
 been some time since in hospital, labouring under 
 disease of the prostate gland, and chronic in- 
 flammation of the bladder, and likewise on ac- 
 count of the man's intemperate habits. 
 
 I shall now consider the treatment to be 
 adopted in cases similar to that at present in 
 hospital, in which the laceration of the urethra 
 is unaccompanied by a division of the integu- 
 ments, and which has been followed by reten- 
 tion of urine. Obviously, the primary object of 
 the surgeon should be to pass a full- sized catheter 
 through the orifice of the urethra into the blad-
 
 12 LACERATION OF THE URETHRA. 
 
 der, and draw off whatever urine may be lodged 
 in the viscus : the introduction of the instrument 
 may, in such cases, be often facilitated by di- 
 recting the point of the catheter along the upper 
 surface of the urethra, by which means, if the 
 canal should have been lacerated on its inferior 
 surface only, we will, in general, succeed in 
 passing the instrument into the bladder : in cases 
 of this kind rude force would only add to the 
 dangerous position of the patient ; here delicacy 
 of touch, and lightness of hand, are indispensa- 
 ble qualifications on the part of the surgeon. 
 
 If the instrument has been passed into the 
 bladder, and there should be no evidence of 
 urine having been extravasated into the cellular 
 membrane of the perineum, or elsewhere, the 
 catheter must be retained in the bladder, with 
 the view of carrying off the urine directly from 
 that viscus, and thus preventing it from becom- 
 ing extravasated into the cellular tissue at the 
 seat of injury : here leechings to the perineum 
 may be called for, the patient must be closely 
 watched, to ascertain whether urine may be ex- 
 travasated or pus formed, and then, bat not till 
 then, are we, as a general rule, justified in 
 cutting down on the injured urethra. If, on the 
 other hand, there should be evidence of extrava- 
 sation of urine, we are imperatively called on to 
 make, without delay, a deep and sufficiently ex- 
 tensive incision through the integuments and 
 fascise of the perineum, to the seat of injury ; a 
 free outlet will thus be afforded for the urine 
 extravasated, and, at the same time, its further 
 infiltration prevented. The operation of the 
 perineal section should be conducted in the fol-
 
 LACERATION OF THE URETHRA. 13 
 
 lowing manner : — the patient having been placed 
 on a table, in the same position as for lithotomy, 
 the surgeon should pass a full-sized catheter 
 down to the injured portion of the urethra, where 
 it is to be held with steadiness by an assistant ; 
 the operator should then cut down through the 
 mesial line on the end of the instrument, and lay 
 bare the urethra ; the catheter is next earned on 
 into the bladder, and retained there by a suitable 
 apparatus. 
 
 In D. Ml 's case an attempt was made 
 
 to pass an instrument into the bladder, through 
 the orifice of the urethra, previous and subse- 
 quent to the patient's admission into the hospi- 
 tal, but without success, an occurrence which 
 not infrequently happens in these cases, from 
 displacement of the lacerated extremities of the 
 urethra, either from the deposition of coagulated 
 blood, or from muscular contraction. 
 
 If a case of laceration of the urethra should be 
 combined with a wound of the perineum, and 
 that an instrument cannot be passed from the 
 orifice of the m^ethra into the bladder, from either 
 of the preceding causes, if the patient be visited 
 soon after the infliction of the injivry, the distal 
 extremity of the urethra, at the wounded part, 
 can generally be discovered. Under such cir- 
 cumstances, the best method of managing the 
 catheter is as follows : — Having first introduced 
 it through the distal end of the urethra into the 
 bladder, next pass a probe from the orifice of the 
 canal down to the wound, by which means we 
 can readily conduct the top of the catheter 
 through the anterior part of the urethra, having 
 accomplished which, of course the probe is
 
 14 LACERATION OF THE URETHRA. 
 
 withdrawn, and the catheter retained in the 
 bladder. 
 
 In the treatment of laceration of the urethra, 
 complicated with infiltration of urine, after a ca- 
 theter has been passed into the bladder, and the 
 effused urine liberated by suitable incisions, the 
 constitutional treatment of the case must then be 
 attended to, mucilaginous drinks in small quanti- 
 ties will be here of service, and camphor mixture, 
 with opiates, frequently prove useful. When 
 the sloughs are detaching, the patient will require 
 to be supported by generous, light diet ; at this 
 stage preparations of bark, ammonia, &c, are in- 
 dicated. The best local applications, when the 
 sloughs are being detached, are poultices, either 
 simple or medicated ; in the advanced stages sti- 
 mulating applications, such as the Unguent. Elemi 
 Comp., are found most useful. In the subsequent 
 treatment of cases of lacerated urethra, it is ne- 
 cessary to pass an instrument, from time to time, 
 in order to keep the urethra free, one of the most 
 intractable forms of stricture of the urethra 
 being that which follows on a rupture of that 
 canal. 
 
 Authors recommend us to retain the cathe- 
 ter in the bladder, in cases of laceration of the 
 urethra combined with an external opening, until 
 the wound in the perineum shall have been com- 
 pletely healed; but, in the great majority of 
 cases, the presence of the instrument will, after 
 a longer or shorter time, excite irritation of the 
 bladder and constitutional disturbance, as oc- 
 curred in the case of D. M'l . Under such 
 
 circumstances, we must immediately withdraw 
 the catheter, and order the patient hip baths,
 
 IACEEATION OF THE T/EETHEA. 10 
 
 mucilaginous medicines, and opiates, either by 
 the mouth or rectum ; when, under this mode of 
 treatment, the irritability has perfectly sub- 
 sided, the patient may be in a position to again 
 tolerate the presence of the instrument, until the 
 wound in the perineum shall have healed. 
 
 If the patient is able to bear the continued 
 presence of an instrument in the bladder, it will 
 be necessary to change it every third or fourth 
 day, because in these cases catheters are liable to 
 become rapidly encrusted at their extremities, 
 and some instruments very soon give way under 
 the combined influences of heat and urine. 
 
 The haemorrhage which took place in M'l 's 
 
 case, on the sixth day after the injury, arose, in 
 all probability, partly from the artery of the bulb 
 having been involved in the sloughing process, 
 and also possibly from some vessels in connexion 
 with the diseased prostate gland, for the urine 
 expelled through the catheter in the bladder was 
 deeply laden with blood, and the haemorrhage, 
 which recurred on the seventh day, was not 
 completely arrested until the patient was placed 
 fully under the influence of gallic acid, at which 
 time the presence of the acid in the urine was 
 readily detected by the addition of any sesqui- 
 salt of iron. 
 
 THE EXD. 
 
 Printed by J. M. O'Toole, 13, Ha-wkins'-street.