NITRATE OF SILVER IN ERYSIPELAS. applied several times on the inflamed part and for two or three inches beyond the inflamed margin on the Bealthy skin. It requires to be applied very freely all over the scalp, where it scarcely or never produces vesication. In about twelve hours it will be seen if the solution has been well applied. If any inflamed spot be unaffected by it, it must be immediately re-applied to it. Sometimes even after the most decided application of the nitrate of silver the inflammation may spread, but it is then generally much less severe, and it is eventually checked by the repeated application of this remedy. I have in some cases of traumatic erysipelas, found the inflammation to spread more severely and more rapidly than in the idiopathic, but by the free repeated application of the nitrate of silver, it has at length been subdued. The following cases are selected to illustrate this mode of treatment :- CASE I. On the 6th of August, 1844, I visited Miss A., 20 years of age, of very delicate constitution, and of a strumous diathesis. She had been exposed to the rain, and had neglected to change her damp clothing. She experienced the common symptoms attending a cold, accompanied by a slight erysipelatous inflammation of the right side of the cheek and nose. The constitutional symptoms were so slight, and the pulse so little accelerated, that I wished to avoid the application of the nitrate of silver, thinking the inflammation might be subdued by other remedies. I directed thirty grains of ipecacuanha as an emetic, and in three hours after its operation two pills, containing three grains of chloride of mercury, and eight grains of the compound extract of colocynth, followed by a purgative of salts and senna, repeated every three hours until it had operated freely. 7th. Early the following morning, although the emetic and purgative had operated satisfactorily, she was labouring under a severe attack of fever; the pulse was 140, and the erysipelas had spread considerably on her face and forehead, and slightly on her scalp. I opened a vein in the arm, and bled her in the semi-recumbent position to the amount of twelve ouuces, when she became faint. Her head being shaved, the concentrated solution of the nitrate of silver was applied upon and beyond the whole of the inflamed surface, and also around the ears, to prevent them becoming inflamed. I applied it very freely over one half of the scalp, thinking this might be sufficient, as only a small portion of the forehead was affected. I prescribed two grains of the chloride of mercury, with two of antimonial powder, every six hours. There appeared no increase of the inflammation or the 8th, and the pulse, 120; the bowels had been well moved. 9th. She had a restless feverish night, attended with slight delirium, the pulse being 120. There was no increase of erysipelas on the face, but it was spreading on the remaining part of the scalp. I applied the 459 solution of the nitrate of silver over the remaining part of the scalp. Neither of the ears were in the least affected. The solution of the nitrate of silver had apparently formed a barrier, over which the erysipelas did not spread. On the 10th the patient was in every respect improving. From this time Miss A. recovered without interruption. CASE II. I visited Miss B., aged 30 years, on the evening of the 18th of December, 1843. She had been indispused several weeks. There were considerable fever, a quick pulse, and pain of the head, and she had a patch of erysipelas on the upper part of the nose, and a little across the lower part of the forehead. I prescribed an emetic of ipecacuanha, followed by a dose of chloride of mercury and compound extract of colocynth, and the sulphate of magnesia in infusion of senna. On the morning of the 19th, the erysipelas had spread all over the face, and as high as the forehead, close to the scalp, and there was no abatement of the constitutional symptoms. I bled her whilst sitting up in bed until she fainted, and directed the head to be shaved, and I then applied the solution of the nitrate of silver all over the face, and one half of the scalp. In the evening I applied the solution of the nitrate of silver over the remaining part of the scalp; having found that one ear had become inflamed, I applied the solution both upon it and around the other ear affected. 20th. The fever was considerably abated; the pulse was 100. From this day the patient was convalescent. CASE III. I visited Miss C., aged 20 years, on the 14th of September, 1844. She had a sense of coldness and pain of the limbs the day before; she had then a slight degree of erysipelas on the left side of the nose, cheek, and upper lip. I directed an emetic and pill, with the compound colocynth powder and chloride of mercury, followed by an active dose of infusion of senna and sulphate of magnesia. In the evening I found the erysipelas increased and spreading towards the ear; the lower eyelid was considerably swollen, but the erysipelas had not reached the forehead; pulse 100; no pain of the head. I applied the strong solution of the nitrate of silver all over the inflamed surface and the surrounding healthy skin for several inches, particularly around the ear. A grain and a half of chloride of mercury, with two grains of the antimonial powder, was given every six hours, and a saline effervescing medicine every three hours. 16th. The application had been effectual, and there was no increase of the erysipelas; the pulse was 80. CASE IV. Mr. J. S., aged 30 years, had slight febrile symptoms on the 11th of December, 1813, which arose from exposure to cold. He had taken aperients and saline medicines. Two days afterwards there was a patch of erysipelatous inflammation on the right side of the face, without any considerable increase of fever. The nitrate of silver was well applied on the inflained part, and on the surrounding skin. There was no further extension of erysipelas. It will be observed in the two last cases, when the nitrate of silver was promptly applied, before the erysipelas had produced severe constitutional symptoms, that the progress of the disease was instantly arrested, and that the patients speedily recovered. In the case of Miss B——————, although the erysipelas at first was suffered to proceed, the application of the nitrate of silver to the whole scalp prevented any cerebral affection, and the patient was convalescent in a short time. In the first case related there were restlessness and delirium fifteen hours after the application of the nitrate of silver, but it was observed that the scalp where the nitrate of silver had not been applied was inflamed, and on the decided application of the nitrate of silver on the whole of the scalp, the delirium ceased. From these cases, as well as from my experience of many years, I conclude that the speedy application of the nitrate of silver will arrest the progress of erysipelas, and prevent cerebral mischief. It is also of great practical importance to subdue erysipelatous inflammation in the commencement, for I have observed when the attacks have been severe, that the patients afterwards become more subject to a recurrence of the disease. kept unknown to us by the designation of lunar caustic, ON THE TREATMENT OF BURNS AND SCALDS. By CLEMENT CARLYON, M.D., Truro. number of the Provincial Medical and Surgical Journal, The paper of Dr. Payne, of Nottingham, in a late relative to the use of treacle as an application to burns, is borne out in all its recommendations, by my experience of an analogous mode of treatment. The main object appears to be the complete exclusion of the air from the scalded or burnt surface. The circumstance of a negro child, which bad fallen into a vessel of boiling molasses, having been snatched from death, and almost from suffering, by being immediately plunged into a heap of cotton, which adhered to every portion of the skin and thereby excluded all excess of air, is well known. The result was perfect recovery without the application of any further means whatever. So extraordinary a case drew the attention of the faculty to the modus operandi of the cotton. It was agreed that the total exclusion of air from the injured parts was the chief thing; and from that time (half a century ago) to the present, this has been, more or less, the governing principle in the treatment of fearful accidents. Where nothing better is at hand, powdering the parts thoroughly with flour has been found to answer well. Time out of and liniments, (such as oil and lime-water) in these cases; and they still continued to be extensively used, but their efficacy is far inferior to that of the agent recommended by Dr. Payne, or to that of clarified honey. The great obstacle to the general and free use of the nitrate of silver, even at the present day, appears to arise from the impression on the minds of many surgeons that it is a caustic-a destructive agent. If they could be divested of that idea, and use it as freely as they would a common blister of cantharides, their fears would soon subside, from repeatedly observing the safety of the application, and also its beneficial effects.ind it had been the practice to use neutral cerates In my own practice I have always considered it a safer remedy than cantharides, as it may be applied freely over a surface, even where very active inflammation exists, or where there is an extensive surface denuded of its cuticle. This remedy has also the advantage of not affecting the bladder, or producing strangury. The nitrate of silver is not a caustic in any sense of the word. It subdues inflammation, and induces resolution and the healing process. It preserves, and does not destroy, the part to which it is applied. If we compare a caustic, as the hydrate of potassa, with the nitrate of silver, we find that the bydrate of potassa destroys and induces a slough and the ulcerative process; but if we touch a part with the nitrate of silver, the eschar remains for a time, and then falls off, leaving the subsequent parts healed. Whenever the latter could be procured, I have invariably recommended it, smearing the scalded surface with it in a luke-warm state, and then covering the parts with cotton, cotton-wadding, or lint. I have had no experience of the use of treacle, but I have often said if honey be not at hand, use treacle. The fact is, that honey, even when clarified, which improves and facilitates its application, is of the two, the more perfect shield; and where the injury has been superficial, whether the cuticle has been removed or not, it may not even be necessary to repeat the application. After the application of the honey and cottonwadding, attention should invariably be directed to the If an ulcerated surface secreting pus be touched by the nitrate of silver, the succeeding discharge is imme-temperature of the part, so as to reduce it or raise it by the application of damp cloths and pledgets diately converted into lymph; it is the property of the of linen. bydrate of potassa, on the contrary, to induce not only ulceration but suppuration. In short, the peculiar properties of the nitrate of silver have long been In cases of no great severity this is all that will be required to be done; it being merely necessary to continue the covering till the total absence of pain and tenderness indicates a return to the healthy state. In any further suggestions from me, that the same *those dreadful cases, which are too frequently occurring, | practice is applicable to a variety of local affections, where the very powers of life are shaken and succumb, snch (e.g.) as ulcerated chilblains, &c., where the it must be obvious that so simple a mode of procedure affected parts are weak and irritable. would be unavailing. The treatment ought, of course, to vary with the attendant circumstances, regard being nevertheless had to the vast importance of protecting the injured parts as much as possible from the access of air. I was once desired to step into a cottage, by which I was passing, to see a child, four or five years Hospital Reports. ST. PANCRAS DISPENSARY. OF THE SYSTEM WHICH IS ACCOMPANIED By EDWARD BALLARD, M.D., Lond., Physician to of age, the lower half of whose person was literally CASES ILLUSTRATIVE OF THE CONDITION burnt to death; the skin was as bard as the hardest leather, from about the navel downwards, whilst all above had a natural appearance. There was no expression of uneasiness in the child's countenance, and to my astonishment, a bit of gingerbread was eaten readily and with apparent gratification. There was no perceptible pulse, no manner of chance of life being prolonged beyond a very brief period,she in fact lived for about an hour from the time I first saw her. It is evident that in this instance no application could bave done the least good; and between such cases and the mildest that occur, there will be an incalculable gradation. When particular methods of treatment therefore are recommended, regard must be had to the limits within which they can reasonably be expected to be of service. In all cases of breach of surface, from the most trifling abrasion of the cuticle, (to which the application of a bit of white-brown paper is better than any other,) to the most extensive ulceration, there is no indication of cure so important as that of the exclusion of air. In the course of a long continued practice, I have witnessed many cases of traumatic tetanus, but I do not recollect an instance where the precaution of keeping the wounded or ulcerated parts well together, and well covered and protected from the access of the external air, had been sufficiently attended to. Some years since, a good deal was written about the efficacy of the balsam of Peru, as an application to painful ulcers, and to parts approaching to a state of mortification; such, for instance, as Pott's well known eases of mortifying extremities. It is to that eminent surgeon we were first indebted for the substitution of a lenient mode of treatment for severe measures in 'these cases, which are often dependent on irremediable causes, and admit only of palliative treatment. But 1 bave seen, again and again, most surprising benefit to arise from anointing the parts, even when extensively discoloured, and almost black, with clarified honey; carefully covering them, when so anointed, with folds of cotton-wadding, and placing them in the easiest 'possible position. The inunction will require to be repeated at intervals of one or more days; and the * greatest care must be taken to envelope the parts well with the cotton. By this simple mode of treatment the living colour has returned, and the parts bave been preserved under circumstances which were deemed hopeless. In such cases the balsam of Peru might be too stimulant; but, if honey were not at hand, I would recommend treacle as its substitute. CASE VI.-CHRONIC RHEUMATISM. A. L., aged 28 years, presenting no hereditary tendency whatever to disease, has been married nine years, and in that time has had four children and one miscarriage. She nursed her two first children from eighteen months to two years, and has had one at her breast now for more than a twelvemonth; applied at the Dispensary on the 18th of June, 1816. It appears that for more than two years she has been the subject of painful swelling of the small joints of the hands and feet. Her illness commenced shortly after the birth of her third child, in consequence of exposure to the draughts of air and dampness of a washhouse, with pains in all the joints, large and small, of a severe kind, but without any redness or swelling, and without any febrile disturbance. As these pains left her, the small joints of the hands began one by one to be affected with pain, redness and swelling; and from time to time the metatarso-phalangal joints of the feet became similarly affected. At present all the smaller joints of the hands and the metatarso-phalangal joints of the feet are painful, tender, and swollen; in those of the hands which have been more recently affected there is mobility, with redness and more or less fluctuation, while those which have been longest affected are incapable of being fully extended are not red, and do not appear to contain fluid, but are heard to crack on being freely moved. The heels are also tender and painful, the wrists and ankles swollen and painful, but not red; and there are pain and tenderness in the legs, knees, thighs, hips, arms, elbows, and shoulders. All these pains are relieved by warmth. She feels languid and weak, and is frequently chilly in the mornings. Has occasional pain across the loins; her appetite is defective, but there is very little thirst; bowels open; tongue presents a slight whitish fur; pulse 95; small and weak; urine full-coloured, acid, specific gravity 1031, rather cloudy, with a moderate cloud-like sediment, consisting almost entirely of octobedra, some of them being very minute. No albumen. Ordered to wean her infant. R. Potassii Bromidi, gr. iij.; Inf. Calumbæ, oz. iss. Fiat haust. quartis horis sumend. 25th. Pain considerably improved, has put on her boots this morning which she has not been able It will occur to the experienced practitioner, without to do for the last fortnight. Urine four pints in the last twenty-four hours, pale, acid, specific gaavity 1015, containing no octobedra. The Bromide of Potassium has been increased to five grains. June 30th. Was exposed to a draught on the 27th, and since then has suffered from headache, tenderness of the scalp, and increase of all her pains, but does not feel so languid in the mornings. Auge Potassii Bromidum, ad gr. viij. Remarks.-Rheumatism, especially chronic rheumstism, and still more particularly that form of it which manifests its alliance to gout, by attacking the small | joints in preference to the large ones, is not commonly met with in persons previously in robust health, but apparently requires for its development a constitutional predisposition, derived from hereditary or chronic debilitating causes. Perhaps it is for this reason that July 1st. Urine passed this morning, specific gravity chronic rheumatism is so difficult to deal with, and 1025, contains an abundance of octohedra. 8th. No improvement; urine of specific gravity 1025, contains very few octohedra. Omit. Med. R. Potassii Iodidi, gr. v.'; Inf. Calumbæ, oz. iss,, ter die sumend. 14th. Much the same'; urine in all respects as on the 8th. Auge Potas. Iod., ad gr. viij. 24th. Pains have not been any better; urine has ap to this time been of lower specific gravity, that of the last twenty-four hours 1019; octohedra remain small and few. Omit. Med. R. Vini Colchicí, m.xx.; Aq. Menth. Pip. oz. iss. Fiat haust ter die samend. 29th. Has not improved so far as the extremities are concerned, but there has been less pain in the head. Urine of last twenty-four hours, four pints, cloudy, with a cloud-like deposit occupying one-third of its bulk, specific gravity 1029, re-action very acid. The deposit contained an abundance of moderately large octohedra. Auge Vin. Colchici, ad dr. ss. frequently so little under the influence of remedial agencies. Perhaps it is on this account also that oxalate of lime, though by no means constantly excreted with the urine, is so, not uncommonly, during its progress. Chronie rheumatism is familiar to every one as a sequel of the acute, but it may also be chronic from the first; in other words, there may be no febrile disturbance to mark its origin, and the only perceptible ailment may be debility, conjoined with the local dis ease. An example of this most cbstinate and intractable form is displayed in the case before us. The patient attributed her illness to the operation of cold and wet, which no doubt co-operated with the tendency derived from the debilitating influence of over-lactation, &c., in the production of the disease. She appeared to be benefitted at first by the administration of the bromide of potassium; but this, as well as the iodide, failed to give relief when her complaint was exaggerated by renewed exposure. Colchicum produced more permanent relief, and its full effect was followed not by a diminution, but by a remarkable increase of the oxalic deposits. Whether the less violent operation of that medicine had any thing to do with the ultimate disap20th. Medicine purged her from the 14th to the 18th,pearance of the oxalate from the urine, I may be perand from this time the pain became less violent and the headache ceased. Urine of last twenty-four hours cloudy, with a cloudy deposit, containing an abundance of octohedra some very large, some aggregated; re-action acid, specific gravity 1030. Omit medicine. August 10th. Finds her general health improved, and with the exception of the arms the pains are all better. Head and eyes were very painful yesterday. Urine contains very few octohedra. Auge Vin. Colchici, ad m. xlv. 25th. The arms have have been more painful since the omission of the medicine; has taken a fresh cold and has suffered a febrile attack with headache and vomiting. Urine contained abundance of octobedra as before, with a slight excess of lithate of ammonia. To resume medicine, with Vin. Colch., dr. ss. September 7th. Pains have been less for the last week. The urine of the 4th was of specific gravity 1016, and contained only a few octohedra, 11th. Has had no medicine since last report, and pains have been worse. No octohedra in this morning's urine. Oct. 13th. Has been very little better up to this date, but is improved in general strength. The urine examined from time to time was found to contain no octohedra. Contin. haust; R. Tinct. Aconite, oz. ss; Linim. Saponis, oz. iss. Fiat Linim. partibus dol. infric. 29th. Finds relief from the use of the liniment; suffered for the last week from rheumatic pains affecting the side of face and jaw; general health improved; urine of this morning of natural colour, with a moderate very light cloud at the bottom, consisting of an abundance of octahedra; re-action strongly acid; specific gravity, 1023. Discharged. mitted to doubt, in consequence of having observed CASE VII.-LUMBAGO. C. B., aged 63 years, by occupation a charwoman, badly off in her circumstances, and unable to procure a sufficiently nutritious diet, applied at the Dispensary on August 18th, 1846. She states that three weeks ago she did an unusually hard day's work, connected with much stooping, the windows of the rooms being constantly open. The following night she had no sleep, and in the morning was attacked with pain of TREATMENT OF UNION MEDICAL OFFICERS a shooting character through the loins, extending down the back part of the thighs to the calves of the legs. She never suffered from rheumatism before. At the present time the pain is limited to the loins and calves of the legs; is worse by day than by night, appearing to be relieved by the warmth of the bed. It gives her great pain to stoop or raise herself from the stooping posture. There is some tenderness in the loins, and that part is copiously perspiring. She is pale, weak, and desponding; the only feverish symptom which she has is a sense of heat in the palm of the hands, and over the abdomen. She has lost her appetite, and ber bowels are habitually costive. Three days -ago ́she had some watery sour eructations for the first time in her life. She states that her urine is scanty, but not opake. Ordered R. Calomel, gr. iij; Pulv. Zingib., gr. ij.; Palv. Jalapæ, gr. xv.; Fiat pulv. statim sumend! R. Beeberinæ Sulph., gr. v.; Ext. Gent., q. s., pro pil ter die sumend. 25th. The lumbar pains she considers more severe, but those in the calves have disappeared. She gots her feet wet two days after I saw her, and has suffered 463 Remarks.-I would direct attention here to the seat which the rheumatism occupied in reference to the ordinary employments in which she was engaged. The stooping posture, predisposed to lumbago, rather than articular rheumatism, on exposure to an exciting cause on the principle which hospital practice frequently illustrates that, parts which are most exerted are commonly those first or even solely attacked with the disease, or at any rate they are those which suffers from it most severely. I have seen this illustrated in the University College Hospital, in the case of the upper extremities being preferred by the disease to the lower, or one arm selected by it rather than the other. Dr. Williams notices the same phenomenon in his valuable work on the "Principles of Medicine," referring it with great probability to the retention of some of the products of the transformation of the muscular textures, the elimination of which the system frequently attempts, as in the present case, by the establishment of local Sweats. PROVINCIAL from coryza and cough since. Appetite is improving Medical & Surgical Journal. * and there has been no return of the eructations; bowels have been freely purged. Continue pil.; Omni nocte sumat Pil. Rhei. Co., gr. x.; Applic.. Empl. Picis lumbis. Sept. 1st. The lumbar pain has been very severe, but is much less so now; catarrh is lessening; states that her urine has been very high coloured; bowels insufficiently acted on. Repet, Palv. Cathartic, alternis diebus. Contin. Pil. Bebeerinæ. 4th. Considers herself stronger; catarrh has not beat quite disappeared; lumbar pains distinctly less and less constant; urine passed this morning cloudy, but rather high coloured, depositing a very abundant dense fawn-coloured sediment; specific gravity, 1026; reaction acid; no albumen. The deposit consists of lithate of ammonia, entangling and concealing an abundance of octohedra, of large size, both separate and aggregated, which became obvious on warming it. Continue Pulv. Cathartic and Pil. 8th. Still some lumbar pain remaining. Two days ago vomited some watery matter after eating some fat food; bowels not sufficiently acted upon. Continue Pil. Bebeerinæ. R. Olei. Crotonis gtt., ij.; Mice panis q. s. pro, pil., viij.; Capt. j., omni nocte. 11th. Bowels act regularly twice a-day; lumbar pains disappearing; some cough remaining still; urine has not been opake since the specimen examined on the 4th; that passed this morning is rather pale, slightly cloudy, and presents a slight cloud-like deposit, which contains some circular thin plates, with concentric markings, but no octohedra ; specific gravity 1011. 15th. Has no pain worth mentioning, but is still low-spirited; bowels act once daily; urine contains no oxalates or other saline deposit. 18th. Is much stronger, and can walk with much less fatigue; is less low-spirited, and complains only of slight weakness of the ankles; appetite improving; bowels regular; urine presents no oxalates or other saline deposit-Discharged. WEDNESDAY, AUGUST 25, 1847. The proceedings at the Anniversary Meeting of the Provincial Medical and Surgical Association at Derby, were highly satisfactory, and in reference to several subjects of importance to the welfare of the Association, presented features of considerable interest. Upon some of these we shall hereafter find opportunity to enlarge, but on the present occasion we are more particularly desirous of directing attention to that part of the proceedings which has reference to the treatment of the Medical Officers of Poor-Law Unions. The subject was, on this occasion, formally introduced to the notice of the Association by a deputation from a meeting of gentlemen holding these appointments, which had recently been held at Matlock Bath, and the resolutions passed at that meeting, on the question of the remuneration of the Union Medical Officers for their services, and the treatment experienced by them from the Poor-Law authorities, were read and ably supported by Mr. Cantrell and Mr. Tasker, two of the deputation The statements of these gentlemen were listened to with deep interest, and evidently made a considerable impression, calling forth the sympathies, not only of those who had suffered or were suffering under like indignities and injustice, but also, we believe, of almost every gentleman present. The response which was made to this statement by Mr. Douglas Fox, Dr. Conolly, Dr. Hodgkin, Dr. Hutchinson, and other gentlemen, though not themselves personally interested in the subject, yet of the highest reputation for genuine benevolence, and |