surgeon will hesitate for an instant to make bold incisions.

Dr. Macfarlane offers some remarks on the comparative advantages of large and small ones.

"I have attempted, in several cases, to contrast the practice of Mr. Hutchison, who makes a number of small incisions into the affected parts, with that of Mr. Lawrence, who recommends one or two long incisions to be made in a direct line through the middle of the inflamed surface. When the disease extends over an entire extremity, and the tension is uniformly diffused, and so great as to indicate an affection of the subfacial cellular texture, I have experienced more benefit from one or two long incisions, than from smaller and more numerous ones. But when the disease is exterior to the fascia, as most frequently happens, and there exists an unequal degree of swelling and tension in different parts of the affected surface, at some distance from, and not in a direct line with, each other, indicating the presence of gangrene or suppuration, in circumscribed portions of the cellular texture, one or two long incisions have not appeared to me to be so successful in either relieving the urgent symptoms, or checking the progress of the disease, as making a number of small cuts into those detached and distant parts of the inflamed extremity in which the swelling and tension predominate."

This is judicious advice, and we know not that we could usefully add to it. It is evident that on this, as on other occasions, the dispute has been carried to extremes, and that circumstances must regulate the length, as well as the situation of incisions. We must say that in general one free incision is better than two or three imperfect ones, but a cut of more than a certain length becomes of itself a serious complaint.We repeat that the management of the individual case must be left to the discretion of the surgeon.

"M. O., æt. forty-six, when admitted on the 6th May, 1826, had the right side of the face affected with an erysipelatous inflammation of a dull red colour, which had commenced three days previously on the right cheek, where the cuticle had been accidentally abraded. He was a dissipated and debilitated subject; his pulse was one hundred and twenty, and feeble; the tongue dry and furred; but the skin was cool, and the functions of the sensorium undisturbed. The affected parts were covered with flour, and, after opening the bowels by a mild purgative, two grains of the sulphate of quina were ordered every six hours in an ounce of wine.

On the 8th, the disease had extended over the scalp to the opposite side; the pulse was more rapid and feeble; the pupils contracted and irritable; the tongue typhoid; and there was hiccup, with low muttering delirium and drowsiness. The wine was increased, small doses of the carbonas ammoniæ prescribed, and the quinine continued. In five days the inflammation had ceased to spread; the cuticle desquamated; his strength improved; and he was dismissed on the 28th."

This case displays a feature which is not uncommon. A patient with erysipelas is apt to become low in a sudden manner. On one day the symptoms are scarcely alarming-on the next, they may wear the worst characters of typhus. It is the anticipation of this rapid depression that constitutes a great part of the surgeon's tact in the treatment of this disease. He must learn to distinguish when the pulse is beginning to falter, when the tint of the erysipelas is altering or waning, when the constitution is tired of its efforts. Unless he can do this he will probably lose many patients during his career. The following case may afford some illustra tion of these remarks.

CASE 2. Fatal Erysipelas.

"M. F., æt. 8, had been in the In

cases.

CASE 1. Erysipelas of the Face, treated by Stimulants and Tonics.

quence of an ulcer on the abdomen, between the pubes and umbilicus, which had nearly healed, when erysipelas commenced on the surrounding

integuments, on the 1st of July, 1826. The disease extended rapidly over the abdomen, front and sides of the chest, neck, shoulders, and arms, and the affected parts were hot, painful, of a bright red colour, and, in some places vesicated. Vomiting and purging were produced by the emeto-cathartic mixture; a few leeches were applied, and afterwards a tepid spirit lotion. On the 2d, she was delirious; the inflammation was extending; the tongue was typhoid; the pulse was rapid and feeble; and the prostration of strength more decided. Wine, quina, and carbonas ammonia were ordered; and, during a continuance of the tonic treatment, the inflammation lost its vivid red colour, and ceased to extend. Her strength, however, decreased rapidly; vomiting and hiccup supervened; she became comatose, and died during the night of the 5th, with all the symptoms of typhus gravior.

The only morbid appearances discoverable on dissection, were superficial and deep-seated congestion of the brain, with a slight effusion of serum under the arachnoid.

We here see how rapidly prostration supervened-how feeble were the powers of medicine when it had occurred. Let not the young practitioner be rashly tempted into active antiphlogistic treatment in the early stage of erysipelas. He may repent,it.

CASE 3. Phlegmonous Erysipelas of the Arm-cured by Incisions.

arm,

A. R., æt. 49; when admitted on the 3d of February, 1832, his left arm, foreand hand, were greatly swollen, tense, and of a dark red colour, the disease having commenced six days previously without any known cause. The affected parts were hot and painful; there were several large vesications on the inner side of the fore arm, which contained milky serum and greenishcoloured lymph, and on the outer side, in one or two places, obscure fluctuation was perceptible. Four incisions were made through the skin and cellular membrane of the fore arm, (two of these were five inches, and the others

two and a half inches in length,) and gave exit to a small quantity of pus. The divided integuments retracted considerably, and the tumid cellular substance, which had a red appearance, bulged out at the incisions. Immediate ease was obtained; the inflammatory appearances and constitutional excitement diminished rapidly; and when the bleeding had stopped, which amounted to twelve ounces, oiled lint was applied to the incisions, and the arm covered with a tepid spirit lotion. In a few days resinous ointment was substituted, and a bandage applied, under which the parts continued to heal slowly.

We have only room for allusion to another subject, erysipelas of the scalp.

During

"When erysipelas affects the head, the skin, and subjacent cellular texture are the parts generally affected, and the ordinary antiphlogistic means seldom fail in removing it. But when the disease is seated under the aponeurosis, diffuse suppuration and sloughing are speedily produced, unless prevented by the free and timeous use of incisions. I have seen more than once the neglect of this treatment prove fatal. the Summer of 1826, a robust labourer was admitted into the Infirmary under my care, several days after an attack of phlegmonous erysipelas of the scalp had terminated in extensive suppuration. The head was enormously swollen; the scalp, which was ulcerated in various points, had a spongy or boggy feel, and was completely detached from the skull. Although incisions were employed to favour the escape of matter and the separation of sloughs, nearly the whole integuments of the head were destroyed by ulceration, and the patient died in a few days from effusion on the brain."

In a former number of this Journal we gave a very full report on erysipelas of the head and face, and on diffuse inflammation of the cellular tissue beneath the aponeurosis of the occipitofrontalis muscles. In that report will be found an attempt at pointing out the distinctive marks of this serious affection, and cases illustrative of the value

of incisions. This is a subject of the utmost practical importance. We shall copy one case from Dr. Macfarlane.

Case 4. "A. C. æt. 38, received a small puncture-wound over the middle of the left parietal bone, on the 7th of February, 1827, and on the 10th he was admitted into the Infirmary. There was a slight blush of redness around the wound, which appeared to be suppurating, and the integuments of the left side of the head were greatly swollen, painful and oedematous. He complained acutely of pain and throbbing in the head; the pulse was 108, and strong; the tongue furred, but moist; the skin hot and dry. He was immediately bled to twenty ounces; twentyfour leeches were applied to the left side of the head, followed by a cold lotion; and free vomiting and purging was produced by the emeto-cathartic solution. On the 11th the disease had extended to the right side and fore-head; the swelling and pain had greatly increased, and the general disturbance was aggravated. Notwithstanding a repetition of the leeching, with frequent doses of calomel and James's powder, the progress of the disease was not arrested. On the 12th, the whole scalp was involved, and the integuments, although little discovered, were mously swollen,and pitted on pressure. As, besides the affection of the subcutaneous cellular tissue, there was also present a considerable tumefaction of the parts under the aponeurosis; and as the ordinary antiphlogistic means had failed in controlling the disease, I made six incisions into the scalp, in various points, each being about two inches in length, and carried through the aponeurosis. Sixteen ounces of blood, apparently arterial, were lost; the pain was immediately relieved, and the swelling diminished rapidly. For several days there was considerable discharge from the wounds, but no sloughing of the exposed cellular substance took place. He left the hospital, quite recovered, on the 2d of March."

enor

In conclusion we may hint some deficiences in this report. The varieties of erysipelas might have been discrimi

nated with more precision-the progress of the disease, and the characters requiring alterations in the treatment might have been more pointedly described the distinction between the ordinary erysipelas and diffuse inflammation of the cellular tissue might have been an useful subject of allusion. We certainly think that so practical a surgeon as Dr. Macfarlane might have remedied these deficiencies even in a report. Yet still we are pleased to find that he has adopted such judicious views, and recommended such appropriate treatment.

BIRMINGHAM EYE INFIRMARY.

REPORT FOR THE YEAR 1833. By Mr.

MIDDLEMORE, Assistant-Surgeon.*

The following numerical statement displays the relative frequency of various affections of the eye; amongst the poorer classes in Birmingham,and probably in most great towns.

Simple acute conjunctivitis, 230. (a) Chronic conjunctivitis, 112. Acute conjunctivitis, with pustules on the conjunctiva, 123. Acute conjunctivitis, with pustule or ulcer on the cornea, 124. Acute conjunctivitis,with puriform secretion, 87. Purulent conjunctivitis of newly-born infants, 41. Irritable conjunctivitis, 44. Strumous conjunctivitis, 70. Pterygium, 7. Corneitis, 13. Vascularity of the cornea, 11. Opacity of the cornea, 149. Conical cornea, 5. (b) Staphyloma of the cornea, 12. Impaction of foreign bodies in the cornea 17. Simple acute sclerotitis, 4. (c) Rheumatic sclerotitis, 11. Staphyloma of the sclerotica, 4. Morbid attenuation of the sclerotica, without distinctly-formed staphyloma, 3. Affections of the membrane of the aqueous humour 14. Simple acute iritis, with or without ulcer or opacity of the cornea, onyx, or hypopion, 47. Chronic iritis, 9. Syphilitic iritis, 6. Strumous iritis, 7. Prolapse of the iris, 6.

Provincial Transactions, Vol. II.

Fungus from the iris, 5. Vacillation of the iris, 5. Cataract, 17. (d) Dislocation of the lens, 15. Choroiditis, 7. Retinitis, 2. Glaucoma, 4. (e) Hydrophthalmia, 2. Suppuration of the eye-ball, 7. Atrophy of the eye-ball, 3. Fungoid, and various anomalous tumors of eye-ball, 4. Neuralgia of the eye-ball, 7. Oscillation of the eyeball, 5. Amaurosis of various kinds and degrees, 100. Diseases of the lachrymal passages, 19. Epiphora, 14. Strabismus, 8. Tinea, 105. Lippitudo, 12. Hordeolum, 5. Ectropium, 3. Entropium, 6. Inflammation of the eye-lids, 16. Edema of the eyelids, 9. Ulceration of the eye-lids, 6. Ptosis, 4. Adhesion of the eye-lid of the globe, 3. (f) Tumours in the eyelids, 27. Wound of the eye-ball and its appendages, 42."

CHANGES IN THE TARSAL CARTILAGES.

Mr. Middlemore alludes to a fact which he has observed that obstinate chronic inflammation of the conjunctiva occasionally depends on a morbid state of the tarsal cartilages. Surgeons should be familiar with the fact, in order to avoid the liability to error in forming their prognosis.

"Several obstinate cases of chronic inflammation of the conjunctiva, depended on a shrivelled, uneven, an irregularly ossified state of the tarsal cartilage, and, although not absolutely curable, were yet capable of considerable alleviation by appropriate treatment. In very old persons, changes, in the figure, the size, the consistence, and other characters of the tarsal cartilage,frequently take place, and, among these alterations, the undue incurvation of its extremities, or a shrivelling of its texture, with the deposition of specks of ossific matter, are the most common; and, of course, any material irregularity of surface or change of figure it may undergo, will influence the surface and condition of the palpebral conjunctiva which covers it, and produce certain effects upon the eye, correspondent, in their extent, to the changes the conjunctiva may have sustained.

In a case of tumour of the eyelid which I recently attempted to remove, I was surprised to find that it consisted of a mass of cartilaginous matter, deposited upon the cutaneous aspect of the tarsal cartilage; it was, in fact, nothing more than a great and irregular enlargement of that part."

STAPHYLOMA.

Mr. Middlemore recommends an ope ration for staphyloma, which he has now practised for many years. It is only a slight modification of the prac tice recommended by Scarpa, Guthrie, and others for some forms of the disease, but Mr. Middlemore considers its applicability more extensive, than they would appear to have done. He relates a case in illustration of his opinion and advice.

Case. Sarah Mace, æt. 20, has a large spherical staphyloma of the left cornea, consequent on an attack of gonorrhoeal ophthalmia. The diseased eye-ball is somewhat inflamed, and the opposite eye is in a very irritable state.

66

Having placed her upon a table as for the operation of extraction, I introduced Beer's knife, at about an equal distance from the summit and base of the staphyloma, and brought out its point at a corresponding situation on the opposite side, and by gently urging the knife forward, a small semicircular flap was formed, which was immediately removed by the convex-bladed scissors, by an incision which constituted, as respects its outline, a portion of morbid cornea, of an equal size, and of the same form. The lids were then carefully closed, and a roller so applied, as to keep them in apposition with the globe.

The operation cccasioned very little pain; no bad symptom followed its performance, and in the course of a few days the opening in the cornea had closed, chiefly by the adhesion of its edges to a small portion of lymph in the centre. As this lymph became absorbed, the part diminished in magnitude, and at the present time, the previously staphylomatous eye is smaller

than the opposite and healthy globe, which is partly owing to the partial absorption of the morbid cornea, a circumstance which generally takes place when a portion has been removed from its centre for the cure of staphyloma."

Where the eye-ball is much enlarged, and the divided edges lie widely apart, it is better to bring them into contact, for the purpose of preventing the reproduction of the malady, of obviating the occurrence of acute inflammation

of the exposed interior of the eye-ball, and, also, of diminishing the risk of staphyloma, which is apt to occur if the interior of the globe becomes filled with fresh secretion, before the matter

of reparation possesses a sufficient degree of firmness to resist the pressure from within.

RHEUMATIC SCLEROTITIS.

The real nature of this disease is of ten overlooked, and its progress is consequently unchecked. If the inflammation is obstinate, the pain intense, and somewhat periodical, the eye-ball not being particularly vascular, and the deep-seated textures being unaffected with evident acute inflammation, Mr. Middlemore is in the habit of employing the following treatment, with suc

cess.

An active cathartic is first prescribed, and, afterwards, a few grains of calomel and Dover's powder, to be taken every night at bed time, and three or four grains of quinine about thrice daily. A small quantity of the strong mercurial ointment, blended with a grain of opium, is directed to be rubbed above the eye-brow, about the situation of the supra-orbitary nerve, every evening, if the pain in the eye-ball and orbit is intensely severe. If this plan fails to afford much relief, half a drachm of the wine of colchicum is directed to be taken thrice daily, and two pills are given in the evening, consisting of five grains of blue-pill, and six of the extract of conium. By these means, with the aid of fomentations, Mr. Middlemore is seldom foiled in his treatment of the complaint,

DISLOCATION OF THE LENS.

Passing over some remarks of Mr. Middlemore's, we may state that it is his object to point out the general mode of practice adapted for the relief of the more common cases of this affection.

An adult patient, perhaps, presents himself at the Infirmary, who, after sustaining a severe fall upon the head or concussion of the body, or after some violent straining effort, may have perceived a dimness of vision, and uneaball. On carefully examining such an siness and inflammation of the eyeeye, it will, very probably, be found that the lens is slightly opaque, that it is pressed, but not forcibly, against the iris; and that there is some degree of external ophthalmia, with a slight zonular arrangement of vessels around the cornea. In such a case, different surgeons would pursue different methods of treatment. Some would directly remove the lens-others would merely resort to measures for the relief of the inflammation-and others would then extract or break up the lens. For diminish the inflammation first, and reasons into which we need not enter, and many of which will be obvious to those acquainted with ophthalmic surgery, Mr. Middlemore recommends the

last-mentioned mode of treatment-the subduing of the immediate acute sympthe lens, if it has not been absorbed, toms, and the subsequent removal of and if it constitutes an adequate personal deformity, or continues to augment the severity or prolong the exist

ence of inflammation.

If the dislocation of the lens is asso

ciated with a blow on, or wound of, the eye, then the nature of that injury

must be taken into consideration. Mr. M. believes that, as a general rule, it would be useless and injurious, in such circumstances, to attempt the extraction of the lens. The dislocation of the lens, and the inflamed condition of

"The dimness of vision may, of course, depend on concussion of the retina, and may not be owing to the displacement of the crystalline."