onward small quantities of chloral were injected, and the patient progressively improved to perfect recovery. In commenting on this case, Surgeon-Major Hall calls attention to the fact that a resonant sound was emitted by the usual area of cardiac dulness, and that the sounds of the heart were almost entirely absent; and he thinks that at the commencement of an attack the contractions of the heart become more forcible, the calibre of the arteries becomes smaller, and there is generally increased arterial tension, probably caused by excessive stimulation of the vasomotor centre. As the cold stage becomes intensified there is almost a continuous systole, no time being allowed for diastole. The absence of the pulse at the wrist is due, therefore, to an opposite cause than in syncope, the vessels and the heart being alike intensely contracted. Acting on this theory, he maintains that stimulants, useful in syncope when the heart is flaccid and relaxed, are harmful in cholera. The treatment he recommends is that all premonitory diarrhoea should be stopped with gingerade made with sulphuric acid, which last should be taken in halfdrachm to one-drachm doses. No alcohol or opium should be given, but plenty of iced water; and chloral injections into the muscles should be at once commenced; nourishing soups may after a time be given, and if secondary fever follow, quinine may be administered.-(British Medical Journal, Sept. 21, 1878.)-Practitioner, October, 1878.

SCARLATINA FOLLOWING SURGICAL OPERATIONS.

J. W. M.

To the London Medical Record for October 15, 1878, Dr. T. F. Chavasse contributes a full abstract of an interesting lecture on the above subject, which appeared in Le Progrès Médical, September 14, 1878. The author of the lecture, M. Trélat, narrates two cases in which a very abrupt eruptive fever, having all the characters of scarlatina, appeared on the day following an operation-the patients having previously presented nothing abnormal. This was not a mere coincidence or chance, for—as M. Trélat shows-this sequence of scarlatina upon surgical operations has been often noticed and recorded. In 1858, M. Germain Sée, after a tracheotomy, noticed an eruption closely allied to scarlatina. In 1864, in a communication to the Pathological Society of London, Mr. Maunder stated that he had seen scarlatina supervene after two lithotomies had been performed upon children. The discussion which followed brought to light a certain number of similar facts. Dr. Broadbent had seen three cases; Dr. Crisp, a fatal case after circumcision; Mr. Callender, a case after lithotomy; Mr. H. Lee, three cases; Dr. Martin, one case. In 1868, M. Verneuil published (Gaz. Hebdomad., No. 46, 1868), and subsequently through his pupils (Tremblay, Gaz. Hebd., 1870, et Thèse de Paris, 1876), some observations on cutaneous manifestations, some true eruptions following septicemic conditions. In a work recently translated

into French (Leçons de Clinique Chirurgicale, Traduction de M. Petit, 1877), Sir J. Paget has devoted a short chapter to the explanation of analogous facts. He mentions ten cases observed in children. Mr. Howard Marsh, in an additional note to the chapter, confirms, on all points, the opinion of Paget, and reports eight cases. Mr. Thomas Smith (in the same note) says that, in forty-three children upon whom he practised lithotomy, seven had scarlatina, and the eruption varied according as it appeared on the first to the third day after the operation. One of M. Trélat's pupils, M. Cartaz, observed the following case during the campaign of 1870:— A young guard, aged 20, was brought to the ambulance with a penetrating wound of the knee, caused by a firearm. Resection of the knee was practised four days after the injury, the patient refusing amputation. The third day after the operation, scarlatina appeared, the diagnosis of which was only tardily arrived at, as at first, before the eruptive stage, it was believed to be pyæmia, on account of the intensity of the fever. No scarlatina existed at that time in the ambulance, but ten days afterwards two cases were noted. M. Trélat observes that these facts are the more remarkable and worthy of study, as for a long time scarlatina has been known to follow delivery in conditions analogous to scarlatina after operations. M. Hervieux, in an epidemic which he observed, found that the patients of the Maternity Hospital, who were attacked, presented symptoms of the fever in the early days of the week following the confinement, and then there was no epidemic of scarlatina in Paris. In more recent times, gynæcologists have been much occupied with this question; and an interesting discussion was raised two years ago at the Obstetrical Society of London, some wishing to make scarlatina play a particular rôle in the pathogenesis of puerperal fever, others seeing a frequent complication, presenting ties of reconciliation with the traumatism of delivery. This puerperal scarlatina, as it has been designated, resembled in every point in its course and evolution that now described; the same rapid commencement about the second or third day after delivery; the frequent absence of premonitory symptoms; the irregular course and divergence from the normal type. In a long and important work, founded on no fewer than 141 observations, Olshausen has dealt with this subject. In his memoirs (Archiv für Gynäkologie, Band ix., Heft II.), are established the points of similarity between operative scarlatina and puerperal scarlatina. M. Trélat concludes his lecture with the following résumé in the form of propositions:-1. After slight operations, complications disquieting at the onset may arise, which are no other than those of scarlatina. 2. This scarlatina has not the features by which the disease is generally recognised: the commencement is more sudden-it appears in the first days after the traumatism; the throat is sometimes but little affected; in a word, the symptoms and course are anything but typical. 3. The wound, however small it may be, suffers from the invasion and evolution

of this complication; its cicatrisation is greatly retarded. 4. The different septicæmic eruptions must not be confounded with this scarlatina; the course and symptoms will make the diagnosis easy.

J. W. M.

CROUP CURED BY HYPODERMIC INJECTION OF SULPHATE OF ATROPINE.

DR. DE PONTÈVES, of Antibes, has published a full account of a case of croup where a fatal termination seemed inevitable, but which resulted in recovery, owing, he believes, to hypodermic injections of sulphate of atropia. On the third day of the attack he found his patient—a child three years old to whom the usual remedies had been given, in a state of commencing asphyxia. The efforts to breathe could be heard in the street; the epigastrium, instead of rising at each inspiration, was hollow; the face and neck were enormously swollen and of a violet colour; there had been no attempt at vomiting, though large doses of sulphate of copper had been given. At once three drops of a one per cent. solution of sulphate of atropine were injected by a Pravaz syringe, on the left side of the neck, on a level with the pneumogastric. At the end of a few minutes a change for the better took place, the respiration became less frequent, and the crowing diminished. Four hours afterwards the child was found tranquil, and, though the respiration was still troubled, dyspnoea was no longer intense. A second injection was given and the amelioration shortly afterwards became very marked. A few days afterwards the recovery was complete. A priori the treatment is a rational one. The real cause of death in croup does not reside in the false membranes. M. Jaccoud, in his Traité de Physiologie Interne, speaks of the "very numerous cases in which croup kills without laryngeal obstruction sufficient to explain death.” He adds that, "though often the expulsion of the false membrane is followed by great relief marking the diminution of the dyspnoea, yet the cases are far from rare in which the remission is absent or inappreciable— a fact sufficient to prove that croupal dyspnoea has more causes than the obstruction of the larynx by exudation." When the pneumogastric nerves of dogs are divided in the neck, what always happens is the occlusion of the glottis from paralysis of the recurrents, and after death there is found intense congestion of the lungs, pulmonary edema, dilatation of the smaller bronchi, and vesicular emphysema. Now these symptoms and lesions are also those observable in croup and capillary bronchitis. The essential cause, therefore, of asphyxia in croup seems to be the paralysis —more or less complete-of the pneumogastric. This view is supported by the fact that it is difficult, and often impossible, to produce vomiting. Belladonna, being an excitant specially of the pneumogastric, appears to be indicated in cases such as have been detailed.-L'Union Médicale.

S. W.

THE DUBLIN JOURNAL

OF

MEDICAL SCIENCE.

DECEMBER 2, 1878.

PART I.

ORIGINAL COMMUNICATIONS.

ART. XIV.-Necrosis without Suppuration. By WILLIAM COLLES, M.D., F.R.C.S.I.; Surgeon to the Queen; Regius Professor of Surgery in the University of Dublin; Surgeon to Steevens' Hospital.

IN Vol. LXIV. of this Journal (September, 1877) I have recorded a case of what the surgeon (Dr. Deely) previously in attendance and I considered acute necrosis, in which profuse suppuration, formation of external callus casing, and the rapid absorption and disintegration of sequestrum were all completed in the space of seven months.

I subsequently received a communication from Mr. Morrant Baker, in which he records a case of what he has named necrosis without suppuration. In his paper he gives details of the case, in which the train of symptoms differed so materially in all respects from those that are generally accepted as denoting necrosis, that he was fully justified in his description, and deserves thanks and credit for drawing the attention of surgeons to the subject. Having lately met a case presenting many peculiar features, and supporting the views of Mr. Morrant Baker, I take the opportunity of here recording it:

Miss, aged fifteen, a healthy-looking girl, was thrown from a carriage, and received some bruises about the face; also there was VOL. LXVI.—NO. 84, THIRD SERIES. 2 I

observed a slight transverse wound about a fourth of an inch at the ulnar side of the left wrist close to the joint. Through this opening projected a small piece of very rough bone, which was considered by her medical attendants, Drs. Wilmot and Kavanagh, to be the lower end of the ulna broken off and projecting. It could not be restored or retained in

position.

I saw her two days after the accident, and perceived a slightly fœtid odour from the wound, which, however, might have been attributed to commencing suppuration.

She was put under the influence of chloroform, but we could not restore the natural form to the limb. We therefore agreed to remove the projecting loose portion of bone. With this view I caught the projecting point in a forceps, and passed a director behind it. I was surprised to find the extent to which the director went, and the freedom from all obstruction of ligamentous or other attachment. Having bent the hand backwards, and pressing the director inwards, there slipped into the vessel underneath a portion of bone about two inches long. On examining the forearm the bones seemed quite naturally in their positions, but were perhaps slightly larger than those of the opposite limb; the motions perfect. Splints were applied more as a precautionary measure than from any necessity. There was slight suppuration, but no bad symptoms supervened. On examining the bone extruded, we found it about two inches long, much smaller than we would expect in a person of her age, and quite devoid of periosteum; no cartilage or epiphysary end, but a small rough deposit of new bone; the upper end irregular, jagged, but in no part did we find any appearance of its having been acted on by living parts, and on section-which was difficult from the dryness and friability of the bone-the medullary cavity was the same as in ordinary section of bones.

On further inquiry we found that about eight or nine years ago she fell and received what is called a sallyswitch fracture of both bones; this was treated by splints and long rest; she recovered with perfect use of the limb, and the parents remarked only a slight thickening of the bone.

That this was a case of necrosis there can be no doubt; and if it was the result of injury, it must have been of only two days' a Viewed externally this is evidently a deposit of new bone.