healthy constitutions, amputation must be performed early—for thus the
chance of ultimate success is increased, while the danger of delay is
the same as in cases of gangrene caused by severe injury.
OF ERYSIPELAS.
Erysipelas is an inflammation of the external surface, accompanied
with peculiar symptoms and appearances, the morbid action being
modified by the texture in which it occurs. According to the various
circumstances attending the disease, it has been divided into several
species: phlegmonous, bilious, œdematous, gangrenous, acute, malignant,
&c. The term _Erythema_ is applied to cases of rash or efflorescence,
unaccompanied with fever, swelling, or vesication.
Inflammation of the skin only, is marked by bright redness, not
circumscribed, and disappearing when pressed. By pressure, the
bloodvessels are emptied for a time, the part sinks and becomes pale;
but, on removing the pressure, it soon regains its former colour and
relative situation; when these circumstances concur, the part is said
to pit. There is no tension,—the pain is not throbbing, but of a
burning or itching kind, and there is often a degree of _œdematous_
swelling. Swelling does not occur to any great extent, however, during
the existence of the inflammation in the skin and rete mucosum;
but the parts sometimes become much swollen after subsidence of
the inflammatory action, the vessels having relieved themselves by
effusion of serum; and afterwards the œdematous surface often assumes
a yellowish hue. In some cases, the serous effusion is from the
first, more extensive than in others, and hence the term _œdematous_
erysipelas, or inflammatory œdema. Upon the decline of inflammation, a
serous fluid is often effused also in great quantity under the cuticle,
giving rise to vesications, resembling the blisters produced by the
application of boiling water to the skin; and from this circumstance,
erysipelas has been classed amongst cutaneous affections in the order
bullæ. The erysipelatous redness does not terminate abruptly, and is
not defined by a distinct boundary, as some have asserted, but becomes
gradually lost in the surrounding parts. It frequently involves the
contiguous parts one after another, and extends with great rapidity.
It often leaves one part suddenly, and attacks another, either in the
neighbourhood, or situated at a considerable distance; in other words,
metastasis takes place. The disease takes on this erratic character
without our being able to assign any good reason for it; and this form
of the disease is frequently attended by symptoms of typhoid fever.
When it disappears suddenly, or is repelled by cold applications,
affections of the internal organs sometimes supervene, as of the
bowels, lungs, or brain; the diseased action leaving the external
surface, and attacking the deeply-seated organs; thus, in a case of
erysipelas of the ankle and foot, the external symptoms disappeared
suddenly, and an affection of the lungs supervened, under which the
patient sunk; and in erysipelas of the face and scalp, the sudden
disappearance of the redness is frequently followed by delirium and
coma. Again, in acute disease of an internal part, the symptoms are
much meliorated, and often entirely removed, by inflammation of the
skin being induced artificially, or occurring spontaneously.
The integuments of the face and head are frequently attacked by
erysipelas, in consequence of wounds and bruises of the face or scalp,
even though very slight, and it often takes place here spontaneously,
as in other parts of the body.
Erysipelas commonly arises from constitutional derangement, as is
shown by the symptoms which precede it, and also by the efficacy
of internal remedies in checking its progress; in such instances,
external applications, unaccompanied with constitutional treatment,
produce little or no effect. It is often produced around a wound by
the employment of improper dressing, rancid ointments, or irritating
plasters, by a too free use of the part, or by the friction and
irritation of the patient’s clothes. It occurs most readily in those
who live freely, indulging in the imprudent use of spirituous liquors,
and whose constitutional powers are thereby considerably weakened. It
is also said to be sometimes caused by violent passions, as anger or
grief; and by exposure to cold, or to heat,—the former acting only
as a remote, the latter as an immediate cause. As an example of its
occurring in consequence of heat, it is a common remark, that cooks,
who are necessarily much exposed to the fire, are frequently the
subjects of erysipelas of the face; but in the majority of such cases,
there may be other causes in operation,—the abuse of ardent spirits,
and habitual overcharging of the system with stimulating food. It is
more commonly met with in summer than in winter. And in certain states
of the atmosphere, even in healthy situations, a degree of erysipelas
is apt to occur after wounds by operation or accident.
It is often periodical, especially in females who have ceased to
menstruate, always recurring at regular intervals; it attacks parts of
the body, most generally the face, and in some cases monthly, in some
once in the year, and in others once every two years. It sometimes
appears to occur as a natural means of relief from impending affections
of more serious nature, as of the system or of internal organs. Those
who have once been afflicted with the disease become more liable to its
attacks.
Erysipelas is generally preceded and accompanied with more or less
disturbance of the digestive organs. In _Bilious_ Erysipelas, the
portion of skin affected is said to present a more yellow colour than
in the phlegmonous, the derangement of the digestive organs is greater,
and hence the origin of the distinctive term; fits of shivering occur,
the patient complains of a bitter taste in his mouth, and the tongue is
furred and of a brown colour.
In the _Phlegmonous_, in which other textures than the skin are often
affected, viz., the subcutaneous and intermuscular cellular tissue and
the fasciæ, the pain is more intense, and of a throbbing kind; the
swelling is hard, more deeply seated, and more extensive; there is
considerable tension; and the redness is of a darker hue. Nausea and a
bitter taste in the mouth do not precede the erysipelatous appearance,
but the skin and tongue are dry, and there is great thirst. When the
disease begins to subside, then the foul tongue supervenes, with the
bitter taste and nausea.
Erysipelas, of a contagious and violent character, frequently occurs,
and is apt to spread extensively, in badly aired situations, where
a number of patients with sores are crowded together, without due
attention being paid to cleanliness and proper dressing.
_Hospital Erysipelas_, as this species is termed, is nearly allied to
that dreadful disease, Hospital Gangrene, and the two affections are
often blended. It comes on after operations, or in patients who have
sustained an external injury by accident. In unhealthy hospitals it
not unfrequently appears in previously sound parts, and without any
assignable cause; and, from its following the slightest wound, recourse
cannot be had with safety even to venesection, cupping or leeching.
It is a dreadful scourge in many hospitals, more especially during
particular seasons of the year—during hot, damp weather, and in spring
and autumn, attacking the patients indiscriminately.
Of late years Erysipelas appeared in the Royal Infirmary of Edinburgh,
during the wet and changeable summers which prevailed; some of the
cases were very severe, and a few terminated fatally. It was very
satisfactory, however, to observe that it did not spread as it used
to do formerly, that patients occupying the beds immediately around
those affected, though afflicted with sores and in indifferent health,
remained exempt from the disease; and that many of the most severe
cases did not originate in the house, but were brought from the crowded
and unhealthy parts of the city. The same may be said of the disease as
it has shown itself in the North London Hospital since it was opened
for the reception of patients up to the present time.
Hospital Erysipelas is for the most part preceded by violent
constitutional symptoms, derangement of the chylopoietic viscera,
shivering, brown tongue, and a bitter taste in the mouth; if there
is a sore on the body, it assumes a sloughy aspect; the surrounding
skin becomes of a dark red colour, and there is a feeling of tension,
accompanied with a burning pain. The erysipelas extends rapidly, and
generally terminates in suppuration and sloughing of the cellular
substance, or, if inertly treated, in immediate gangrene of the parts.
The concomitant fever is generally low, and though, in the first
instance, the circulation may be vigorous, symptoms of debility will
speedily appear. It will be more fully dwelt upon, along with Hospital
Gangrene.
In all cases of erysipelas there is more or less concomitant
fever, modified by the extent of the local affection—by the age
of the patient—by the previous habits and state of health—by the
constitution—and by other circumstances. The pulse is accelerated, and
is either of a sthenic or asthenic character, according to the state
of the system and type of the prevailing fever. There is headache,
languor, thirst, restlessness, and even delirium, especially when the
face or scalp is the seat of the disease.
Erysipelas may terminate in resolution. If this takes place in the
first stage of the disease, the redness gradually declines, along with
the swelling, the cuticle exfoliates, and the part regains its usual
appearance, the skin remaining loose and shrivelled. If it occurs after
vesications have formed, the effused fluid is absorbed, a scab forms,
and desquamates along with portions of the cuticle.
It may terminate in suppuration, when the inflammation has extended
to the cellular substance. This termination is most frequent when
the disease is situated in an extremity, seldom when in the face,
though small purulent collections occasionally form in the eyelids.
Circumscribed collections of pus often present themselves after the
disappearance of the erysipelatous inflammation; but the purulent
matter is generally diffused through the filamentous tissue, and is of
a thin, unhealthy appearance, and mixed with sloughs of the cellular
substance. By the infiltration of matter, the integuments, fasciæ, and
muscles are extensively separated from each other, in consequence of
which the parts frequently die, their nutritive supply being cut off.
Acrid sanious matter is often infiltrated extensively into the
subcutaneous cellular tissue round a wound or sore. The superimposed
integuments are of a dark brown colour, and the part is boggy.
Sloughing of the cellular membrane here takes place in consequence
of the infiltration, and not from inflammatory action having
been established. The affection has been termed Diffuse Cellular
Inflammation, but a more proper appellation is Diffuse Cellular
Infiltration; the cellular tissue, even where treatment is adopted at
an early period, can scarcely be prevented from perishing.
Erysipelas, if properly treated from its commencement, will seldom
terminate in gangrene of the skin. This termination is occasionally
observed, however, in patients whose constitutions have been extremely
debilitated.
In mild cases of erysipelas, attention to the state of the bowels, and
regulation of diet, will often be sufficient to remove the disease.
When there is much disorder of the digestive organs, and particularly
of the biliary secretions, emetics may be given at the commencement;
these are productive of but little good in the more advanced stage, and
their place is advantageously supplied by nauseating doses of antimony,
combined or not with purgatives. One-eighth of a grain of tartarised
antimony may be given in solution every hour, with or without a
due quantity of the tart. potassæ and sodæ, or Rochelle salt. The
hydrargyrum cum creta is often given with great benefit when the tongue
is dry and covered with a brown crust: it may be combined sometimes
advantageously with the compound powder of ipecacuanha. With the same
view calomel with antimonial powder may be exhibited. The exhibition
of saline purges is attended with great good in some severe cases.
Such medicines tend to subdue any arterial excitement that may exist,
evacuate the bowels, promote perspiration, remove the superabundant
bilious matter, and serve to restore the healthy functions of the
liver. In severe cases, more especially of phlegmonous erysipelas,
in which there is acceleration of the pulse, and a degree of febrile
excitement, general bleeding may be had recourse to; but it must be
employed with caution, for the symptoms of increased vascular action
may arise from constitutional irritation, and not be meliorated by the
depletion. The practice is superseded by the timeous and free local
bleeding from incisions, as will be noticed by and by. The exhibition
of the extract of aconite in this and other inflammatory affections, is
often followed by great abatement of vascular excitement, so that the
necessity for abstraction of blood is done away with. The medicine may
be given in doses of half a grain in substance, or dissolved in pure
water, and repeated every third or fourth hour. The sensible effect is
relaxation of the surface, and frequently profuse perspiration; the
arterial pulsations are diminished in frequency and force. The extract
of belladonna, in doses of one-sixteenth of a grain, may then be
substituted with great advantage, and often with the most extraordinary
effect upon the disease. In very many cases, the strength is from the
first to be supported by all possible means, by nourishing diet, by the
exhibition of wine, quinine, and other tonics; more particularly in old
people—in constitutions debilitated by disease—in unhealthy situations,
and when the fever is of a typhoid kind. Bleeding by leeches is not
admissible, for the leech-bites prove a source of irritation, and are
liable to suppurate; erysipelas has often been produced by leeching.
In erythema, the mere outer surface of the skin only being slightly
affected, and not to any very great extent, advantage sometimes
results from the application of nitrate of silver. A strong solution
may be pencilled upon the part, or, after being wetted, the affected
surface may be gently rubbed over with the solid caustic. The pain and
uneasy sensations in the part being thereby diminished or removed, and
extension of the disease seeming to be arrested. Discoloration caused
by such practice is of little consequence, as desquamation must follow.
It is questionable how far it may be safe to apply lunar caustic to any
extensively inflamed surface, more especially of the head and face,
lest metastasis should occur. The inflammatory action in the skin is
subdued by the application, whilst it may advance, in the cellular
tissue, to suppuration and sloughing, if other means are not adopted;
and from the hard and blackened state of the cuticle, the condition
of the subjacent parts is not readily perceived. The remedy is only
applicable to erythema, and most advantageously as a means of bounding
it. The line should be drawn at some distance from the affected
tissues; and if so, it is seldom that the disease oversteps it.
Local abstraction of blood, by puncture or incision, proves exceedingly
beneficial in cases of erysipelas, whatever its degree. It must be
borne in mind by the practitioner, when called to treat the disease,
that the state of parts is very various, and this may depend upon
the original nature of the disease, upon its site or duration. The
surface of the skin only may be affected—that and the subjacent
cellular tissue may be involved, gorged with serous, lymphatic, or
purulent infiltration—there may exist great tension of the parts, with
a sloughy state of the cellular tissue, established in addition to
suppuration—and again, there may be infiltration of the subfascial and
intermuscular tissues, leading ultimately to exposure and exfoliation
of bones or disease of articulations.
From inattention to these circumstances, the treatment being often
directed to the name of the disease, great discrepancy of opinion, as
to the most proper local management, has arisen; there has accordingly
been a controversy as to whether the blood should be drawn from mere
punctures from limited incisions, or from long gashes extending from
one joint to another.
In cases not very severe or extensive, when the skin only is affected,
the constitutional treatment already mentioned is first to be employed,
and then the affected part must be freely punctured with a fine lancet,
at numerous points, as recommended by Sir R. Dobson. These punctures
should reach the vascular layer, but not go deeper: the serous
effusion, if there be any, is thereby evacuated—the over-distended
vessels are relieved of a considerable portion of their contents—and
the œdematous swelling, with the formation of phlyctenæ, is prevented.
The part is afterwards to be fomented for half an hour, or an hour,
with bags containing chamomile flowers or hops; the fomentation,
repeated at intervals, proves highly grateful to the feelings of the
patient, allays any irritation which the making of the punctures may
have produced, and keeps the skin perspirable. Under this treatment,
every vestige of erysipelas will generally disappear in the course of
a few days. In more severe cases, especially in the extremities, the
parts must be freely incised. The incisions ought to extend through
the integuments and cellular substance, and their length and number
must be proportioned to the extent and severity of the affection. One
or two pretty free incisions, if made in the proper place, where the
greatest degree of boggishness, marking the disorganised state of the
tissues, is discovered, will generally suffice—the vast good and the
relief afforded depends partly upon the abatement of the tension,
in consequence of the evacuation of the effused fluids—upon the
unloading of the over-distended bloodvessels of the part, and upon the
acceleration of the suppurative process, which is often critical. The
constitution is, probably, relieved by the suppuration of the wounds,
and the consequent drain of the offending particles.
Some surgeons have disapproved of long incisions, alleging that they
are tedious in healing, and prefer making numerous small ones; but
it is difficult to understand how the cure should be more tedious in
the one case than in the other, when the actual extent of divided
surface is the same. According to my experience, several free incisions
are made with less pain than a number of trifling scratches, and
heal as soon, whilst by the former the purpose of the practitioner
is much better fulfilled: the same good effects result from them as
from punctures in the more slight cases, if they are made at the
commencement of the disease; and if the affection is in its advanced
stage, the effused fluid, and the sloughs, are discharged, and the
infiltration of pus, and destruction of parts in consequence of the
matter being confined, are prevented by its being allowed a free exit
as soon as it is formed. Incisions then are made both in the early
stage of the disease, and after effusion has occurred: in the former
case, they are justifiable, because they arrest its progress; in
the latter, they are absolutely necessary, to prevent its injurious
effects. The parts are to be fomented, and afterwards covered with
a common poultice, containing no oil or grease, or with soft lint
saturated with tepid water, and covered with oiled silk, to prevent
evaporation.
When the erysipelas has gone off, the incisions are treated as common
wounds, by dressing and bandage. After punctures, or incisions, more
or less blood is allowed to flow, according to circumstances. It often
escapes from the vessels of the part in great profusion; this, in many
cases, may be prejudicial or excessively dangerous. In the extremities
the flow can readily be arrested by elevation of the part, or by
pressure, for a short period. In erysipelas of the face, punctures
are preferable to incisions, as by the employment of the former the
countenance is no way disfigured; if, however, in erysipelas of the
scalp, the integuments become swollen, and present a puffy feeling,
whilst at the same time cerebral symptoms supervene, free incision or
incisions, through the whole thickness of the covering, and in the
direction of the fibres, must be made. If erysipelas be thus actively
treated, it may be safely affirmed that the disease will not often,
unless accompanied with symptoms of putrid fever, terminate fatally;
if these means are employed early, the constitutional disturbance will
be modified or prevented, and no derangement of the cerebral functions
will ensue.
Powders, such as flour, chalk, and camphor, &c., have been applied
to the erysipelatous surface, but are of little use, and, by their
irritation, frequently prove injurious on the bursting of the vesicles.
They are applied, according to some, with the view of cooling the
surface, and after all the part may be seen enveloped in folds of
flannel. Cold application, such as the spirituous and evaporating
lotions, containing vinegar and spirits, liquor acet. ammoniæ,
Goulard’s extract, &c., may, in many cases, afford temporary relief,
but their use is fraught with the utmost danger; for their direct
tendency is to produce metastasis, and if that be to an internal
organ of importance, the result is too generally fatal. Or if the
erysipelas, on leaving the part originally affected, attack another
also superficial, the local treatment has to be commenced anew. If
these lotions are to be employed at all in this disease, they must be
made tepid.
In case of the translation of erysipelas to any important part,
blisters may be applied to the surface which it has left, or to any
other in the neighbourhood, with the view of recalling the disease to
its original and less dangerous situation:[8] the actual cautery has
even been recommended. In the great majority of cases, however, such
means are unavailing.
In Hospital Erysipelas, purging cannot be carried to any great extent
with safety, and general bleeding is seldom if ever admissible unless
the patients previously robust and in good health, in whom the disease
has occurred in consequence of their being conveyed to a distance and
during hot weather, after an accident or wound, and in whom the fever
is of a violent inflammatory nature. In civil hospitals, the patients
are generally in a weak state before the accession of this disease; and
in their case, after the stomach and bowels are regulated, stimulants
are more requisite. Great attention must be paid to cleanliness, the
sores must be frequently dressed, and the same sponges must not be
used for different individuals: in order to prevent contamination by
the promiscuous use of sponges, it is better to clean the parts around
sores with lint or tow, and to destroy immediately such dressings as
have been used. The apartments must be well ventilated, and those who
are affected with the disease should be separated from the rest of the
patients. The local applications will vary according to the particular
circumstances of each case. Strong escharotics may be required to clean
the surface of the sores, and put a stop to the sloughing. The nitric
acid will answer the purpose well, and is less objectionable than some
remedies that have been used; such as the arsenical solution, or the
red hot iron.
OF FURUNCULUS AND ANTHRAX.