SECOND SECTION.-OF CERTAIN PECULIAR KINDS OF INFLAMMATION.

I.-OF ERYSIPELAS.

RICHTER G. G., Diss. de Erysipelate. Goetting, 1744.

4to.

THIERENS, A. L., Diss. de Erysipelate. Lugd. Batav., 1790.

WINKEL, L. H. O., Aphorismi de cognoscendo et curando Erysipelate. Erlang.,

1794. 8vo.

FERNE, W. C. S., Diss. de diversâ Erysipelatis naturâ. Franc ad Viadr., 1795. 4to. DESAULT, Observations sur Diverses Espèces d'Erysipèles; in Journal de Chirurgie, vol. ii. p. 13. 1791.

RUST, das Pseudo-Erysipelas, eine noch nicht hinreichend erkannte Krankheitsform; in his Magazin, vol. viii. part iii. p. 498.

HUTCHINSON, A. C., Practical Observations on Surgery. 2nd Edit. London, 1826. chap. ii.

PAULI, über Phlegmone telæ cellulosa; in RUST's Magazin, vol. xxvii. p. 129. LAWRENCE, WILLIAM, Observations on the Nature and Treatment of Erysipelas; in Medico-Chirurg. Trans. vol. xiv. part i. p. 1.

DUPUYTREN, Du Phlegmon Diffus; in Leçons Orales, vol. ii. p. 289.

FENGER, C. E., Diss. de Erysipelate ambulanti. Haoniæ, 1842.

81. Under the terms Erysipelas, St. Anthony's Fire, (Rosa, Erysipelas, Lat.; Rose oder Rothlauf, Germ.; Erysipele, Fr.,) is usually understood an inflammation of the lymphatic vascular network overspreading the surface of the cutis, in which, not unfrequently, the skin, glands, and Malpighian mucous net, but more rarely the cellular tissue and muscles lying beneath, partiticipate. Under this general notion are included a number of diseased conditions which are considered as modifications of erysipelas, but in their nature are entirely different from it. RUST has the merit of having pointed out their special points of difference, and recognises a True Erysipelas (Erysipelas verum seu exanthematicum, Lat. ; äcte Rose,Germ.) and a False Erysipelas (Erysipelas spurium seu Pseudo-Erysipelas, Lat.; unächte Rose, Germ.)

[HUNTER long since observed, that "most inflammations that are not of the true adhesive and suppurative kinds are called erysipelatous, although, probably, they do not in the least belong to it." (p. 269.) And CHELIUS has echoed him in the above observation, that a number of diseased conditions, which are considered as modifications of erysipelas, in their nature are entirely different from it." But he has not at all, by his arrangement, mended the matter, and I have, therefore, pointed out, first, the different applications of the terms erysipelas and erythema, which are employed by him very contrarily to our ordinary usage of them; and, afterwards, I have shown that one of his forms of erythema is really that important disease, inflammation of the cellular tissue, which, by other writers as well as by him, is confounded with inflammation of the skin, and often mentioned as gangrenous erysipelas. It is, however, right to observe that our author has, at the end of paragraph 83, shown that he is not unaware of the impropriety of considering this disease as an affection of the skin.-J. F. S.]

82. The True Erysipelas appears without any local disposition to disease, but with previous general indisposition, which is usually shown by

weakness and heaviness of the limbs, listlessness, pain in the region of the stomach, loaded tongue, nasty taste in the month, disposition to vomit, more or less active fever, head-ache, wandering, lethargy, or madness,—as a pale uncircumscribed redness of the skin, fading into yellowish, which spreads unequally, is shaded off towards the edge, disappears on pressure with the finger, but returns when the pressure is removed. After the appearance of the erysipelas the fever generally diminishes or disappears; but every fresh attack is accompanied with fever. The seat of this erysipelas never extends beyond the lymphatic-vascular net overspreading the surface of the cutis. The severity of the disease is as various as is the condition of the part first attacked; it, however, usually subsides under critical discharges of perspiration and urine, and with scaling of the skin; it never runs into suppuration, but only, with weakly constitutions and other concurrent circumstances, into ulceration and gangrene, in consesequence of which the destruction of the surface of the body extends to the parts beneath, and there ensues, not a bounded fluctuating abscess, but an open, wide-spreading, putrid, ulcerating surface. If the scaling of the skin, critically following the erysipelas, be disturbed by moist remedies, by cold and so on, dropsical swelling ensues. This erysipelas is very fugitive; it subsides of itself; but more commonly after the ex ternal use of moist remedies, of cold, or on mental emotions, and so on, it suddenly quits the surface, and causes inflammation of the brain, chest, or belly, madness, convulsions, paralysis, and so on. The true causes of this erysipelas are biliary irritation, disturbance of the functions of the liver, collections of gastric impurities, use of indigestible food, obstruction in the portal system, and a prevalence of peculiar atmosphere and temperature, in consequence of which it seems to be commonly epidemic, especially towards autumn and during summer.

Compare BALLING, das Akklimatisations-Erysipelas; in Heidelberg Klinischen Annalen, vol. vii. p. 176

The Vesicular Erysipelas (Erysipelas vesiculare, bullosum) is a variety of this kind of erysipelas, in which either at the onset, or in the course of the disease, vesicles of various size arise, sometimes like a miliary eruption, sometimes like peas or hens' eggs, which often run together, and, after bursting, form crusts, or, frequently, spreading

sores.

[(1) The disease here described as true erysipelas by CHELIUS, is the erythema of English practitioners, and which has been well described by WILLAN (a) as a nearly continuous redness of some portion of the skin, attended with disorder of the constitution, but not contagious" (p. 472;) and BATEMAN (b) observes, that "it differs from erysipelas inasmuch as it is a mere rash or efflorescence, and is not accompanied by any swelling, vesication, or regular fever." (p. 119.) RAYER (c) speaks of it as a superficial inflammation of the skin, characterized by morbid redness and heat. and the absence, for the most part, of papulæ, vesicles and pustules. (vol. i. p. 98.) Elsewhere he observes, that "it is the first stage of a number of cutaneous affections, but when permanent it constitutes a disease in itself." (p. 95.)

The vesicular erysipelas, which CHELIUS considers merely as a variety of his erysi pelas, is a distinct and definite disease, the acute erysipelas of WILLAN and BATEMAN, which "most frequently occurs in the face, affecting usually one side of it only; sometimes it seizes one of the extremities, and in both cases it is ushered in by a smart feverish attack. The colour is higher than in the other species of the disease, and the burning heat and tingling in the part are exceedingly distressing. The swelling generally appears on the second night or third day of the fever; the vesications rise on the fourth and fifth, and break or subside on the fifth or sixth, when the redness changes to a yellowish hue, and the swelling and fever begin to diminish; and on the eighth day

(a) On Cutaneous Diseases. Lond., 1808. 4to. (b) A Practical Synopsis of Cutaneous Diseases

according to the arrangement of Dr. WILLAN. London, 1819. 8vo. 15th Edition.

(c) Traité Théorique et Pratique des Maladies de la Peau. Paris, 1926. 2 vols. 8vo.

both disappear; on the tenth the new cuticle is commonly left exposed, the old one having separated, and the brownish or dark scab, which had formed where the fluid of the vesications had been discharged, having fallen off." The disease runs its course more quickly in the young than in those of more advanced age; and "the vesications, in the latter instances, are often succeeded by a profuse discharge of acrimonious lymph for several days, so that scabs do not form. Suppuration very rarely occurs in this species of erysipelas, especially when it affects the face." (pp. 126, 7.)

From this description it is quite evident that CHELIUS is incorrect in making his vesicular erysipelas a variety of his true erysipelas; the latter being really erythema, and therefore an exanthematous disease, whilst the former, which is our acute erysipelas, is a bullous disease. It was necessary also to make these observations to prevent the confusion which would otherwise arise from the acceptation in which CHELIUS uses the terms erysipelas and erythema, differing so entirely from that in which they are employed by English writers.-J. F. S.]

83. The Spurious Erysipelas or Pseudo-Erysipelas is a continual inflammation of the skin with some redness, (Erythema,) which has nothing in common with the true erysipelas but its external appearance, and is produced by any pretty strong irritation of the skin. Influences of this kind are, scorching by the sun, slight burning, cold, irritating ointments and plasters, cantharides, mustard plaster, horse-radish, the juice of toxicodendron, hard rubbing, wounds and injuries of all kinds, stagnant humours, swellings, hardenings, and so on. Hence inflammation of the skin is produced, either directly or indirectly; in the first case appearing immediately, in the second as a consequence of some other disease, which has been excited by inflammation. The inflammation of the skin, thas produced, is either superficial, or it penetrates deeper into the substance of the skin. The former is more like erysipelas, but the latter has rather the character of phlegmonous inflammation, and the more the cellular membrane and muscles are attacked by it, so much the less does the disease deserve the name of inflammation of the skin.

84. According to its various causes, Pseudo-Erysipelas is divided into two kinds :

First. The Erythema idiopathicum, which is merely consequence of external irritation (from cold, heat, corrosive substances, slight injuries, and so on.)

[A very frequent form of idiopathic erythema is that caused by friction, and commonly known as Intertrigo, which is well exemplified in the chafing of the skin in fat persons; often also noticed in the folds of the skin of the neck, groin and hams, and behind the ears of infants, and resulting from inattention to cleanliness, the moisture and sebaceous secretions which are left on the delicate skin of these parts irritating it, so that often the character of the perspiration is changed to clamminess, and its quantity increased, and, where it can dry, superficial thin scabs are formed, even before excoriation of the skin occurs, which soon takes place, and, if left alone, runs on to gangrene. Erythema may also originate from the flow of other natural secretions over the skin, as the spittle over the chin and neck, if the lower lip be imperfect, or do not retain its proper place; the urine, in incontinence or in perineal fistula; the tears over the cheek; and so also the increased and altered mucous discharge from the nostrils during catarrh, will cause severe erythema of the upper lip.-J. F. S.]

Second. The Erythema symptomaticum, consensuale, which is the simple reflection of another disease of the structures lying deeper beneath the skin. This other disease may be,

A. An inflammatory or serous distension of the tendinous expansions, and aponeuroses, with the intensity of which the accompanying inflammation of the skin increases, and oftentimes spreads very far, as, for instance, in oedema, in injuries of the head, in whitlow, and so on.

[This is the "erysipelatous inflammation" which, HUNTER says, "often arises from

accident; but then it is commonly a secondary inflammation, although not always; for, the first shall have gone off, and, when the suppuration was to take place, it shall have come kindly on, but afterwards the erysipelatous shall take place. It is more

*

commonly a cutaneous inflammation than situated in the deeper-seated parts; although, in some constitutions, every inflammation, wherever it exists, will most probably be of this kind; however, the skin appears to be most susceptible of it, because it will spread over a prodigious surface of skin, while it does not affect even the cellular membrane underneath. * ** It is more common in the summer than in the winter, more especially in hospitals; and, I think, takes place oftener after wounds on the head than any other. I have often seen it begin round a wound on the scalp, extending itself over the whole head and face; the eyelids being very much swelled, the ears thickened, and it has advanced to the neck, shoulders and body; creeping along both arms, and terminating at the fingers' ends: that which attacks the body, often goes along the body to both thighs, down the legs, and terminates at the ends of the toes; and, while this is going on, it is as expeditiously cured behind, and the skin peels off the cured parts: however, this is not always the case; it often stops, and where it proceeds so far, it is commonly becoming milder." (pp. 270, 1.)

The form of the disease just described by HUNTER, is the erratic erysipelas of WILLAN and BATEMAN. It, however, more commonly occurs on the limbs and body, than on the head, and frequently accompanies punctured wounds, or poisoned wounds in dissection. In the latter cases, it is often extremely troublesome, and continues for weeks; making its appearance in the neighbourhood of the wound, after the more severe symptoms, either without or with suppuration and sloughing, have subsided, and the patient seems nearly convalescent: it will run up and down finger after finger, consecutively, and I have known the fingers thus affected twice or thrice during the same attack.

That form of the disease which sometimes follows scalp-wounds is rather the adematous erysipelas of WILLAN and BATEMAN than the erratic. It is described by those writers" of a paler red, or of a yellowish-brown colour, is accompanied by less heat and local distress" than true, or even erratic erysipelas; " its surface is smooth and shining, and, if it be strongly pressed with the finger, a slight pit remains for a short time." The scalp swells enormously, and the disease spreads more or less slowly and extensively, till "the whole face is much enlarged, so that the form of the features is scarcely recognised, and the appearance is not unaptly compared by WILLAN to that of a bladder distended with water." (p. 127.) Generally, as far as I have observed, this edematous erysipelas is not accompanied with vesication.-J. F. S.]

B. A metastatic deposit in the cellular tissue, periosteum, and glands, in gastric, rheumatic, arthritic, and puerperal diseases. In such cases, when the masses deposited are fluid, the parts attacked quickly die, and are given up to the ulcerative process. Often, within a few hours, in a previously healthy part, (mostly of the thigh or leg, especially on the right side in persons advanced in years,) a redness of the skin comes on with fluctuation and diffused pain, in which, after opening the abscess, whole sheets of dead cellular tissue may be withdrawn; and, if the periosteum be involved, the bone may be felt bare. Usually, however, its course is not so quick; the local pain is preceded by more or less severe shiverings which, from their repeated accessions, resemble an ague. The fever continuing, the skin is rosy red at the painful parts, and somewhat œdematous, so that it retains the impression of the finger. The fever becomes more active, the swelling harder, the redness bluish, the skin grows shining and blisters, the cellular tissue is hard and firm, the urinary and fecal discharges are changed and suppressed; with accompanying restlessness, and great agitation. At this point the disease seems to stand still; the heat, tension, and pain are unaltered; the vesicles have the same appearance. If at this time the skin and cellular tissue be cut into, a quantity of whitish fluid with a little pus escapes, a few days after, less of the thin fluid, and more pus; and, still later, a whitish lardlike substance, and upon pressure only a very little pus; the cellular tissue is dead. When it has gone thus far, the skin is destroyed, the

vesicles burst, a whitish ichorous fluid is discharged, whitish or blackish spots appear which quickly spread, the cellular tissue is thrown off in large patches, the skin is entirely separated from the underlying parts, all the connecting cellular tissue between the muscles is destroyed, the skin becomes gangrenous, the suppuration is very plentiful and offensive, the destruction spreads and exhaustion follows with copious sweats, purging, and so on. If the patient's powers revive, and the disease be arrested, the formation of granulations and cicatrization is always very tedious, on account of the great destruction of the cellular tissue (1). If the masses deposited be solid, they sink into the substance of the cellular tissue, inflame and harden it, and destroy its vital relations, without causing actual death. This degeneration frequently does not occur until after several weeks, and appears with accompanying redness of the skin and with a somewhat painful, far-spread, deep-seated hardening (2). The termination of this disease (which KLUGE has commonly observed in the scrotum, and which I have seen upon the hand and fore arm) is either a tedious resolution with gradual subsidence of the redness and hardness, or death of the degenerated organ, in which the size of the part is increased, the previous hardness becomes doughy, fluctuation takes place, and the above-described destruction and ichorousness ensues (a).

[(1) This is the inflammation of the cellular tissue, to which I slightly adverted at p. 72 ; and, although very commonly confused with erysipelas, or, as by CHELIUS, with erythema, it is decidedly different from either, although both occasionally run into it. JOHN HUNTER was well acquainted with it, as will be presently seen, though he included it with erythema, under the common title erysipelatous inflammation, which he does not describe at all. He says:-"The erysipelatous inflammation is very peculiar; and most inflammations that are not of the true adhesive and suppurative kind are called so, although probably they do not in the least belong to it; and this may arise more from the want of terms, than the want of discrimination." (p. 269.) After describing erythema, which it is quite certain he means, restricting it to the skin, he proceeds :-" When it (the inflammation) goes deeper than the skin into the cellular membrane, it often suppurates; but then I suspect it is not the true erysipelatous; for, in such cases, it commonly produces mortification in the cells, by which air is let loose; this gives a strange feel, neither of fluctuation nor crepitation, and, as there are no adhesions, the matter finds an easy passage into the common cellular membrane, increasing the same kind of suppuration wherever it comes; and, as mortification is a consequence of these inflammations, putrefaction ensues, and the discharge becomes very offensive. * When it produces suppuration in the cellular membrane it is often dangerous, both from the disease itself and the cousequences of the matter diffusing itself much farther.

The sores seldom ulcerate; they should be opened early, or the matter either gets into the cellular membrane from the want of adhesions, or it separates parts that are only attached, as the periosteum from the bone, muscles from muscles, etc. Whereas the true suppurative ulcerates briskly, which therefore should not be opened early, but allowed to burst" (pp. 271, 2.)

So far as it goes, HUNTER has well described this disease; but he speaks of it as if invariably consequent on erythema, which is more rare than its following erysipelas, which he does not mention at all. It is perfectly true that, from both these diseases, the inflammatory action may descend, and attack the cellular tissue; but very commonly the inflammation begins in that tissue; and the redness of the skin is only secondary, and symptomatic of the mischief going on beneath.

Inflammation of the cellular tissue arises frequently without any apparent cause, but sometimes follows a graze or slight wound or contusion of the skin. It commences with swelling, tension and dusky redness of the limb, (almost invariably attacking the extremities,) is very painful, and has a doughy feel; it spreads very rapidly, downwards as well as upwards if it have commenced on the upper or on the middle of the lower member of the limb. The pain and tension increase, the redness becomes darker, and, if not interfered with, large patches of the skin assume a gangrenous character, sometimes accompanied with large vesications loaded with dirty serum, but very often without

(4) KLUGE; in RUST, as above, p. 525.