104

ERYSIPELAS-Inflammation of Cellular Tissue.

them. Pressure upon the skin not unfrequently gives a crackling sensation. The gangrene of the skin continues spreading, and, generally, in the course of forty-eight hours or less, the greater part, or the whole, of the skin is sloughy. If there be sufficient power, ulceration takes place at the edge of one or other slough, and a little ichorous exudation is observed, which subsequently is followed by fetid pus, and sloughs begin to separate, simultaneously with which the character and quantity of suppuration are improved and increased, till the whole of the dead parts are thrown off; but this is a result which can scarcely be expected, for the patient is generally worn out before this can take place. The constitutional symptoms in this disease are at first those of great excitement and general disturbance; the skin burning hot and dry; the pulse quick and full; the alvine secretion unhealthy and the tongue dry; the patient becomes restless, soon wanders, becomes delirious, often violently, and then drops into a typhoid state, in which condition he speedily sinks. The disease is easily distinguishable from erysipelas, by the absence of vesication at the onset, and by its darker redness; also by its usually occurring in the limbs. But, as I have already mentioned, erysipelas may subside into it, as it not unfrequently does when attacking the scalp, and occasionally also when the face is affected, specially when the regions of the orbits are concerned, in which cases I have seen some very fearful sloughing of the cellular tissue in those cavities.

The disease generally attacks adults, and more especially persons accustomed to large quantities of beer and spirits, and gross feeding. In such persons the disease often seems to occur spontaneously, and at other times from the slightest cause, as a mere scratch. But I do not agree with CHELIUS that metastasis is generally, if ever, the cause of the disease.-J. F. S.]

(2) I have once or twice seen this degeneration in the scrotum; and I think I have noticed it occasionally in the legs of people addicted to drinking, in whom it seems to have been a commixture of adhesive deposit with the serum of cedema. But, many years ago, I had under my care a woman, between twenty and thirty years of age, whose face was thus affected, consequent on repeated attacks of erysipelas previous to my seeing her. Her forehead, and face especially, were considerably swollen and fiery red, having the appearance of skin distended with oedema, and threatening to burst; but it had not any such disposition. When pressed, it was found firm and but little yielding. She did not suffer pain in any material degree, but was principally inconvenienced by both eyelids being included in the disease, and so swollen that their apertures were little more than narrow horizontal slits, so that without bowing her head much forwards she could see nothing immediately below her for a considerable distance. All sorts of constitutional and local remedies having been employed without avail, it was proposed to her that some slices (they could only so be properly called) should be taken out of the swollen eyelids. To this she readily assented, being anxious for the slighest chance of relief; and, performing an operation similar to that for entropium, I removed a horizontal slice from between each tarsus and the corresponding edge of the orbit of both eyes, digging down to the bone, to the depth of half an inch, and cutting through cellular tissue literally converted into brawn; the gaping edges were then brought together, and, at first, she seemed a little benefited; but the wounds soon healed, and no advantage was derived. In a second operation, I removed some short vertical slices from the lower lids, but not with much immediate advantage. I have constantly seen her up to the present time, and, probably from the contraction of the scars, the apertures of the lids are increased but are still small. The face is also somewhat less, but it is still very full and deformed.-J. F. S.]

GULLIVER (a) mentions two peculiar affections of the cellular tissue which he has observed, and which he believes by no means uncommon among soldiers on service, who frequently "complain of inability to sustain the fatigue of marching, in consequence of swelling and pain in the feet and ankles, produced by this exercise. In many instances the cause of the affection is very obscure, and in some it may probably be ascribed to simulation; but I have seen cases in which the complaint was evidently connected with a change of structure in the subcutaneous cellular membrane of the legs, generally presenting itself in one of two forms.

"In the first and most numerous class of cases, after the patient has been long subjected to the inconvenience of swelling around the ankles and back of the feet, the disease assumes a more inveterate character, that of thickening and induration of the subcutaneous cellular texture, so as to leave no further doubt of the incapacity of the man for active service. In one instance, in which the disease attacked the right leg, the part was

(a) Remarks on certain Affections of the Cellular Tissue of the Legs; in Edinburgh Medical and Surgical Journal, vol. xlvi. 1836.

constantly bedewed with perspiration, emitting a peculiarly offensive odour. The affection sometimes occurs in both extremities, and frequently in one only.

"In the second description of cases, although the soldier assigns the same cause of disability as in the preceding, the anatomical character of the disease offers a marked difference. There appear simply to be induration and rigidity, without thickening of the subcutaneous cellular substance. I know of no specific term by which it could be appropriately designated. The lower part of the leg, and frequently the back of the foot, appears hide-bound, the limb feeling hard and smooth, from loss of extensibility in the filamentous web, which no longer possesses that yielding looseness necessary to the due performance of its functions, so that the smallest fold of the skin cannot be grasped between the thumb and finger. The affection is unattended by swelling, except incidentally from unusual exertion. The examples which have come to my knowledge have been invariably confined to one extremity. *** Of the first, which, in its advanced stage, may be considered as a species of compact cedema, we find no account in the accurate Treatise of Dr. CRAIGIE, and only a doubtful notice by Dr. OTTO; of the second, I am unaware of any description." (p. 309.) The chronic induration and thickening of the cellular substance may probably arise from a variety of causes, of which repeated attacks of erysipelas appear to be one; but the first two cases described in this paper, as well as others which I have seen, were not preceded by inflammatory symptoms. Nor was there any swelling or pain in the tract of the absorbing vessels.” *** It would appear merely conjectural to refer the affection to a change in the veins; but the following circumstances are worthy of remark in connexion with the subject,-viz., the examples of phlegmasia dolens, from inflamed veins; of cedema of the lower extremities, from the accumulation of clots in the veins of the limb, without their obvious inflammation, and of chronic edema from the irregular congestion of the capillaries, without any discoverable alteration of the venous trunks during life.

"But we have no reason to suppose that the induration without thickening of the cellular substance is dependent on any change in the veins; and, until the precise anatomical character of the disease has been shown by dissection, the descriptive appellation should be admitted with reserve. From the unaltered size of the limb, it is difficult to ascribe the hide-bound condition of the part either to hypertrophy or atrophy of the cellular substance; for which reason it appears most probable that the affection is simply an induration or rigidity of this texture,-an effect probably of very slow inflammatory action, sometimes arising from local injury, and not unfrequently without any assignable cause." (pp. 311, 12.)

This latter form is very curious, and I believe entirely undescribed, nor does it readily admit of solution. The former kind seems to me very similar to the brawny condition above mentioned.-J. F. S.]

85. Symptomatic pseudo-erysipelas is distinguished from the idiopathic or common inflammation of the skin produced by irritation; the inflammatory redness is not so distinctly spread; at some little spots it is more intense, here and there inclining to violet; the affected part is less hot, more doughy, sometimes also hard and knotty, and often at the very beginning of the disease, distinctly fluctuating to the touch. The patient does not complain of such burning, but of a gnawing or beating pain, not proportioned to the degree of inflammation, and situated deeply in the limb. The swelling also bears no proportion to the degree of inflammation, but is in direct relation to the pain. Painful and knotty hardening of the skin frequently precedes its inflammation. When the inflammation has taken place, it always spreads farther, usually, however, more slow than quick, creeping, as it were, towards the affected parts. The ordinary means of resolution are of little use; in most cases, the disease is chronic, and single spots are often observed, which suddenly become more sunken, more or less distinctly fluctuating, mortified or destroyed in some way or other. All the external causes which could have given rise to ordinary inflammation of the skin are deficient also at the beginning of the disease. 86. The etiology of pseudo-erysipelas is clear from what has been already said of its several kinds. In reference to the necrotic hardening of the cellular tissue, which is the most usual cause of pseudo-erysipelas, it must

be remarked that, although its origin is in many cases obscure, yet a peculiar state of atmosphere, specially the operation of severe cold and a certain change of temperature, must contribute much to it. Hence this disease occurs more frequently in winter and in the coldest months, than at any other time of the year, more frequently in weakly people and on the lower limbs, more commonly in advanced age and in the male sex.

87. The Treatment of simple erysipelas requires especially action on the biliary and cutaneous systems. Emetics have generally here the best effect if employed early, and cannot be replaced by purgatives. If after their operation the fever continue, cooling acid purgatives with suitable antiphlogistic diet must be employed. Not until the fever has entirely or for the most part subsided and no further indication for depletory remedies exists, can sudorifics alone be relied on. Only if the erysipelas, especially on the face, be accompanied with high inflammatory fever, the head thereby attacked, the erysipelatous parts swollen, burning, and painful, accompanied with confusion and determination of blood to the head, should blood-letting or bleeding with leeches behind the ears be employed before the use of emetics, and at the same time the blood should be withdrawn from the head by warm foot-bathing, mustard poultices upon the calves of the legs, and so on. It is always, however, to be remembered, that erysipelas, even when connected with inflammatory fever, will not bear the same active antiphlogistic treatment as other inflammations, and is specially prone to return after any exhaustion.

[Two very different plans of constitutionally treating erysipelas are employed in this country, and, curious as it may appear to be, with success. The old method, still largely practised, is that on the antiphlogistic plan, first clearing the bowels, and then employing salines and antimonials; and, when the inflammatory action has subsided, administering gentle tonics, as tincture of calumba and the like. This treatment, which formerly I have seen constantly practised, and to which I have been personally, often in my youth, subjected, was generally very successful, and is, by many practitioners, still considered the best. The second mode is directly the reverse, and was, I believe, first introduced, fifteen or twenty years since, by my friend and colleague, Dr. WILLIAMS. It consists in the entire reliance on wine (port wine usually) given often to the amount of eight and twelve ounces a day, varying according to the age and condition of the patient's constitution, but without any consideration of the stage of the disease. And this practice has certainly been very successful, and is at our hospital now almost invariably followed. I prefer, if the case come under my care early, besides administering a dose of calomel and rhubarb, (which should never, under any circumstances, be omitted,) to give some saline and antimonial for twenty-four hours; rarely beyond that time do I defer giving the wine, the effect of which in checking the progress of the erysipelas is, generally, soon very decided. Bleeding, either from the arm or by leeches from the head, is, I believe, very unadvisable. The disease almost invariably occurs in constitutions without power, and therefore bleeding favours rather than diminishes it.-J. F. S.]

88. The Local Treatment of true erysipelas has no other object than to defend the diseased part against external injury, which may be effected by the use of dry warmth, by bags of camomile and elder flowers, by warm flannels, and so on. All moist, especially wet or greasy remedies, are injurious, as they repel the erysipelas, or produce oedematous swelling of the part. If, after the fever and swelling have for the most part ceased, there remains an oedematous, colourless swelling, the herb bag must be smeared with camphor, or the swelling covered with green-oil cloth, and swathing of the part made use of. According to RUST, only the vesicular erysipelas and its varieties, especially if they exhibit a more chronic than acute course, require the application of moist warmth in a proper vehicle, for which purpose GOULARD's lead wash with a small addition

of laudanum is best. If the erysipelas run into ulceration or gangrene, attention must be paid to giving free escape to the ichor; the general and local treatment must be regulated, as before mentioned, according to the character of the fever, and the rules given in reference to abscess and gangrene, and clearance of the bowels, must be especially remembered.

[The local treatment of erysipelas is very simple; warm or cold washes, as may be most agreeable to the patient's feelings, consisting of water with a little spirits of wine, are best, and I think preferable to either warm or cold lead wash, which renders the cuticle harsh and unyielding.

If there be much tension of the skin, the practice recommmended by DOBSON of making a dozen or twenty punctures with the point of a lancet is very beneficial, and agreeably relieves the hide-bound sensation which the patient feels.-J. F. S.]

89. In idiopathic erysipelas the treatment must be guided according to the degree of the inflammation. General antiphlogistic treatment is rarely necessary in this case; usually the application of leeches and of cold water or lead wash are sufficient for resolution.

[Leeches should never, under any circumstances, be applied locally, as the irritation resulting from their use itself frequently excites erysipelas or rather erythema. If absolutely requisite, puncture with the lancet is to be employed.-J. F. S.]

90. In erythema consensuale the treatment varies according to its original cause. If it depend on the tension of aponeurotic expansions, incisions, warm bathing, friction with mercurial ointment, warm fomentations and poultices must be applied. If the erysipelas appears only as a reflection of deeper disease of the periosteum, of the tendons, or of cellular tissue, so long as the disease continues purely inflammatory, abstraction of blood, leeching, applications of cold lead wash and free mercurial friction, and, in metastasis especially, mercurial laxatives and warm aromatic fomentations, must be used; in gastric symptoms, with loaded tongue, heartburn and the like, a vomit should be first given, by which principally the course of the disease is rendered less severe. But, if gangrene or ulceration have occurred in the deeper parts, and there appear a spot particularly discoloured or fluctuating, it must be opened and the wound dilated with the bluntended bistoury upon the finger in every direction where the destruction of the cellular tissue has occurred, in order to discharge the pent-up ichor and the often large pieces of completely dead cellular tissue. The further treatment consists in supporting nature to throw off the destroyed parts, to sustain the sinking powers, and to produce good suppuration. According to RUST, there may be applied locally bark, camphor, myrrh, charcoal, camomile flowers, turpentine oil, camphorated spirit, pyroligneous acid, spirituous aromatic fomentations, and so on; internally, powerful tonic remedies are to be used in connexion with mineral acids, and, if thereby a good suppuration is produced, the healing may be aided by the application of a moderately compressing bandage. I have, however, noticed, that under this stimulating local treatment, the destruction and unhealthy suppuration as well as the general irritation have increased, and that by the use of warm fomentations and a suitable general treatment improvement has been much more quickly produced; I, therefore, only use warm applications locally. In great hardening of the skin and of the underlying cellular tissue, I have always effected a perfect resolution by mercurial infriction and malt baths.

[Neither leeches, cold washes, nor mercurial friction are, according to my experience, of any material advantage, and therefore hurtful, as causing waste of time. The best

local treatment, and which I almost invariably adopt, is, when the skin is tense, shining, and deep red, to make several incisions, according to the extent of the disease, from an inch and a half to three inches in length, which I think preferable to very long cuts, just through the skin into the cellular tissue, which should be so disposed that every four should have interposed between them a sort of diamond-like space, and thus, when several cuts are made, the skin has a net-like appearance, and yields in every possible direction. The object is not to obtain blood, which, indeed, I generally endeavour to avoid by bathing for a few minutes with cold water, if there be any disposition to bleeding, but to allow the cells of the cellular tissue to empty themselves of the fluid with which they are loaded, the effect of which is, that the skin, being further relieved of tension, is less likely to slough, and the tissue itself being no longer squeezed by the effused serum, the blood passes freely through its capillary vessels, and its life is preserved, instead of it becoming strangulated. If the tension be not sufficiently relieved, or if the disease be continued up the limb, it will be necessary to make additional cuts from day to day, which is the only chance we have, that I am aware of, to prevent the death of the cellular tissue, and it each time relieves the patient's sufferings most remarkably. In one instance of a man who had inflammation of the cellular tissue of the back of the hand, resulting from a strain, and which travelled up to the chest, I made about thirty cuts, mostly three inches in length each; during the course of the week, nearly the whole cellular tissue of the arm sloughed; but he completely recovered, his arm, however, closely resembling a piece of scored pork.

In these cases brandy, wine, porter, general good feeding, and humouring the appetite, are absolutely necessary, and infinitely preferable to medicine, which should be restricted to an opiate, or an occasional dose of castor oil, as needed.-J. F. S.]

91. In the treatment of the various kinds of erysipelas, we have given the treatment proper for each, and which has been proved by experience. The opinions, however, of the most distinguished physicians differ from each other in many important points on this subject. Thus the incisions should only be made in pseudo-erysipelas, and of the suitable length and depth, according to RUST, DUPUYTREN and LAWRENCE; while, according to HUTCHISON (a), they should be made early and in considerable numbers; but DOBSON (b) employs numerous punctures with a lancet in all kinds of erysipelas and on all parts of the body. In pseudo-erysipelas DUPUYTREN (c) professes, in some cases, to have effected a satisfactory resolution by blistering the diseased part: he, however, considers this remedy as doubtful, as in other cases he noticed deterioration and sloughs occurring after its use. But, in all cases of common erysipelas, if the tongue be moist and little red, the skin moderately hot, and slight general reaction connected with the local inflammation, he considers the suppuration produced by one or more blisters upon the inflamed part as the best mode of effecting resolution. Some (d) would arrest the extension by the application of a blister at the margin of the erysipelas; but others (e) entirely reject their use. BRETONNEAU (f) and VELPEAU (g) have had the happiest results from moderate compression of a limb attacked with inflammation, even when the transition to suppuration seemed unavoidable and all other remedies had failed. LAWRENCE and DUNCAN have, on the contrary, observed bad effects resulting from this practice (h).

[Another mode of attempting to check the spread of erysipelas, is that of enclosing it, if small, within a space bounded by a belt, a quarter or half an inch wide, made on the skin with nitrate of silver; or, if a limb be affected, by gartering it in the same way

(a) Case of Erysipelas, with Remarks; in Med.Chir. Trans., vol. xiv. p. 213.

(b) On Treatment of Erysipelas by Punctures; in Med.-Chir. Trans., vol. xiv, p. 206.

(c) DUPUYTREN, as above, p. 322. OLIVET, Thèse, de l'Erysipèle Phlegmoneux, p. 30.

(d) RocHE et SANSON, Nouveaux Elémens de Pathologie Medico-Chirurgicale, vol. i. p. 352. LAWRENCE, as above, p. 63.

(e) RAYER, Traité des Maladies de la Peau, p. 125. (f) Sur l'Utilité de la Compression dans les Inflammations Idiopathiques de la Peau. Par., 1815. (a) Mémoire sur l'emploi du Bandage Compres sif dans le Traitement de l'Erysipèle Phlegmoneux, de la Brûlure et des plusieurs autres inflammations aigues des membres; in Archives Générales de Médecine, Juin, 1826, p. 192.

(h) LAWRENCE, as above.