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 ædematous 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 oedematous 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 oedematous, 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

ERYSIPELAS-Inflammation of Cellular Tissue.

103

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 consequences 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.

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-eigh hours or less, the greater part, or the whole, of the skin is sloughy. If there be suffcient 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 ths 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 erys pelas, 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 subsice 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 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 oedema. But, many years ago, I had under my care a woman, between twenty and thirty years of age, whose fate 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 svollen 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 ower 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 oedema, 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 oedema 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.)

دو

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