MALIGNANT PUSTULE, AND HOSPITAL GANGRENE.

97

advisable to leave the separation of the parts to nature and saw off the bone.

Full reports of observations on this subject are to be found in THOMSON (a) and in SAMUEL COOPER (b).

78. The treatment of malignant pustule varies according to the accompanying symptoms. The local treatment consists in cutting out the pustule by a circular incision, and afterwards cauterizing the edges of the wound with nitrate of silver or sulphuric acid, (also with the actual cautery,) and placing upon it charpie moistened with oxymuriatic acid. The slough is to be covered with a softening bran poultice, and, after it is thrown off, the treatment of the wound is to be simple. If the pustule be not deep, but the slough much outspread, it is proper to make deep scarifications and employ the remedies just mentioned. If general symptoms are not present, it is only necessary to use sulphuric acid or HALLER'S acid mixed as a drink. If there be indications of gastric impurities, emetics must be employed in divided but sufficiently effectual doses, and, if they do not operate, purging, or vinegar clysters must be used. If the powers sink and nervous symptoms appear, strengthening and stimulating medicines are required; bark, serpentaria, arnica, valerian with elixir of vitriol, hydrochloric acid, and so on. But bleeding is rarely required, unless in decided plethora and great determination of blood to the head and chest.

On malignant pustule see

LARREY, as above, vol. i. p. 52.

HUFELAND'S Journal, vol. li. part v.; vol. liv. part iii.; vol. lvi. part iv.

RUST's Magazine, vol. xv. part i.; vol. xvi. part iii.; vol. xvii.

J. N. HOFFMANN, der Milzbrand, oder contagiöse Carbunkel der Menschen, mit Beruchsichtigung einiger damit zu verweckselnder Krankheitsformen und einer fragmentarischen Uebersicht des bei den Thieren herrschenden Milzbrandes. Stuttgardt, 1827. 8vo.

RASEDOW, die schwarze Pocke; in Journal von VON GRAEFE, u. VON WALTHER, vol. vii. p. 185; vol. xii. p. 549.

SCHROEDER, über die schwarze Blatter; in RUST's Magazin, vol. xxix. part ii. WENDROTH, über die Ursachen, Erkentniss und Behandlung des contagiösen Carbunkels. Sangershausen, 1838.

79. It is apparent, from the nature of the causes of hospital gangrene, already mentioned in what way this dangerous complication of wounds and ulcers can be guarded against. Care must be taken as much as possible for purity of air and proper diet with a moderate use of wine; the greatest cleanliness of the bandages must be observed, the wound must be washed with a light aromatic infusion or with diluted alkaline solutions, and symptoms of gastric impurity must be removed by vomiting and purging. Emetics are especially advised by POUTEAU, DUSSAUSOY, and others, as the most important remedies at the beginning of the disease. They recommend them as being of themselves capable of stopping the advance of the disease.

If the peculiar changes occur in the wound or in the sore, (par. 35,) washing the whole surface with good vinegar, after thoroughly cleansing with charpie, and frequently moistening the bandage with vinegar, is often sufficient at the onset to restore the wounds in a few days to their former condition. For the same purpose also is the solution of arsenic recom(a) As above, p. 538. (b) Dictionary of Surgery, article Mortification. VOL. I.

H

mended. If the surface of the wound do not improve in appearance, its entire extent should be touched with nitrate of silver, or conical pieces of caustic laid in the viscid mass. But, under these circumstances, the most important remedy is the free application of the actual cautery to the whole surface of the ulcerated part. The slough is to be covered with powdered bark and turpentine or some stimulating salve, and when the slough has separated, the appearance of the wound must determine whether the application of the cautery is to be repeated or not. Besides these means, the following may also be recommended; decoction of bark, diluted mineral acids, especially hydrochloric acid, yeast poultices, spirituous lotions, brandy and myrrh, aloes and camphor, hydrochlorate of ammonia with water and vinegar, spir. terebinth, ung. styrac. and Egyptiacum, balsam of copaiva, solutions of bichloride of mercury and nitrate of silver, butyr of antimony, pyroligneous acid, lemon juice and so on.

80. General treatment, suited to the different condition of the patient, must also be connected with this local treatment. At the onset, if symptoms of irritation and active febrile excitement are present, acid drinks, especially dilute mineral acids, are serviceable; in impurities of the stomach, emetics; in great weakness, bark and other tonic remedies; only in rare cases is a strict antiphilogistic plan of treatment called for. The diet must of course correspond with the general treatment, and care should be taken for purity of air and keeping the patient apart from others.

On hospital gangrene compare

POUTEAU, Euvres Posthumes, vol. iii. 1783. 8vo.

GILLESPIE, LEON, Observations on the Putrid Ulcer; in London Medical Journal vol. vi. p. 373.

1785.

DUSSAUSSOY, Sur la Gangrène des Hôpitaux. Genève, 1787. 8vo.

BLANE, G., M.D., gives an account of this gangrene, by the name of Malignant Ulcer, in his Diseases of Seamen, p. 502, 3rd Edit., London, 1799.

TROTTER, M.D., describes it by the same title in his Medicina Nautica, vol. ii. p.170; vol. iii. p. 467.

BELL, JOHN, Principles of Surgery, vol. i. p. 136.

LESLIE, De Gangrænâ Contagiosâ. Edinburgh, 1805.

JOHNSON, CHARLES, M.D., de Gangrænâ Contagiosâ Nosocomiale. Edinburgh, 1805. THOMSON, JOHN, in his Lectures on Inflammation, p. 456.

RENARD, über den Hospitalbrand. Mairz, 1815. 8vo.

GERSON, über den Hospitalbrand, nach eigenen Erfahrungen. Hamburg, 1817. 8vo. H. BLACKADDER, Observations on Phagedæna Gangrænosa. Edinburgh, 1818. 8vo. W. WERNECK, kurzegefasste Beiträge zur Kenntniss der Natur, der Entstehung, der Verhutung und Heilung des Hospitalbrandes. Salzburg, 1820. Large 8vo.

BRAUER, Observationes quædam de Gangrænâ Nosocomiali, quæ anno hujus sæculi XIV. Lipsiæ inter milites variarum nationum grassata est. Lipsiæ, 1820.

ALEXANDER, über den Hospitalbrand; in Hippocrates Magazin von SANDER und WAEPTER, vol. v. p. 1-220.

DELPECH, Clinique Chirurgicale de Montpellier, vol. i. p. 78.

BOGGIE, in the Transactions of the Medico-Chirurgical Society of Edinburgh, vol. iii. p. 1. 1828.

OLLIVIER, A. F., Traité experimental du Typhus Traumatique, Gangrène ou Pourriture des hôpitaux. Paris, 1822.

8vo.

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 cellulosæ; 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.; Erysipèle, 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 erysipelas, 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, 1826. 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, thus 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