Part 8

“3. Continues in much the same state as yesterday; pulse 104, of good strength; tongue clean and moist; bowels moved once; skin natural; appetite good; suppuration very free. Cont.

“5. Suppuration copious; a portion of the dead parts left have separated, and left a healthy florid granulating surface. Continues much the same.

“6. Discharge copious, and much less fetid; bowels regular; pulse 100, of good strength; tongue clean; appetite good; wishes for more food. To have an additional chop. Cont. alia.

“8. The greater part of the sloughs have separated, and have left a healthy florid granulating surface; no change in the general symptoms. Continue.

“9. The stump looks well, and the posterior part of the cut end of the bone is covered by healthy granulations.

“In some notes of this case, kindly furnished me by the late Professor Fergus of King’s College, who had an opportunity of watching the appearances for some time before the admission of the patient here, it is mentioned that the flow of blood in the veins was exceedingly slow, and that hard knotty tumours could be felt in the parts before they became sphacelated. These swellings all along preceded the mortification. It is mentioned, besides, that the patient had a sort of fit, but that it could not exactly be ascertained whether or not she lost consciousness. Her left arm is said to have been motionless from and after that time. There is considerable discrepancy in the accounts of the mode of invasion, and of the duration of the disease, before the line of separation became apparent. A period of six weeks is stated in our case-book to have elapsed from the attack to the admission of the patient into this hospital. It would appear, however, from the other history, that not more than three weeks had passed over. The old lady is not very distinct in her account; at one time she makes a statement with great minuteness, and very soon after contradicts herself on almost every point. When pressed on the subject, she states that she got disgusted with her condition, became despondent and careless about everything, and that her recollection is not now very good.”

“S.W., aged 16, was admitted March 12, under the care of Mr. LISTON. She is a servant girl, of sanguine temperament and good constitution. On Friday, March 9, she was cleaning the outside of a parlour window, and stood on the sill. The window-sash, upon which she was depending for support, being suddenly drawn down by a person inside, she was precipitated into an area, a distance of fifteen feet. She was immediately picked up, and conveyed to the hospital. The house-surgeon detected a compound fracture of the ulna, and a fracture of the radius, both fractures being a little above the wrist-joint of the right arm. The fracture was adjusted, and the wound, which was inferiorly to, and behind, the wrist, dressed in the usual manner. A dose of house-medicine was administered; suitable directions were given in case of the occurrence of pain or swelling; she was sent home, and desired to remain quiet. The following morning (Saturday) she was visited by the house-surgeon, who found her comfortable, but she had passed a sleepless night. On Sunday morning the affected part became so intolerably painful that she tore off the splints and bandages, which one of the dressers of the hospital had a short time before readjusted; in the evening she was in great pain, and the arm was much swollen.

“12. To-day (Monday) she was admitted into the hospital; water-dressing was applied to the wound. The bandages were reapplied, and an anodyne administered in the evening, with the effect of producing some rest.

“13. The pain and swelling were so great during the night that the house-surgeon was called up to see her, and ordered the application of fomentations; this morning she is much more comfortable.

“14. On removing the whole of the apparatus this morning early, mortification was found to have taken place in the limb; at the time of Mr. Liston’s visit in the middle of the day, the limb was very swollen, the fingers were of a black colour, the forearm livid, there were vesications near the elbow with fetid discharge. There was a good deal of fever with slight delirium; pulse irregular, quick. Mr. Liston considered the only chance the patient had was the immediate amputation of the limb at the shoulder. The patient’s consent having been readily obtained, Mr. Liston proceeded at once to the

“Operation.—He first introduced a long double-pointed knife under the acromion, and brought the point out at the lower and posterior border of the axilla, by this means the joint was laid open; the flap thus formed of a portion of the deltoid was raised, and the head of the bone separated from its attachments. The other flap was formed from the integuments and muscles in front. The axillary, and one other vessel, required ligature. The edges of the wound were drawn together by three points of suture, and cold water-dressing applied. One grain of muriate of morphia was given. In the evening, several strips of isinglass plaster were applied, and the edges approximated. The delirium ceased after a short but refreshing sleep.

“15. Passed a good night; has had little pain; feels very comfortable this morning; she is cheerful, and has little fever; pulse 86, regular. The wound looks healthy.

“April 2. Since the above date, the patient has been gradually improving in her health and strength, and she is now able to walk about the ward.”

In gangrene occurring after exposure to cold, amputation should not be had recourse to till after the line of separation has formed; and in this case the constitutional symptoms are much less urgent, and the object of the operation might be frustrated by its being performed in parts, which would speedily become sphacelated. The amputation may be performed either at the line of separation by cutting the ligaments or bones, as was done in the case from which the accompanying sketch was taken, and when the line of separation is well declared; or, if by these means a good covering is not likely to be had for the exposed surface, the incisions may, in these cases, be with safety and propriety made in the living tissues, at the most convenient point.

In gangrene arising from obstruction or injury of blood vessels, in 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.