Part 9

Erysipelas may terminate in resolution. If this takes place in the first stage of the disease, the redness gradually declines, along with the swelling, the cuticle exfoliates, and the part regains its usual appearance, the skin remaining loose and shrivelled. If it occurs after vesications have formed, the effused fluid is absorbed, a scab forms, and desquamates along with portions of the cuticle.

It may terminate in suppuration, when the inflammation has extended to the cellular substance. This termination is most frequent when the disease is situated in an extremity, seldom when in the face, though small purulent collections occasionally form in the eyelids. Circumscribed collections of pus often present themselves after the disappearance of the erysipelatous inflammation; but the purulent matter is generally diffused through the filamentous tissue, and is of a thin, unhealthy appearance, and mixed with sloughs of the cellular substance. By the infiltration of matter, the integuments, fasciæ, and muscles are extensively separated from each other, in consequence of which the parts frequently die, their nutritive supply being cut off.

Acrid sanious matter is often infiltrated extensively into the subcutaneous cellular tissue round a wound or sore. The superimposed integuments are of a dark brown colour, and the part is boggy. Sloughing of the cellular membrane here takes place in consequence of the infiltration, and not from inflammatory action having been established. The affection has been termed Diffuse Cellular Inflammation, but a more proper appellation is Diffuse Cellular Infiltration; the cellular tissue, even where treatment is adopted at an early period, can scarcely be prevented from perishing.

Erysipelas, if properly treated from its commencement, will seldom terminate in gangrene of the skin. This termination is occasionally observed, however, in patients whose constitutions have been extremely debilitated.

In mild cases of erysipelas, attention to the state of the bowels, and regulation of diet, will often be sufficient to remove the disease. When there is much disorder of the digestive organs, and particularly of the biliary secretions, emetics may be given at the commencement; these are productive of but little good in the more advanced stage, and their place is advantageously supplied by nauseating doses of antimony, combined or not with purgatives. One-eighth of a grain of tartarised antimony may be given in solution every hour, with or without a due quantity of the tart. potassæ and sodæ, or Rochelle salt. The hydrargyrum cum creta is often given with great benefit when the tongue is dry and covered with a brown crust: it may be combined sometimes advantageously with the compound powder of ipecacuanha. With the same view calomel with antimonial powder may be exhibited. The exhibition of saline purges is attended with great good in some severe cases. Such medicines tend to subdue any arterial excitement that may exist, evacuate the bowels, promote perspiration, remove the superabundant bilious matter, and serve to restore the healthy functions of the liver. In severe cases, more especially of phlegmonous erysipelas, in which there is acceleration of the pulse, and a degree of febrile excitement, general bleeding may be had recourse to; but it must be employed with caution, for the symptoms of increased vascular action may arise from constitutional irritation, and not be meliorated by the depletion. The practice is superseded by the timeous and free local bleeding from incisions, as will be noticed by and by. The exhibition of the extract of aconite in this and other inflammatory affections, is often followed by great abatement of vascular excitement, so that the necessity for abstraction of blood is done away with. The medicine may be given in doses of half a grain in substance, or dissolved in pure water, and repeated every third or fourth hour. The sensible effect is relaxation of the surface, and frequently profuse perspiration; the arterial pulsations are diminished in frequency and force. The extract of belladonna, in doses of one-sixteenth of a grain, may then be substituted with great advantage, and often with the most extraordinary effect upon the disease. In very many cases, the strength is from the first to be supported by all possible means, by nourishing diet, by the exhibition of wine, quinine, and other tonics; more particularly in old people—in constitutions debilitated by disease—in unhealthy situations, and when the fever is of a typhoid kind. Bleeding by leeches is not admissible, for the leech-bites prove a source of irritation, and are liable to suppurate; erysipelas has often been produced by leeching.

In erythema, the mere outer surface of the skin only being slightly affected, and not to any very great extent, advantage sometimes results from the application of nitrate of silver. A strong solution may be pencilled upon the part, or, after being wetted, the affected surface may be gently rubbed over with the solid caustic. The pain and uneasy sensations in the part being thereby diminished or removed, and extension of the disease seeming to be arrested. Discoloration caused by such practice is of little consequence, as desquamation must follow. It is questionable how far it may be safe to apply lunar caustic to any extensively inflamed surface, more especially of the head and face, lest metastasis should occur. The inflammatory action in the skin is subdued by the application, whilst it may advance, in the cellular tissue, to suppuration and sloughing, if other means are not adopted; and from the hard and blackened state of the cuticle, the condition of the subjacent parts is not readily perceived. The remedy is only applicable to erythema, and most advantageously as a means of bounding it. The line should be drawn at some distance from the affected tissues; and if so, it is seldom that the disease oversteps it.

Local abstraction of blood, by puncture or incision, proves exceedingly beneficial in cases of erysipelas, whatever its degree. It must be borne in mind by the practitioner, when called to treat the disease, that the state of parts is very various, and this may depend upon the original nature of the disease, upon its site or duration. The surface of the skin only may be affected—that and the subjacent cellular tissue may be involved, gorged with serous, lymphatic, or purulent infiltration—there may exist great tension of the parts, with a sloughy state of the cellular tissue, established in addition to suppuration—and again, there may be infiltration of the subfascial and intermuscular tissues, leading ultimately to exposure and exfoliation of bones or disease of articulations.

From inattention to these circumstances, the treatment being often directed to the name of the disease, great discrepancy of opinion, as to the most proper local management, has arisen; there has accordingly been a controversy as to whether the blood should be drawn from mere punctures from limited incisions, or from long gashes extending from one joint to another.

In cases not very severe or extensive, when the skin only is affected, the constitutional treatment already mentioned is first to be employed, and then the affected part must be freely punctured with a fine lancet, at numerous points, as recommended by Sir R. Dobson. These punctures should reach the vascular layer, but not go deeper: the serous effusion, if there be any, is thereby evacuated—the over-distended vessels are relieved of a considerable portion of their contents—and the œdematous swelling, with the formation of phlyctenæ, is prevented. The part is afterwards to be fomented for half an hour, or an hour, with bags containing chamomile flowers or hops; the fomentation, repeated at intervals, proves highly grateful to the feelings of the patient, allays any irritation which the making of the punctures may have produced, and keeps the skin perspirable. Under this treatment, every vestige of erysipelas will generally disappear in the course of a few days. In more severe cases, especially in the extremities, the parts must be freely incised. The incisions ought to extend through the integuments and cellular substance, and their length and number must be proportioned to the extent and severity of the affection. One or two pretty free incisions, if made in the proper place, where the greatest degree of boggishness, marking the disorganised state of the tissues, is discovered, will generally suffice—the vast good and the relief afforded depends partly upon the abatement of the tension, in consequence of the evacuation of the effused fluids—upon the unloading of the over-distended bloodvessels of the part, and upon the acceleration of the suppurative process, which is often critical. The constitution is, probably, relieved by the suppuration of the wounds, and the consequent drain of the offending particles.

Some surgeons have disapproved of long incisions, alleging that they are tedious in healing, and prefer making numerous small ones; but it is difficult to understand how the cure should be more tedious in the one case than in the other, when the actual extent of divided surface is the same. According to my experience, several free incisions are made with less pain than a number of trifling scratches, and heal as soon, whilst by the former the purpose of the practitioner is much better fulfilled: the same good effects result from them as from punctures in the more slight cases, if they are made at the commencement of the disease; and if the affection is in its advanced stage, the effused fluid, and the sloughs, are discharged, and the infiltration of pus, and destruction of parts in consequence of the matter being confined, are prevented by its being allowed a free exit as soon as it is formed. Incisions then are made both in the early stage of the disease, and after effusion has occurred: in the former case, they are justifiable, because they arrest its progress; in the latter, they are absolutely necessary, to prevent its injurious effects. The parts are to be fomented, and afterwards covered with a common poultice, containing no oil or grease, or with soft lint saturated with tepid water, and covered with oiled silk, to prevent evaporation.

When the erysipelas has gone off, the incisions are treated as common wounds, by dressing and bandage. After punctures, or incisions, more or less blood is allowed to flow, according to circumstances. It often escapes from the vessels of the part in great profusion; this, in many cases, may be prejudicial or excessively dangerous. In the extremities the flow can readily be arrested by elevation of the part, or by pressure, for a short period. In erysipelas of the face, punctures are preferable to incisions, as by the employment of the former the countenance is no way disfigured; if, however, in erysipelas of the scalp, the integuments become swollen, and present a puffy feeling, whilst at the same time cerebral symptoms supervene, free incision or incisions, through the whole thickness of the covering, and in the direction of the fibres, must be made. If erysipelas be thus actively treated, it may be safely affirmed that the disease will not often, unless accompanied with symptoms of putrid fever, terminate fatally; if these means are employed early, the constitutional disturbance will be modified or prevented, and no derangement of the cerebral functions will ensue.

Powders, such as flour, chalk, and camphor, &c., have been applied to the erysipelatous surface, but are of little use, and, by their irritation, frequently prove injurious on the bursting of the vesicles. They are applied, according to some, with the view of cooling the surface, and after all the part may be seen enveloped in folds of flannel. Cold application, such as the spirituous and evaporating lotions, containing vinegar and spirits, liquor acet. ammoniæ, Goulard’s extract, &c., may, in many cases, afford temporary relief, but their use is fraught with the utmost danger; for their direct tendency is to produce metastasis, and if that be to an internal organ of importance, the result is too generally fatal. Or if the erysipelas, on leaving the part originally affected, attack another also superficial, the local treatment has to be commenced anew. If these lotions are to be employed at all in this disease, they must be made tepid.

In case of the translation of erysipelas to any important part, blisters may be applied to the surface which it has left, or to any other in the neighbourhood, with the view of recalling the disease to its original and less dangerous situation: the actual cautery has even been recommended. In the great majority of cases, however, such means are unavailing.

In Hospital Erysipelas, purging cannot be carried to any great extent with safety, and general bleeding is seldom if ever admissible unless the patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hospitals, the patients are generally in a weak state before the accession of this disease; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals: in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to destroy immediately such dressings as have been used. The apartments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local applications will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the surface of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some remedies that have been used; such as the arsenical solution, or the red hot iron.

OF FURUNCULUS AND ANTHRAX.

Furunculi, or Boils, most generally occur in unhealthy constitutions, particularly in those individuals who are habitually addicted to the use of ardent liquors: they seem to arise from, at least they follow, disorder of the digestive organs. Their seat is in the skin and subjacent cellular tissue.

They generally occur in those parts which are possessed of little vitality, as in the back, buttocks, shoulders, the posterior part of the neck, &c. They are seldom single, are often numerous, and vary in size from a pea to a pigeon’s egg.

A boil is of a conical form, elevated above the surface of the body; its base is hard and firm, whilst its apex is acute, soft, of a white colour, and exceedingly painful; the pain experienced in the tumour is severe and burning. From the comparatively trifling nature of the affection, the assistance of the surgeon is seldom required, and hence the apex of the tumour generally gives way either spontaneously, or in consequence of being scratched by the patient, or rubbed by the clothes; the purulent matter, which is generally small in quantity, and mixed with blood, is thus discharged. This, however, is attended with but little relief in bad forms of the affection; for at the lower part of the cone is situated a considerable quantity of mortified cellular tissue, which must be evacuated before the cavity can heal.

In this unhealthy species of inflammation, resolution cannot be expected; on the contrary, suppuration is the natural termination of the disease, and must be hastened by poultices and fomentations. A simple or crucial opening, according to circumstances, must afterwards be made in the apex of the tumour, so that the sloughs of the cellular tissue may be permitted to escape readily. In the advanced stage, the sloughs are the irritating cause by which the inflammatory action is prolonged, and on their removal the cavity contracts speedily.

If there is much derangement of the digestive organ, it may frequently be found necessary to administer an emetic. If the bowels are slow and the liver torpid, calomel and antimony are highly useful, or other mercurial preparations may be given, in combination with active purgatives; if the state of the secretions is more natural, these medicines may be administered in alterative doses. The mineral acids are often usefully administered, with the view of removing the disposition to the formation of boils. Twenty minims of the aromatic sulphuric acid may be given twice or thrice a day in any convenient vehicle. Anodynes are occasionally required.

Anthrax or Carbuncle maybe considered as a severe form of boils. It occurs in the plague, and is a characteristic symptom. It appears in the same parts, and apparently from the same causes, as the boil. The tumour is of a more flattened form, slightly elevated above the surface, and frequently of great extent; the base is deeply-seated, hard, and unyielding. The integuments are at first of a bright colour, but afterwards assume a dark-red or reddish-brown hue. The pain is violent and burning. The process of suppuration is very tedious, and the matter that is formed is small in quantity. If the tumour is not interfered with, ulceration occurs in its surface, producing various apertures, through which the matter is evacuated, the discharge is thin and unhealthy, excoriating the neighbouring surface; and the mortified cellular tissue, remaining at the base of the swelling, keeps up the irritation. The extent of a carbuncle is frequently great, both as to width and depth; on the back, or buttocks, it not unfrequently attains an immense size. In one instance, the whole posterior part of the neck was involved; the cellular tissue, muscles, and tendons, sloughed; and the vertebræ were ultimately exposed. In another case, the whole occiput, the posterior and lateral parts of the neck, and the space betwixt the shoulders, exhibited one continuous mass of carbuncle. By making free incisions, procuring early separation of the sloughing parts, and supporting the strength of their constitutions, both patients recovered, though considerably advanced in life.

It seldom occurs in the face or head, and when it does, it generally proves fatal. In a male patient in the Edinburgh Royal Infirmary, aged forty-eight, a carbuncle of the size of a very large orange was situated in the centre of the forehead; by active local and constitutional treatment, he soon got well.

The affection is sometimes attended with typhoid symptoms, rigors, profuse perspiration, nausea, vomiting, disordered bowels, loss of appetite, anxiety, restlessness, difficult respiration, palpitations, faintings, pale-white tongue, low pulse, pale or turbid urine, headache, giddiness, drowsiness, and, in severe cases, with delirium. In old or exhausted patients, the prognosis is unfavourable.

An early and free incision must be made into the tumour; if the swelling is large or extensive, the preferable form of incision is the crucial; the ill-formed matter is thus evacuated, the slough exposed, and more readily allowed to escape. If the mortification of the cellular tissue be extensive, and the sloughs prove firmly adherent, the free employment of the caustic potass will be found of much service, the half-dead cellular substance being thereby completely destroyed, and the surrounding parts stimulated to a new and superior degree of action, necessary for the removal of the mortified parts, and reparation of the breach of surface. Poultices and fomentations may afterwards be employed, followed by the warm-water dressing, medicated or not. The stomach and bowels must be put into proper order by the exhibition of suitable medicines; and the vis vitæ may be still farther supported by the administration of tonics and stimulants. If, after the separation of the sloughs, the exposed surface shall assume an indolent or debilitated action, stimulating dressings, such as turpentine liniment, or elemi ointment may be employed.

Such practice will be found sufficient to procure a speedy and favourable termination of the disease, in this country, where we have not to combat any of those malignant diseases with which carbuncle is accompanied in other climates.

OF INFLAMMATION OF THE MUCOUS MEMBRANES.

Mucous Membranes and the skin are analogous in structure, somewhat similar in function, and sympathise closely with each other in health and in disease. Both are endowed with that peculiar degree of sensibility which enables them to bear with impunity the impressions of foreign bodies; and both are protected from the influence of these bodies by an inorganic covering; the cutis and rete mucosum by the epidermis; the corium of mucous membranes by a laminated epithelium. They are the seat of all excretions, and by them all substances are introduced from without into the system. The capillary portion of the vascular system appears to have somewhat the same arrangement in both; the distribution of blood to the mucous membranes being, however, more copious. At the commencement and extremity of the alimentary canal, they insensibly pass into each other by means of an intermediate structure, of which the prolabium may serve as an example. In particular circumstances, they change into each other, both in appearance and in function. Thus, in prolapsus of the gut or of the vagina, the discharge from the protruded mucous surface after a time subsides, the rugæ disappears, the membrane becomes thickened and indurated, and gradually assumes an appearance exactly resembling that of the skin. In natural paraphymosis, the delicate membrane which, in the healthy state of parts, lines the internal surface of the prepuce, becomes converted into a cuticular covering. In neglected and long-continued excoriation of the nates, the raw surface, which was at first tender and irritable, and discharged a serous fluid, becomes villous, less sensible, and discharges a fluid similar to a mucous secretion. In sinuses also of long duration, the secreting surface becomes changed, so as to resemble a mucous membrane, and the discharge, from being purulent or gleety, becomes mucous, or at least resembles a mucous fluid,

A mucous surface, when inflamed, has for a short time, perhaps, at first, its functions suspended; it then furnishes a secretion, increased in quantity, and but little changed in appearance from the healthy fluid; afterwards the discharge resembles purulent matter, and is termed muco-purulent. When, however, the inflammation is violent, the discharge becomes bloody, or is altogether suppressed, and the membrane is thickened. Inflammation of a mucous membrane is very apt to spread with great rapidity, in this respect resembling the corresponding affection of the skin. It is attended with a sense of itching, and a burning pain. This pain is much increased by the muscles surrounding the parts being thrown into action, as in expelling their contents, more especially if these be of an acrid quality. The membrane is thickened, and of a spongy appearance; its surface is red, and sometimes covered with flakes of lymph; occasionally it is much softened, and coated with a viscid adherent mucus; and it would appear, in many instances, that, in acute inflammation, the membrane is generally softened, whilst it becomes indurated from chronic inflammatory action. When the inflammation is violent, and consequently rapid, considerable quantities of lymph are effused either on the surface of the membrane, or into the submucous tissue: and the lymph subsequently becoming organised, the membrane is much thickened, and a contraction is the consequence. The functions of a part lined with mucous membrane are more or less deranged, in consequence of the vitiation of the secreted fluid.