LEAVES FROM THE CASE-BOOK OF A PRACTISING PHYSICIAN

JohnCharles Hall
1849 The Lancet  
10 Heec denum sunt quae non subgesset phattasiae ]maginatricis temeretas, sed phsenomena practice edocuere."—SYDNNHAM. LEAF THE FIFTH. 2s th Nitrate-of Silver of Advantage as a Local Application in Erysipelas ? ? THE term " erysipelas" has perhaps been applied in a more vague and indefinite manner than any other we employ in the medical vocabulary. It would be foreign to the object with which these papers are written to enter at length into disputations as to what constitutes the distinction
more » ... ween erysipelas and erythema. Dr. Watson has proposed, with a view to the formation of more settled opinions in respect to 'erysipelas, that the term should be restricted to " that disease in which the integuments of the face and head become diffusely inflamed, the term ' erysipelatous inflammation' may properly enough be applied to other cases similar to this, in so far as the condition of the skin is concerned; but in what-I should consider true erysipelas, in the medical sense of the word, there are other characters belonging to the disorder quite as important as, and more distinctive than, the cutaneous affection:" Dr. Willow mentions four kinds of erysipelas:*— 1. E. P7ùegmonides. 3. E. Gangrenosum. 2. E. (JJ]dematodes. 4. E. Erraticum, each too well known to require notice here. In the first editions of Dr. Bateman's work, erysipelas was classed amongst the "$ullae;" in the last edition it is regarded as one of the exanthematathe editor concluding, that "although vesications certainly occur in severe and aggravatedcases, yet in the great majority of cases this symptom is absent;" and unless it be an invariable attendant on the disease there is more propriety in placing the disease in its present class (Exanthemata) than where it formerly stood in Dr. Bateman's work. In the first species (phlegmonous erysipelas) the eruption -is accompanied with great pain and a severe burning-sensation; the tingling-and excessive heat of the part is <:onstantly-complained of; the colour is more of a dull, livid scarlet than the rosy tint peculiar to the other kinds; the swelling generally appears on thesecond night or third day of the fever; and extends to the cranium from the face; the cutis only is affected, and in the line of its progress is elevated, and shows -a-well-defined edge, the diseased parts appearing upon the healthy almost like embossed work."t Vesications, when they are present, arise on the fourth or fifth day, and subside or burst on the sixth; the redness melts into a yellow tint, the fever declines, and the swelling diminishes. When gangrene takes place there is disorganization of the cellular tissue, which comes away in shreds, bathed in pus; the integuments are livid, deprived of their vitality, and if the sufferer recover, an agglutination of muscle, fascia, and skin having taken place, the motion of the affected part is more or less impeded. Happily, phlegmonous erysipelas, excepting when the lower extremities are attacked, very frequently, under appropriate treatment, terminates in resolution; in the legs and feet this result cannot so often be hoped for; suppuration takes place, the cellular tissue in these parts having as great a tendency to suppurate, or nearly so, as the eyelids and scrotum. This result is always attended with a great deal of mischief; the pus collects, not into one large cavity, but in innumerable small points, and large portions of the cellular structure come away. Nor is the mischief confined to this part only; the skin becomes altered in colour, assuming a dark, dingy hue, and perishes, not so much from inflammation as from want of nourishment. This was clearly pointed out by Dupuytren, who observed, that * EpV<T"1I'e^a, from epvw, 2reas, indicative of its tendency to wander; according to others, from epc8por, expressive of redness. Celsns speaks of it as " ignis sacer ;" and Lucretius writes-Et simul ulcerimus quasi inustis omne rubore, Corpus, ut est, per membra sacer quom diditnr ignis." t Bateman's Synopsis, eighth edition, p. 148. l Clin. Chir. t. ii. P. 29. "mortification of the skin is very common in the leg, where the nutrient arteries, being deeply placed, communicate with the integuments by small branches only, and the destruction of the cellular substance destroys at the same time all these slender branches." This kind of erysipelas is very common on the face and head, but here the disease very seldom ends in mortification, which Bateman and Dupuytren both justly ascribe to the distribution of the temporal, frontal, and occipital arteries. In oadematous erysipelas, (which is attended with considerable danger when it invades the head-and face, and which commonly attacks persons of debilitated and impaired constitutions, the inflammation is sub-acute, and the swelling pits as in common osdema. The vesications are small=and numerous, rise on the third or fourth day after the appearance of the swelling, and in two or three days more the parts are covered with thin, dark-coloured -seabs. Dr. A. T. Thomson has remarked, that this species is often accompanied-with an affeetion of the throat and fauces, evidently erysipelatous: thesymptoms-are, a red blush over the velum palati and uvula; slight tumefaction, and considerable pain on deglutition; after a few days, excoriation and superficial ulceration sometimes extend to the larynx, affecting speech and respiration, sometimes to the pharynx and cesophagus.* Gangrenous erysipelas commences "sometimes," says Dr. Willan, "like one and sometimes like the other of the foregoing species, and most commonly occurs in the face, neck, or shoulders; it is not improbable that this is only an increased degree of the first species. It is accompanied with symptoms of low fever, and with delirium, which is soon followed by coma, which remains through the subsequent course of the disease; the colour of the affected part is dark red; and scattered phlyotense, with a livid base appear upon the surface, and frequently run intogangrenous ulcerations. Even when it terminates favourably, suppuration and gangrene of the muscles, tendons, and cellular tissue, often take place, producing little caverns and sinuses, which contain an ill-conditioned pus, together with. sloughs of the parts destroyed by mortification, which are evacuated at length from the ulcers; -it is always a slow-and precarious disease, and irregular in the period of its termination. A peculiar form of gangrenous erysipelas, often fatal,. occasionally occurs in infants a few-days after birth, especially in lying-in hospitals, and the noisome, dark, unventilated, badly-drained, and confined dwellings of the poor, in the back courts of London and our larger towns. Here, too, is theabode of fever and cholera; indeed, from such localities, how can fever ever be absent? a In London, and every large city, the chief localities of disease and premature death are the narrow courts and lanes inhabited by the poor, and the majority of victims are supplied from the working dasses. The districts thus unhealthy are well known to all who have paid the slightest possible attention. to the subject of. life, health, and disease, as influenced by locality; and to them it is known, as certainly as the large red cross on the door, and over it, " Lord, have mercy upon us," in the days of the plague, denoted that house to be visited by the pestilence, that in all densely populated neighbourhoods, where the by-lanes are closed at one end, dirty, narrow, and badly drained-the houses ill-constructed, and without the means for ventilation, eleaniiness, or. decency, there will most assuredly be found those diseases which spread from such abodes to the more favoured habitations of the wealthy. Here, too, are the congenial abodes of drunkenness, idleness, profligacy, crime; here recruits are daily trained, not only for the workhouse and the hospital, but for the prison and the gallows-for filth, destitution, and crime herd together-sisters of our neglect, they are naturally congenial and inseparable companions. It is there-fore manifest that the time must come when a wise govern-ment will feel that it is necessary to consider this question. more seriously than it ever has been regarded yet, for humanity and justice in the safety of the commonwealth, our duty to our neighbour and our God, alike demand that our energies should be devoted to the removal of those causes which at present so fearfully increase the bills of mortality, and very seriously affect the health of towns. In these unhealthy districts, not only does this form of the disease (gangrenous erysipelas) appear a few days after birth, but even at birth vesication and incipient gangrene may occasionally be observed. In such young patients the attack generally commences at the umbilicus or genitals, and extends * A very interesting paper on this affection of the throat appeared in the Medico-Chirurgical Transactions of Edinburgh, vol. ii., from the pen of Dr. Stevenson, descriptive of the disease as it appeared at Arbroath.
doi:10.1016/s0140-6736(02)89926-3 fatcat:d5ksnlza3bg25fnp3a6tnwep7q