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 Another Random Document on
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“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.
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:8 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.
In inflammation of this tissue, metastasis is also apt to occur, from
one part of the membrane to another, and from the membrane to
the external surface. Cynanche, for instance, often follows upon
erysipelas of the face and scalp, and vice versâ.
The passages, the internal surfaces of which are invested by a
mucous membrane, are those subservient to respiration, nutrition,
generation, and the urinary secretions; in other words, the mucous
surfaces are the Pneumogastric and the Genito-urinary. Their
particular diseases will be treated of hereafter.
 OF INFLAMMATION OF THE SEROUS MEMBRANES.
On such an extensive subject it is unnecessary to enter fully; not
that the inquiry is uninteresting, or that a knowledge of the diseases
of the internal cavities, and the mode of treating them, is not
required of the surgical practitioner before he can enter into
practice, with safety to his patients and comfort and satisfaction to
himself, but we have a very important class of diseases to bring
under review in a limited space, and it is properly the province of
others to treat of internal disorders, and to describe the best mode
of alleviating or curing them. It is, however, the duty of the surgeon
to treat the inflammatory affections of some of the serous
membranes, and the consequences of inflammatory action in most
of them; and it is therefore highly necessary that he understand the
symptoms, progress, and consequences of such actions. The
affections of the serous membranes are principally under the
management of the physician; but they not unfrequently follow
wounds and surgical operations, and the diseases of several of them
are purely surgical. Inflammation of a serous membrane is attended
with heat and pain, aggravated by motion of the parts and by
pressure; the natural secretion is increased in quantity, the process
of exhalation being incited, and that of absorption weakened; the
serous fluid accumulates. The secretion becomes altered in quality,
and assumes a milky appearance; lymph is effused, generally mixed
with purulent matter, and floats in the fluid, or adheres to the
surface of the membrane, which is rough and flocculent. The
adherent lymph becomes organised, being penetrated by numerous
bloodvessels; and thus the original membrane is, in many instances,
much thickened, chiefly from the addition of new matter, though also
from enlargement of its bloodvessels and opening out of the
primitive tissues, principally the subserous cellular. When inflamed
serous surfaces, which have been altered, both in texture and
function, in consequence of inflammatory action, remain for a short
time in contact with each other, lymph is effused and penetrated by
bloodvessels from each surface; thus the new deposit is organised,
and forms a medium of connection. By this process the parts are
intimately united to each other, and consolidated into one mass; or
are merely approximated, and joined, at one or more points, by
portions of lymph, in some cases thin and narrow, in others
extensive and of considerable thickness; the adhering bands either
extend in a straight direction, from one surface to another, or
interlace, forming a sort of network. After adhesions of various kinds
have been formed, they are often lengthened and attenuated in
consequence of the motion of the parts, as is particularly the case
with adhesions between the pleura costalis and pulmonalis. When
they have been of considerable duration, they often resemble the
original membrane from which they were deposited, becoming thin
and transparent, smooth on their external surface, and furnishing a
serous secretion. Not unfrequently, inflammatory action in this tissue
terminates in suppuration; and the pus, secreted by the membrane,
accumulates in the most dependent part of the cavity. By collections
of matter, whether serous, sero-purulent, or purulent, within a
serous cavity, the functions of the contained viscera are deranged,
much impeded, and in many instances morbid actions are excited in
them. The inflammation, whether it terminates in resolution, or
proceeds to serous effusion, adhesion, or purulent secretion, is
attended with constitutional disturbance, and the symptoms are
proportioned to the original intensity of the action, and the extent
and kind of its termination. The effusion of lymph, and consequent
adhesion, is, however, in many circumstances, a highly salutary
process, as in wounds and injuries of the hollow viscera: effusion of
their contents being thereby prevented, and the patient being saved
from the danger attending violent inflammation of those cavities and
their coverings, caused by the escape of a greater or less quantity of
irritating extraneous matter. Purulent collections also, in the solid
internal viscera, are thus allowed to discharge themselves externally.
The nature, symptoms, and consequences of inflammation of serous
membrane, will be more fully considered under the diseases of
particular parts.

OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.

Inflammation of the synovial surface occurs in consequence of
wounds, bruises, or sprains, and often from exposure to cold; from
the latter cause, the knee and elbow joints most frequently suffer, as
they are generally more exposed to its influence, and not so well
covered with muscular substance as the others. Constitutional
diseases, such as certain fevers, are followed sometimes by effusion
of serous fluid into joints. Purulent matter is also deposited in joints
during certain forms of suppurative fever; and this is attended by
rapid change of structure.
There is heat, throbbing, pain, and swelling of the part, sometimes
redness of the surface, and great constitutional disturbance; the
symptoms and appearances, however, vary much, according to the
extent of the joint which is involved. When part of the capsule is
affected, the inflammation spreads rapidly over all the surface; the
synovial membranes resembling the serous in this respect, as well as
in healthy structure and function. Like the serous, too, they are shut
sacs, are smooth on their surface, and furnish a secretion, the
synovial, for facilitating the motion between opposing surfaces; it is,
however, somewhat more glairy than the serous. Neither, in their
healthy state, are possessed of much sensibility, nor are ligaments,
tendons, tendinous sheaths, and bursæ, which two latter textures
resemble in every respect the synovial; when inflamed, they become
most exquisitely sensible. The incited action of the bloodvessels is
followed by increased discharge, which is less glairy and albuminous,
partaking more of the serous character. When the incited action soon
terminates, and the activity of the absorbents is diminished, the fluid
accumulates within the joint, producing Hydrops Articuli. This
accumulation of fluid in joints may take place without being
preceded by any apparent inflammation, and may remain a long
time without any visible change of structure in the membrane. The
knee is more frequently the seat of dropsy than any other joint.
When the action is more violent, and is not actively opposed, lymph
is effused on the inner surface of the membrane, or is deposited
amongst the ligamentous and cellular tissues external to the joint, in
consequence of which, the membrane and external ligaments
become thickened, and of an almost cartilaginous consistence.
Serum is effused into the more superficial cellular tissue, filling up
the hollows around the joint, concealing the protuberances of the
bones, and producing a globular swelling. The articulating surfaces
become ulcerated, and matter forms within the capsular ligament; or
the pus is deposited exteriorly to the joint, and gradually approaches
the surface. But although ulceration is so prone to occur in the
cartilages, the synovial membranes do not readily take on this
action, unless from the progress of matter, formed within the joint,
towards the surface. The synovial lining of the bursæ and sheaths of
the tendons are extremely indisposed to ulcerate; and it may be
remarked, that, while suppuration without ulceration is common in
the synovial membranes, the cartilages, on the other hand, afford
frequent instances of ulceration without suppuration, of which more
particular mention will be made in the sequel. The cartilage is
occasionally swelled and softened where the disease has long
existed.
Along with ulceration of the cartilage, a portion of it may become
dead, or either state may occur separately; and in many cases, the
substance of the bone also becomes affected, of which two classes
of cases may occur, viz., great inflammation on the articular surface
of the bone, with separation of the cartilage by the ulcerative
process in this situation; and inflammation of the medullary web,
leading to atrophy of the cancelli, collections of pus therein, or even
death of a portion of the spongy texture of the bone, as will be more
particularly treated of in the chapter on diseases of the osseous
tissue. These changes often compose the primary disease, and to
them the affections of the synovial membrane and other parts
succeed.
Such occurrences are attended with alarming disturbance of the
constitution, with fever, and even with the most threatening and
dangerous symptoms, such as delirium and coma. If the patient
survive, and the matter be evacuated from the joints by openings
into its cavity, hectic fever is almost certain to supervene.
An opinion has been broached lately by Mr. Key, that the ulceration
of cartilage was consequent upon the increased vascularity and
thickening of the synovial membrane, that the cartilage, in fact, was
removed by the action of the vessels ramifying in the membrane,
and the prolongations or fringes from it in its diseased condition.
Occasionally these fringes correspond, in a remarkable manner, to
the breach of surface in the cartilage; but again, ulceration is
frequently met with far removed from the membrane. It is also seen,
in cases where an opportunity is afforded of making the examination
in the earlier stage of disease, that ulceration exists to some extent
whilst the synovial membrane is unaffected. And certain cases, in
which the cartilage is affected with hypertrophy, and the common
form of atrophy of this part in old people, are altogether adverse to
Mr. Key’s views. When ulceration takes place at a point removed
from the attachments of the synovial membrane, it appears to
proceed more frequently from the attached than from the free
surface of the cartilage; then the adventitious membrane occupying
the rugged spaces, and which under the microscope appears highly
vascular, is connected apparently with the medullary web.
In acute inflammation of the synovial membrane, and in cases where
the cartilage is ulcerated, the pain is very intense, and the spasms of
the limb most distressing. This happens when the surface is
ulcerated, and perhaps to no great extent. We know that in the
horse an ulcerated hollow in the cartilaginous covering of the
navicular bone, not so large as to contain a grain of barley, will
cause such lameness and suffering as to render the animal so
affected perfectly useless. If he is not destroyed at this stage, as
many valuable animals have been, the mischief extends, and
terminates in extensive disease of that and the neighbouring bones
and articulations. It is different if the disease commence, as it
sometimes does, in the human subject, in the cancelli of the bone,
and on the attached surface of the cartilage, the free surface
remaining some time entire and smooth. When the synovial
membrane is primarily affected by chronic disease, the pain is in
general trifling, often not complained of, and swelling of the part,
from effusion, into the joint or neighbouring bursæ, first attracts
attention, after it has existed, perhaps, in a slight degree, for a
considerable time. The joint is stiff, and pain is experienced from
extensive motion; on this account the patient is disinclined to use it,
and it is soon tired by the slightest exertion. The swelling becomes
more solid, though still remaining elastic, and the feeling of
fluctuation diminishes. Effusion of lymph follows that of serum, the
latter having been absorbed; the motion of the joint is still further
impeded, and the articulation is distorted; the patient keeps the limb
in the most easy position, generally that of partial flexion, in which it
becomes almost immovably fixed. The cause of the flexed position,
which is almost pathognomonic of knee disease, being preserved,
seems to be that the limb is insensibly brought into it in order to
take the pressure off the interarticular apparatus, the ligamenta
mucosa and alaria,—these swell—the muscles of the hamstrings get
contracted from habit, and a difficulty, even after the disease is
completely subdued, is often enough experienced in procuring
complete extension. The muscles, from disuse, shrink, the adipose
substance is absorbed, the shafts of the bones also are diminished in
size, get into an atrophied state, as the phrase is, and thus the
whole limb is rendered slender and wasted, so as to make the
swelling of the diseased articulation still more conspicuous. The
bones are softened, and the muscles are of a white colour, as in the
limbs of the paralytic or bedridden, and resemble more cellular than
muscular tissue. The wasting of the muscles and loss of power often
precede the appearance of disease; this is frequently observed in the
shoulder-joint, the deltoid shrinking, and almost disappearing, before
any disease in the articulation is suspected by the patient. Not
unfrequently, also, this wasting occurs without obvious cause, or any
affection of the joint. When the disease is advancing, the patient
may feel no acute pain, but merely a reluctance to use the limb; and
from this, if long continued, the muscles, and afterwards the bones,
become wasted. Wasting of the limbs in children, often of one of the
lower, frequently arises from disorder of the bowels, and the
irritation and debility attendant on teething. This must be
distinguished from the wasting accompanying diseased joint. The
history of the case, the period at which the weakness of the limb
was observed, and its appearance, will lead to a correct diagnosis.
The swelling is often irregular, being more protuberant at one part
than another, from the fluid or the addition of solid matter being
accumulated where the least resistance is afforded; but the slighter
inequalities are generally filled up by œdema of the cellular texture.
As the disease proceeds, matter forms in the joint, and is often
attended with great pain and fever; or the pus is effused into the
bursæ, into the surrounding cellular tissue, or into the filamentous
tissue amongst the tendinous sheaths of the muscles in the
neighbourhood; being allowed to remain without an outlet, it at
length communicates with the cavity of the joint. Portions of the
cartilages are absorbed, though this, as already noticed, may occur
at the very commencement of the disease; the subjacent bone
becomes affected by ulceration, or perhaps its vitality is partially
destroyed. When matter has accumulated, a portion of the capsular
ligament generally ulcerates, the pus escapes, and is ultimately
discharged externally.
When the disease begins with swelling, which is of a chronic
character, and produces but little inconvenience, and when the more
urgent symptoms supervene after the swelling has continued for a
considerable time, there is every reason to suppose that the disease
has originated in the synovial membrane, or perhaps in the osseous
cancelli, and this is generally met with in poorly fed and strumous
subjects. But when the first symptoms have been pain and stiffness
of the joint, without change of its appearance, and when the
swelling has occurred after these symptoms have been of some
duration, then it is probable that the cartilages are the primary seat
of mischief. For the most part, however, the symptoms have a
general resemblance in most chronic affections of the joints, and all
the apparatus is sooner or later involved. When the cartilage has
been extensively absorbed, a grating sensation is felt in moving the
articular surfaces of the bones upon each other. In consequence,
also, of the softening and disorganisation of the lateral and other
ligaments, the affected articulation at length becomes unnaturally
loose, which is owing in some measure, also, to the muscles being
wasted and paralysed from pain and disuse. At an earlier stage of
the disease, the joint may be rigid from deposition of lymph into the
contiguous cellular tissue, and contraction of the muscles.
Purulent matter not unfrequently collects in the substance of the
bones, which in all cases ultimately become softened in a
remarkable manner. In many subjects, without actual disease of the
osseous tissue, the heads of the bones are so altered in consistence,
are so deficient of earthy matter, as to be easily cut with a knife. It
has been a matter of dispute, whether, in this affection, the
articulating extremities of the bones are enlarged or not; and the
supposition that they are always more or less increased in size, or
hypertrophied, has arisen from the extensive effusion and indurated
state of the soft parts being mistaken for this enlargement. In the
first stages of the disease, they are seldom, if ever, enlarged; but
when ulceration of the bone has occurred, new osseous matter is
deposited to a greater or less degree in the neighbourhood of the
ulcer,—an attempt by nature towards a cure, but too often an
ineffectual one. The bones, in strumous subjects, are often much
enlarged, from collection of purulent matter in their substance giving
rise to a sort of spina ventosa. I removed the upper extremity of a
boy lately on account of extensive disease about the elbow. The ulna
to near the wrist was swollen enormously by purulent collections in
its medullary canal. In cases when the whole of the articulating
extremity of the bone is not enlarged, still that portion which is more
immediately concerned in the articulation is often considerably
expanded.
Frequently when the knee is the seat of the disease, the lymphatic
glands in the groin are enlarged; and when the elbow or wrist joints
are affected, there is often a similar enlargement of the glands in the
axilla: such glandular tumours have not rarely been confounded with
those accompanying malignant disease, and measures which were
absolutely necessary for the salvation of the patient, have thus been
delayed or neglected.
When the disease is extensive, and has endured for a considerable
period, hectic fever supervenes, and is aggravated after the
abscesses give way. The patient becomes much weakened and
emaciated, and loses his appetite; the pulse is rapid, with night
sweats, diarrhœa, &c.; and from a continuation of the hectic cause,
the life is endangered. In some cases, however, the health is
restored, and the disease abates spontaneously; in others, the
disease is arrested, and a complete cure accomplished, by the
careful employment of such means as will be afterwards mentioned.
The appearances produced by inflammation and consequent disease
of the synovial membrane, are the following. In the first stage, the
internal surface of the capsular ligament, and the rest of the synovial
membrane, is found of a red hue, its formerly colourless vessels
being now made apparent, from enlargement and consequent
injection with a greater quantity of red blood; and the serum within
the cavity of the joint is more abundant than in the natural state.
When the disease has been of longer continuance, the membrane is
found considerably thickened, its usual smooth glossy surface is
destroyed, it is irregularly flocculent, and frequently of a light yellow
colour.
The interarticular adipose tissue also seems to be increased in
volume, from being infiltrated with a serous fluid, by the discharge
of which the diseased bloodvessels may have attempted to relieve
themselves. When the inflammation has been intense, or of long
duration, lymph is secreted, and deposited on the external surface of
the membrane, forming an intimate union between it and the
ligaments, and producing thickening of the external apparatus. Or
the lymph is also effused on the inner surface of the membrane, to
which it adheres and becomes organised; this is generally
accompanied by the formation of purulent matter; the organised
effusion is often so extensive as to conceal almost the whole of the
synovial membrane, excepting portions of its delicate reflexions
which invest the articulating cartilages. By the lymphatic deposit, to
a less degree, the folds also of the synovial membrane adhere to
each other, whereby the motion is still farther impeded, and the
pain, when attempted, increased. Occasionally the synovial
membrane is found enormously thickened, much softened in texture,
and of a brown hue, when the disease has been of a very chronic
character. Along with these appearances, serum is generally found
effused, in a greater or less quantity, into the cellular tissue exterior
to the ligamentous covering. In cases in which the matter has
formed and remained long within the cavity of the articulation, the
synovial membrane and the ligaments become blended into one soft
mass, the internal surface of which is lined with a thick coating of
lymph, as in the case of common abscess. If purulent matter is
effused externally, and communicate with the joint, the capsular
ligament will be found to have ulcerated and given way at certain
points, forming apertures, usually of small size, and with ragged
margins.
All these appearances may exist without disease of the cartilages or
extremities of the bones; but generally they are
also affected at the same time. At first the surface
of the cartilage is slightly irregular and rough, and
the change is not observed, unless on minute
inspection. Afterwards the surface is marked with
small depressions, which may be numerous, and
are surrounded with irregular and somewhat
serrated margins. They gradually increase in depth
and extent, and the subjacent bone is ultimately
exposed at one or more points, as here shown.
Often the greater part of the cartilage is removed
by absorption; the bone is exposed, opened out in
its texture, softened, of an irregular surface, and
in some places excavated, containing a thin ichorous fluid; the
process of ulceration has also extended to the osseous tissue.
Sometimes scales of cartilage of considerable size are either
completely detached, having become dead, and been thrown off by
the natural process, and are found lying loose in the cavity of the
articulation; or they are all but separated, adhering by one or more
very slender attachments.
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