Elements of Surgery

by Robert Liston

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 The practice is superseded by the timeous and free local bleeding from incisions, as will be noticed by and by.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.