Elements of Surgery. Robert Liston

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.

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      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