ON THE TREATMENT OF ERYSIPELAS.

398 suited to the existing of wine or other sti. mulants at the commencement of many in. flammatory or congestive forms of erysipelas, To the Editor of THE LANCET. must, in my opinion, be considered to be SiR,-On the treatment of erysipelas by among those causes which operate in the Mr. Wilson, in his nineteenth lecture on production of so much mortality in this Diseases of the Skin, reported in THE complaint. Indeed, in order to give the paLANCET, for April 22, 1843 (page 97), I beg tient even a chance of recovery in many to make a few observations in your valuable cases, a very opposite mode of management, so far as my experience extends, must be pages. Mr. Wilson, in a summary manner, di- adopted. In the local treatment of erysipelas Mr. rects the attention of his audience to the modes of treatment to be adopted in the com- Wilson recommends either evaporating mencement of an attack of erysipelas, and, lotions or fomentations, the temperature to like many other writers on this subject, cau- be determined by the feelings of the patient. tions them against the too free use of such One or other of these applications, so far as means as are calculated to produce debility, my information extends, is generally used. a state so much feared in the management of A few years ago an opportunity was kindly erysipetatous cases. He afterwards calls afforded me, during several months, of seetheir attention to the mode of treatment re- ing the practice of many of the most emi. commended by Dr. Robert Williams, which nent practitioners attached to the principal he (Mr. Wilson)" regards as judicious and hospitals in Great Britain and elsewhere, admirable, and well suited to become a and the evaporating or fomenting applicastandard for your imitation. The mode, tions appeared to be most in use; yet some then (says Dr. Williams) in which I am in of these gentlemen, who stand at the very the habit of treating idiopathic erysipelas, head of the profession, employed no local whatever may be the part affected, or with application whatever. Now, if I be correct whatever symptoms it may be accompanied, in the observations that I have always made :—The patient is put on milk on the effects of these applications, as well is as diet, thebowels gently opened, and from as on the effects of the want of any applicafour to six ounces of port wine, together with tion, I would range them among those causes which render erysipelatous affections so sago, allowed daily.’" So uniform a mode of treatment recom- severe and dangerous to those who are the mended for imitation by Mr. Wilson, and subjects of them. In my view, such local actually practised by Dr. Williams, in a dis- management is neither suited to arrest the ease so varied in its nature and in its degree progress of the disease nor to alleviate the of violence, appears to me to be as extraor- sufferings of those for whose relief it is emdinary as it is, in my view, pregnant with ployed. Wet applications of every kind danger to the sufferers. On the same applied to the tender inflamed surface of an grounds, I presume, may the homoeopathist erysipelatous part, keeps up, at least, a very and hydropathist maintain that their modes irregular temperature, and as the principal of treatment are suitable to every form of mischief at the beginning is chiefly external, disease. There can scarcely be a greater the varied temperature is apt to repel the proof of the absence of correct views re- eruption to the more internal and vital parts, garding any complaint, or its appropriate and this adventitious state lays the foundatreatment, than when so great discrepancy tion of the principal difficulties and danger. exists among medical men respecting the The want of any local application to the mode to be pursued in its management as is parts affected is equally injurious, for the exhibited in the treatment of erysipelas. It inflamed and irritable surface being exposed has been insinuated by many of the profes- to the friction of either the bed or bodysion that patients often recover in spite of clothing, or even to the influence of the attheir bad treatment, but in severe cases of mosphere, increases the irritation of the parts, disease, in which the resisting and restora- renders the patient uneasy and restless, and tive powers of the system are nearly ba- disturbs the system generally to a greater lanced by processes of a controlling and viti- degree than seems to be imagined by those ating nature, it is clear that a mode of treat- who practise it. ment which is favourable to an increase of Having made these observations, I shall the morbid tendencies must be hazardous, briefly relate the mode of procedure which I and often fatal, to the patient. Thus, it have pursued for upwards of twenty-five must intuitively appear to every ordinary years, in this large manufacturing town, observer, that no disease, so varied and com- where erysipelas frequently prevails in a plicated in its nature as erysipelas, can on severe, and, occasionally, in a fatal form. any account be so generally conducted to For a considerable period of my professional a favourable termination by any uniform career the opinion that I have formed remode of treatment as when the nature of the garding the origin of disease is, that the complaint is first duly considered, and the nervous system, or some portion of it, K ON THE

TREATMENT OF ERYSIPELAS.

follows

treatment

employed

symptoms. The

use

399

always the part primarily and abnormally with it as thick as a penny-piece. The flour affected, and that the system then generally thus applied is to be kept in its place by a or

partially participates in the derangement.

This view I consider essential in order to the proper and successful treatment of erysipelas. In the production of this complaint an irritating agent, as a current of cold air, for example, is applied to the face and head, when the sentient and motive organs of the affected part assume a peculiar and altered action, which in its turn exerts an influence on the vascular system, and the result of these changes operate unfavourably on the blood as well as on the various organic functions. Thus, it is evident that when the disordered state of the nerves, the origin of all the mischief, is skilfully treated at the very commencement, the affection of the system will either entirely, or, in a great measure, be prevented, and the usual dangerous and fatal results in almost every case averted, In order to obtain these desirable ends the following mode of treatment pursued by me during the period already mentioned has accomplished all that the practitioner can rea-

sonably expect. At my first visit, if the patient’s skin be hot, pulse quick, with headach, and other febrile and inflammatory symptoms, at the same time that the erysipelatous part is turgid and tender, blood is immediately taken from the arm, the quantity being proportioned to the strength of the patient and the violence of the symptoms-I may state that from ten to thirty ounces, according to circumstances, may be safely taken. I very seldom repeat the bleeding; indeed, repeated bleeding should be practised with great caution, except when

some

internal

the

lungs, participates in the inflammatory action: when repeated free bleeding will be requisite ; but even in this state of things the oppression at the chest will, in the end, be more safely and certainly relieved by nauseating doses of antimonial tartar, even to gentle vomiting, than by bleeding to the extent that the symptoms inorgan,

as

dicate. The next step in the treatment is to immediately cover the erysipelatous parts with a material soft, light, and warm, as a soothing application, and sufficiently compact, in order to lessen the rapid evaporation from the burning and inflamed surface ; it should also be sufficiently porous to admit into its substance the acrid exhalations from the diseased parts, otherwise vesications and suppuration would more frequently occur, By the use of such means an uniform temperature is kept up on the surface, the parts are soothed and relaxed, and the repulsion of the eruption prevented. The application which I use for these purposes is one of the very oldest description, namely, fine flour, well dried at a fire, and applied warm over the parts affected, and so as to be covered

thin fleece of cotton-wool, and the whole to be secured by a thin muslin napkin. As long as the parts continue hot and flushed, the flour should be changed every eight or twelve hours, and fresh flour applied as at the first. This form of application has a great advantage over others, not only on account of its greater safety, but it is more agreeable, and gives the patient less trouble in its application. One or two hours after bleeding and dressing of the affected parts a. smart purgative should be administered, containing five grains of calomel. After the operation of the purgative two grains of calomel and five grains of antimonial powder should be given to the patient every eight hours, for the purpose of determining to the surface of the body and regulating the secretions, which in many instances are much

deranged. By the use of these means the febrile and inflammatory symptoms are greatly alleviated in the course of three or four days, when the antimony and calomel should be suspended. If the calomel and antimony do not operate freely and easily on the bowels mild dose of salts or castor-oil should be administered every second day, until the acute symptoms are subdued. In the acute forms of this disease the patient generally a

little for several nights, and in order to procure this desirable end a dose of muriate of morphia, combined with an antimonial, may be given to the patient on the fourth night, or even sooner, if the febrile symptoms are lessened, with generally the most agreeable and advantageous effects. In another form of this complaint, in which the patient is of a weakly habit, pulse not much accelerated, skin cool, and the appearance of the erysipelatous part of a dusky colour, bleeding is in general inadmissible, but all the other means should be rigidly attended to. As in this form it is more necessary to bring the patient under the influence of the calomel than in the more acute cases, one grain of calomel, with five of the antimony, is generally the quantity I use every six or eight hours. These means, with the flour externally, have an excellent effect in determining to the surface of the body and relieving the internal parts, as well as in exciting the torpid state of the circulation, which is always present in such cases. In my view it is a great error, in this form of the complaint, to consider its symptoms as the result of debility, and to commence its treatment by stimulants and cordials. Such procedure in bad cases frequently aggravates the symptoms, and renders the state of the patient more precarious. In both forms of the complaint, however, as soon as the disturbed condition of the system is considerably corrected, any real symptoms of

sleeps

400

debility that may arise should be combated arnica montana in bruises, incisions, sprains, by nourishing diet, and even cordials and sti- and other affections more particularly remulants. The risk of inducing dangerous garded as belonging to surgery. Since that debility in acute cases of erysipelas by the time the numerous additional cases illustra. use of an ordinarily active antiphlogistic tive of the value of arnica, have increased so treatment, during the first few days, is quite fast, that I have given up recording them ideal ; the danger arises not only from the particularly. My attention has, however, neglect of removing the causes of the com- been arrested to a case so strikingly illus. plaint by the use of proper means, but actu- trative of these benefits, that I have thought ally also by accumulating the evil by the it to be my duty to forward it to your When suppuration Journal. use of improper means. To the Royal Jennerian London Vaccine takes place the pus should be evacuated, but when the case is properly managed and seen Institution, last Thursday, a mother brought early this result seldom occurs ; I have only her child to receive the certificate of protec. seen it twice in all my experience. tion. After receiving it she exclaimed, Scarifications, so much recommended and " You, Sir, saved this child’s life," and a practised in this complaint, I deem to be sel- fine little fellow he was. I had quite forgot-

dom if ever necessary, if the means I haveI ten the circumstance. I asked the name, be carefully put in operation ; and, on reaching home, examined my book indeed, except in hospital practice, I cannot of cases, and found the following:ŇAlfred conceive how they are to be tolerated. Wyatt, 1.’June 20. Aged three months and a By the above modes of treatment, then, I fortnight; child apparently dying. A little have good grounds for stating that erysipe- girl that nursed the child had let him fall, latous complaints are, in a great measure, and he, in falling, fell upon his head. The robbed of their severity and danger; for by mother had obtained somewhere a powder, such management for upwards of twenty- but the child became worse. He had been five years, I have never lost a case when I in a severe fever ever since the accident. attended the patient from the beginning of His eyes were half closed, and the peculiar the attack, excepting in a very few instances, cast of countenance indicative of affection of head was present; in fact, I feared the in children under two years of age. In THE LANCET for May 13, 1843 (page child would die before he reached home. I 248), Dr. Henderson, in a mild and gentle- told the mother to let me know the state of manly manner, notices my remarks on his the child on the following day, my belief case. In labours like the one related by being that I should hear of his death. I Dr. H. there is, so far as I have observed, ordered three globules* of aconite in two always unnatural obstructing actions of the ounces of water, a fourth part immediately, uterus, or the children would be born sooner and four hours after the first dose of aconite than even in his case. The resisting spas- a dose of arnica, three globules, in two modic contractions being less powerful than ounces of water, a fourth part as a dose, and the propelling efforts of the uterus, the child to repeat the aconite and the arnica, alter. is gradually advanced until the head is born,nately, every four hours. when, in not a few instances, the expulsive! 21 (i. e., the next day). The mother" came efforts in a great measure cease, and theto me and said, weeping with joy, He is spasmodic contractions being now no longerlaughing to-day." Her gratitude was great; resisted by the advancement of the child,, she said she thought that before she should contraction takes place around its neck. Toreach home yesterday he would have died. show that my opinion is not hastily formed,,I ordered another aconite mixture and anI refer Dr. Henderson to my sixth and tenthL other arnica mixture, a dose of each once a illustrative cases. I am, Sir, yours respect-day, and the result was then health, and on JOHN CRAIG. CRAIS. fully, Thursday last the agreeable notice, " You, May Paisley, 30,1843. Sir, saved this child’s life." Arnica is now used most extensively by MAKING BELIEVE allopathic practitioners, so much so, that the TO following notice has been deemed necessary: Ň" The great and increasing demand for ADMINISTER ARNICA.* tincture of arnica has led many drug merchants to vend a root which is not that of the To the Editor of THE LANCET. montana."-British Journal of Hoarnica the two since I drew is years just SiR,ŇIt Yours sincerely, maeopathy. ; of the medical attention profession, through JOHN EPPS, Epps, M.D. the medium of your Journal, to the invaluMay 27,1843. able benefits to be derived from the use of

pointed out

f

* The child did not use arnica externally, Our worthy correspondent had entitledI " his letter Arnica and its Uses," but anand the globules of aconite were impregnated examination of his prescription, in the note,, with aconite tincture at the octillionth diluinduces us to prefix a more correct heading.tion, and the globules of arnica tincture at —ED. L. the billionth dilution. *