GEN. VI. Erythema period the opposite or right arm exhibited an intumeSPEC. V. Erythema scence on its anterior part, occupying about a hand's anatomicum. breadth of the flexor muscles, which was punctured on the same evening and discharged about a tea-spoonful of serous fluid, but without relief; and within an hour or two afterwards, being the eighth day from the accession of the disease, he expired. from dissec tion. Erythematic blush a pathogno mic symptom. Swollen parts some tate. The pathognomic blush that spreads over the region of the pectoral muscle has a peculiar feel that is not easy to be described; it yields to pressure like a quagmire, or piece of sponge; and is hence called boggy by Mr. Lizars*, and doughy by Dr. Colles †. In the case of Dr. Pett it was found by Mr. Travers ‡ to crepitate, a times crepi- secretion or extrication of air having apparently taken place. There is often a considerable degree of uneasiness in the punctured or abraded spot which has proved an inlet to the virus, sometimes, indeed, amounting to an agonizing and intolerable pain, though without any visible show of inflammation, or too slight to be regarded. The accession of the fever is usually accompanied flammation. with great anxiety and dejection of spirits, and often an unwonted irritability of temper. The nervous and depressing character of the fever is indeed obvious from the first, and the patient rarely rallies into any degree of hope or composure where it proceeds to a fatal termi Sometimes extreme pain in the punctured spot, but without in Nature of the fever. Fatal issue. Sometimes more favourable. Prognosis in such cases. nation. In very many cases, however, its issue is of a happier kind; and where this occurs, sometimes, about the eighth day, a gentle diaphoresis or diapnoë lubricates the harsh and burning skin, a sound and refreshing sleep succeeds, the pain and inflammation diminish, and the patient advances to recovery in a straight path. But more generally an effort is made to form lodgements of imperfect pus, bloody serum or gangrenous ichor, often of all these combined, in particular parts of the affected side, most * Trans. Medico-Chir. Soc. Edin. Vol. 1. p. 496. GEN. VI. SPEC. V. from dissec tion. from se commonly indeed in the axilla; which swells into an enormous bag, and, if not opened by art, bursts spontaneously Erythema and discharges the complicated and pent-up fluid to an anatomicum. amount of several pints; the whole of the cellular mem- Erythema brane on the affected side being broken down into the general mass, with numerous sloughs and skeins of fibres detached from the adjoining muscles and thrown out in loose bundles. The cure is long, and doubtful, in proportion to the range of the ulceration, and the extent of Occasionthe gangrene: and the patient is often so much reduced ally fatality as to be in danger of falling a sacrifice from hectic fever condary efor some other secondary affection. But when he has fects. reached this stage he generally succeeds in the end, though the skin over the injured part is considerably shrivelled from the loss of the cellular texture beneath, and often attached to the subjacent muscles. Such is the progress of the disease when the contagion habit or idiomeets with a habit or constitution favourable to its mischievous action, and which yields at once to its influence. But, as in other contagions, so in the present, we perceive a striking diversity in this respect. The habit or idiosyncrasy of most anatomists fortunately renders them altogether unsusceptive of its impression, and they escape from its arrest. And hence, in all probability, the reason why but few comparatively are ever affected with this fearful complaint, though handling dead bodies for years, and with hands chapped or punctured in various points. A peculiar syncrasy necessary to take ef for the virus fect. Such habits not common and hence very nume rous escapes. habit or idi osyncrasy tially pro tects. Progress of the disease There are others who seem to possess constitutionally In some the a modified protection, though they cannot escape altogether; in whom the virus finds a less easy course of only parabsorption, and, by being delayed in its progress towards the axilla, opens its assault at the point of contagion, becomes concentrated, and spreads its chief brunt in that quarter. In this case the disease commences with local, instead of with constitutional symptoms, and the latter are even at last rather a sympathetic sequel, as in numerous cases of simple irritants, than a diacritical part of the disorder. The punctured hand or finger is not in such cases. Commences locally inof stead constituti onally; SPEC. V. from dissec. tion. GEN. VI. only vehemently painful, but swells and becomes conErythema siderably inflamed; the inflammation, characterized by anatomicum. heat, redness, pain, and enlargement, gradually shoots Erythema up the fore-arm; and if not checked in its progress ascends to the shoulder, and fixes itself in the axilla, or spreads still further into the side of the chest. But the virulence is usually diluted as it widens; and, though the constitution suffers much from symptomatic fever, the inflammatory action is often confined to the arm alone, where it seems to aim at forming a chain of abscesses from the hand to the elbow, and sometimes to the shoulder or axilla. and is less virulent. This distinction clearly marked in practice. odour bursts forth from the body, accompanied with profuse sweat. This distinction is so clearly marked and closely adhered to, that I have scarcely ever heard or read of a case that proved fatal, where the disease has opened with local inflammation, nor often where it has been accompanied with any great degree of danger : while, on the contrary, nothing can be more dangerous than the same disease, Occasionally where the constitutional symptoms take the lead. In a an offensive few instances a most offensive smell has been found to accompany the diaphoresis which occasionally breaks forth over the body. In the case of Mr. Whitlaw, Dr. Duncan describes it as "a profuse dark-coloured clammy sweat, of a smell so exceedingly fetid and disagreeable that it could neither be borne by the patient himself, nor by his attendants. It was in such abundance as not only to wet his body-clothes, but also the bed-clothes, and stained them of a dark colour, so that they could with difficulty be washed white again. When the patient awoke out of this state of slumber, in which he had continued during the perspiration, he felt great relief of all the symptoms."* The diaphoresis was in fact critical; and, so far as I have seen, it never occurs but in those that recover; and usually, if not always, is an accompaniment of the disease where the local symptoms take the lead, and in a considerable degree concentrate the virus. It must not, therefore, be confounded with that cada Generally critical and favourable. • Trans. Medico-Chir. Soc. Edin. ut suprà. 505. verous smell which is sometimes emitted from the body a short time before death, and is a melancholy harbinger of that event. GEN. VI. SPEC. V. Erythema anatomicum. Erythema from bite of venomous and espe sent; rapid. The inflammation that most nearly resembles the ery- from dissecthema before us, is that produced by the bite of the more tion. venomous serpents, and especially of the rattle-snake; Erythema and as, in all these cases, a specific virus is universally admitted, analogy, in addition to the reasons already serpents, urged, leads us to a like cause in the present instance. cially the The chief difference is in the greater degree of virulence rattle-snake, approaches or malignity that characterizes the serpent's fang, and the the nature greater rapidity of its mischief. A bite from the fang of of the prethe cobra de capello or hooded snake, the coluber Naja but is still of Linnéus, generally destroys life in twenty-four hours, more vioand from the fang of the rattle-snake (crotalus horridus lent and Lin.) in a shorter time, if no curative means be had recourse to. In both, the local and constitutional sym- General description. ptoms take place nearly simultaneously, and persevere in their double attack. The bitten limb swells instantaneously from the part affected, and the inflammation shoots with great speed up its entire length to the body; and, if it be the arm, associates the axilla in its malignant career; and, if life continue long enough, darts down the side over the pectoral muscle, and produces there the same kind of erythema as in the disease before us. The vital fluid, however, is from the first exhausted suddenly, as though by a stroke of lightning; the blood ceases to flow in the smaller vessels of the swollen part; the superincumbent skin feels deadly cold, the action of the heart is so weak that the pulse is scarcely perceptible; the stomach so irritable that nothing can be retained on it ; dejection and horror overpower the mind, and a low muttering delirium forms the closing scene. Very powerful stimulants applied instantly may post- Sphacelus pone the catastrophe, and sometimes even in the bite of generally destroys if the rattle-snake produce a cure; but if the tide of life be the first kept moving till the venom has exhausted its malignity, the debility is usually so extreme, and the field of spha- vered from. celus so extensive, that the unhappy sufferer too often symptoms are reco falls a victim to the local mischief, when he has even Erythema triumphed over the constitutional assault. GEN. VI. SPEC. V. anatomicum. Erythema tion. Striking illustration. A striking example of this occurred a few years ago from dissec in St. George's Hospital, in a patient whose progress the present writer watched with deep interest. He took notes on the occasion; but the account has been since given so much more minutely by Sir Everard Home, that he will chiefly copy from his statement*. The patient, by name Thomas Soper, twenty-six years of age, attempted, Oct. 17, 1809, to raise a rattle-snake confined in a cage in a public show-room in Piccadilly, by irritating him with a foot-rule, but the snake continued quiet. The foot-rule was dropped into the cage, and the man had the rashness to introduce his hand to take it away. The serpent instantly seized upon it, and bit it in two places. The bites took place at half past two o'clock p.m.: and the wounded man instantly applied to a neighbouring chemist, who gave him a dose of jalap, as he considered him in a state of intoxication from the incoherency of his language, which was probably the effect of great terror. The hand almost immediately began to swell, and he applied for aid at St. George's Hospital by three o'clock, or within an hour after the attack. The swelling had by this time extended half way up his fore-arm: the skin on the back of the hand was very tense, and the bitten part acutely painful. At four o'clock the swelling had gained upon the elbow, and at half past four the pain had extended to the axilla, and the swelling within a short distance of it: the skin was cold, the pulse beat a hundred strokes in a minute, the man complained of sickness, but his answers were incoherent. Ammonia, camphor, and ether were freely administered internally; and the two former were also applied externally. The symptoms continued to augment, with the exception that the patient was collected at times, and expressed a hope of recovery; but for the most part his mind Phil. Trans. 1810. p. 75. |