384 Cases of Irritatire Erytt, ema, by Dr. l~aw.

ART. XXIV.~Cases of Irritative Erythema. By Ro~1.'iu' L~.w, M. D., Fellow and Censor of the King and Queen's College of Physicians in Ireland, Physician Extraordinary to Sir Patrick Dun's Hospital.

M,~.tW,~ET FALLON, mtat. 20, unmarried, three days since went out in the rain barefooted ; in the evening she was seized with a severe shivering and violent headach. Admitted into hosl)i- tal file flfird day of her illness ; her left knee and wrist were very much swollen and red ; file left cheek, also, under the eye, cxhlbited a similar swelling, marked with a deep crimson blush. Pulse frequent, full, soft, and compressible; tongue covered wifl~ a thick slimy fnr ; respiration very much hurried ; great prostration of strength, and depression of spirits. Leeches and stupes were applied to the swollen parts, and aftbrdcd some relief. I now ventured upon a small bleeding, more wifll a view to see what appearance the blood would exhibit, and as a guide to me in the treatment I shotfld afterwards adopt, than that I was very sanguine that it would do much good.

V. S. ad ~viii. 1~. Aquae acetatis ammon. ~ii.

Mistur. camphor. ~iii. Vini seminum colchici 5i. Syrupi aurantii 5vii. Misce. Cochlear. duo ampla tertiis horis sumenda.

The view I took of the case was, that it was one of acute rheumatism, accompanied with greater prostration of strength than I had before witnessed in this disease. "lira small quan- tity of blood drawn (not exceeding four ounces) exhibited a dark gory appearance, and was loosely coagulated, such as we have observed when vcnesection has been employed in cases of typhoid fever. I did not require this index of tim depressed state of the system to make me change my plan of treatment. Bulla b filled with a dark bloody fluid, presented themselves on

Cases of Irritative Erythema, by Dr. Law. 385

different parts of the body, especially in tlle situation of tlle parts which were originally swollen and red: The powers of life seemed to be completely prostrate. She had a low, mutter- ing, incoherent delirium.

l~ Sulphat quininm, gr. xii. Carbonatis ammonia~, ~i. ~,onfect. aromatic qs. fiant boll quatuor, sumat unum tertiis

horis. Strong beeftea; porter.

Some of ~ the bull~e gave way, discharging a dark ichor- ous fluid, and leaving the skin in a shrivelled state ; she gradu- ally sunk into a deep coma; the breathing became stertorous, and she expired, without the system seeming to make the slightest rally. The friends of the patient would not allow the body to be examined. Although the swellings and redness of the joints led me to believe this to be a case of acute rheuma- tism, modified by a debilitated constitution, I soon reco.~maized in it the features of the irritative erythema which attends dis- section wounds ; there was a close analogy between the symp- toms of each.

IRRITATIVE ERYTHEMA OCCURRING IN AN INDIVIDUAL LABOURING

UNDER ACUTE PLEURISY.

George Hyland, aetat. 25, labourer, a strong muscular man, and who affirms that he has always been temperate in his habitsj admitted into hospital August the 26th. On the 18th lie got a severe wetting, and in two days afterwards was seized with a violent pain across his chest ; at the same time he had a com- plete loss of appetite, and excessive thirst; he was now obliged to confine himselt" to his bed. On the 23d instant was bled from the arm, with some relief. On admission into hospital he exhibited the following symptoms: Pulse 112, strong, round, and full ; skin hot; respiration 40 in a minute, laboured ; ake nasi dilate considerably; decubitus on the right side, occasion- ally on the back. Percussion yields a clear resonant sound in

VOL. IL NO. 6. 3 E

386 Cases of lrritati~'e Erythema, by Dr. Law.

the right side of chest, both anteriorly and posteriorly, as aI~o

in superior half of left side, both betbre and behind ; tile iJdb-

riot half of this side, both anteriorly and posteriorly, emits a

dull, dead sound. Respiration puerile in the right side ; alto- gether absent in inferior let~t, both anteriorly and posteriorly; heard feebly, and, as it were, muffled, * in anterior superior hair,

while it is bronchial in posterior superior half. T h e heart pul- sates in the epigastrium ; the left side of the vhest is pail)ably dilated. H e feels no pain in the chest, but on attempting to

make a fidl inspiration, has the sensation of a tight cord confin- ing the lower part of his left side ; he has neither cough i~or expectoration. (Diagnosis ; considerable eflhsion into cavity of

the left pleura.)

V. S. ad ~xii .

I~ Tartari emetiei gr. iv. Aquae ~v. Tineturve opii gutts, xx. Syrupi Ji. Misee. Sumat cochlear, duo ampla tertiis I oris.

27th. Blood neither buffed nor cupped; mixture vomite(l

him three times. Pulse 104, more strong, fidl, and vibrating ;

respirations 24 in a minute, not so labonred; al~ nasi do not

dilate so much as on his coming into hospital; slethost.opie

phenomena same as beibre noticed ; he lies on his back, with

inclination to right side ; cotmtenance expresses mttch anxiety.

R: Calomel gr. vi. Tartari emetiei gr. i, Opii purl gr. it. Conserv. ros. q. s. Fiant pilulm quatuor, sumat unam tertiis horis. Linimen-

turn ammonim lateri affecto infricandum.

'* I have adopted this term, to express that feebleness of respiration which is heard in the pulmonary tissue, when it has not been sufficiently compressed to have its cellular structure rendered quite impenetrable to the air.

Cases of lrritative Erythema, by Dr. Law. 387

28th. Pulse still soft, full and vibrating; skin hot and dry. A number of small turnouts, resembling furuncuU with vesicu- lar apices containing bloody serum, now made their appear- ance upon different parts of the body, especially upon the ex- tremities. The right eye is quite closed from tumefaction with erysipelatous redness of the lids.

29th. Wandered much through the night, and is now in a heavy sleep, almost approaching to coma. Pulse* retains its round, soft, vibrating character; tongue covered with a dry brown crust ; the tumefaction and erysipelatous redness now extended to the right lid, in consequence of which this eye also is completely closed; the redness has spread to the forehead. An esyslpelatous blush, resembling gout, occupies the right great toe, and is also in circumscribed patches on tlm backs of both hands.

]~ Carbonat. ammon. 5i. Sulphat. quininve 5ss. Confect. aromatic q. s. Fiant boll sex, surest unum tertiis horis. A pint of port wine ; strong beef tea.

September 1st. Pulse softer, and more compressible ; he raved much during the night ; he now seems very restless and uneasy. The puffing and redness of the eyelids have increased so much that the eyes are completely hid ; vesicles, containing a dark ichorous fluid, have formed uponthe right upper lid. A deep erysipelatous blush extends from the dorsal surfaces of both fingers and toes up along the extremities. The small tu- mours, which first presented themselves like furunculi, have now assumed very much the appearance of the shrivelled pustule of small-pox. There is a swelling about midway up the left leg,

* There is a full, quick~ and bounding pulse, which has no relation to inflam- matory action, and a small and concentrated pulse of no extraordinary frequency which properly belongs to it.--Travsrs on Consti;utional Irritation.

388 Cases of Irritative Erythema, by Dr. Law.

external to file spine of tile tibia, with palpable fuctuation, but no discoloration of the skin.

2nd, Pulse 152, very feeble ; he can scarcely be roused ; the discharges from the bowels pass invohmtary; he has a diffi- culty in protruding his tongue, which is brown and shrivelled ; respiration more hurried and laboured; occasional ronchus morlentium. The tumefacfion and redness have increased in extent and intensity ; some of the small pustular elevations, first observed, have given way, and discharged a dark bloody fluid; their appearance, when emptied of their fluid contents, closely resembles the "burnt blister," the skin which enclosed the mat- ter lying loose and shrivelled. He expired in the evening of this day.

The disease, which developed itself after he came into hos- pital, was of so serious a nature as to make us, if not altogeth0r forget, at least to attach a secondary importance to the affection of the chest, for which he originall$ came under our care.

Examination of the Body seventeen Hours after Death.-- Great emaciation, considering the short duration of the illness. The body emits a fetor not unlike that which proceeds from one that has died of confluent putrescent small-pox. The whole surface~ both trunk and extremities, studded more or less thickly with acuminated conical elevations, some resem- bling the pustules of small-pox, but without the areola of ia- flammatihn ; others have.more the appeaz-anoe of the eruption, of varicella or modified smallpox ; others, . again, resemble the bulla~ of pemphig~s gangrenosus.

On dividing the cartilages of the 5th and 6th left ribs, some greenish unhealthy .pus oozed out, which, when the sterrmm was raised, proved to be the contents of.two or three circumscribed. abscesses which had formcd in the cellular membrane con- necting the pleura pulmonalis and costa2is in this situation. On opening the chest, with a view to see the position occupied by the fluid and lung in the cavity of the pleura, the base of the

Cases of Irritative Erythema, by Dr. Law, 389

tung was found to be lifted up from the diaphragm, and was on a level with the nipple of the breast. The fluid (which was a straw-coloured serum, with shreds of Iymph floating in it) filled all the cavity of the side, except where the lung, pushed upwards and forwards, lay applied to the anterior wall of the thorax, from the clavicle to about the height of the nipple of the breast ; the lung was retained in this position by the cellular membrane, which constituted the matrix of those abscesses, from which the matter proceeded on dividing the cartilages of the ribs. Long adhesive bands traversed the fluid from the pleura costalls to the pleura pnlmorralis. The lung, much di- minished in size, was of a dense, spongy consistence, and had lost all trace of its cellular texture. The right side of the chest was quite sound. The liver was of a marbled nutmeg co]our ; the other viscera seemed healthy. The swelling on the front of the left leg, when cut into, gave issue to about two ounces of greenish pus, tinged with blood; there was no thickening, or appearance of lymph, bounding the space occupied by this mat- ter. The muscular structure, in fhe immediate vicinity of the matter, seemed as if it had been dissolved in it ; it had quite lost its natural consistence.

What an unexpected complication presented itself in the ease we have just detailed ! How shall we designate it ? Shi~]l we call it gangrenous erysipelas ; or pemphigus gan~enosus; or irritative erythema ? Whatever term we may apply to |t, in order to convey an idea of the cutaneous eruption, we must ad- mit that the constitutional symptoms resembled the effects of an animal poison introduced into the system.

Ellen Read, setat. 32, married ; eon~ned about two months ago, since when she has never been in good health. About a week since was exposed to cold and rain, and the next day was seized with shivering and pains in her bones. Her wrists now became swollen and red, and being considered to be labouring under acute rheumatism, she was bled, purged, and got Dover's powder. After three days, she complained of headach and

390 Cases of Irritative Erythcma, by Dr. Law.

deafimss, and fell into a stupid comatose s "rate, for which a blis- ter was applied to tim nape of her neck. She now came under my care, when I found large condylomatous swellings, of a bluish colour, in different parts of file body; there were also numerous pustules, containing a yellowish purulent matter, and large vesicles or bullm, containing a bluish serous matter, in various parts. The back of each hand was swollen, and covered with a deep erysipelatous blush. The nose was very much swollen and red ; flits swelling and redness extended to each lower eyelid, and involved tile cheeks under the eyes, so flint the angle between the nose and cheeks was quite filled up ; the skin covering the swelling was of a deep crimson hue, and was raised either into pustules containing a yellowish purulent fluid, or into bull~e filled either with a dark serous matter, or with a clear transparent fluid ; some of them had given way" and dis- charged their contents, leaving the skin shriveUed. Pulse 180 in a minute, small and compressible ; respiration hurried and jerky (saccadde) ; frequent sighing ; great restlessness aad agi- tation ; complains off the impossibility of becoming warm; bowels too free ; excessive thirst; the body emits a heavy sick- ening fetor. No appreciable change took place in the symp- toms for two days ; she then fell into a deep coma, with ster- torous breathing, and occasional muttering delirium, and thus expired.

The examination of the body threw no light upon the nature of the disease. The blood was unusually fluid, and of a black gory appearance. The condylomatous turnouts contained an unhealthy greenish pus.

The three cases which we have just detailed suggest to us many considerations of pathological interest. 1st. When and under what circumstances do we meet with a similar'train of symptoms ? what are the prominent features of the disease ? does the eruption produce the constitutional symptoms ? or is it merely an external evidence of some peculiar virus introduced into the system ?

Cases of Irritative Erythema, by Dr. Law. 391

We have seen the disease so frequently associated with local injury as to look upon it as essential to its production. But the injury in some cases has been so slight, that we have had a difficulty in reconciling the severity of the effects with the insignificance of the cause. We are therefore obliged to ac- ~mnt tbr the phenomena by some peculiarity in the system, whether original or acquired. This peculiarity may be im- pressed upon the system by some mysterious intemperies of the atmosphere, whose precise nature we are utterly at a los6 tQ fathom. In what other way can we account for the fact, de- tailed by Dr. Butter in his work on the Plymouth Dock-yard disease, that fifteen men in working health should receiv~ wounds so slight as not to oblige them to relinquish their em- ployments; and that, in the course of a short time, these wounds should create fever and irritation, of which death was a com- mon result. Although in no instance did the disease arise ex- cept after local injury, still the same injuries, and more severe, had been received over and over again without such serious re- sults ; and here we find the entire fifteen cases occurring within a few months, although at the time there was nothing new in the nature of the men's employment, nor in any thing instru- mental to the local injury, from which we could suspect the in. troduction of any virus into the system ; nor was there any con- stitutional irregularity in the individuals to furnish us with data to predicate that slight injuries would be attended with such t~arihl results, the strongest and most vigorous constitution, equally with the weakest, falling a prey to the disease, following upon an apparently insignificant injury. W e must, therefore, from our inability to account for such unusual results from com- mon causes, refer them to some unknown condition of that uni- versal agentwthe atmosphere. How often have we observed erysipelas in the same way to present itself as an epidemic in the wards of an hospital, and to fasten itself upon every injury, so that the surgeon isdeterred from o~rating for fear of this

complication.

392 Cases of Irritative Erythema, by Dr. Law.

We next come to consider if there be any local injury which is, per se, competent to produce the disease we have described, independent of any favouring influence. Although We be- lieve wounds received in dissecting are of this nature, still by no means to the extent generally supposed. How many such wounds are received without any disagreeable consequence ; and even in most of these cases which have been attended with untoward sequela,', have we not been able to detect some pre- existing constitutional derangement ? Still there are some dis- section wounds which seem endowed with the fatal prerogative of producing the disease, no matter in what state of vlgour the system may have been at the time of the infliction of the injury. Wounds incurred in the dissection of subjects of puerperal fever seem to have a peculiar claim to this melancholy pre-eminence.

Is there any purely constitutional disease, unconnected with local injury, which bears any resemblance to that which we have just described ? Small-pox seems to us to bear a close re- semblance to it in many particulars; in it we have frequently thesame nervous derangement exhibitedin file general agitation, and restlessness, with delirium terminating in coma. We have often, too, the variolus eruption assuming the character we have just observed as being present in the cases we have detailed, the pustules often containing a bloody serous fluid, and the in- tenrening skin covered with a deep erythematous blush, or ex- hibiting either petechiae, or more diffused ecchymoses. Such a case of small-pox lately fell under my care ; the pustules con- rained a bloody fluid; the interposed skin was covered with petechive ; into the cellular membrane surrounding the kidnies a large quantity of blood was infiltrated.

Abemethy has well observed that fevers, produced by local disease, are the very identical fevers which physicians meet with when there is no external injury ; and in his description of what he terms s)znpathetic or irritative fever, he describes what we had met with independent of local injury.

Cases of Irritative E rythema, by Dr. Law. 393

In the cases we have detailed, the constitutional disturbance seemed to have preceded the local affection, or cutaneous-erup, tion ; and this latter to have re-acted, as it were, upon the consti- tution, impressing a peculiar modification upon the symptoms. Thus does the fever precede the eruption in small-pox ; and this eruption gives rise to the secondary fever, which is modi- fied, in some degree, by its extent and circumstances. Thus do we observe the characteristic distinction between small-pox and the varioloid disease to consist in the existence of secondary fever in the former, and its complete absence in the latter, al- though we often find the eruptive fever of the latter incompara- bly more violent than that of the former. We must refer this distinction ~of secondary fever to the severer injury inflicted upon the skin and cellular membrane by the eruption. Nor is it the only ease in which extensive injury of the skin awakens a similar train of alarming symptoms; burns and scalds, when the oecupy much extent of suriZace, and even in some cases where they are less extensive, but occur in the neighbourhood of the cavities, give rise to the same constitutional tumult, which Mr. Travers, in his valuable work on constitutional Irri- tation, ascribes to the important position occupied by the skin as the organ of exhalation, or as an expansion of the sentient extremities of the nerves, the destruction of which must propa- gate an immediate shock to their source and centre, the brain. W e may adopt this explanation and say, that the morhific virus (for such it would seem to be) acting, like the variolous matter, upon the skin, the seat of tangible impressions, and eonvertin~ natural into morbid sensations, the irritation from thence is communicated to the brain, the organ to which sensations, whe- ther healthy or morbid, are first transmitted, and from which they are reflected upon the organs re~malating the different func- tions, vi~.., circulation, respiration, temperature, and secretion ; an4 these are the funetiom which exhibit the derangement in

�9 uch c ~ .

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394 Cases of lrritative Erythema, by Dr. Law.

The cases we have detailed strikingly illustrate the de- rangement of these several functions. The sensorium was dis- turbed in all. In one case (Read) the pulse was 180 in the minute ; there was a proportionate hurry of the respiration ; this same case exhibited feebleness of tile power of generating animal heat, indicated by the constant complaint of inability to become warm.

Every symptom and circumstance connected with these cases bespoke a disproportion between the power and action of the system ; or in the expressive language of Hunter, an increased disposition to act without the power to act with. This is, in fact, file definition of an irritable habit, or an irritable condition of the system.

That this condition of the system is essentially connected with debility is proved by the fact that the best illustration of it is furnished by tile effects of h~emorrhage. As in the disease we have just been considering, so in hemorrhage, one of the most striking features, or most constant remote effects, is a hurry of the heart's action. There is no cir- cumstance, connected with this morbid condition, has led to more practical mischief than this, from its cause being mis- taken or overlooked. Again and again have I seen a practi- tioner, by the extent to which he has pushed his depletory mea- sures in the treatment of an acute disease, produce this hurry of the circulation, and then, mistaking this effect of his treatment for the index of continuing inflammation, persist in tile same measures, and thus add fuel to the flame ; thus proving the evil consequence of depending upon a single symptom to guide our treatment.

We shall now very briefly advert to the treatment which we conceive suited to this modification of disease. The high but irregular excitement with the debilitated energies of the system tells us no less emphatically what we should avoid, than what we should do. Any, even the slightost evacuation should be resorted to with extreme caution ; and this should not go be- yond the bare emptying the intestines, for to do more would

Cases of h'ritative Erythema, by Dr. Law. 395

be to increase the debility and consequent irritation of the system.

As to bleeding in these eases, we should scarcely have al- luded to it, feeling at a loss to conceive what end could be pro- posed tn resorting to it. It seems to us a shade more reasona- ble than to bleed a person with a view to recover him from the shock caused by a fall, or to bleed upon the first return of ani- mation after syncope. Still it has been practised, and exten- sively practised ; but every one, whose opinion has been formed upon the results of his experience as to its effects, agrees in reprobating it. Abernethy remarks, we are not warranted td bleed in eases of irritative inflammation and fevel; because these maladies are indicative of weakness, and likely to induce greatly augmented debility.

We now come to tile positive treatment. As debility and irritability (as its consequence) constitute file essence of the dis- case, we can be at no loss as to the classes of medicines among which we are to look for our remedial agents. Tonics and an- tispasmodics at once suggest themselves to us, the former with the view to sustain the flagging energies of the system, and

thus indirectly to quiet the tumult ; the latter to bring down or reduce the irregular action to the level of the diminished power. Quinine, ammonia, camphor, are the medicines upon whiehwe especially rely to fnlfil the indications we have in view. Nor shall we be deterred by the wandering or delirium from the exhibition of wine and opium. The judicious application of these two remedial agents involves points of the nicest practice which can engage the attention of a physician, and constitutes, as it were, a touchstone of his ability or incompetency to dis- tingnish between two morbid states, which, though they often

exhibit themselves under features scarcely to be distinguished,

are still no less diametrically opposed in their essential nature than in the treatment they demand. In the cases we have de- tailed, we saw that there were two distinct stages of nervous disturbance ; one, to uze the language of Mr. Travers, an active

396 Cases ~" lrritatire Erytherna, by Dr. Law.

sensitive stage ; the other, that in which the active excitement has given way to coma, interrupted only by a low muttering de- lirum. A quick rapid pulse, the constant accompaniment of the first stage, exposes it to the liability of being confounded with inflammation, and to the consequent error in treatment. I t is not long since I met an old practitioner in consultation ; the ease upon which we met was that of a lady who had been thrown from a jaunting car. When we met, four days had elapsed since the fall ; she complained of internal soreness, the effect of the shock, but had no distinct pain ; she was in a h i ~ degree of excitement; pulse 130, hard and wiry; skin hot and dry ; she stated that she had had no sleep since the accident occurred. I had the advantage of my medical friend, inasmuch as I had had previous opportunities of observing how the con- stitutional irritabillty of the individual modified any affectiort under which she laboured. Our views, therefore, differed no less as to the cause of the high excitement than as to the treat- ment. He, looking upon it as tile announcement of some se- rious inflammation, suggested a bleeding usque ad ~xx. ; to this, of course, I could not, consistently with the view I took of tire case, consent, but suggested a draught of forty drops of lauda- mun in camphor julep. Her husband, who was an apofllecary, and capable of understanding the difference of our views, adopted mine, and administered the draught I proposed. After two hours she fell into a quiet, tranquil sleep, broke out into perspiration, and the next morning I found a very al- tered person indeed; she had quite lost the anxious expres- sion she had had the day before ; her skin was soft ; pulse 84, relaxed ; no thirst. I shall make no further observations upon this case, than to ask, if the effects produced were such, what might we have expected from an opposite plan

In the second stage, or that in wl~ich the excitement

gives way to coma, interrapted by low muttering deli-

rium, we require the stimulating effect of opium. It too

On the Chemical ,4c lion ( f the z'~Ll, t~m,lo- Ell'oh'it Cm'rc,nt. ;~q7

often hal)pens that when this sCage has arrive'l, the season ibr interference with any ]prospect of advantage has passed by. Small doses of opium; carbonate of auv.nonia; blisters to the head, sinaifisms to the feet, present a tai~,t hope of benefit.

ArtT. XXV.--J~bte on the Chemical Action Of the ,lhtgneto-

Electric Gurrent. By ROBERT J. KAnE, M. R. I.A., Pro- fessor of Chemistry to Apothecaries' Hall. Extracted from a Letter to the Secretary of the Royal Irish Academy.

" SiR, " AVT~R many unsuccessfid trials, I have succeeded

ill effecting the decomposition of water by means of the current of' electricity induced in a conductor by tile action of a magnet. The form of apparatus used for generating the current was the disk revolting rapidly between the poles of a magnet. Intend- ing to follow up incessantly the developement" of this important principle, I shall not remark filrther at present, but hope to be very soon able to communicate to the Academy the details of the experiment, as well as the other results to which it promises to lead.

" I remain, dear Sir, ~ours, &c.

" ROBERT J. KANE.

" To the Rev. R. M'DonneH, D. D. " Secretary to the Royal Irish Academy."