/ 
0     J   j            //Z-^^^^s^.
               A$   HISTORY,  <mmm   X

 Of the Erysipelatous  Inflammation  that recently ttppeared
   in \ the Massachusetts  General Hospital.    By  George
   Haywarc, M.D.

 J. he  occurrence of erysipelas  in this  institution,  and its
 occasional appearance there for several months, have excited
 no small degree  of attention,  and have given rise  to exag-
 gerated and false statements of its extent and fatality. With
 a view  to correct these, as well as to exhibit  facts  as they
 really existed, I have been induced to draw up this  article.
   1.  The first case of  this disease occurred in April 1826.
 The patient was  a large muscular man of  about 25  years of
 age, from  the country,  who was  admitted in consequence of
 having  been run over by a loaded Avagon, a few hours after
 the accident.   The os  femoris  of  the  left side was frac-
 tured, a deep wound was made  on the outside of  the right
 thigh, which  penetrated  to the bone, and there was a  se-
 vere  compound  fracture  of the  little finger of   the  left
 hand, which made  its removal  necessary.   The  accident
 occurred  on the 8th.   A disposition to gangrene  appear-
 ed in the  wound  of  the  thigh  on the  11th,  and some
 marks of erysipelatous  inflammation on the  surface of  that
 limb.    This inflammation continued  to  increase,  and  ex-
 tensive  sloughing soon took  place from  the  wound ;  and
 though  it  Avas  dressed twice a-day,  and  the most powerful
 antiseptics used, the fetor was nearly insupportable.  The
 patient continued to sink; the  erysipelas extended over both
 lower extremities;  the  sloughing and offensive discharge in-
 creased ; he Avas very restless and in great pain, till two days
 before his death, when he became comatose,  and  at length
 died on the 2d of May.  There was reason to believe that
he had been habitually addicted  to the  immoderate  use of
ardent spirits.   The Avard was  fumigated, before and  after
his death, with the  gas of chlorine, and  all means that Avere
practicable Avhile  the patients remained in  it, were employed
to  purify it.  As soon as he was dead, every thing connect-
ed with his bedding  establishment Avas  removed, and  the
                    1 
2
mattrass on  which he had lain was so much injured that it
was never  used again in the house.
   2.  The  subject of the second case, a healthy young man,
Avas admitted'in consequence of a  fracture of  the tibia and
fibula of the left leg just  above the  ankle.   The  accident
occurred on the 8th of June, near the Hospital, and the pa-
tient was brought immediately there.   On the  12th there
was some appearance of erysipelatous inflammation about the
ankle, and  on the 16th  it had extended up the leg,  and ap-
peared also on the face  about the left eye.  The disease now
rapidly  spread, the face and whole  head became enormously
swollen, a  black spot showed itself on the limb near the an-
kle, and the  patient was affected  with  a violent delirium.
These symptoms  were unabated till the  26th,  when  a fa-
vourable change took place, and the inflammation gradually
subsided, Avithout the occurrence of sloughing.  By the 1st
of July the disease Avas nearly gone, but on the 11th there
was a slight return, Avhich continued a day or  two only, for
there was no vestige of it on the  16th ;  he Avas discharged
August  2d, perfectly well.  It may be perhaps Avorth while to
remark, that  during the violence of the erysipelatous inflam-
mation,  there  seemed to be  no disposition  Avhatever  in the
bones to unite. This patient occupied a ward on a story be-
Ioav the one in Avhich the  other  patient died, and betvveen
the wards occupied by these patients there was no commu-
nication.
   3.  On the  15th of June,  a young man  labouring under
fever, was suddenly attacked Avith erysipelas, which  appear-
ed first  in the face, and spread with great rapidity, affecting
the eyelids to such an extent as to close the eyes complete-
ly,   He was delirious from the first appearance of the  ery-
sipelatous inflammation, and  sunk under it on the 18th.  He
was of course under the care of the physician.
   4.  The  next case occurred on the 21st of June, in a me-.
dical patient, who was  just recovering from a severe attack
of continued  fever, by Avhich he was extremely reduced.
The disease  shoAved itself about the face and head, and the
patient died on the fourth day after its appearance. 
   5.  On the 27th of June a large tumour, situated near the
angle of the  jaw,  was  removed  from a healthy woman of
about 40 years of age.   The  operation, from the size and
situation of the tumour, was necessarily severe, and the ex-
ternal carotid  artery  was tied.   All appearances were favour-
able till July 1st, when there Avas a slight indication of ery-
sipelas on the  right cheek under the eye ; the Avound how-
ever continued to look well.   On the  2d  the disease had
extended, and the wound began to assume an unhealthy as-
pect.  The eyelids were so much swollen as to close the
eyes,  and the patient Avas delirious.    The  inflammation
continued to  increase daily,  suppuration took place  about
the  upper eyelids, the wound  assumed  an  unfavourable as-
pect, and began to  slough.  On the  8th she was decidedly
worse ; her pulse was small and rapid ;  the delirium very
much increased ;  she had had no sleep for forty-eight hours,
and refused to take  both medicine and food.   Some sleep
having been procured on the night of the 8th, she was found
better on the  following morning.   She became more rational
on the 10th;  the inflammation was subsiding, and in  a day
or two the wound began  to granulate ; and  on the  4th  of
August, it being entirely healed, she was discharged well.
   6. A medical patient,  who had been labouring for a long
time under ascites and general anasarca to such an extent  as
to render her case hopeless, but  who  was  in a much more
comfortable state than she had been for a length of time, Avas
suddenly attacked on the 21st of July Avith erysipelatous in-
flammation on one of the lower extremities.   It spread with
great rapidity, and  assumed a violent character,  and  proved
fatal on the 23d.
   It may be proper to remark, that the  first case  was the
only one  that had hitherto occurred in the  ward in  Avhich
the disease originally appeared, though  all  the  cases men-
tioned had been confined to that side of the house.
   7.  On the  9th  of September, however, a man  was admit-
ted Avith a scrophulous disease of the testis, into the  room in
which the first patient died, and  on the  17th he  was attack-
 ed with erysipelatous inflammation about  the ankle of the 
4
right leg.   This extended to the thigh,  and afterwards ap-
peared on the head and face.   It  began  to  subside on the
23d, was very slight by the 26th,  and on the  30th he was
entirely well.
   8.   On the 29th of September, a man, of a bad habit  of
body, with an ulcer of long standing about the tendo Achil-
lis, was admitted  into the  upper Avard of the  other side  of
the house, as remote as possible from"the place  in which
the disease had hitherto  appeared.   On the 3d of October,
erysipelas was discovered on the leg about the ankle, and  in
course of the day extended up to the groin.  It was more ex-
tensive on the following day,—the mind was wandering, the
pulse  feeble and rapid, the  tongue parched, and the skin hot
and dry.   All his symptoms had gradually become  worse till
the 7th, Avhen vesications appeared on  the limb, and he  con-
tinued to sink till the  10th, when  he  died.  This patient's
system was much impaired  by intemperance.
   9.  A medical patient, who was convalescent, was attacked
with erysipelas about the right ear on the 26th of October.
It  extended on to the  side of the face and temple,  down the
neck, and upon the scalp,  with considerable  redness  and
swelling, and some vesication.    In a day or tAVO the disease
subsided in some measure on  this  side, and appeared  in  a
much milder form  on  the  other.  It never assumed a very
serious aspect, and entirely subsided  by the 31st, and he Avas
discharged well on the 11th of December.
   10. A girl, of about  15 years of age,  with scrophulous
ophthalmia, was affected with erysipelas on  the face about
the last of October.   The disease in her case Avas compara-
tively mild, and nothing unusual  occurred in the course of it.
It  continued four or five days only, without any violent  con-
stitutional symptoms, and at the  end  of that period, she  was
as well as usual.
   11. A healthy girl, eighteen years old, Avho  had been in
the hospital a few weeks with an ulcer on the leg, was at-
tacked with  erysipelas about the head, on the 7th of  No-
vember.   It extended over  the  Avhole face in the  course of
two or three days, so as to close the eyes,  and produced an 
5
enormous swelling of the head, attended with deafness.   In
this case however the symptoms were not of the worst cha-
racter ;  the mind was not in the least affected, and in a fort-
night from the attack, the patient had recovered her health
entirely.
   12. The next case of this disease occurred in an unhealthy
man, of a scrophulous habit, 34 years of age, who had his left
testicle  removed on the 23d of December.   For a few days
after  the operation, every thing  appeared  to  be  going  on
well, and the wound was  rapidly healing ;  but on the night
of the 31st he  was seized with a violent rigor, followed by
a hot fit, and pain in the right arm,  though there  was nei-
ther swelling nor redness.   On the morning of January  1st,
the arm was considerably swollen and  discoloured, the co-
lour however was much darker than is  usual in erysipelas.
The pulse was very rapid and feeble, the tongue parched, and
the skin hot.  In the course of the day he  became delirious,
and died in the  afternoon.
   13.  A man 32 years of age, who had been in the hospi-
tal about three weeks for an abscess on the head, of which
he was  nearly well,  in  the same ward with the last patient,
was attacked in the night of the day on which the other died,
with  a  chill followed by  great  heat.   In the morning the
disease  appeared about the head and face, which were much
swollen, and almost covered  with vesications.   The disease
began to subside on the sixth day, and by the  tenth  was
nearly gone.   During its progress,  suppuration took place in
the upper and lower eyelid  of  the right  eye, and in the
lower eyelid of  the left eye, and openings were made in
them, by which a considerable quantity of pus Avas discharg-
ed.   An abscess also formed on the head  behind the  right
ear,  which was opened ;  the original  one, on account of
which he came  to the hospital, was on the left side.  After
all the symptoms of the erysipelas had disappeared, and the
patient  was about taking his discharge,  he  was attacked in
the night with  an epileptic fit, to which  he had been sub-
ject.  He stated in the  morning  that he  had  had a slight
one the  preceding night;  he  seemed  as  well as usual; a
                    2 
6
light diet and a cathartic were  ordered for him, and he  in-
tended to go home the next day.   In the night following he
was seized with another fit, and expired in a few moments,
before any one in the ward could get to him.
   14. On the night of the 6th of January, four days after
the attack of the last patient, a man in the same ward,  la-
bouring under chronic diarrhoea, in a state of extreme debi-
lity, without the slightest prospect of recovery,  was seized
with a chill, followed by heat, with  soreness about the ear.
He soon became delirious, and continued to sink, till the af-
ternoon of the 8th, when he died.
   15. A healthy man, on whom the operation of tying the
external iliac artery had been performed on the 25th of No-
vember, was the next subject of this disease.  All his symp-
toms after the  operation had been favourable till the 25th of
December, when a swelling appeared between the  spine of
the ilium and the wound ;  this suppurated  and was opened
on the 31st.   In a few  days  after,  erysipelatous inflamma-
tion made its appearance in the neighbourhood of the  open-
ing, extending for a few inches on to the abdomen ;  it yield-
ed however soon to the  remedies  employed, though  the
wound was slow to heal, and the patient was not discharged
well till the 16th of February.   This  patient  was in a part
of the house very remote from the three last.
   16. A medical patient, in a ward adjoining the one in which
the disease first appeared, was attacked on the 7th of January
with swelling and redness of a deep colour of the left eyelids.
In the course of the  day the redness and swelling did not in-
crease, though he complained of great soreness of  the face.
The erysipelas in this case  never assumed a very threaten-
ing or severe character,  but subsided almost entirely in the
course of three or four days.   The patient was a man of re-
gular  habits and good constitution, and not  much debilitated
by his previous disease.
   17. About the time that the  last patient was attacked, a
female, in whom the brachial artery had been tied,  was  af-
fected with erysipelas.  It appeared particularly about  the
arm, though it extended somewhat up the  neck, and  there 
7
  were some slight appearances of it on the body.   She reco-
  vered in the course of three or four days.   It should be ob-
  served,  perhaps, that she  had been in the  house several
  months, and during that  period  had had  several attacks of
  the disease, all of which however were mild.
     Thus it appears that no less than six cases of this disease
  occurred within a week, three  in the ward in which the first
  patient died, one in the adjoining one, and  the other two in
  remote parts of the house.  This was a very large number,
  when compared with the number of patients in the institu-
  tion, as it constituted one-tenth of the whole.  Hitherto the
  disease  had excited but little alarm, as there had rarely been
  more than one  or two cases at the most at a time, and usual-
  ly a very  considerable interval  elapsed between  them,  so
' that not a suspicion had been excited  that  it was owing to
  any peculiar state of atmosphere  in  the  hospital.   The as-
  pect of things  was now however entirely changed, and the
  medical attendants  recommended  to  the  trustees, that  no
  more patients should be admitted at present; that all who
  were in the house should be  discharged  as soon  as it could
  be done with safety and convenience; and that, if necessary,
  a house should be provided in the neighbourhood, to receive
  for a time  those who  could not be  otherwise  disposed  of.
  These recommendations were  promptly attended  to, and on
  the 15th of January only twelve persons  remained,  all of
  whom were on that day removed to a house in Vine-street,
  in the immediate  neighbourhood of the hospital.
     The  first inquiry then, was, in  what way this erysipela-
  tous inflammation had been kept in existence in the house
  for so long a time, or to what peculiar circumstance Avas this
  singular fact owing ?   The situation  of  the Massachusetts
  General Hospital is remarkable for its salubrity and adaptation
  to the wants of such an establishment; and1 it will not, I am
  confident,  be  thought hazarding  too  much, by those Avho
  have been conversant with its internal arrangement, to  say,
  that in  point of cleanliness it may challenge a comparison
  with the best regulated hospitals in Europe or this country.
  There was one  circumstance however in which it differed 
s
 from other institutions of the kind ;  I refer to the manner of
 warming and ventilating it.   All  the wards,  with two  or
 three exceptions, were warmed  by furnaces placed in the
 cellar.  The hot air, which was external air heated by the
 furnace, was admitted  at the upper part of the ward,  and  at
 the bottom there was an outlet for the escape of the foul air.
 This was considered better than to admit the air from below,
 both for the purposes of warmth  and ventilation, and it an-
 swered the first purpose perfectly at all times, and the other
 in great measure as long as  fire was kept in the  furnaces.
 But when this was extinguished, the patients, to prevent the
 Avards from becoming cold, shut the ventilators, and there be-
 ing no fire-places in the rooms, there wTas consequently little
 or no circulation of air during the night.
   The following fact may be mentioned in corroboration of
 the opinion, that the disease was probably OAving to  a  want
 of complete ventilation.   The alms-house in Leverett-street
 was, till the erection of the hospital, the only public recep-
 tacle for the sick poor, as well as  the paupers of the town,
 and though it was far  from being  clean, 1 cannot learn that
 any case of erysipelas occurred there  from the time of its
 erection till its removal in 1825.   For several years I was
 well acquainted with the state of that house, part of the time
 as a student of  medicine, and a part of the  time as the phy-
 sician, and during the whole  of that period there was  not a
 single case of this disease.  It  is not improbable,  that  there
 may have been one or two solitary instances at other times,—
 it  would be remarkable if it were otherwise;  but that it ne-
 ver prevailed there to any extent,  I am absolutely certain.
 The reason of this exemption I conceive to be the fact, that
 the rooms, in. which the patients were kept, were spacious,
 well ventilated,  Skid had large open fire-places.
   In the house  of industry at  South  Boston, on  the  other
 hand, which, besides having every  advantage  of situation, is
 far cleaner than the  old alms-house, and is intended only for
 the reception of  paupers, erysipelatous inflammation, of the
 same character precisely  as that which appeared in the hos-
pital, has already several  times occurred.   The rooms,  ap- 
9
propriated to the sick in this house, are small, have but one
window, communicate with an entry warmed by a  furnace,
and a part of them are not provided with fire-places.
   It seems to me to be no objection to this opinion, that se-
veral of the cases in the hospital occurred during the  sum-
mer ; for the windows in the patients' rooms being all closed
at night, and there being of course  no  fire in the furnaces,
there was  consequently but little change of air.   It is a fact
also, and certainly a striking  one, that not a single case ap-
peared in any room in which there was a fire-place ; and it
is not  less remarkable, that not a case  has  occurred in the
house since the patients have been re-admitted, though nearly
five months have elapsed  since it  was  re-opened, a period
of exemption more than double in length of what has existed
since the occurrence of the first case,—and during this very
period  the disease has been unusually prevalent in various
parts of the city.   This must be attributed chiefly, I think,
to the more complete ventilation of the wards ; for the hospi-
tal, though perfectly clean, is  not more  so  than formerly,
and the number of patients is as great  as  it has frequently
been before.
   As soon as the patients  were removed from  the hospital,
the following  means were  employed by the advice of the
medical attendants to purify it, and to prevent the recurrence
of the disease.   All the  mattrasses were ripped open, the
tickings washed, the  hair  picked and  baked, having  been
first exposed five days and nights  to the air, during which
period   the thermometer was  most  of the time  below zero,
all the windows in the house  were kept open for the  same
length  of time.   After this, the wards were first fumigated
with sulphur, then with the gas of chlorine ;  all of them were
white-washed, and part of them were painted ; the wood work
in those that were not painted was washed with lime water.
Fire-places were then made in all  the wards,  with two or
three exceptions only, and  these were rooms of a very small
size.  Fortunately this could be done Avithout much difficulty,
as flues were left in the walls originally from an apprehension,
that  the furnaces might not warm  the  building  sufficiently. 
10
The bedsteads .were left  out  doors,  exposed  to the  wea-
ther which was  intensely cold for  several days, and  then
carefully washed.   The house having been scoured through-
out was ready to receive patients, and  they were accordingly
readmitted on  the  3d of February, it having  been closed
nearly three weeks.  As was remarked above, almost five
months have  elapsed  since their return, without the occur-
rence of a single case.  The furnaces  are still used to warm
the building, and small fires are  lighted  in the fire-places  suffi-
cient only to promote a free circulation of air.   The state of
the atmosphere is certainly more agreeable in the wards than
before the alteration ; it has lost all that closeness, which, at
times when the heat was great, was extremely unpleasant, if
not unsalutary.
   Nothing occurred  in the progress  of this disease at this
time to warrant a belief, that it was propagated by contagion.
The second patient was not  admitted into the hospital  for
more than a month  after the death of the first, and in no in-
stance were any of  the nurses or attendants attacked with it,
nor did it seem possible in any case to trace  it from one pa-
tient to another.  An atmosphere, capable of producing ery-
sipelas in those predisposed to it, seems to have been gene-
rated by the first patient;  and  this was never entirely re-
moved, from the want of sufficient ventilation,  till after all
the patients were discharged  from  the  house.  I am not dis-
posed  to deny, in opposition  to the opinion of the late Dr
Wells of London, as given in his ' Observations on Erysipe-
las,' in the second  volume of the  Transactions of a Society
for the improvement of Medical and Chirurgical Knowledge,
that the disease ' may, sometimes at least, be communicated
from one person to  another,'  though I must confess that no-
thing has ever occurred  under my OAvn  observation,  that
would incline me to think Avith him.
   It would not accord with the object of this paper to detail
minutely the medical character and treatment of the erysipe-
las,  as it existed  in the hospital at  this time ; a feAv general
remarks on these points are all that I  shall offer.
   It was evidently  a disease  of debility, affecting those with 
11
 most severity, who were already exhausted by previous ill-
 ness, or whose systems were broken down by intemperance.
 Not a death occurred of an individual, who was either not de-
 bilitated by sickness, or whose constitution was not impaired
 by former indulgence in the use of ardent spirits. It seemed to
 demand, in most of  the cases certainly, the treatment  first
 recommended, I believe,  by Dr Fordyce, and since so  suc-
 cessfully followed  by Dr Wells and many other eminent phy-
 sicians  of Great Britain, I mean that of administering Peru-
 vian bark in large and frequent doses, and keeping the affect-
 ed parts bathed with diluted alcohol.
   Evacuants  were rarely  required;  in a few instances,
 emetics or mild cathartics followed immediately by the bark,
 were found useful.   The bark was not given in such doses
 as Dr Fordyce speaks of, that is, one drachm of the powder
 every hour ; it is  rare, that the stomach will retain it in such
 quantities, and  it  is  still more rare I believe that  such a
 quantity is required.  Dr Wells, a firm believer  of  the  cor-
 rectness of this practice, never  gave it to such an  amount,
 nor did he think it necessary.   It is difficult, during the de-
 lirium which so commonly attends the disease,  to induce pa-
 tients to take it in  this form, and the  sulphate  of quinine
 was found to be an excellent substitute.   In recurring to the
 records, the largest  quantity of  powdered bark administered
 to any patient with erysipelas, I find to have been one ounce
 in twenty-four hours ; a pint of brandy, however, was taken
 during the  same period.   Of the sulphate of quinine thirty-
 six grains were given in divided  doses of six grains  each, in
 the same length of time to another patient.   Great use  was
made of wine, porter, brandy,  the infusion of bark and the
tincture of the sulphate of quinine as auxiliaries, and in some
of the worst cases,  these alone were employed, as the patients
would reject every thing but liquids.