Erysipelas.
Synonym:—St. Anthony's fire.
Definition:—An acute endemic and epidemic disorder due to the presence of the streptococcus erysipelatis, now believed to be identical with the streptococcus pyogenes, manifesting itself by a characteristic inflammation of the skin and subcutaneous tissues, which, although distinctly circumscribed, spreads rapidly. The inflamed area is deeply red, hot and painful. There is a moderately high fever and some prostration.
Etiology:—The distinction, which was once supposed to be established between the streptococcus of erysipelas and the ordinary pus-producing streptococcus—the streptococcus pyogenes—is no longer recognized. The specific origin of the disease is therefore denied.
The disease develops most commonly upon an abraded or broken skin. I have known, however, of several cases of facial erysipelas which started from the same spot, where no abrasion could be found, and almost on the same day of the same month, on several successive years. The disease is commonly endemic. Epidemics depend upon a distribution of the infection, which can usually be determined and explained. This is true in hospitals and in other institutions where invalids are congregated. It is carried by a careless midwife or obstetrician from a typical case to puerperal patients, resulting in quick infection. It occurs most commonly in winter and in the early spring months, and among those of previously impaired health, or those who are exposed to severe weather. It is more common in damp weather and among male patients and readily attacks wounds and injuries that have not had strict attention and care. It is more frequent between the ages of twenty and thirty years. Nearly forty per cent have had previous attacks, and it is not uncommon that it recurs three, four or five times. Alcoholics and patients suffering from tuberculosis, Bright's disease, diabetes mellitus, or other cause of permanent health impairment, are especially liable to infection. Puerperal cases are readily infected.
Symptomatology:—In erysipelas the prodromal symptoms extend over a period of from two to seven days. A sense of general ill feeling, with headache, precedes an attack, with restlessness, a slight fever, some irritation in the throat and a mild cough. The appetite is gone and there is constipation. The onset varies in different cases; with some there is a sharp chill, an abrupt rise in the temperature and rapid pulse, prostration and some delirium. With others there is burning, tingling, and perhaps itching, over a given spot on the surface of the skin, usually on an exposed surface of the face or head. This is most often at the side of the nose, but it may be on the cheek, ear, forehead or scalp. In one of the author's cases it appeared on the outer surface of the upper arm, immediately below the shoulder. The patient may be yet about his work, while feeling indisposed. A distinct redness then appears at this point, which soon becomes hot, hard, painful and shining. This spreads rapidly and there is soon apparent a distinct line of demarcation between the healthy and the inflamed surface.
The patient now has a succession of chills, and the temperature rises to perhaps 105° F. As the inflamed surface is swollen, this is raised above the healthy skin, and the line can often be felt as well as seen. This line advances as the inflammation advances. In some cases—those most active usually—with marked constitutional symptoms, the color is deep red and the surface is shining, but where the onset is less rapid the color is of a dull, dark red, or dusky hue. This inflammation involves the integument and cellular tissues beneath, into which there is often infiltration. This produces great distortion of the face and countenance. The eyes are closed and their location almost obliterated, the ears are enlarged and forced out of their usual position. When on the tip of the nose, the appearance is almost hideous, and the pain and distress are unbearable because of the unyielding character of the structures.
In those cases known as erysipelas migrans the inflammation may change its location and progress down the arms, or onto the other portions of the body and abate at the point of original invasion. By this course it may successively attack almost the entire surface of the body before it is under control. This, however, is a rare form. In some cases the epidermis is separated and blebs, blisters, vesicles or bullae may appear. Occasionally these ultimately fill with pus or pus may form beneath the entire integument in the cellular tissue or from the intense infiltration gangrene may develop with distinctly marked outlines.
The constitutional symptoms become aggravated as the disease advances, and by evening of the third day, in severe cases, the temperature may have risen to 106° or 106.5° F. In the latter part of the night the temperature falls two or three degrees, and during the remission there is a slight abatement of the symptoms. In the migratory form of the disease the temperature varies greatly on different days and at different times on the same day, the pulse continuing full and soft. Just before the fever begins to decline there is a fading of the extreme redness of the skin, and an abatement of all the phenomena, although in extreme cases occasionally there may be slight increase of the local symptoms, even after the temperature has reached the normal point.
There is extreme nervous excitability and restlessness in some cases, while in others there is dulness and inactivity. Severe headache is common, and some delirium, especially during the early or middle part of the night. In drunkards delirium tremens has been precipitated by an attack of this disease. As the symptoms persist marked deterioration of the blood occurs, and in a small percentage of cases typhoid phenomena develop, with dry, dark coated tongue and dark mucous membranes of the mouth and sordes.
There is a form of erysipelas in which there is extreme swelling and oedema of the surrounding tissues, which may be filled with pus, with sluggishness of the local circulation and perhaps discoloration. This is designated as phlegmonous erysipelas. There may be frequent and persistent relapses in this disease, and it may be present in a child at its birth, when it is known as erysipelas neonatorum.
An attack of erysipelas confers no immunity to the patient, but rather predisposes him to a recurrence of the disease.
Complications and Sequelae:—The occurrence of phenomena designated as typhoid, is due to general septicemia, which develops early in some cases and is a serious factor. The presence of albumin in the urine is very common. Abscesses are the rule in badly managed cases, rather than the exception. Rheumatism, occurring from four to six days after the development of the disease, and persisting even after the local symptoms have abated, is of not infrequent occurrence. Involvement of the lung structures, inducing pneumonia, bronchitis and pleuritis, may occur also, and endocarditis and pericarditis have been induced, also synovitis, nephritis and cystitis, as well as iritis and otitis media.
When chronic disease is present in patients attacked with erysipelas the chronic condition may suddenly assume grave proportions and terminate fatally. In patients impaired in health the disease is liable to be more severe and protracted—less amenable to treatment.
Prognosis:—In patients of previous good health and those suffering from the first attack the prognosis is good, as the disease in these is not difficult to manage. It is the complicated cases that assume serious proportions, and those occurring in patients of previously debilitated constitution.
Treatment:—It is the author's practice to pay the first attention to the temperature and pulse at the onset of the disease. Aconite and veratrum may be used with excellent results in small and frequent doses. The latter remedy may be spread over the local reddened and inflamed surface with a camel's hair pencil. Its internal specific indication is a red stripe down the center of the tongue.
The directly specific remedy is rhus toxicodendron. If the local symptoms are sharp and conspicuous and the temperature is not too high, this alone will meet the indications satisfactorily. It should not be omitted and its use will establish confidence in its influence. Five drops of specific rhus in three ounces of water is given persistently as long as the circumscribed bright redness remains, in hourly dram doses. The remedy is especially indicated when with the bright redness there is vesicular eruption. When the redness is darker, the tincture of iron in ten minim doses every three hours is indicated. In my early practice I invariably painted the inflamed surface and an area of the healthy skin, perhaps half an inch wide outside of and beyond the line of demarcation, with this remedy in full strength. I have had no better results from other remedies.
When the case is deeply seated, or when it involves the pleura or the peritoneum, or when rheumatic symptoms or symptoms of synovitis occur, bryonia will be sharply indicated and should be persistently given. Muscular aching and diffused soreness will abate under the influence of small doses of macrotys. Belladonna in small doses is sharply indicated in many cases of this disease, especially if the surface is of a dark but dull hue and smooth and shiny. Its influence upon the capillary circulation in phlegmonous cases is most pronounced and satisfactory and in a direct line with the physiological action of the remedy. It overcomes local stasis and induces equalized capillary circulation. Apis mellifica is indicated where there is much tumefaction and edema, especially if the urine is deficient, of high specific gravity and of dark color, with irritation and some sharp pain in its passage.
When the symptoms have abated, the temperature not above 100° F. and the skin and tongue moist and soft, the tongue cleaning, quinin will be of much service in supporting the strength of the patient and in re-establishing the functional action of all organs. It can be given in conjunction with the tincture of iron with good results.
In cases that have had a sudden sharp onset, with pronounced symptoms, in previously strong, vigorous patients, a hypodermic injection of pilocarpine at the onset will often abort the active phenomena. This may be repeated once or twice within the first eighteen hours if the temperature is high, but should be abandoned after the first day. If delirium is present at the first, this remedy is especially serviceable. Echinacea, locally and internally, will be of immense service in septic and phlegmonous cases and where the phlegmonous tendency threatens. It is the remedy also for gangrenous cases and where abscesses have formed whether mild or severe. Gauze wet with this remedy should be applied over the diseased surface and retained, covered with rubber protective. From ten to twelve drops internally every two or three hours will destroy sepsis within the system and greatly inhibit pus formation, when such a tendency exists. Where the local manifestations are extreme the agent can be injected directly into the structure toward the outer margin with pronounced results.
For the nervousness and sleeplessness gelsemium and hyoscyamus are accessible, or small doses of chloral or sodium bromid in full doses with or without very small doses of morphin. A prescription, each dram of which contains five grains of the above bromide and one-sixteenth of a grain of morphine and one minim of specific hyoscyamus may be given in dram doses every half hour, for two hours, and then discontinued. Three or four doses are usually sufficient. This produces freedom from pain and distress and quiet sleep, with none of the untoward symptoms of the morphin. Further external measures are the application of a carbolic paste or a lanolin ointment containing boric acid, carbolic acid, ichthyol or bismuth subnitrate. The use of a wet gauze boric acid dressing confined with oiled silk or rubber protective will act promptly. Or a dilute solution of sulphurous acid is often of much service.
Other general constitutional symptoms will be met according to indications. Typhoid conditions will need baptisia or turpentine or hydrochloric acid in addition to some of the remedies named, especially echinacea.
The diet should be generous, concentrated, very nutritious and easily appropriated. A salt water sponge bath is efficacious, especially while the fever is present. Cold sponging at this time is among the available measures. Complications, as stated, must be met as indications suggest.
