process is such that the epidermis is raised from the tissues below by
the free exudation of the serum of the blood. In this way vesicles,
or, more commonly, bullæ, develop upon the surface. Bullæ thus formed
may be typically perfect, but are often exceedingly irregular in
contour, having an appearance which is suggestive of the blistering of
a surface by boiling water. The bullæ may be well distended and filled
with a perfectly limpid serum. This fluid may, however, in the course
of a few days become purulent, the contents in such case drying into
crusts. In the severest types of the disease gangrene results from the
intensity of the dermatitis, and the loss of tissue which thus occurs
is repaired by the processes of granulation and cicatrization.
The migration of erysipelas from one part to another of the surface is
sometimes so extensive as to invade from time to time the larger part
of the superficies of the body. Erysipelas of this ambulant character
may also, after invading the entire surface of the body, be relighted
at the point where it first appeared. In other cases this phenomenon
of recurrence or reawakening on patches of skin traversed by the
disease may be noticed only after moderate extension from a given
point. Reddish or rosy-colored islets then appear as new centres of a
fresh extension-process upon an integument whose swollen tissues still
exhibit the evidences of the prior invasion. In still other cases
similar islands of fresh disease are recognized in advance of the
elevated edge and tongue-like prolongations which mark the onward
progress of the erysipelatous inflammation over areas previously
unaffected.
The swelling of the involved tissues is one of the most characteristic
features of erysipelas. By this is meant not the tumefaction simply of
the superficial portions of the integument, nor the tumefaction which
may be measured by the height of the affected above the level of the
unaffected skin at the edge of the involved area, but a swelling much
more than this, involving the entire skin, and often indeed the
subcutaneous tissues, differing, of course, in the extent to which it
advances in different cases. In those of severe grade the swelling is
enormous, an affected limb assuming the elephantiasic aspect, while
the deformity thus induced in the head is fully as great as that seen
in the height of confluent variola. In such cases the neighboring
ganglia are, as a rule, enlarged and often painful.
It is indeed this swelling which gives to erysipelas of the head and
face its peculiar physiognomy. The disorder is apt to find its
starting-point in the ear, the side or point of the nose, or one
cheek. At this moment it may be possible to recognize the fact that
the adjacent mucous membrane is also involved. Thence the disease
progresses over the face, and possibly over the scalp also, the
resulting tumefaction being occasionally, as already stated, enormous.
Thus the eyes are usually closed and sealed by the swollen lids and
the orbital depressions are effaced. The lips, enormously pouting and
reddened, project from the swollen visage to as {633} great an extent
as the tumid ears, which, for similar reasons, depart from the usual
plane. The mouth, nares, and eyes alike are covered with mucous
secretions, possibly commingled with the contents of bullæ which have
formed and broken. Crusts may thus collect near the mucous outlets.
The tongue is dry, parched, and cracked, and exhibits a reddish-brown
hue. In less severe cases it may be seen to be covered uniformly with
a thick yellowish or yellowish-white paste. The fauces and buccal
membrane are reddish in color, glazed, and dry.
The patient having this serious form of the malady is indeed in a
critical condition. There is usually a coincident coma or delirium.
The pulse is either greatly accelerated and full, or thready,
fluttering, and destitute of rhythm. The temperature rises to 105° F.,
and even higher. In this condition a fatal issue may be heralded by
collapse, with decadence of the external evidences of the disease, or
by the occurrence of blood-filled blebs, or indeed by larger or
smaller areas of the surface falling into gangrene. This latter
accident may also involve the mucous surfaces, large patches of the
buccal membrane, the gums, and even the palate, losing their vitality
and showing as greenish-black, insensitive tracts, quite firmly
attached to the healthy tissue. These accidents may be of very rapid
occurrence, more particularly in the case of individuals prone to
exhibit the severest forms of the malady, such as very young infants
and those enfeebled by advanced age, by alcoholism, or by any of the
cachexiæ.
Other types of erysipelas, chiefly noticeable by reason of their
location, are those spreading from the umbilicus, the genital region,
the sites of vaccination, of varices of the lower extremities, and the
surfaces near the seat of surgical accidents and operations.
The various names which have been, especially by older writers, given
to the several expressions of this disorder relate almost exclusively
to their external characteristics. Among these may be mentioned--E.
ambulans, e. erythematosum, e. bullosum, e. glabrum, e. levigatum, e.
miliare, e. oedematosum, e. pemphigoides, e. phlyctenulosum, e.
puerperale, e. vaccinale, e. variegatum, e. verrucosum, and e.
vesiculosum.
The resolution of erysipelas in favorably terminating cases is
accomplished by very gradual amelioration of symptoms. The swelling
begins to subside, usually between the third and sixth days. The blebs
that have formed then disappear by absorption, bursting, desiccation,
or crusting, and subsequent exfoliation. Desquamation of the involved
surface may be a prominent or a very insignificant feature. When the
patient with erysipelas capitis enjoys a favorable crisis in his
disease, there is occasionally noted a very rapid amelioration of the
symptoms. The tumefaction speedily subsides, the features become
recognizable, and defervescence is complete. Throughout the course of
all attacks the febrile process and the erysipelatous blush proceed
pari passu with but little deviation of the severity of the one from
the intensity of the other.
The complications and sequelæ of the disease are less numerous than
they are grave. In erysipelas of the head there is usually a rapid
shedding of the hair, though in convalescence the growth of the hair
may be restored. An obstinate seborrhoea sicca may, as after variola,
linger long afterward upon the scalp; here also, as in other {634}
portions of the body, one or many abscesses may form in the
subcutaneous tissue after the resolution of the dermatitis; while in
phlegmonous erysipelas these abscesses may accompany the disease at
its height.
Lymphangitis and adenopathy are common complications of erysipelas,
the former betrayed in thickened and often knotted cords, which may be
felt radiating from involved areas to neighboring glands. A singular
modification is often undergone by the integument affected with
erysipelas which has also been the seat of other cutaneous disorders.
In this way lupus, psoriasis, chronic eczema, and some of the
syphilodermata have been relieved.
Besides the surfaces of the nasal, pharyngeal, and buccal mucous
membranes which have been indicated as at times involved by the
disease, the inflammatory redness and swelling may extend to the
epiglottis, the larynx, and the trachea. Croupous and other forms of
pneumonia, pulmonary oedema, and pleuritis have been not rarely noted.
In erysipelas of the head the membranes of the brain may inflame and
serous effusions distend the ventricles.
The joints may be inflamed either by sympathy or by direct extension
of the erysipelatous inflammation to the periarticular tissues, or yet
by the occurrence, in or about them, of metastatic abscesses in
septicæmic conditions.
The peritoneum may be also acutely or subacutely inflamed in
erysipelas, though it is doubtful whether the accident occurs in
consequence of the extension of the disease to this membrane from the
skin of the abdominal wall. The same may be said of the endocarditis
and pericarditis noted by several authors. Of all other complications,
it may be said that they can usually be assigned to the occurrence of
either septicæmia, or pyæmia, or to the development of metastatic
abscesses.
With respect to the eyes, a distinction should be drawn between those
attacks originating in deep or superficial affections of the globes
and those in which the visual organs are merely involved as by
accident in the extension of the disease. In the former case deep
orbital abscesses or inflammatory affections of the iris and retina
may be followed by erysipelas of the lids or neighboring parts, while
in the latter event the issue is more commonly a transitory
conjunctivitis, lachrymation, and photophobia, which soon disappear
when the disease has declined. The cornea, being unmacerated with pus
as in severe variola, commonly escapes perforation.
Erysipelas is a disorder which, without question, produces in a
certain proportion of patients a susceptibility to recurrent attacks.
This susceptibility, however, is less a systemic tendency to the
development of the disease than a peculiar liability to recrudescence
originated by chronic local ailments. Thus catarrhal, ulcerative, and
other affections of the nasal mucous membrane are particularly apt to
originate repeated erysipelatous attacks in the integument covering
the nose, and the same is true of the skin in the vicinity of the
orifices of fistulous sinuses and varicose veins.
The forms of disease which are often described as instances of chronic
erysipelas belong to several classes. There are, first, those in which
are observed recurrent attacks of true erysipelas. Second, those in
which a chronic eczema or dermatitis produces a circumscribed patch of
infiltration {635} in a skin having a lurid reddish hue, which is also
the seat of marked subjective sensations, chiefly itching. The
well-known forms of chronic eczema erythematosum of the face in middle
years or advanced life are commonly, and erroneously, regarded as
erysipelatous in character. Third, there is a peculiar dermatitis, of
the cheeks chiefly, with regard to whose identity as an erysipelatous
affection there is much doubt. The skin is infiltrated in a
circumscribed patch, and has a peculiarly glossy red hue. It is
essentially a chronic disorder, the affected patch remaining unchanged
for months at a time, and then exhibiting aggravation in consequence
of accidental exposure to heat or traumatism. These patches may be
relics of relapsing forms of erysipelas; and in my experience are more
commonly encountered in the subjects of chronic alcoholism.
PATHOLOGY AND MORBID ANATOMY.--The pathological changes exhibited in
the erysipelatous skin are those of an exudative process involving the
cutaneous and subcutaneous tissues. Nothing specially different from
the phenomena observed in a simple dermatitis can be recognized by the
microscope alone. Biesiadecki's careful investigations[2] certainly do
not disclose any such specificity. The epithelia are swollen with
serous fluid, and the exudate, though largely serous, contains also
the corpuscles recognized in plastic lymph. It is this serum, rapidly
invited to the surface by the acuity of the exudative process, which
raises the epidermis into the bullæ described above. The nuclei of the
bodies recognized in the exudate are evidently in a state of division
and consequent multiplication. The epithelia of the rete mucosum are
swollen and stretched. The connective-tissue elements in the derma are
also swollen, and exhibit reversion to the embryonal state. There is
within each a relative increase of protoplasm, as a consequence of
which they undergo a species of liquefaction. The blood- and
lymph-vessels enlarge and are crowded with corpuscles. The
subcutaneous tissue participates in this process, its elements being
filled with finely granular cells disseminated or in aggregated
masses. The chief peculiarity of this exudation, and of these changes
in the tissue-elements where it recurs, is the rapidity with which,
when involution is in progress, the fluid is absorbed and the
inflammatory elements disappear. When abscess or gangrene complicates
the erysipelatous inflammation the changes are not different from
those recognized in dermatitis calorica.
[Footnote 2: _Sitzungsber. d. k. Acad. der Wissen._, Wien, ii., 1867.]
The changes noted in the viscera are also of a congestive and
inflammatory type. According to Ponfick,[3] there is at times a
parenchymatous degeneration of the muscular tissues of the large
vessels, and of the extremities, as well as of the kidneys, liver, and
spleen, the latter organ occasionally undergoing softening. The mucous
surfaces of the mouth, larynx, lungs, and alimentary canal have also
been found affected with oedema, congestion, and infiltration, rarely
terminating in ulcerative changes.
[Footnote 3: _Deutsch. klin._, No. 20, 1868.]
DIAGNOSIS.--The diagnosis of a typical case of erysipelas is so simple
that the nature of the malady is often recognized by those unskilled
in such matters. It is difficult to mistake for any other affection
the circumscribed, swollen, shining, and rosy-reddish patch of skin,
accompanied by fever or marked malaise, with adenopathy of near
glands, and often with a history of traumatism to which the origin of
the disorder may be readily referred.
{636} It is to be distinguished from dermatitis in its various forms
(venenata, medicamentosa, phlegmonosa, suppurativa) by its
characteristic features, and by the frequent absence in these
inflammations of a febrile reaction and of a shining, rosy-red hue of
the skin, and by the peculiarities described above of the elevated
margin of the erysipelatous area.
Eczema, especially in its chronic erythematous forms, exhibited in the
face of adults in middle and later life, is of much slower
development, is productive of itching, is ill-defined in contour, and
is not accompanied by fever.
Erythema in all its varieties is a purely hyperæmic affection and
unaccompanied by fever. In erythema multiforme there is an exudative
process by reason of which various papules, nodosities, and at times
even bullæ, appear upon the surface. None of them, however, are
accompanied by a diffused area of redness spreading at the periphery.
All of its lesions are circumscribed, and rarely affect the face.
Pemphigus could only be mistaken for the form of erysipelas bullæ, but
its lesions do not rise from a broadly inflamed area; they rather have
attended with each a distinct individual halo when the integument from
which they spring is at all congested. They are also rarely
accompanied by a febrile process.
Scarlatina, though a febrile affection, is readily distinguished from
erysipelas by the appearance of its exanthem, symmetrically and
generally developed over the entire surface of the body, or
progressively and symmetrically from the upper to the lower segment of
it. The exanthem has also a dull scarlet color or the boiled lobster
hue, differing thus from the rosy-red and shining patch of erysipelas.
Urticaria also is often of symmetrical development, is rarely
accompanied by fever, and is characterized by typical wheals, which,
however closely packed together, never have the smoothness of the
surface affected with erysipelas.
PROGNOSIS.--The prognosis of a simple case of uncomplicated erysipelas
occurring in an individual in fair health and possessed of a
reasonable degree of vigor may be regarded as favorable. Even in the
weakness of infancy a large area may be involved in the disease and a
high degree of fever be aroused without alarming results.
Erysipelas should, however, always be regarded as a serious disease or
a serious complication of any existing malady. It is often a grave
feature in surgical injuries. Erysipelas involving the entire surface
of the face and head is always a formidable affection. In the
puerperal state it is dreaded by every accoucheur.
All these circumstances are rendered more portentous by the existence
of the disorder as a complication of any other grave malady, or by its
occurrence among the subjects of alcoholism, struma, phthisis, or
various other cachexias, and among the aged. Occurring in epidemic
form among the inmates of prisons, camps, and hospitals, the mortality
of the disease may be increased tenfold.
TREATMENT.--The prophylaxis of erysipelas is that of all contagious
diseases. It involves isolation of the affected individual,
disinfection of body- and bed-clothing before the latter are again
employed upon the persons of others, and destruction by fire of all
dressings which have been in contact with the integument.
{637} The hygienic management of the patient is not to be neglected.
The complete ventilation of the sick chamber is to be secured, and its
temperature uniformly sustained at a point between 65° and 70° F.
The general treatment of the sufferer need not greatly differ from
that commonly pursued in the febrile state by modern therapeutists.
There is but little confidence to-day in the methods by venesection
and purgation, upon which at one time reliance was placed. Cool or
cold water may be freely employed when there is hyperpyrexia, either
by general bathing or by wrapping the patient in sheets dipped in and
wrung out of the same fluid. The results are favorable as regards the
bodily temperature, and are not productive of danger, though water
thus applied has no effect upon the local disorder of the skin. Iced
or cool water, by the ice-bag or compresses, is specially indicated as
a topical application for the head when there is delirium or other
indication of disturbance of the cephalic centres, irrespective of the
invasion of the scalp and face by the erysipelatous inflammation. The
sulphate of quinia in full doses is indicated especially when there is
any tendency to remittence in the febrile accessions, but is not known
to possess any power to cut short the disease. In many cases of
erysipelas the febrile condition is readily managed by the
administration of the simpler remedies found grateful to the palate of
the sufferer, such as iced, acidulated, and effervescing draughts,
with perhaps the employment of the spiritus Mindereri or the spirit of
nitrous ether. In other cases the mineral acids can be substituted
with advantage for the latter. With many American physicians it is
customary to add to these remedies the tincture of the root of
aconite, with a view to its effect upon the pulse.
Few internal remedies, however, have in this country enjoyed as much
popularity with the profession in the treatment of erysipelas as the
muriated tincture of iron in full doses. Its use, first suggested for
this purpose by Bell in 1851, has here steadily gained in favor since
its general adoption. It is well to give it in doses of not less than
20 or 30 drops, repeated every two or three hours, diluted with water.
When there is high fever, and especially if the secretion of urine is
scanty, the following formula will be found valuable:
Rx. Tr. Ferri Chloridi;
Sp. Ætheris Nitrosi;
Glycerinæ _aa._ fl. drachm i. M.
S. A teaspoonful in water every three hours.
This preparation of iron certainly seems, in many cases, to shorten
the disease, but, per contra, it is to be remembered--first, that in
many other cases it has been found to exercise no control whatever
over the severest manifestations of the disease; second, that in other
countries, especially in Germany, where it is rarely employed, the
mortality from the disease is no greater than elsewhere.
The widest difference in practice has obtained relative to the local
treatment of the affection. They who have had the fortitude to content
themselves with watching the evolution of the specific dermatitis,
merely protecting the skin by dusting over it a simple powder or
leaving it covered with a cold compress, have certainly no worse
results to tabulate than those who entertain a belief in the efficacy
of the abortive treatment of the local disorder.
{638} No remedies, locally applied, can be recognized as certainly
possessing the power to cut short the inflammation. Those which enjoy
the highest reputation for topical employment are saturated solutions,
hot and cold, of the hyposulphite of sodium, of boracic acid, and of
the bicarbonate of sodium; salicylic acid; iodoform in powder; and,
quite lately, resorcin. Hot fomentations of the erysipelatous patch
are in general most grateful to the patient, and with these an opiate
and astringent effect can be obtained, as by a hot lead and opium wash
or by solutions of the sulphate of iron or of alum and tannin. Useful
methods of applying these are by the medium of borated cotton, oakum,
tow, or spongiopiline, covered with oiled silk or the Lister
protective material.
Other medicaments which have enjoyed favor in the topical treatment of
the disease are lime-water and linseed oil (carron oil), sulphur in
powder, carbolic acid, camphor, the oil of turpentine, collodium,
cataplasms and ointments containing mercury, lead, zinc, tar, and
tannin.
Respecting the measures adopted with a view to checking the extension
of the disease at the periphery of the patch, the belief in such a
possibility has been wellnigh abandoned. For this purpose the nitrate
of silver, caustic potash, tincture of iodine, and similar substances
have been boldly and broadly applied, alike over the sound and
affected integument, with the production of an artificial dermatitis
intended to supplant that which was previously in progress. Again and
again has the local inflammation transgressed these artificial limits;
and when they have been by it apparently respected there has been
little ground for believing that the result was due to the treatment
pursued. Inasmuch as the disease is often self-limited and distinctly
limited in its progression over the surface, it is manifestly
difficult to determine that its limitation in any given case is the
result of topical agencies. These agencies have, moreover, the marked
disadvantage of adding their irritative effects to those incidental to
the dermatitis.
The surgical treatment of erysipelas invading special regions of the
body or the deeper tissues is a matter of importance. Free incisions
are requisite for the liberation of pus, and all abscess cavities
should be treated antiseptically and stuffed with iodoform or
resorcin. Great tension of the lids demands free incisions in the long
diameter of either, and the same surgical procedures are often
demanded in erysipelas of the scrotum or of the labia in the female.
Gangrene and sloughing are to be treated in accordance with the
principles recognized as important in the management of these
accidents in general.
The mouth when involved may be benefited by gargles containing the
chlorate of potassium, alum, tannin, the compound tincture of
cinchona, or by the use of the spray with a saturated solution of
boracic acid in rosewater. Kaposi lays stress, in all cases of
erysipelas of the face, upon the importance of searching for and
evacuating all dental abscesses and pustules seated upon the
Schneiderian membrane. Crusts in the nasal cavity are to be soaked
with vaseline and removed by washing, their re-formation being
prevented by the insertion of small tampons smeared with a bland
ointment or oily fluid. Abscesses in other portions of the body, not
suspected as being etiologically significant, are to be carefully
searched for and emptied, whether occurring about the anus, the
genitals, or the legs.