Synonym.—St. Anthony's Fire.
Definition.—An infectious disease, characterized by an acute and specific inflammation of the skin and subcutaneous tissues, attended by a shining redness, which spreads rapidly; marked swelling and pain, and which finally terminates in desquamation. A fever of variable intensity, moderate prostration, and supposed to be caused by the streptococcus erysipelatis.
Etiology.—The cause is undoubtedly a specific toxin or germ which gains entrance into the lymph channels through an injury to the skin. Modern pathologists ascribe the cause to the streptococcus erysipelatis of Fehleisen, though this is perhaps identical with the pus-producing streptococcus. If this be true, the old division of idiopathic and traumatic erysipelas will have to be discarded; for there is undoubtedly some injury to the surface, although it may not be perceptible, whereby the infection finds entrance. This may be surgical or accidental, such as an intertrigo or an acute pustule, or the abrasion may be within an orifice and not visible, as in the nose or mouth, or the traumatism may be of the uterus during the puerperium.
Predisposing causes are, poor hygienic surroundings, which in former times were the cause of so much erysipelas in hospitals, and following confinements. Age also predisposes to this lesion, those being the most susceptible who are between the ages of twenty and thirty. Previous attacks also render one more susceptible, thus being different from all other contagious diseases.
Pathology.—Erysipelas is a true dermatitis, involving the skin, subcutaneous, and mucous surfaces. The blood-vessels are dilated and distended with blood, and cell-infiltration may extend into the deeper tissues, where suppuration is apt to take place. The cocci are found in the lymph spaces of the affected area, while beyond this they are found in the lymph vessels, where the battle is fought and won by the leukocytes (phagocytes).
Aside from the local affection, the toxin in severe cases causes granular degeneration of the heart, kidneys, spleen, and liver. According to Osier, some of the worst cases of malignant endocarditis are secondary to erysipelas.
Symptoms.—The period of incubation is variable, it being from three to ten days after the entrance of the infection before the development of the disease. The prodromal symptoms are common to inflammations generally; viz., headache, loss of appetite, furred tongue, partial arrest of the secretions. These terminate in the chill in the adult, or more likely in a convulsion, if the patient be a child. Following the chill, reaction occurs, with rapid rise in temperature, the thermometer registering 103° the first day, 104° the second, and 105° to 106° by the third or fourth day, usually the days of greatest intensity. The pulse is full and bounding, the tongue is coated with a dirty fur, or it is brown and dry. The skin is dry and more or less constricted, the urine is scanty and high colored, and the bowels are constipated.
The local affection begins with a bright-red spot, slightly raised, more or less edematous, and with a tendency to spread rapidly. The part is hot, swollen, and painful, and often slight blisters form upon the affected part. If that part be the face, the favorite seat of the disease, the swelling extends to the eyes, which it soon closes; then involves the ears, which become enormously enlarged; and finally, when at its height, the features of the patient are so obliterated as to render him unrecognizable by his nearest friends.
The pain, during this period, is of a burning, itching, or tingling character. Where the fever is high, the patient is restless, and delirium is not uncommon. There is some slight remission in the fever in the morning, though the fever is active from four to seven days when the inflammation reaches its height, the fever rapidly subsides, and by the tenth day the patient is convalescent.
With the decline in temperature the redness fades, the swelling subsides, and desquamation of the skin follows. If the scalp has been involved, a long-continued alopecia results.
Diagnosis.—The diagnosis of erysipelas is generally quite easy. Beginning with a chill, there is the early appearance of the local inflammation, in the form of a bright-red spot, and marked tumefaction, the redness rapidly and uniformly spreading. The surface being hot and painful, can hardly be taken for any other affection. Urticaria, erythema, acute eczema, or rhus poisoning, are not attended by the severe constitutional disturbance, and so are readily excluded in making the diagnosis.
Prognosis.—The prognosis is favorable; for while the fever is very active and the constitutional disturbance marked, the mortality is very low. In old and impoverished subjects, the prognosis must be guarded, and also in infants and in puerperal women.
Treatment.—The treatment will be both constitutional and local, and if we forget, for the time being, the name of the disease, and treat the patient specifically, there is no question as to the outcome.
For the full, strong pulse and high temperature, give veratrum twenty drops, to water four ounces; a teaspoonful every one or two hours. To aid the sedative the patient should be sponged with warm water. If the tongue be pasty and dirty, sodium sulphite, a saturated solution every three hours, will be our-best remedy.
Where the tongue is red and dry, muriatic acid will give relief, or if the doctor must give iron, this is his case: muriate tincture of iron one-half drachm, aqua dest. and simple syrup of each two ounces; a teaspoonful every two hours. Where the tissues are blue and full, tongue broad and moist, echinacea one to two drachms, aqua dest. four ounces, will be indicated. Of this give a teaspoonful every hour. Where the patient complains of burning and smarting, and there are one or more vesicles formed, and where the pulse is sharp and hard, rhus tox. is our best remedy; thus, aconite five drops, rhus tox. ten drops, water four ounces; a teaspoonful every hour. If the patient is dull and drowsy, the pupils dilated, belladonna ten drops, to water four ounces, is the remedy to use; but if the patient is restless with flushed face, or if there is active delirium, gelsemium replaces the belladonna. These remedies, given according to the above conditions, will tide the patient safely through the most severe attacks of the disease.
The local treatment will also depend upon certain conditions. Where the pulse calls for veratrum, the local lesion is red, hot, and painful, here the part should be painted with full-strength veratrum every three hours, and we may add to this agent a little glycerin to keep the surface moist. Where the part is dusky, belladonna and glycerin may be applied every two or three hours. Dr. Webster speaks highly of echinacea as a local remedy, and I am satisfied that its use would be beneficial. Where the part is intensely hot and painful, cold water will be found not only grateful to the patient, but also of benefit.
The diet should be fluid in character and highly nutritious. Milk, sherry whey, malted milk, egg's beaten in milk, and fruit juices will be appropriate. The patient should be nursed as in any other contagious disease, care being taken as to cleanliness of bed and linen and good ventilation.