The disease tends to spread spasmodically and irregularly, and the direction and extent of its progress may be recognised by mapping out the peripheral zone of tenderness. Red streaks appear along the lines of the superficial lymph vessels, and the deep lymphatics may sometimes be palpated as firm, tender cords. The neighbouring glands, also, are generally enlarged and tender.
The disease lasts for from two or three days to as many weeks, and relapses are frequent. Spontaneous resolution usually takes place, but the disease may prove fatal from absorption of toxins, involvement of the brain or meninges, or from general streptococcal infection.
Complications.—Diffuse suppurative cellulitis is the most serious local complication, and results from a mixed infection with other pyogenic bacteria. Small localised superficial abscesses may form during the convalescent stage. They are doubtless due to the action of skin bacteria, which attack the tissues devitalised by the erysipelas. A persistent form of œdema sometimes remains after recurrent attacks of erysipelas, especially when they affect the face or the lower extremity, a condition which is referred to with elephantiasis.
Treatment.—The first indication is to endeavour to arrest the spread of the process. We have found that by painting with linimentum iodi, a ring half an inch broad, about an inch in front of the peripheral tender zone—not the red margin—an artificial leucocytosis is produced, and the advancing streptococci are thereby arrested. Several coats of the iodine are applied, one after the other, and this is repeated daily for several days, even although the erysipelas has not overstepped the ring. Success depends upon using the liniment of iodine (the tincture is not strong enough), and in applying it well in front of the disease. To allay pain the most useful local applications are ichthyol ointment (1 in 6), or lead and opium fomentations.
The general treatment consists in attending to the emunctories, in administrating quinine in small—two-grain—doses every four hours, or salicylate of iron (2–5 gr. every three hours), and in giving plenty of fluid nourishment. It is worthy of note that the anti-streptococcic serum has proved of less value in the treatment of erysipelas than might have been expected, probably because the serum is not made from the proper strain of streptococcus.
It is not necessary to isolate cases of erysipelas, provided the usual precautions against carrying infection from one patient to another are rigidly carried out.
Diphtheria
Diphtheria is an acute infective disease due to the action of a specific bacterium, the bacillus diphtheriæ or Klebs-Löffler bacillus. The disease is usually transmitted from one patient to another, but it may be contracted from cats, fowls, or through the milk of infected cows. Cases have occurred in which the surgeon has carried the infection from one patient to another through neglect of antiseptic precautions. The incubation period varies from two to seven days.
Clinical Features.—In pharyngeal diphtheria, on the first or second day of the disease, redness and swelling of the mucous membrane of the pharynx, tonsils, and palate are well marked, and small, circular greenish or grey patches of false membrane, composed of necrosed epithelium, fibrin, leucocytes, and red blood corpuscles, begin to appear. These rapidly increase in area and thickness, till they coalesce and form a complete covering to the parts. In the pharynx the false membrane is less adherent to the surface than it is when the disease affects the air-passages. The diphtheritic process may spread from the pharynx to the nasal cavities, causing blocking of the nares, with a profuse ichorous discharge from the nostrils, and sometimes severe epistaxis. The infection may spread along the nasal duct to the conjunctiva. The middle ear also may become involved by spread along the auditory (Eustachian) tube.
The lymph glands behind the angle of the jaw enlarge and become tender, and may suppurate from superadded infection. There is pain on swallowing, and often earache; and the patient speaks with a nasal accent. He becomes weak and anæmic, and loses his appetite. There is often albuminuria. Leucocytosis is usually well marked before the injection of antitoxin; after the injection there is usually a diminution in the number of leucocytes. The false membrane may separate and be cast off, after which the patient gradually recovers. Death may take place from gradual failure of the heart's action or from syncope during some slight exertion.