The discharges from this region are infectious, and caution should be observed in dressing such cases. A finger pricked by a pin from a dressing may subject the individual to loss of life. The dressings containing the discharges should be burned immediately.
The path of infection is usually through a wound, and as soon as discovered a case of erysipelas should be separated from all surgical cases, or if the erysipelatous patient cannot be isolated, he should be removed from proximity of other wounded individuals.
Erysipelas which follows injury, however slight, is termed traumatic. The terms “idiopathic” or “spontaneous” should be restricted to those cases in which the path of infection is not discovered.
Symptoms.
—With the exception of the local appearances, they are essentially the same in both of the above-mentioned forms. The characteristic feature of the disease is a dermatitis with its peculiar roseate hue, which it is impossible to describe in words. In tint it differs slightly from that noted in certain cases of erythema. It is, however, accompanied by an infiltration of the structures of the skin, so that the area which is reddened is at the same time elevated above the surrounding surface. Its edges are often irregular. As exudate takes the place of blood in the tissues, the red tint merges into a yellow. At this time there is more induration of the skin and tendency to pit on pressure. Vesication of this involved area is now frequent, the vesicles often coalescing and forming large blebs and bullæ, which fill with serum that may become discolored or purulent. When exposed to the air, unless the tissues become gangrenous, this serum usually evaporates and forms scabs. This disturbance of the skin is always followed after a number of days by desquamation. This infectious dermatitis shows a constant tendency to spread in all directions. Its most characteristic appearances are limited to the margin of the enlarging zone, while in its centre there may be evidences of recession of the disease. If it commences in the vicinity of a wound it will probably spread in all directions from it. Beginning in the face, it usually spreads upward; in the trunk, in all directions; if on the extremities it tends to migrate toward the trunk. Wandering erysipelas is a term often applied to these phenomena. The metastatic expressions of the disease have been described.
When this affection attacks a recent wound the local appearances are not essentially distinct from those mentioned under Septicemia. The wound margins separate to a greater or less extent, the surfaces slough, and a characteristic seropurulent discharge occurs. Granulating surfaces usually become glazed—often covered with a membrane resembling that of diphtheria; deep sloughs may occur, undermining of wound edges, even hemorrhages from destruction of vessel walls. In rare instances, however, under the influence of the microbic stimulation granulations proceed faster than normal.
Whether the disease proceeds from an injury or not, the constitutional symptoms vary but little. There is usually a period of malaise with nausea, followed by alimentary disturbance, coating of the tongue, elevation of temperature, sometimes with occurrence of chill. Complaint of pain or unpleasant sensation will lead to examination of the area involved, when the above symptoms will be noted, with evidences of lymphangitis and enlargement of lymph nodes. When chill occurs it is followed by pyrexia. Temperature fluctuates, with a tendency to assume the remittent type. When the disease subsides spontaneously it is by a gradual process of betterment and subsidence of temperature. In other instances the constitutional symptoms assume more or less of the septicemic or typhoid type, and it is seen that the patient’s condition is practically one of mild septicemia, which often proves fatal.
When the disease assumes the phlegmonous type the constitutional symptoms become more and more typhoidal and the septicemia becomes most pronounced. Locally exudation goes on to the point of threatening, even of actual, gangrene, unless tension is relieved by incisions. Pain is usually intense, partly because of confined exudates beneath resisting structures. More or less rapidly the local and constitutional signs of pus formation are noted, and unless these are observed and acted upon early there will not only be suppuration, but more or less actual gangrene, so that not only pus, but sloughs of tissue will be discharged through the incision, or will, when this is delayed, make their escape by death of overlying textures.
In all phlegmonous cases there is practically coincidence of septicemia, already described, and of the local appearances above noted. In proportion to the extent of the lesion in these phlegmonous cases, and failure to afford relief, will be the opportunity for septic intoxication.
The mucous membrane does not always escape, and even in the nose, the pharynx, the vagina, and the rectum a distinctive erysipelatous lesion may be found. The disease may travel from the pharynx through the nose and involve the face, or through the Eustachian tube to the ear and thence to the scalp, or vice versa. Erysipelatous laryngitis is to be feared on account of edema of the glottis, which would soon be fatal unless overcome by intubation or tracheotomy. An infectious exudation into the lungs is also known to follow erysipelas, and has been considered an erysipelatous pneumonia. The cellular tissue of the orbits may also be involved, when abscesses will occur, which should be opened early; the parotid and other salivary glands may become involved, usually in suppuration.