The principles and practice of modern surgery

by Roswell Park

Many cases are accompanied by much gastric irritation, which it is difficult to explain. Ulcers are sometimes found in the intestines, as after burns. These usually give rise to bloody diarrhea. The cerebral symptoms may be simply those of delirium from irritation or of meningitis from infection. Strange phenomena have followed the disease in certain instances—cessation of neuralgic and of vague, unexplainable pain, improvement in deranged mental condition, spontaneous disappearance of tumors, etc. Advantage has been taken of this last in the treatment of these cases. (See [Cancer].)

It is quite likely that some of the worst forms of phlegmonous erysipelas are due to mixed infection. To inject the bacillus prodigiosus together with the streptococcus of erysipelas will greatly enhance the virulence of the latter, so that reaction may proceed even to gangrene.

Postmortem Appearances.

—These are not distinctive, but are a combination of local evidences of suppuration and gangrene, with the deterioration of the blood, the softening of the spleen, etc., which are characteristic of septic poisoning. Only in the skin, and then under microscopic examination, can any pathognomonic appearance be discovered. This will consist in the crowding of the lymphatic vessels and connective-tissue spaces with cocci, in the evidences of rapid cell proliferation, in the quantity of exudate, in vesication, sloughs, etc.

Diagnosis.

—Diagnosis of erysipelas should be made mainly from various forms of erythema, from certain drug eruptions, and from other forms of septic infection which do not assume the clinical type of erysipelas. The gastric symptoms of this disease are sometimes produced by certain poisonous foods or the distress which is produced by medicines, such as quinine, antipyrine, etc.

Prognosis.

—The majority of instances of idiopathic erysipelas run a certain limited course, although the eruption may spread to almost any distance upon the body. When the disease attacks surgical cases, and especially when it involves wound areas, the prognosis is not so good. When the disease assumes an epidemic type and involves cases of all kinds, it will be found to have a virulence that may make it a most serious affair. In proportion to the extent to which it assumes the phlegmonous type it will be found locally, if not generally, destructive. The ordinary case of facial erysipelas will recover with almost any treatment. Nevertheless meningitis may develop, and even a mild case is to be treated with care and caution.

Treatment.

—Danger comes from two sources—septic intoxication and local phlegmons or gangrenous destruction. Each is therefore to be combated. Treatment should consist of isolation. There is no specific internal treatment for this disease. Tincture of iron, which was long vaunted as such, has proved unsatisfactory, and is of benefit only as a supporting measure in a limited class of cases. Constitutional measures should be employed: First, for the purpose of maintaining free excretion by bowels and kidneys; second, for the purpose of supporting and maintaining strength; third, for tonic and stimulant measures in prostrated and debilitated patients; and, fourth, for the purpose of combating intestinal sepsis or intoxication from any other source. The robust patients with this disease need no particular tonic. The aged, the enfeebled, the dissipated, the prostrated individuals, and the confirmed alcoholics are those who need vigorous stimulation, partly by alcohol and quinine, and partly by strychnine, preferably given hypodermically, and by the other diffusible stimulants by which they may be kept alive. Pilocarpine, given subcutaneously and pushed to the physiological limit, has been praised by some. If along with prostration there occur restlessness and delirium, then anodynes and hypnotics are serviceable, and should be administered to meet the indication—morphine hypodermically and any of the agents which produce sleep are now most beneficial. Finally, if there is any drug which can be administered in doses sufficient to saturate the system with an antiseptic which shall at the same time not prove fatal because of toxicity, this is the ideal medicament for constitutional use only. Such a drug is not known, but it will be well to give some near approach to it internally, as by administering corrosive sublimate, salol, naphthalin, or something else of this character in doses as large as can be tolerated.