A system of practical medicine. By American authors. Vol. 1

by Unknown

ETIOLOGY.—Authors have in general assigned different causes to the forms of erysipelas hitherto regarded as either idiopathic (or medical) or traumatic (or surgical). The modern view, however, is that which regards all cases as alike produced by the absorption of the toxic agent capable of exciting this peculiar inflammation of the skin. The peculiarly well-characterized symptoms of the disease—for example, when it affects the head and face—were long regarded as etiologically distinct from the affection which complicates surgical injuries and wounds. But a closer study of many of the cases first named has again and again disclosed the fact that they originated in such traumatism, for example, as the piercing of the lobule of the ear for the insertion of an ear-ring, a carious tooth, an alveolar abscess, or a pathological product in the antrum of Highmore.

The disease is equally common—apart from the puerperal state—in both sexes and at all ages, and occurs under favorable circumstances in all seasons of the year. It is unquestionably at times spread by direct contagion, either from the living or dead body affected with the disease. Such contagion may occur mediately or immediately. It is, however, not readily shown to be producible by the media of clothing and other articles which have been in contact with a diseased surface. The contents of the bullous lesions which appear upon the erysipelatous surface are inoculable; and the disease has in this way been transferred not only to men, but also, by Orth and others, to the lower animals, and even from one of the latter to another of the same species.

Certain it is, however, that the disease does occur, characterized by symptoms indistinguishable from those to be recognized in the contagious type of the malady, where the most careful investigation wholly fails to reveal the cause, and where the disorder rapidly spreads if the conditions for its extension are favorable. Under these circumstances it is wisest at present to admit that the exact etiology of erysipelas is unknown. Its relative frequency in the puerperal state is unquestionably to be explained by the favorable local conditions which at such times exist in the female for the development of all septic disorders.

As regards the circumstances which might be supposed to specially favor its development, these the capriciousness of the disease, which is its striking characteristic, often quite disregards. Thus, on the one hand, it may and often does prevail, year after year, in certain hospitals, and even in certain wards of a single hospital, especially where these are crowded with patients. But it may also repeatedly spare masses of men affected with disease of a different type when the latter are gathered together in prisons or camps, and indeed even may appear among such individuals and fail to spread to others who are in close proximity to them.

With respect to the propagation of erysipelas from infected to sound individuals, a contrast is exhibited when the transmission of variola, for example, is compared with it. Thus, it is well known that the mildest cases of varioloid may be sources of malignant forms of variola to the unprotected, while those who are partially protected and exposed to the virus of confluent forms of the disease may exhibit the mildest symptoms of varioloid. In erysipelas, however, it is tolerably certain that there are different degrees of virulence to be recognized in different cases, and that the disease at times is transmitted in its different types. Thus, traumatic erysipelas is much more closely related to childbed fever than the varieties of the disease appearing upon the head and face, which cannot be attributed to traumatism, surgical accidents, dental abscesses, or local injuries of the antrum of Highmore. Parturient women frequently escape infection when the erysipelatous disorder is of the so-called medical type. Per contra, it is to be noted that women who are prone to the relapsing and so-called chronic forms of erysipelas are particularly apt to suffer from that involvement of the genital organs, peritoneum, spleen, and febrile movement whose sudden occurrence after confinement is so portentous.

SYMPTOMATOLOGY.—The disease is usually announced by the occurrence of a chill, which may precede by a day or but a few hours the appearance of the cutaneous disorder. The rigor may be severe or mild in grade, so that it may even be forgotten by the patient till his attention reverts to it in connection with the resulting symptoms. There may be simultaneously some gastric distress, rarely of severe character. These symptoms are commonly followed by a febrile reaction. In other cases the first recognized symptoms of the malady occur in the skin, the patient scarcely recalling the fact of a slight preceding malaise.

The cutaneous lesions appear in the form of a circumscribed oedema and redness of the surface, often preceded and usually accompanied by a sensation of tension, heat, and burning pain. This macule, plaque, or patch of diseased integument is in its typical features characteristic. It is distinctly or irregularly circumscribed; its oedematous condition elevates its level decidedly above that of the adjacent integument, so that there is a somewhat sudden descent from the former to the latter for a space of from one to two or more lines. The redness is also of a bright crimson hue, and the reddened surface has a sheen or glossy appearance uniformly displayed over its area. It disappears under the pressure of the finger, leaving a yellowish-white color in the region of impact, the erysipelatous blush rapidly returning when the circulation at the surface is restored. This smooth and shining condition of the reddened patch is so characteristic of erysipelas that it arrests the attention of the diagnostician as soon as he observes it. According to Zuelzer, it is caused simply by the tension of the epidermis. When first observed it may occur in the form of circular, small or large coin-sized patches, or in streaks, striæ, and radiations, or as very irregularly disposed, rosy, and shining marblings or mottlings of an oedematous surface.

The skin thus affected is hot to the touch, tender, firm, and smooth. It is occasionally the seat of pruritic sensations, more commonly of a peculiar sensation of heat and burning.

In the course of two or three days the involved area spreads uniformly or irregularly and centrifugally from the point first involved, after which time, in mild cases, the disease persists without apparent change for a few days more, prior to its decadence by resolution. This final stage of the malady is characterized by a progressively diminishing fever, moderate desquamation, gradual disappearance of the oedema, and a color-change to the darker shades of bluish-red or to a light brown. In this form of the disease the erysipelatous patch, after being fully developed, does not tend to spread from the affected to the unaffected surfaces; and, as a consequence, the affection may complete its entire career in less than a fortnight.

In other cases, however, a remarkable tendency is developed to the progressive spreading of the inflammation from one point or surface of the body to another, the parts first affected paling as the disease passes on to involve those in the vicinity, or being yet deeply involved while the process of peripheral extension is in progress. In yet other cases the red blush sweeps away from its first position in tongue-like projections over a tumid and painful skin, while the region first invaded becomes paler, though still preserving its oedematous features. In still another class of cases the advancing ribbon or band of elevated and reddened integument passes over to a new area, leaving the regions it has traversed tumid, painful, and here and there streaked with rosy lines, patches, or irregular gyrations.