ERYSIPELAS

421

ERYSIPELAS¹

Synonyms.—St. Anthony‘s fire; Fr., La rose; Feu sacré; Erysipèle; Ger., Rothlauf;
Rose; Hautrose; Wundrose.

Definition.—Erysipelas may be denned as a specific inflammation
of the skin and subcutaneous tissue, most commonly of the face, charac­
terized by shining redness, swelling, edema, heat, and a tendency, in
some cases, to vesicular and bleb-formation, and accompanied by more
or less febrile disturbance.

Symptoms.—Cases of moderate severity are usually preceded for
several hours to one or two days by prodromic symptoms of constitu­
tional disturbance, such as malaise, chilliness, nausea, and sometimes
vomiting; a decided rigor or feeling of chilliness, with ensuing febrile
action, is rapidly followed by the appearance of the cutaneous eruption.
This latter may develop rapidly, soon involving an area the size of a
palm or larger, or its evolution is more gradual. It frequently begins
at one point, usually where there has been a break in the continuity of
the skin; an area of a dime to dollar size is first noticed, elevated, swollen,
red, and shining, with a glazed appearance; there is a feeling of burning,
often some tenderness, and sometimes a variable degree of itching. The
border is sharply defined, elevated, and bright red, usually scarlet red;
it spreads gradually or rapidly by peripheral extension, and in some cases
there may arise new points of infection near by, spread, and merge into
each other. In the course of several days to a week the disease has
usually reached its acme, and may then cover a great part of the face or
the entire region. On the face it often stops at the edge of the hair or
beard. The parts are elevated, much swollen, and somewhat tense, with
the peculiar shining dark-red surface; or there may be the formation of
vesicles and blebs, which in some cases may subsequently become puru­
lent; exceptionally the part may be partially undermined with serous
effusion. In other instances the deeper parts are involved seriously,
and some sloughing may ensue. Hutchinson has observed cases in which
the characteristics of erysipelatous inflammation are not always present

¹ Some pertinent literature: General: Hutchinson, Archives of Surgery, 1894, vol.
v. p. 300; 1897, vol. viii, p. 1; Allen, Medical News, 1899, i, p. 426; Kaposi (report of
investigating committee of erysipelas in General Hospital, Vienna, 1882-84), Wien.
med. Wochenschr., 1887, Nos. 30 to 35, and full résumé in Archiv, 1888, vol. xx, p. 250.

Etiology and pathology: Fehleisen, Die Aetiologie des Erysipelas, Berlin, 1883;
Pawlowsky (concerning specificity of streptococcus, with some experiments as to the
action of certain drugs upon it), Berlin, klin. Wochenschr., 1888, p. 255; Leroy (showing
persistent vitality of streptococcus), La Gazette Médicale de Montreal, January, 1890;
Pfahler (cases apparently due to other coccus), Philada. Med. Jour., January 13, 1900;
Guarnieri (autopsy showing general streptococcic infection), Archivio per le scienze,
1887, No. 2—abstract in Annales, 1888, p. 249; Denucé, Etude sur la pathogenie et
l'anatomie pathol. de Perysipéle (showing general infection), Paris, 1885.

Treatment—Antistreptococcic serum: Marmorek, Compt. Rend. Soc. de Biol.,
1895, p. 230, and Annales de l'lnstitut Pasteur, 1895; André, Archives de Med. et de Phar-
macie militaires, 1898, p. 340; Cotton, Boston Med. and Surg. Jour., 1899, i, p. 105;
Bristow, New York Med. Soc. Trans. 1899, p. 382; Baum, Medicine, 1899, p. 23.
These four papers are all valuable as showing the present status of this remedy, and
give literature references; Cotton gives full bibliography.

Ichthyol: Unna, Aerztl. Vereinsblatt für Deutschland, 1885, No. 158; Fessler,
Klinische-experimentelle Siudien über Chirurgische Infectionskrankheiten (clinical and
experimental evidence of action of ichthyol), Munich, 1891; Jamieson, Brit. Med. Jour.,
Aug. 6, 1898.

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together; the florid congestion may exceptionally be lacking, the edema-
tous swelling practically constituting the disease, and to which the term
“white erysipelas” could be well applied.

When the erysipelas involves a limb or part of the body other than
the face, there may be some extension in the form of streaks along the
line of the lymphatics. The constitutional symptoms are of various
grades from slight to grave, with the temperature elevated one to several
or more degrees above the normal, according to the extent and severity
of the disease. The temperature is highest toward night; a marked
exacerbation usually signifies renewed activity or a new area of disease.
Occasionally the temperature is subnormal. In severe cases delirium or
stupor may be present, and grave complications of other organs some­
times occur, probably due to toxin poisoning or to general streptococcic
invasion.

After remaining a few days stationary the process begins to subside,
the swelling becomes less pronounced, the redness goes into a brownish
red, and later yellowish and yellowish-white shade, the constitutional
symptoms abate, and the disease in ten days to a few weeks is prac­
tically at end. Desquamation ensues, slight or marked, according to
the severity of the process. When there has been pronounced vesic­
ular or bullous development, these dry into crusts, which finally fall
off, leaving behind temporarily a reddish surface, which gradually fades.

In some instances as the disease spreads at the periphery the older
part clears permanently or again lights up. Or the disease may appear
at a site close by or somewhat distant from the original point of infection.
Thus the case may go on for several weeks or longer, constituting that
variety known under the name of erysipelas ambulans, or erysipelas
migrans. This rare recurrent ambulant type is sometimes designated
chronic erysipelas, although this term is also often given erroneously by
laymen, and occasionally by practitioners, to cases of chronic eczema.

While the face is the most common site of erysipelas, and the one of
chief interest to the dermatologist, other parts are also not infrequently
the seat of the disease; in the latter instances usually starting from some
injury or succeeding a surgical operation. That on the face may extend
over the entire scalp and may even push into the mouth and throat and
nose, or exceptionally may have its starting-point in the latter regions,
and may, indeed, in rare instances be limited to these and neighboring
mucous membranes (Arnott, Mosny, Porter). In the extreme examples
of this class the head, face, ears, lips, and mouth are much swollen, and
the patient disfigured beyond recognition. In a large majority of the
cases observed by dermatologists in skin dispensaries the disease is of a
somewhat slight and limited character; usually starting at some point of
the face, or not infrequently at or just within the nasal orifice, it may
involve only an area of a few inches, lasting two or three days and then
rapidly beginning to subside, with or without desquamation. The
constitutional symptoms in such walking cases are mild, sometimes
scarcely noticeable, but there may be temperature elevation for a few
days of one to three degrees and yet the patient persist in going about his
employment.

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423

Etiology.—The disease is both contagious and infectious, at times
to a marked degree, at other times apparently scarcely at all. There
are probably three causes operative in erysipelas—essential, contributory,
and predisposing. The essential cause is now believed to be a specific
streptococcus, the streptococcus of Fehleisen. That the essential cause
may consist of varieties of micro-organisms other than this streptococcus
is not beyond dispute; in 8 cases investigated at the Philadelphia Hospital
presenting all the symptoms of erysipelas a special diplococcus was noted
differing from the streptococcus of Fehleisen (Pfahler), and Hajek has
found that the disease may be caused by the pyogenic organisms. The
contributing cause, as an abrasion, prick, or slight injury, a lesion of
continuity of the skin, may doubtless be almost considered essential,
although it is not always demonstrable. Infection may, indeed, take
place through the mucous membrane of the mouth, throat, or of the nose,
possibly through a break or abrasion, or from some pent-up pus-collec­
tion. A not uncommon point of infection in dermatologic experience is
a sycosiform inflammation just inside the nostril orifice. Frequently
this latter produces but a small erythematöus and moderately swollen
area, starting at the nose and extending slightly toward the eye and cheek,
which in many instances can scarcely be called true erysipelas; in others,
however, a distinct erysipelatous area arises, and in others again a typical,
somewhat extensive, development of the disease ensues. Ulcers, ex­
coriations, abrasions, a nasolabial fissure, ear-piercing, injuries of various
kinds, may all be instrumental in the development of the disease.

As predisposing causes may be mentioned a poor condition of the
health, general debility, alcoholism, or failing health from organic dis­
ease; in fact, anything which depresses or weakens the vital forces and
lessens the resisting power of the organism. Age seems to be in a meas­
ure of etiologic import, the disease being much more common in those
between twenty to forty and rather unusual in the young or old.

Anders,¹ from a study of his tabulation of present collated cases, ex­
tending over a period of twenty years, shows that seasonable influences
must be counted in considering the etiology of the disease. August gave
the fewest cases, and from then there is a gradual monthly increase until
April is reached, which gives the largest number, and then follows a
rapid decrease. One-half of the cases occurred in February, March,
April, and May, April giving 16 (15.9) per cent. It was further found
that a low barometer and mean relative humidity invariably corre­
spond with the annual period in which the greatest proportion of cases
occur, and the highest mean relative humidity with the months affording
the fewest attacks.

Pathology.—Unna's investigations show that the typical erysip-
elatous inflammation of the cutis is purely of a serofibrinous nature,
which may result in necrosis, the specific germ being the sole pathogenic
factor. One attack of the disease does not protect against other attacks;
on the contrary, it becomes a predisposing factor of some import. Doubt­
less this may be due to the fact that some of the micro-organisms may

¹J. M. Anders, “Seasonable Influence in Erysipelas, with Statistics,” Trans.
Amer. Climatol. Assoc, 1893-94, vol. x, p. 43.

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remain in the integument (Besnier, Hutchinson, Allen, and others).
Maclachlan¹ believes, from his observations, that succeeding attacks
become milder and milder.

There is nothing strikingly peculiar in the histologic findings. The
disease is really an infectious dermatitis, involving the integument and
deeper parts. There is a variable amount of serous exudation into the
skin and subcutaneous tissues, some deposit of fibrin and swelling of the
connective-tissue fibers, and enlargement of the blood-vessels and lym­
phatics. In hairy regions the serous exudation involves the follicles and
hair-sheath, and may result in extensive or complete hair fall. The
corium is invaded, in severe cases, by the streptococci, especially the
lymph-spaces, and this invasion may extend down into the subcutaneous
tissue. Unna finds that in every case the hypoderm swarms with cocci.
In rare instances general invasion has been observed—streptococci being
found in various organs (Guarnieri, Denucé, Lukowsky). Metschnikoff
found an inverse proportion between the collection of leukocytes and
the proliferation of cocci in the skin, which he viewed as a warfare between
these two powers. The serous exudation may be so rapid, especially
in points or places, that vesiculation or bleb-formation ensues. Re­
peated attacks are apt to leave a permanent thickening of the skin,
especially when on the legs.

Diagnosis.—The diagnosis of erysipelas is rarely attended with
difficulty, especially when it occurs upon the face and after surgical
injuries. The important diagnostic points are the character of the onset,
the shining redness, the swelling, the sharply defined elevated border,
and the accompanying constitutional disturbance. The diseases which
at times resemble it, especially in its beginning, are phlegmona diffusa,
erythemata, acute eczema, and dermatitis. Those most likely to give
difficulty are the latter two. Dermatitis from poison-ivy or from some
drugs, such as iodoform, may at first present a somewhat similar appear­
ance, but this lacks the sharply defined border, is usually free from any
constitutional disturbance, and may start simultaneously from several
points. Acute eczema also lacks the sharp elevated border, rarely de­
velops from a single point, and is attended by marked itching, and,
except in infants and young children, is seldom accompanied by any pro­
nounced systemic disturbance. In fact, erysipelas is so distinct a malady
that it ordinarily admits of ready diagnosis, and is rarely to be confused
with other disease, except with anomalous examples of the several affec­
tions mentioned. In doubtful cases several hours’ or a day's observa­
tion is usually sufficient to solve the difficulty.

The slight and limited erysipelatous swelling consequent upon a
chronic folliculitis of the nasal fossa, while it may develop into true
erysipelas, can scarcely be invariably looked upon as of such nature, but
rather an erythema due to pus absorption.

Prognosis.—Erysipelas is, under proper management, not often

a fatal disease, a factor which is not sufficiently taken into consideration

when estimating particular claims made for the various remedies usually

employed, all of which belong in the class of antiseptics, and therefore

¹ Maclachlan, Edinburgh Med. Jour., Aug., 1899.

ER YSIPELAS

425

appropriate for the treatment. Extensive and especially the deep-
seated cases, with grave systemic disturbance and high fever, and those
of distinctly septic type, are to be looked upon as of possible fatal ending.
Erysipelas which invades the entire scalp is also to be considered dan­
gerous. Arising after severe injuries or operations, it is also to be viewed
as of possible serious portent, occurring, as it does, in one probably already
debilitated and with lessened resisting power. In alcoholics and those
with nephritic disease the prognosis is also of greater gravity. On the
other hand, the mild and moderate cases, which make up the largest
number, usually run a somewhat rapid, favorable course. Depending
upon the extent and severity of the disease, its course is run in from one
to several weeks. In those instances in which there is a continual crop­
ping out of new areas the duration may be somewhat prolonged, but,
except in severe cases, more than a month's continuance could be con­
sidered rather uncommon. Loss of hair is usually replaced.

Treatment.—The constitutional treatment of erysipelas consists
in the administration of remedies of a tonic, stimulating character, plain
but nourishing food,—chiefly milk in severe cases,—and the use of drugs
with alleged specific properties. In this latter class tincture of the
chlorid of iron and quinin are those, especially the first, which have the
greatest support. As routine practice it is well to advise both these
remedies, the former in doses of 15 to 40 minims (1.-2.50), the latter,
2 to 3 grains (0.13-0.2), along with moderate doses of strychnin, three
to five times daily, according to the severity of the attack. Other
remedies for special conditions or complications will suggest themselves.
In great depression alcoholic stimulants and ammonium carbonate are
of value. Favorable results in grave cases from a few injections of anti-
streptococcic serum—about 10 cc at an injection—have been reported
(Marmorek, Cotton, Robinson, André, Bristow, Baum, and others).

After all, the external treatment is probably of greatest importance,
especially if the accepted theory of the cause of the disease is considered.
In most of the cases it alone would suffice. Many remedies have been
variously advised, but they may all be included under the head of mild
antiseptics. Along with the remedial applications the larger vesicles
and the blebs should be opened from time to time. When involving the
scalp, cutting the hair is an advantage, and in severe cases should always
be done. A simple and strongly advised application is a 1 per cent,
lotion of carbolic acid, made with equal parts of water and alcohol
(White). Ichthyol as an ointment or aqueous solution of 10 to 25 per
cent, strength has probably, at the present time, the greatest number of
supporters (Unna, Nussbaum, Jamieson, Allen, Elliot, and others),
and to the value of which I can warmly subscribe. The lotion is applied
similarly to the above; the ointment spread upon patent lint or other
fabric, and applied as a plaster, changing one to three times daily, accord­
ing to the condition. The ointment is more grateful to some patients,
and more suitable for those cases in which, especially in the later stage,
there is crust formation. The base of the ointment can be petrolatum, or
equal parts of lanolin and cold cream, stiffened, if necessary, with wax
or spermaceti. These several plans have afforded me good results in all

426                                  INFLAMMATIONS

the cases met with, although in most of the patients the disease was of a
mild grade.

The extension of the process can seemingly be sometimes prevented
by painting over the bordering skin an inch-wide band of a strong solu­
tion of silver nitrate or of iodin tincture.

The milder cases of surgical erysipelas can also be treated satisfac­
torily with the above remedies, but for the treatment of the more severe
cases of this class the reader is referred to works on surgery.

There are many other remedies and methods, such as sodium salicylate
solution (1 : 20) compresses (Besnier, Hallopeau), 1 per cent, picric acid
solution, kept constantly applied (Cavelli, Tassi), and frequent local
baths of 95 per cent, alcohol (Behrend). Pawlowsky's laboratory ex­
periments show that this last rapidly destroys the streptococcus.

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