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Erysipelas is an inflammation of the external surface, accompanied with peculiar symptoms and appearances, the morbid action being modified by the texture in which it occurs. According to the various circumstances attending the disease, it has been divided into several species: phlegmonous, bilious, œdematous, gangrenous, acute, malignant, &c. The term Erythema is applied to cases of rash or efflorescence, unaccompanied with fever, swelling, or vesication.

Inflammation of the skin only, is marked by bright redness, not circumscribed, and disappearing when pressed. By pressure, the bloodvessels are emptied for a time, the part sinks and becomes pale; but, on removing the pressure, it soon regains its former colour and relative situation; when these circumstances concur, the part is said to pit. There is no tension,—the pain is not throbbing, but of a burning or itching kind, and there is often a degree of œdematous swelling. Swelling does not occur to any great extent, however, during the existence of the inflammation in the skin and rete mucosum; but the parts sometimes become much swollen after subsidence of the inflammatory action, the vessels having relieved themselves by effusion of serum; and afterwards the œdematous surface often assumes a yellowish hue. In some cases, the serous effusion is from the first, more extensive than in others, and hence the term œdematous erysipelas, or inflammatory œdema. Upon the decline of inflammation, a serous fluid is often effused also in great quantity under the cuticle, giving rise to vesications, resembling the blisters produced by the application of boiling water to the skin; and from this circumstance, erysipelas has been classed amongst cutaneous affections in the order bullæ. The erysipelatous redness does not terminate abruptly, and is not defined by a distinct boundary, as some have asserted, but becomes gradually lost in the surrounding parts. It frequently involves the contiguous parts one after another, and extends with great rapidity. It often leaves one part suddenly, and attacks another, either in the neighbourhood, or situated at a considerable distance; in other words, metastasis takes place. The disease takes on this erratic character without our being able to assign any good reason for it; and this form of the disease is frequently attended by symptoms of typhoid fever. When it disappears suddenly, or is repelled by cold applications, affections of the internal organs sometimes supervene, as of the bowels, lungs, or brain; the diseased action leaving the external surface, and attacking the deeply-seated organs; thus, in a case of erysipelas of the ankle and foot, the external symptoms disappeared suddenly, and an affection of the lungs supervened, under which the patient sunk; and in erysipelas of the face and scalp, the sudden disappearance of the redness is frequently followed by delirium and coma. Again, in acute disease of an internal part, the symptoms are much meliorated, and often entirely removed, by inflammation of the skin being induced artificially, or occurring spontaneously.

The integuments of the face and head are frequently attacked by erysipelas, in consequence of wounds and bruises of the face or scalp, even though very slight, and it often takes place here spontaneously, as in other parts of the body.

Erysipelas commonly arises from constitutional derangement, as is shown by the symptoms which precede it, and also by the efficacy of internal remedies in checking its progress; in such instances, external applications, unaccompanied with constitutional treatment, produce little or no effect. It is often produced around a wound by the employment of improper dressing, rancid ointments, or irritating plasters, by a too free use of the part, or by the friction and irritation of the patient’s clothes. It occurs most readily in those who live freely, indulging in the imprudent use of spirituous liquors, and whose constitutional powers are thereby considerably weakened. It is also said to be sometimes caused by violent passions, as anger or grief; and by exposure to cold, or to heat,—the former acting only as a remote, the latter as an immediate cause. As an example of its occurring in consequence of heat, it is a common remark, that cooks, who are necessarily much exposed to the fire, are frequently the subjects of erysipelas of the face; but in the majority of such cases, there may be other causes in operation,—the abuse of ardent spirits, and habitual overcharging of the system with stimulating food. It is more commonly met with in summer than in winter. And in certain states of the atmosphere, even in healthy situations, a degree of erysipelas is apt to occur after wounds by operation or accident.

It is often periodical, especially in females who have ceased to menstruate, always recurring at regular intervals; it attacks parts of the body, most generally the face, and in some cases monthly, in some once in the year, and in others once every two years. It sometimes appears to occur as a natural means of relief from impending affections of more serious nature, as of the system or of internal organs. Those who have once been afflicted with the disease become more liable to its attacks.

Erysipelas is generally preceded and accompanied with more or less disturbance of the digestive organs. In Bilious Erysipelas, the portion of skin affected is said to present a more yellow colour than in the phlegmonous, the derangement of the digestive organs is greater, and hence the origin of the distinctive term; fits of shivering occur, the patient complains of a bitter taste in his mouth, and the tongue is furred and of a brown colour.

In the Phlegmonous, in which other textures than the skin are often affected, viz., the subcutaneous and intermuscular cellular tissue and the fasciæ, the pain is more intense, and of a throbbing kind; the swelling is hard, more deeply seated, and more extensive; there is considerable tension; and the redness is of a darker hue. Nausea and a bitter taste in the mouth do not precede the erysipelatous appearance, but the skin and tongue are dry, and there is great thirst. When the disease begins to subside, then the foul tongue supervenes, with the bitter taste and nausea.

Erysipelas, of a contagious and violent character, frequently occurs, and is apt to spread extensively, in badly aired situations, where a number of patients with sores are crowded together, without due attention being paid to cleanliness and proper dressing.

Hospital Erysipelas, as this species is termed, is nearly allied to that dreadful disease, Hospital Gangrene, and the two affections are often blended. It comes on after operations, or in patients who have sustained an external injury by accident. In unhealthy hospitals it not unfrequently appears in previously sound parts, and without any assignable cause; and, from its following the slightest wound, recourse cannot be had with safety even to venesection, cupping or leeching. It is a dreadful scourge in many hospitals, more especially during particular seasons of the year—during hot, damp weather, and in spring and autumn, attacking the patients indiscriminately.

Of late years Erysipelas appeared in the Royal Infirmary of Edinburgh, during the wet and changeable summers which prevailed; some of the cases were very severe, and a few terminated fatally. It was very satisfactory, however, to observe that it did not spread as it used to do formerly, that patients occupying the beds immediately around those affected, though afflicted with sores and in indifferent health, remained exempt from the disease; and that many of the most severe cases did not originate in the house, but were brought from the crowded and unhealthy parts of the city. The same may be said of the disease as it has shown itself in the North London Hospital since it was opened for the reception of patients up to the present time.

Hospital Erysipelas is for the most part preceded by violent constitutional symptoms, derangement of the chylopoietic viscera, shivering, brown tongue, and a bitter taste in the mouth; if there is a sore on the body, it assumes a sloughy aspect; the surrounding skin becomes of a dark red colour, and there is a feeling of tension, accompanied with a burning pain. The erysipelas extends rapidly, and generally terminates in suppuration and sloughing of the cellular substance, or, if inertly treated, in immediate gangrene of the parts. The concomitant fever is generally low, and though, in the first instance, the circulation may be vigorous, symptoms of debility will speedily appear. It will be more fully dwelt upon, along with Hospital Gangrene.

In all cases of erysipelas there is more or less concomitant fever, modified by the extent of the local affection—by the age of the patient—by the previous habits and state of health—by the constitution—and by other circumstances. The pulse is accelerated, and is either of a sthenic or asthenic character, according to the state of the system and type of the prevailing fever. There is headache, languor, thirst, restlessness, and even delirium, especially when the face or scalp is the seat of the disease.

Erysipelas may terminate in resolution. If this takes place in the first stage of the disease, the redness gradually declines, along with the swelling, the cuticle exfoliates, and the part regains its usual appearance, the skin remaining loose and shrivelled. If it occurs after vesications have formed, the effused fluid is absorbed, a scab forms, and desquamates along with portions of the cuticle.

It may terminate in suppuration, when the inflammation has extended to the cellular substance. This termination is most frequent when the disease is situated in an extremity, seldom when in the face, though small purulent collections occasionally form in the eyelids. Circumscribed collections of pus often present themselves after the disappearance of the erysipelatous inflammation; but the purulent matter is generally diffused through the filamentous tissue, and is of a thin, unhealthy appearance, and mixed with sloughs of the cellular substance. By the infiltration of matter, the integuments, fasciæ, and muscles are extensively separated from each other, in consequence of which the parts frequently die, their nutritive supply being cut off.

Acrid sanious matter is often infiltrated extensively into the subcutaneous cellular tissue round a wound or sore. The superimposed integuments are of a dark brown colour, and the part is boggy. Sloughing of the cellular membrane here takes place in consequence of the infiltration, and not from inflammatory action having been established. The affection has been termed Diffuse Cellular Inflammation, but a more proper appellation is Diffuse Cellular Infiltration; the cellular tissue, even where treatment is adopted at an early period, can scarcely be prevented from perishing.

Erysipelas, if properly treated from its commencement, will seldom terminate in gangrene of the skin. This termination is occasionally observed, however, in patients whose constitutions have been extremely debilitated.

In mild cases of erysipelas, attention to the state of the bowels, and regulation of diet, will often be sufficient to remove the disease. When there is much disorder of the digestive organs, and particularly of the biliary secretions, emetics may be given at the commencement; these are productive of but little good in the more advanced stage, and their place is advantageously supplied by nauseating doses of antimony, combined or not with purgatives. One-eighth of a grain of tartarised antimony may be given in solution every hour, with or without a due quantity of the tart. potassæ and sodæ, or Rochelle salt. The hydrargyrum cum creta is often given with great benefit when the tongue is dry and covered with a brown crust: it may be combined sometimes advantageously with the compound powder of ipecacuanha. With the same view calomel with antimonial powder may be exhibited. The exhibition of saline purges is attended with great good in some severe cases. Such medicines tend to subdue any arterial excitement that may exist, evacuate the bowels, promote perspiration, remove the superabundant bilious matter, and serve to restore the healthy functions of the liver. In severe cases, more especially of phlegmonous erysipelas, in which there is acceleration of the pulse, and a degree of febrile excitement, general bleeding may be had recourse to; but it must be employed with caution, for the symptoms of increased vascular action may arise from constitutional irritation, and not be meliorated by the depletion. The practice is superseded by the timeous and free local bleeding from incisions, as will be noticed by and by. The exhibition of the extract of aconite in this and other inflammatory affections, is often followed by great abatement of vascular excitement, so that the necessity for abstraction of blood is done away with. The medicine may be given in doses of half a grain in substance, or dissolved in pure water, and repeated every third or fourth hour. The sensible effect is relaxation of the surface, and frequently profuse perspiration; the arterial pulsations are diminished in frequency and force. The extract of belladonna, in doses of one-sixteenth of a grain, may then be substituted with great advantage, and often with the most extraordinary effect upon the disease. In very many cases, the strength is from the first to be supported by all possible means, by nourishing diet, by the exhibition of wine, quinine, and other tonics; more particularly in old people—in constitutions debilitated by disease—in unhealthy situations, and when the fever is of a typhoid kind. Bleeding by leeches is not admissible, for the leech-bites prove a source of irritation, and are liable to suppurate; erysipelas has often been produced by leeching.

In erythema, the mere outer surface of the skin only being slightly affected, and not to any very great extent, advantage sometimes results from the application of nitrate of silver. A strong solution may be pencilled upon the part, or, after being wetted, the affected surface may be gently rubbed over with the solid caustic. The pain and uneasy sensations in the part being thereby diminished or removed, and extension of the disease seeming to be arrested. Discoloration caused by such practice is of little consequence, as desquamation must follow. It is questionable how far it may be safe to apply lunar caustic to any extensively inflamed surface, more especially of the head and face, lest metastasis should occur. The inflammatory action in the skin is subdued by the application, whilst it may advance, in the cellular tissue, to suppuration and sloughing, if other means are not adopted; and from the hard and blackened state of the cuticle, the condition of the subjacent parts is not readily perceived. The remedy is only applicable to erythema, and most advantageously as a means of bounding it. The line should be drawn at some distance from the affected tissues; and if so, it is seldom that the disease oversteps it.

Local abstraction of blood, by puncture or incision, proves exceedingly beneficial in cases of erysipelas, whatever its degree. It must be borne in mind by the practitioner, when called to treat the disease, that the state of parts is very various, and this may depend upon the original nature of the disease, upon its site or duration. The surface of the skin only may be affected—that and the subjacent cellular tissue may be involved, gorged with serous, lymphatic, or purulent infiltration—there may exist great tension of the parts, with a sloughy state of the cellular tissue, established in addition to suppuration—and again, there may be infiltration of the subfascial and intermuscular tissues, leading ultimately to exposure and exfoliation of bones or disease of articulations.

From inattention to these circumstances, the treatment being often directed to the name of the disease, great discrepancy of opinion, as to the most proper local management, has arisen; there has accordingly been a controversy as to whether the blood should be drawn from mere punctures from limited incisions, or from long gashes extending from one joint to another.

In cases not very severe or extensive, when the skin only is affected, the constitutional treatment already mentioned is first to be employed, and then the affected part must be freely punctured with a fine lancet, at numerous points, as recommended by Sir R. Dobson. These punctures should reach the vascular layer, but not go deeper: the serous effusion, if there be any, is thereby evacuated—the over-distended vessels are relieved of a considerable portion of their contents—and the œdematous swelling, with the formation of phlyctenæ, is prevented. The part is afterwards to be fomented for half an hour, or an hour, with bags containing chamomile flowers or hops; the fomentation, repeated at intervals, proves highly grateful to the feelings of the patient, allays any irritation which the making of the punctures may have produced, and keeps the skin perspirable. Under this treatment, every vestige of erysipelas will generally disappear in the course of a few days. In more severe cases, especially in the extremities, the parts must be freely incised. The incisions ought to extend through the integuments and cellular substance, and their length and number must be proportioned to the extent and severity of the affection. One or two pretty free incisions, if made in the proper place, where the greatest degree of boggishness, marking the disorganised state of the tissues, is discovered, will generally suffice—the vast good and the relief afforded depends partly upon the abatement of the tension, in consequence of the evacuation of the effused fluids—upon the unloading of the over-distended bloodvessels of the part, and upon the acceleration of the suppurative process, which is often critical. The constitution is, probably, relieved by the suppuration of the wounds, and the consequent drain of the offending particles.

Some surgeons have disapproved of long incisions, alleging that they are tedious in healing, and prefer making numerous small ones; but it is difficult to understand how the cure should be more tedious in the one case than in the other, when the actual extent of divided surface is the same. According to my experience, several free incisions are made with less pain than a number of trifling scratches, and heal as soon, whilst by the former the purpose of the practitioner is much better fulfilled: the same good effects result from them as from punctures in the more slight cases, if they are made at the commencement of the disease; and if the affection is in its advanced stage, the effused fluid, and the sloughs, are discharged, and the infiltration of pus, and destruction of parts in consequence of the matter being confined, are prevented by its being allowed a free exit as soon as it is formed. Incisions then are made both in the early stage of the disease, and after effusion has occurred: in the former case, they are justifiable, because they arrest its progress; in the latter, they are absolutely necessary, to prevent its injurious effects. The parts are to be fomented, and afterwards covered with a common poultice, containing no oil or grease, or with soft lint saturated with tepid water, and covered with oiled silk, to prevent evaporation.

When the erysipelas has gone off, the incisions are treated as common wounds, by dressing and bandage. After punctures, or incisions, more or less blood is allowed to flow, according to circumstances. It often escapes from the vessels of the part in great profusion; this, in many cases, may be prejudicial or excessively dangerous. In the extremities the flow can readily be arrested by elevation of the part, or by pressure, for a short period. In erysipelas of the face, punctures are preferable to incisions, as by the employment of the former the countenance is no way disfigured; if, however, in erysipelas of the scalp, the integuments become swollen, and present a puffy feeling, whilst at the same time cerebral symptoms supervene, free incision or incisions, through the whole thickness of the covering, and in the direction of the fibres, must be made. If erysipelas be thus actively treated, it may be safely affirmed that the disease will not often, unless accompanied with symptoms of putrid fever, terminate fatally; if these means are employed early, the constitutional disturbance will be modified or prevented, and no derangement of the cerebral functions will ensue.

Powders, such as flour, chalk, and camphor, &c., have been applied to the erysipelatous surface, but are of little use, and, by their irritation, frequently prove injurious on the bursting of the vesicles. They are applied, according to some, with the view of cooling the surface, and after all the part may be seen enveloped in folds of flannel. Cold application, such as the spirituous and evaporating lotions, containing vinegar and spirits, liquor acet. ammoniæ, Goulard’s extract, &c., may, in many cases, afford temporary relief, but their use is fraught with the utmost danger; for their direct tendency is to produce metastasis, and if that be to an internal organ of importance, the result is too generally fatal. Or if the erysipelas, on leaving the part originally affected, attack another also superficial, the local treatment has to be commenced anew. If these lotions are to be employed at all in this disease, they must be made tepid.

In case of the translation of erysipelas to any important part, blisters may be applied to the surface which it has left, or to any other in the neighbourhood, with the view of recalling the disease to its original and less dangerous situation:8 the actual cautery has even been recommended. In the great majority of cases, however, such means are unavailing.

In Hospital Erysipelas, purging cannot be carried to any great extent with safety, and general bleeding is seldom if ever admissible unless the patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hospitals, the patients are generally in a weak state before the accession of this disease; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals: in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to destroy immediately such dressings as have been used. The apartments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local applications will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the surface of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some remedies that have been used; such as the arsenical solution, or the red hot iron.