Part 101

For the uncommon cases in which the transference of the inflammation is attended with depression stimulants are required, and for those in which meningitis is threatened cutting off the hair and the application of cold to the head, hot mustard foot-baths, local and general venesection, drastics, and irritants to the cutaneous surface, are necessary.

II. Symptomatic or Metastatic Parotitis.

Symptomatic, metastatic, malignant, or suppurative parotitis, as the condition is variously designated, is an inflammation of the parotid gland which occurs during the course of different grave acute diseases, is usually unilateral, and terminates in suppuration, or much more rarely in gangrene, of the gland involved.

ETIOLOGY.--It may occur in association with typhus, typhoid, relapsing, puerperal, and scarlet fevers, or with the plague, measles, dysentery, cholera, and pyæmia, springing into notice at different periods of the {626} course of these affections, which may be regarded as predisposing causes. The exciting cause is perhaps mechanical in nature--namely, the excessive dryness of the mucous membrane of the mouth so common in the severe fevers. This dryness may lead to an occlusion of the orifice of the parotid duct, with retention of the saliva, which fluid, undergoing decomposition, may act as an irritant, producing inflammation, and finally suppuration, of the glandular tissue. This is a likely enough explanation of the causation in some cases, but dryness of the mouth is such a uniform symptom in fever, and suppurative parotitis such a comparatively rare complication, that it cannot be a very active or common cause. Nevertheless, it is impossible to fix upon any other direct cause, though the altered condition of the blood in the conditions mentioned must not be lost sight of as an important etiological factor.

ANATOMICAL APPEARANCES.--The character of the pathological lesions have been well established, owing to the frequent opportunities that arise of examining the diseased gland at different stages of the inflammatory process. When the inflammation has lasted a short time, a day or two, the tubes and acini of the gland are seen on section to be swollen and reddened, and the connective tissue infiltrated with serum and yellowish-red in color; a fluid, either viscid, ropy, grayish in color, or more purulent in character, fills the duct, and may be forced out into the mouth by stroking it in the direction of the orifice. If of several days' longer duration, purulent softening will be noticed in the centre of the acini; this gradually extends until each acinus is converted into a little sac of pus. Then the inter-acinous connective tissue breaks down, and the multiple, minute, purulent collections become converted into a single large abscess or into two or more smaller ones. Next, the pus seeks an outlet. The position of pointing may be on the cheek or in the external auditory meatus--a very common location; again, the abscess may break into the mouth, the pharynx, the oesophagus, or into the anterior mediastinum, the pus burrowing its way along the sheath of the sterno-cleido-mastoid muscle.

While the parotid abscess is forming, suppurative inflammation is apt to be set up in the masseter, pterygoid, and temporal muscles, and from these positions the pus forces its way upward to the temporal or zygomatic fossæ. The periosteum of the neighboring bones, and even the bones themselves, may become involved, and sometimes the cranial bones are partially destroyed, and there is an extension of the inflammation to the brain or its membranes. The middle ear may participate in the general destruction, and the patient is left permanently deaf, if indeed he escape with his life.

The lymphatics, veins, and nerves traversing the parotid are affected by the suppuration in the gland. Irritation of the lymph-vessels results in swelling, tenderness, and suppuration of the lymph-glands. Thrombi form in the jugular vein and its branches, and by breaking down lead to septicæmia and ichorization of the sinuses of the dura mater. The nerves resist for a long time, but seem to act as paths of conduction of the inflammation, the facial nerve leading it to the ear, and the branches of the trifacial to the brain. When gangrene of the gland takes place, the traversing nerves as well as the gland elements are rapidly destroyed.

SYMPTOMS.--Symptomatic parotitis, occurring during the course of {627} any of the diseases already named, produces no change in the general symptoms; if, on the other hand, it occurs during convalescence, the onset is marked by a moderate elevation of temperature and increase in the frequency of the pulse, by thirst, loss of appetite, and sluggish bowels. The tumor, which occupies the same position and thrusts outward the ear-lobe as in mumps, is hard, dense, well defined, and the seat of considerable pain until suppuration takes place, when the latter subsides greatly. The skin over it is red, hot, and tense, and there is much tenderness and little or no pitting on pressure. After the abscess has formed there is well-defined fluctuation on palpation, and at the position of pointing the skin becomes very thin and assumes a bluish-red hue. Gangrene of the gland is manifested by the cadaverous odor, blackening of the skin, the formation of a cavity, and the discharge of ichor and shreds of tissue. The alteration in the expression, the pain in the ear, the difficulty in moving the jaw and in swallowing, are as constantly present here as in idiopathic mumps. It must not be forgotten, though, that when the disease arises during the course of any of the severe infectious diseases, the brain may be so overcome that the subjective symptoms are frequently not complained of.

The course is usually rapid, the abscess pointing on the fourth or fifth day after the appearance of the parotid tumor; occasionally, however, the inflammatory process is much slower, extending over a period of several weeks. The course is also much protracted when secondary abscesses form in other parts of the gland or in the surrounding tissues, when the abscess is transformed into an ichorous cavity, and when gangrene sets in. Ordinarily, where the pus is evacuated by spontaneous rupture or by incision the abscess heals quickly by granulation, leaving the gland enlarged and indurated for some time.

THE PROGNOSIS depends upon the gravity of the original disease, the period of the disease at which the complication occurs, and whether or no mortification sets in. When the vital processes are greatly impaired by the primary disease, the onset of the parotitis, trifling in itself, may prove sufficient to determine a fatal result. The danger of such a result is much increased, too, if the inflammation begins in the earlier stages or during the height of the disease which it complicates, while if it commences during convalescence by far the most frequent result is recovery. Gangrene of the gland involves great risk of life--a risk which increases in proportion to the early date of its onset in the course of the original disease. Even when the gangrenous process ends in recovery, the face is much distorted, the hearing is lost in the ear, and the facial muscles are paralyzed on the affected side. Bilateral symptomatic parotitis has naturally a graver prognosis than the unilateral form.

DIAGNOSIS.--The disease is readily distinguished from idiopathic mumps by the history, the less marked degree of the enlargement and surrounding oedema, the greater degree of pain and tenderness, the hardness of the tumor, the red discoloration of the skin covering it, and the termination in suppuration. Further, it never displays an epidemic tendency.

TREATMENT.--The general treatment of this form does not differ from that of the disease it complicates, though the employment of stimulants in increased quantities may be indicated.

{628} Before the first appearance of tumefaction of the parotid the introduction of a probe or canula into the duct of Steno, associated with pressure on the gland from the outside, may, by forcing from the duct a collection of mucus or muco-pus, abort the inflammation. If this is unsuccessful, a poultice should be applied over the gland to encourage suppuration and pointing externally. As soon as the abscess points the pus must be evacuated by an incision, and, as this has a tendency to close again, a piece of lint must be kept between the lips of the wound.

The enlargement and induration left after the healing of the abscess require the application of tincture of iodine or of compound iodine ointment to the surface.

When gangrene occurs it demands the same treatment, both local and general, as when it is seated elsewhere.

{629}

ERYSIPELAS.

BY JAMES NEVINS HYDE, M.D.

DEFINITION.--Erysipelas is an acute disorder, characterized by the systemic symptoms common to the febrile state, and by an involvement of the integument and deeper parts, the affected surface being tumid, hot, reddened, painful, and often the seat of well-defined bullæ, the process terminating either in complete resolution after cutaneous desquamation or in a fatal result commonly due to complications of the malady.

SYNONYMS.--Eng. St. Anthony's Fire; Fr. Érysipèle; Germ. Rothlauf; Ital. Risipolo.

CLASSIFICATION.--Erysipelas is properly recognized as one of the acute infectious diseases. Though by its symptoms and career it would seem to be properly assigned to the category of the exanthemata, it is yet by most authors set apart from the latter--first, because its career is less specifically defined; second, because its contagiousness is less demonstrable in every case; third, because one attack is not known to confer upon its victims immunity against a second; fourth, because the occasional prevalence of the disease in apparently epidemic form is evidently due to extrinsic causes, and does not depend exclusively upon its sudden appearance among the unprotected; fifth, because no definite period of incubation precedes its earliest manifestations; and, sixth, because at times it appears in local manifestations apparently unaccompanied by systemic phenomena.

HISTORY.--The earliest writers on medicine bear witness to the fact that the disease was recognized at the date when men first made record of human ailments. It has occurred in all parts of the world and at all seasons of the year, sparing neither age nor sex in its development. Zuelzer refers to epidemic occurrences of the disorder, described by Rayer, as visiting the Paris hospitals in 1828; by Schönlein, as existing in Zürich in 1836; by Gintrac, as spreading in Bordeaux in 1844-45; and by Trousseau, as prevailing in the Maternité in Paris in 1858.

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 {630} 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 {631} 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.