Part 103

Urticaria also is often of symmetrical development, is rarely accompanied by fever, and is characterized by typical wheals, which, however closely packed together, never have the smoothness of the surface affected with erysipelas.

PROGNOSIS.--The prognosis of a simple case of uncomplicated erysipelas occurring in an individual in fair health and possessed of a reasonable degree of vigor may be regarded as favorable. Even in the weakness of infancy a large area may be involved in the disease and a high degree of fever be aroused without alarming results.

Erysipelas should, however, always be regarded as a serious disease or a serious complication of any existing malady. It is often a grave feature in surgical injuries. Erysipelas involving the entire surface of the face and head is always a formidable affection. In the puerperal state it is dreaded by every accoucheur.

All these circumstances are rendered more portentous by the existence of the disorder as a complication of any other grave malady, or by its occurrence among the subjects of alcoholism, struma, phthisis, or various other cachexias, and among the aged. Occurring in epidemic form among the inmates of prisons, camps, and hospitals, the mortality of the disease may be increased tenfold.

TREATMENT.--The prophylaxis of erysipelas is that of all contagious diseases. It involves isolation of the affected individual, disinfection of body- and bed-clothing before the latter are again employed upon the persons of others, and destruction by fire of all dressings which have been in contact with the integument.

{637} The hygienic management of the patient is not to be neglected. The complete ventilation of the sick chamber is to be secured, and its temperature uniformly sustained at a point between 65° and 70° F.

The general treatment of the sufferer need not greatly differ from that commonly pursued in the febrile state by modern therapeutists. There is but little confidence to-day in the methods by venesection and purgation, upon which at one time reliance was placed. Cool or cold water may be freely employed when there is hyperpyrexia, either by general bathing or by wrapping the patient in sheets dipped in and wrung out of the same fluid. The results are favorable as regards the bodily temperature, and are not productive of danger, though water thus applied has no effect upon the local disorder of the skin. Iced or cool water, by the ice-bag or compresses, is specially indicated as a topical application for the head when there is delirium or other indication of disturbance of the cephalic centres, irrespective of the invasion of the scalp and face by the erysipelatous inflammation. The sulphate of quinia in full doses is indicated especially when there is any tendency to remittence in the febrile accessions, but is not known to possess any power to cut short the disease. In many cases of erysipelas the febrile condition is readily managed by the administration of the simpler remedies found grateful to the palate of the sufferer, such as iced, acidulated, and effervescing draughts, with perhaps the employment of the spiritus Mindereri or the spirit of nitrous ether. In other cases the mineral acids can be substituted with advantage for the latter. With many American physicians it is customary to add to these remedies the tincture of the root of aconite, with a view to its effect upon the pulse.

Few internal remedies, however, have in this country enjoyed as much popularity with the profession in the treatment of erysipelas as the muriated tincture of iron in full doses. Its use, first suggested for this purpose by Bell in 1851, has here steadily gained in favor since its general adoption. It is well to give it in doses of not less than 20 or 30 drops, repeated every two or three hours, diluted with water. When there is high fever, and especially if the secretion of urine is scanty, the following formula will be found valuable:

Rx. Tr. Ferri Chloridi; Sp. Ætheris Nitrosi; Glycerinæ aa. fl. drachm i. M.

S. A teaspoonful in water every three hours.

This preparation of iron certainly seems, in many cases, to shorten the disease, but, per contra, it is to be remembered--first, that in many other cases it has been found to exercise no control whatever over the severest manifestations of the disease; second, that in other countries, especially in Germany, where it is rarely employed, the mortality from the disease is no greater than elsewhere.

The widest difference in practice has obtained relative to the local treatment of the affection. They who have had the fortitude to content themselves with watching the evolution of the specific dermatitis, merely protecting the skin by dusting over it a simple powder or leaving it covered with a cold compress, have certainly no worse results to tabulate than those who entertain a belief in the efficacy of the abortive treatment of the local disorder.

{638} No remedies, locally applied, can be recognized as certainly possessing the power to cut short the inflammation. Those which enjoy the highest reputation for topical employment are saturated solutions, hot and cold, of the hyposulphite of sodium, of boracic acid, and of the bicarbonate of sodium; salicylic acid; iodoform in powder; and, quite lately, resorcin. Hot fomentations of the erysipelatous patch are in general most grateful to the patient, and with these an opiate and astringent effect can be obtained, as by a hot lead and opium wash or by solutions of the sulphate of iron or of alum and tannin. Useful methods of applying these are by the medium of borated cotton, oakum, tow, or spongiopiline, covered with oiled silk or the Lister protective material.

Other medicaments which have enjoyed favor in the topical treatment of the disease are lime-water and linseed oil (carron oil), sulphur in powder, carbolic acid, camphor, the oil of turpentine, collodium, cataplasms and ointments containing mercury, lead, zinc, tar, and tannin.

Respecting the measures adopted with a view to checking the extension of the disease at the periphery of the patch, the belief in such a possibility has been wellnigh abandoned. For this purpose the nitrate of silver, caustic potash, tincture of iodine, and similar substances have been boldly and broadly applied, alike over the sound and affected integument, with the production of an artificial dermatitis intended to supplant that which was previously in progress. Again and again has the local inflammation transgressed these artificial limits; and when they have been by it apparently respected there has been little ground for believing that the result was due to the treatment pursued. Inasmuch as the disease is often self-limited and distinctly limited in its progression over the surface, it is manifestly difficult to determine that its limitation in any given case is the result of topical agencies. These agencies have, moreover, the marked disadvantage of adding their irritative effects to those incidental to the dermatitis.

The surgical treatment of erysipelas invading special regions of the body or the deeper tissues is a matter of importance. Free incisions are requisite for the liberation of pus, and all abscess cavities should be treated antiseptically and stuffed with iodoform or resorcin. Great tension of the lids demands free incisions in the long diameter of either, and the same surgical procedures are often demanded in erysipelas of the scrotum or of the labia in the female. Gangrene and sloughing are to be treated in accordance with the principles recognized as important in the management of these accidents in general.

The mouth when involved may be benefited by gargles containing the chlorate of potassium, alum, tannin, the compound tincture of cinchona, or by the use of the spray with a saturated solution of boracic acid in rosewater. Kaposi lays stress, in all cases of erysipelas of the face, upon the importance of searching for and evacuating all dental abscesses and pustules seated upon the Schneiderian membrane. Crusts in the nasal cavity are to be soaked with vaseline and removed by washing, their re-formation being prevented by the insertion of small tampons smeared with a bland ointment or oily fluid. Abscesses in other portions of the body, not suspected as being etiologically significant, are to be carefully searched for and emptied, whether occurring about the anus, the genitals, or the legs.

{639} Subcutaneous injections of carbolic acid and other antiseptic solutions have not been rewarded by such results as to establish in any degree their special efficacy.

In all ordinary cases the expectant treatment recommended by Zuelzer is abundantly to be commended. The inflamed tissue is to be dusted with finely-powdered starch, and protected by a layer of soft cotton-wool which exercises a moderate degree of pressure upon it. Antiseptically, the highest ends are thus reached.

The diet of the patient should consist of animal broths, soups, milk, and eggs, with a view to the reparation of the waste incidental to the febrile process. Stimulants are to be freely used in all asthenic conditions. In convalescence the warm water and soap bath is to be employed, followed by dusting of the surface with starch powder or by inunction with vaseline.

{640}

YELLOW FEVER.

BY S. M. BEMISS, M.D.

Yellow fever is a specific, infectious, and communicable disease of one febrile paroxysm.

This definition includes some of the most prominent characteristics of the disease. The malady, however, derives its name from a symptom not mentioned in the definition. The yellow color of the skin and scleroticæ which appears in advanced stages of grave cases of yellow fever, and which becomes especially marked in the cadaver, has ruled its nomenclature. Whatever objections may be urged against the term "yellow fever" as being founded upon a symptom of the disease not always present, it is too strongly fixed in both medical literature and popular usage to justify efforts to change it.

Neither is it liable to beget confusion as long as it is understood that it is to be restricted in its application to a specific fever induced by a specific poison, and that as an incident of its morbid process it produces yellow coloration of the surface so frequently as to suggest the prefix yellow to its title.

ETIOLOGY AND SYMPTOMATOLOGY.--In this day of almost general belief in the theory which holds that each specific disease has its own specific poison or morbific germ, it is scarcely expedient to occupy much space in discussing the propriety of classing yellow fever among the specific maladies.

Whether we rest the decision of this question upon the uniformity of those circumstances and conditions which originate and develop epidemics of yellow fever, or upon the sameness of its symptomatic phenomena wherever observed, we find very nearly as substantial claims to a specific individualization of the disease as any one of the eruptive fevers possesses. Not only are its morbid phenomena so characteristic that even non-professional observers designate it by such epithets as Bronze John, Yellow Jack, Vomito Prieto, etc., but it is inconvertible with other specific affections. This inconvertibility of yellow fever with other diseases is absolute, and affords irrefrangible evidence of the specificity of that germ or poisonous principle which produces it.