and the destruction of the expectoration. This investigation soon led to the discovery of other sources of infection. The examination of cattle showed that aside from tubercular patients themselves, this was one of the most dangerous sources of infection, the poison being conveyed through the milk, butter and cheese. The possibility of infection from this cause is so clearly proven that most civilized countries have taken steps to discover and destroy infected cattle. As to the treating of tuberculosis as other infectious diseases are treated, by quarantine, isolation, etc., there is yet a difference of opinion, but it seems that medical opinion is fast tending in that direction as the only hope of successfully preventing the spread of the disease. Some form of modified isolation will doubtless be instituted that will not prove too great a burden to friends and relatives, and not a source of injustice to the patient suffering from a disease so fatal and at the same time of such a long duration. The tuberculin of Koch and its numerous modifications and improvements by himself and others have not as yet fulfilled the expectations of the medical world, but yet much good has been done and the investigations are still being vigorously pushed by scientific men throughout the world, and it is not too much to expect that greater results will be attained in the near future.

Following the discovery by Koch, investigations have been made as to the specific cause of other infectious diseases, and in many of them the cause has been found to be due to a specific germ-diphtheria, malaria, anthrax, gonorrhoea and probably pneumonia. Also following the tuberculin brought forward by Koch for the cure of tuberculosis, experiments have been made with the inoculation of bacteria of different diseases, and a system of serum therapy evolved which in some diseases, notably diphtheria, has proven of the greatest value in the treatment of these diseases. There is now no question as to the efficacy of the antitoxin treatment of diphtheria, for it has been sufficiently long in use and has been subjected to critical tests in all parts of the world, with practical uniformity in the reports of its benefit. It is claimed to be almost a specific when given sufficiently early and in proper dose. It is applicable to all forms of the disease and at all stages, though as has been clearly proven, the earlier it is given the better the result. The immunization of those exposed, by the use of the same remedy in smaller dose, is beyond question a fact, and it is now generally so used. The investigation into the use of organic fluids has yielded good results in many instances, notably the use of the thyroid extract in myxedema. The study of diseases of the heart and kidneys and the resulting more accurate differential diagnosis, together with more rational methods of treatment, has added years

to the lives of those so afflicted, and in many cases years of comfort to themselves and benefit to the world.

The whole subject of dyspepsia so-called has been critically studied with the result that we no longer try by various combinations of pepsin, pancreatin, hydrochloric acid and other digestive agents, experimentally to remedy the deficiencies of digestion. But by stomach washing and the feeding of test meals, afterward examined, we try to determine accurately just what the fault may be. These methods have resulted in an accuracy of diagnosis and treatment gratifying alike to patient and physician. The advance in this line is one of the most important, for there is no class of diseases more common, and none that while not rapidly fatal, renders the subject more miserable or more trying to his friends.

During the past few years a great amount of study has been devoted to the blood, its changes in composition, in disease, and valuable aids in diagnosis have resulted from this line of investigation; the most striking examples are the accuracy of diagnosis in malarial diseases by the discovery of the plasmodium malaria, the presence or absence of which makes the diagnosis absolute, thus making it possible for us to know at once the disease we have to treat, instead of, as not infrequently happens, the treating of a typhoid case for the first week with large doses of quinine, under the impression that it was a case of malaria. The positive diagnosis obtained between typhoid fever and suppurative appendicitis by the presence or absence of leucocytosis.

The investigations of the neurologist have been productive of much good in the advancement of that specialty, the improvement in the treatment of the insane, the discovery of nervous prostration and the rest cure for its alleviation and the localization of brain tumors which furnish a guide to the surgeon for operation; thus according to H. C. Wood affording early post mortems in cases which might otherwise have drifted away from medical watching. But while a great advance has been made in the investigation of the causes of infectious diseases. little or no advance has been made in the elucidation of the causes of those diseases primarily originating in the nerve centers. The stereotyped treatment of all forms of nervous diseases as practiced for the past twenty years by means of electrical appliances of imposing dimensions, is being recognized by the profession as vastly overestimated in its curative qualities. The field of neurology is as yet a comparatively unexplored one, and much more must be known of the physiology of the nervous system before we can attempt to define its pathology. The serum test of Widal was till recently supposed to be accurate in 95 to 98 per cent. of cases, and is still

so claimed by many, and among them those who have had most experience in its use, but there are reports of the discovery of the reaction in other diseases than typhoid or in those that have had the disease within a few years. The test is being so generally used by experimenters throughout the world that in a short time its limitations will be definitely settled; in any case its value as a diagnostic aid in conjunction with clinical symptoms is assured in this disease which is so difficult of diagnosis in its incipiency, and it is sincerely hoped that the early claims for its accuracy may be confirmed.

There have been great improvements in the preparation and character of remedies and the manner of their administration. Medicines have been given more for their definite physiological effect, which has resulted in the administering of single remedies in place of the complex prescriptions formerly employed. It is rare to see a prescription of more than two active ingredients, and four and six were not an uncommon number. The use of the alkaloids in place of crude drugs, infusions and decoctions has been made possible by the advance in chemistry and pharmacy. This has caused a marked improvement in the palatability of the medicines and much attention has been given to this feature. We do not believe that the efficacy of a dose is increased by its nauseous taste, but that where possible, medicines should be made palatable. The introduction of the tablet triturates has furnished us with a convenient method of dispensing our own medicines in accurate dosage, and has been an efficient weapon against our friends the homœopathists. The administration of small and frequently repeated doses has largely superseded the large dose at longer intervals. It would be impossible to enumerate the new remedies brought forward by investigators, but more often by enterprising manufacturing pharmacists, all offered with high claims of merit and certificates of hospitals and clinicians, many of them soon forgotten even by name, but others proving of real merit and gaining for themselves a permanent place in our materia medica. The coal tar derivatives are among the latter and are among the most useful and generally used in our armamentarium. Formaldehyde bids fair to obtain the first rank as an antiseptic and disinfectant, from its harmless character and germicidal properties, displacing a long list of remedies none of which have stood the test of time.

Perhaps the greatest advance has been in the line of prophylactic medicine-the antiseptic treatment in surgery, the prevention of infection in wounds and after operations; the recognition of the cause and contagious character of erysipelas, puerperal fever, hospital gangrene, the plague, yellow fever and other diseases, has led to a system of quarantine and disinfection, the

establishing of boards of health and the increased power given to them. The education of the people by the public press and the precept of the physician as to the character of diseases and the necessity of reporting those of an infectious natur to the proper authorities, all have been decided advances. When we have a medical representative in the cabinet, as surely we shall have if the earnest efforts of the physicians of the whole country can avail, then we may expect far greater improvements in this direction, with all boards of health governed by uniform laws and under the supervision of one responsible head. This is not too much to expect in view of the great advance made in public hygiene in the past ten years. With the increasing discoveries as to the cause of disease, made by bacteriologists, and the increase of the efficacy of the means for the prevention of disease, the time may come when the greater part of the physician's efforts shall be devoted to these aims instead of endeavoring to cure disease as at present. If this should come about it may be found that the Chinaman is not so far wrong in agreeing to pay his physician only while he is well and that all remuneration shall cease as soon as he becomes ill. Preventive medicine shows most clearly the disinterested character of the physician's work. The fact of the united effort of the physicians of the country, opposed by the people to be benefited, to have laws enacted that militate directly against their own financial interests, can not be parallel in any other profession or calling.

ERYSIPELAS.*

By L. H. Munger, M. D.
Winona, Minn.

Erysipelas has been called the rose, wildfire, St. Anthony's fire, and more recently, infective capillary lymphangitis.

It was known as a disease, described in their writings, and treated in their practice, by our ancient brethren.

Hippocrates relates that cases occurred during a certain cold spring, which involved the throat, which were malignant in type, and generally fatal. He also recounts cases complicating injuries, which, if neglected, or in old or debilitated people, were prone to result in extensive inflammation, often in abscess, or in a slough involving muscle, tendon and bone. He particularized that the discharge was more of a sanious, ichorous result of putrefaction, than

*Read before the Southern Minnesota Medical Association, August 5, 1897.

real pus; that when the scalp was affected, the hair would fall out; that sometimes the slough would be so extensive that part of the skull would exfoliate, or an entire arm fall off, or part or all of a lower extremity be denuded of flesh; but that of all cases the most serious were those involving the pubes and genital organs.

Celsus describes the disease, and says it is very dangerous when it affects the neck and head; also that it may complicate a wound, or may occur idiopthically.

From the time of Galen, much speculation as to the real nature of the disease was indulged in, and it was pretty well agreed that it came from a bilious humor, which, in escaping through the skin, occasioned the phenomena of erysipelas.

Under all their theorizing we can discover the prevalent idea that the disease is not merely a local affliction.

In accordance with the bilious humor theory, they prescribed in the beginning of an attack emetics and cholagogue cathartics.

Topically they used cooling (i. e. narcotic) herbs, vinegar, clay, lead preparations, verdigris, sulphur, alum, etc. And if these failed, and the And if these failed, and the affected part became livid, they made incisions in the skin, and put on poultices and hot fomentations.

When the disease seemed to them to involve the brain, some favored venesection from the ranine arteries, and cooling applications to the scalp.

Certain conditions favor the development of erysipelas, such as cold, damp weather. Cold alone can scarcely be considered a predisposing cause, unless it be cold wind. Some cachexias seem to act as predisposing factors, presumably by lessening the normal resistance of the body to the specific cause. Bright's disease is said by some to be a predisposing cause.

On the other hand, the body seems sometimes to acquire a tolerance of the specific poison, as shown in those instances recorded of persons being attacked with erysipelas immediately on moving into an infected house, while those who preceded them as tenants had lived indefinite periods in the midst of the infection without harm.

In all times a certain specific cause or poison has been deemed the only satisfactory origin of this disease. But it is only very recently that it has been demonstrated that one particular microscopic form of vegetation is the only cause of erysipelas.

Bacteria were discovered over 200 years ago, and were found in this and other diseases, but as late as 1881 Dr. Stille wrote: "Even if it were true, which it is not, that one and the same bacterium is uniformly found in connection with the same disease, the manner in which it occa

sions the specific phenomena of that disease would thereby become no clearer."

After a series of twenty-five experiments in 1879, Tillmanns concluded that the presence of bacteria either in the secretions, or in the tissues, is not constant in erysipelas.

About the same time Orth stated among the conclusions to which his elaborate experiments had led him, that "bacteria stand intimately related to the septic cause of erysipelas, but are only an indirect cause of the disease, and it is probable that in different forms of the disease different microorganisms occur, but thus far no proof of this proposition exists."

Koch published the doctrine in 1880, that "the distinctive microorganism of erysipelas is a bacillus."

But after careful consideration of all known facts, and also the theories deduced, it was allowed to be an unsolved question whether the hypothetical specific contagium acted primarily on the tissues where it entered the body, or on the general circulatory and nervous systems. Also whether the said hypothetical specific contagium entered the system through some lesion of integument or of mucous membrane, or through the normal respiratory mucous membrane, as do the viruses of smallpox, measles and scarlatina.

Since that time it has been demonstrated to a certainty that the specific cause of erysipelas is the streptococcus erysipelatis, which very closely resembles the streptococcus pyogenes.

In fact, for a time they were thought to be identical, but there are slight differences in size and in their manner of grouping, and further, inoculation with streptococcus erysipelatis will cause erysipelas, but not suppuration. And on the other hand, inoculation with the streptococcus pyogenes will always cause suppuration but not erysipelas.

The usual prominent lesion is an exudative inflammation of the skin, sometimes confined to the derma, and sometimes extending to the subcutaneous connective tissue. The exudate contains a large number of white corpuscles, which are said, at least in some cases, to be increased in proportionate number according to the rise in temperature. In severe cases the red corpuscles run together, adhering in masses instead of in rolls. The lymphatic vessels and glands, and sometimes the veins are inflamed. Occasionally the blood coagulates in the veins, forming a thrombus. The coagulum may be washed on and become an embolus, and thus determine a slough. Such accidents are most frequent among those of impaired constitution.

The microorganism which is the cause of the disease, the streptococcus erysipelatis is found mostly in the capillary lymphatics of the skin, probably but very seldom in the capillary bloodvessels. They are abundant in the spreading

edge of erysipelas, but are few in the centre where the inflammation has subsided.

It is probable that the microorganisms gain access always by means of a lesion of the cutaneous or mucous surface. The lesion may be minute, and by the time the disease is manifest, it may not be demonstrable, even if it was at first.

It has long been believed that there was a close relationship between erysipelas and puerperal fever. It is now demonstrated that they are etiologically identical.

was

It is considered dangerous for a person in attendance on erysipelas to attend cases of labor. The contagiousness of this disease thoroughly proven and generally recognized long before the nature of the cause was discovered. It has been conveyed by humanized vacine virus, and has been conveyed long distances by fomites. This is too familiar to bear enlarging upon. The stage of incubation varies from two to seven days. It is ushered in by a chill, fever, often nausea, sometimes vomiting, and a rapid pulse. The temperature usually soon rises to from 103° to 105° F., and I have seen it mount to 1061° in the first 24 hours.

At the site of invasion there soon appears redness, swelling and an itching or burning sensation. The parts acquire a doughy feel. The part affected is quite clearly defined, but its margin is often irregular. Frequently blebs form during the height of the inflammation, which may become quite large. After the inflammation subsides, the cuticle desquamates. The temperature is irregular in course. Each extension of the inflammation causes new rise of temperature. There are frequent remissions, but seldom an intermission until the dermatitis has subsided. The full strong initial pulse is apt to become weak as the case progresses. The tongue is coated. Lymphatic tenderness and swelling may precede the evident skin inflammation by several hours or even days. In the idiopathic cases, the most common place of beginning of the skin inflammation is at the root of the nose, then next in frequency on the cheek and on an ear. The more vascular the part affected the greater will be the degree of swelling, as when. it affects the face or the genitals.

Its extension is very often not constant and continuous, but intermittent. Erysipelas quite

frequently attacks the lower limbs of old people who have varices. In its extension from the initial point, it is usually from face toward scalp, or from extremity toward trunk. It has been noted as a curious fact that erysipelas rarely involves the chin.

The fever commonly leaves by crisis. With the dissipation of the swelling, the skin desquamates in large flakes. The new skin has a very red color which is slow in fading away.

The so-called phlegmonous erysipelas affects both the skin and the connective tissue beneath it, and is more or less diffuse in character. The phenomena differ owing to change of place and surroundings. The sthenic form is generally limited in extent. The asthenic form more diffused.

In the sthenic cases the lymphatic system is able to establish a barrier to the spread of the infection, while in the asthenic type the infection is widely disseminated. Consequently we often see small sloughs form in the sthenic form, and in the asthenic much more extensive gangrene or diffused suppuration. It is probably true that a purely erysipelatous infection causes sloughing and gangrene, but that when suppuration occurs, there is a mixed infection. Sooner or later if no incision is made, the skin is eroded, and thin foetid pus and shreds of dead connective tissue are discharged, so that the skin is undermined, muscles burroughed out extensively, and large cavities formed. With this local course there will be high fever, delirium, and the usual symtoms of sepsis, hectic, sweats, wasting, diarrhoea, and sometimes metastatic abscesses.

In less active cases of this type of erysipelas, there may be only smooth, shiny swelling, not so red, more dull brown, and on incision there exudes only bloody serum.

Old and feeble patients, and those of broken constitution, as from intemperance, and cachectic, scrofulous and syphilitic children, are more liable than others to the gangrenous form of disease. When gangrene is imminent, the skin of the affected part assumes a dusky red color, which pressure does not dissipate. The heat and pain become less severe. The swelling is circumscribed and doughy. Vesicles form and break, leaving a denuded spot which exudes an offensive, watery fluid, and the part dies.

In other cases of high fever and other grave symptoms there appear from the fifth to the tenth day, or even later, one or more dark spots in the affected area, which are cold, moist and insensible. The cuticle separates with or without vesicles having formed. The fever increases in intensity, strength fails, tongue dries, and the patient sinks and dies. Of these forms, one depends more especially upon the lack of resisting power in the affected tissues, the other upon the relative intensity of the infective inflammation.

When malaria prevails erysipelas is sometimes complicated with a bilious vomiting, pain and tenderness of stomach, constipation or bilious diarrhoea, scanty yellow urine and jaundice.

Other cases are called metastatic, from the fact that the inflammation subsides in one place and appears in some other part of the body.

In new born children it is commonly fatal. Usually the infection takes place at the umbiliThe inflammation first appears either at

cus.

the umbilicus or on the pubes, and spreads both up and down.

Erysipelas of the peritoneum runs a rapid course. The vital powers are overwhelmed; collapse and death usually speedily follow.

The diagnosis may at times be made before the eruption appears, on the evidence of the swelling and tenderness of the lymphatic glands of the part, especially if there is any known prob

able source of infection.

The eruption is a uniform pink or rose color. In the throat it may be of a dusky hue. With the advent of the eruption the skin rapidly swells and there is a sense of burning. There is a marked ridge at the edge of the inflamed area. The temperature quickly rises quite high. It is distinguished from simple lymphangitis by the redness being uniform and not in streaks corresponding to the lymph vessels. From erythema, which is more superficial, less elevated, and not so distinctly limited.

The common idiopathic form is rarely fatal. The epidemic and puerperal varieties most generally fatal. There are cases of all intermediate degrees of severity and fatality.

The subject of prophylaxis is very important, yet I shall say but little on that head. As a proper measure of precaution, persons having to handle a case of erysipelas should refrain from attending cases of obstetrics, or from ordinary surgical operations, until they can cleanse themselves from all infection.

Each case of erysipelas should be isolated, and cared for in a well ventilated apartment, and cleanliness, surgical cleanliness, be observed in the care of the case.

Hippocrates used cold water as a local dressing, if there was no ulceration.

Paul of Egina used blood-letting (if the strength of the patient would permit), cholagogue medicines, ointments and cooling lotions. Also in some cases emollient poultices, with or without anodynes, and later, astringent lotions. He recommended incisions when mortification threatened to occur. In the chronic stage, which is observed in some cases, he used hot and salt water.

There was quite a general agreement of opinion in those times against general or routine depletion by blood-letting, but in favor of cholagogue cathartics

As one follows the history of the treatment of erysipelas it is found to be founded on the rational indications as they were then interpreted. We endeavor to work on the same general principles today.

Some cases need only local protectives and palliatives. In some depletion may be tolerated or really indicated, and in a middle and much. larger class of cases, a general supporting and tonic treatment is necessary. Again, a certain

portion of cases need really only to be let alone. Others are almost necessarily fatal. A middle class is open for the judgment and skill of the physician to show its benefit. Ordinarily, having isolated the case in a well ventilated room, secure from drafts of air and dampness, having such persons only as are needed in attendance, the inflamed part should be protected from strong light and from the air. Of local applications for protection, cooling and palliative effect, there are many in use, all more or less useful in the estimation of different practitioners. The part may be dusted with lycopodium, starch, flour, zinc oxide, etc., and then covered with a layer of cotton. Vaseline alone, or as the base with various medicaments, may be used, as zinc oxide, lead preparations, belladonna, etc. The white of egg, with or without alum, has been used. Mucilages and mucilaginous poultices have been used, but do more harm than good.

The weight of testimony has always been against blood-letting as routine treatment. At present it is seldom, if ever, used.

Dr. Stilè says that "apart from the surgical treatment of phlegmonous erysipelas, local applications have not the slightest influence upon the course or issue of the disease beyond that which they exert as protectives and palliatives." He goes on to say that as palliatives, various astringent and stimulant applications are useful by protecting the inflamed part from the irritation of the air, by repressing vascular action, or overcoming stagnation. Of the astringent applications he mentions lime water liniment, alum, cream, lead, zinc, iron in solution or powder. In other cases collodion, solutions of gutta percha, and of sodium salicylate. Bandages have been found to be dangerous, as they are so liable to cause ulceration and gangrene. As stimulants he mentions blisters applied over the entire inflamed part, or on the sound skin in a ring around the infected spot, to prevent the spread of the inflammation.

Nitrate of silver has been used instead of the blister. Iodine, of which the compound tincture is painted on the affected skin. Turpentine liniment has been thought by some to have a specific virtue in being destructive to the virus. of the disease. A great many remedies might be yet mentioned, all of which have been used and thought to be of value, as applications, such as calcium iodide, camphor, mercurial ointments, bromine solution, etc., etc.

I have before mentioned the use of cathartics and emetics. These were and are good remedies to begin with in many cases, especially the cathartics, removing putrescible material from the alimentary canal, and quickening the emuctories. In the typhoid state to which many cases tend, alcoholics, turpentine and carbonate of ammonia are of use, as in the same