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and the destruction of the expectoration. This to the lives of those so afflicted, and in many investigation soon led to the discovery of other cases years of comfort to themselves and benefit sources of infection. The examination of cattle to the world. showed that aside from tubercular patients The whole subject of dyspepsia so-called has themselves, this was one of the most dangerous been critically studied with the result that we no sources of infection, the poison being conveyed longer try by various combinations of pepsin, through the milk, butter and cheese. The pos- pancreatin, hydrochloric acid and other digestive sibility of infection from this cause is so clearly agents, experimentally to remedy the deficiencies proven that most civilized countries have taken of digestion. But by stomach washing and the steps to discover and destroy infected cattle. As feeding of test meals, afterward examined, we try to the treating of tuberculosis as other infectious to determine accurately just what the fault may diseases are treated, by quarantine, isolation, etc., be. These methods have resulted in an accuracy there is yet a difference of opinion, but it seems of diagnosis and treatment gratifying alike to that medical opinion is fast tending in that direc- patient and physician. The advance in this line tion as the only hope of successfully preventing is one of the most important, for there is no class the spread of the disease. Some form of modi- of diseases more common, and none that while fied isolation will doubtless be instituted that will not rapidly fatal, renders the subject more misnot prove too great a burden to friends and rela- erable or more trying to his friends. tives, and not a source of injustice to the patient During the past few years a great amount suffering from a disease so fatal and at the same of study has been devoted to the blood, its time of such a long duration. The tuberculin of changes in composition, in disease, and valuable Koch and its numerous modifications and im- aids in diagnosis have resulted from this line of provements by himself and others have not as yet investigation; the most striking examples are fulfilled the expectations of the medical world, the accuracy of diagnosis in malarial diseases but yet much good has been done and the inves- by the discovery of the plasmodium malariæ, the tigations are still being vigorously pushed by

presence or absence of which makes the diagnoscientific men throughout the world, and it is sis absolute, thus making it possible for us to not too much to expect that greater results will know at once the disease we have to treat, inbe attained in the near future.

stead of, as not infrequently happens, the treatFollowing the discovery by Koch, investiga- ing of a typhoid case for the first week with tions have been made as to the specific cause of large doses of quinine, under the impression that other infectious diseases, and in many of them it was a case of malaria. The positive diagnosis the cause has been found to be due to a specific obtained between typhoid fever and suppurative germ—diphtheria, malaria, anthrax, gonorrhea appendicitis by the presence or absence of leuand probably pneumonia. Also following the cocytosis. tuberculin brought forward by Koch for the cure The investigations of the neurologist have of tuberculosis, experiments have been made been productive of much good in the advancewith the inoculation of bacteria of different dis- ment of that specialty, the improvement in the eases, and a system of serum therapy evolved treatment of the insane, the discovery of nervous which in some diseases, notably diphtheria, has prostration and the rest cure for its alleviation proven of the greatest value in the treatment of and the localization of brain tumors which furthese diseases. There is now no question as to nish a guide to the surgeon for operation; thus the efficacy of the antitoxin treatment of diph- according to H. C. Wood affording early post theria, for it has been sufficiently long in use mortems in cases which might otherwise have and has been subjected to critical tests in all drifted away from medical watching. But while parts of the world, with practical uniformity in a great advance has been made in the investigathe reports of its benefit. It is claimed to be al- tion of the causes of infectious diseases. little most a specific when given sufficiently early and

or no advance has been made in the elucidation in proper dose. It is applicable to all forms of of the causes of those diseases primarily originatthe disease and at all stages, though as has been ing in the nerve centers. The stereotyped treatclearly proven, the earlier it is given the better ment of all forms of nervous diseases as practhe result. The immunization of those exposed, ticed for the past twenty vears by means of elecby the use of the same remedy in smaller dose, trical appliances of imposing dimensions, is beis beyond question a fact, and it is now generally ing recognized by the profession as vastly overso used. The investigation into the use of or- estimated in its curative qualities. The field of ganic fluids has yielded good results in many neurology is as yet a comparatively unexplored instances, notably the use of the thyroid extract one, and much more must be known of the in myxædema. The study of diseases of the physiology of the nervous system before we can heart and kidneys and the resulting more ac- attempt to define its pathology. The serum test curate differential diagnosis, together with more of Widal was till recently supposed to be acrational methods of treatment, has added years curate 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 homeopathists. 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.

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real pus; that when the scalp was affected, the sions the specific phenomena of that disease hair would fall out; that sometimes the slough would thereby become no clearer." would be so extensive that part of the skull After a series of twenty-five experiments in would exfoliate, or an entire arm fall off, or part 1879, Tillmanns concluded that the presence of or all of a lower extremity be denuded of flesh; bacteria either in the secretions, or in the tissues, but that of all cases the most serious were those is not constant in erysipelas. involving the pubes and genital organs.

About the same time Orth stated among the Celsus describes the disease, and says it is conclusions to which his elaborate experiments very dangerous when it affects the neck and had led him, that “bacteria stand intimately rehead; also that it may complicate a wound, or lated to the septic cause of erysipelas, but are may occur idiopthically.

only an indirect cause of the disease, and it is From the time of Galen, much speculation probable that in different forms of the disease as to the real nature of the disease was indulged

different microorganisms occur, but thus far no in, and it was pretty well agreed that it came proof of this proposition exists. from a bilious humor, which, in escaping

Koch published the doctrine in 1880, that through the skin, occasioned the phenomena of

"the distinctive microorganism of erysipelas is erysipelas.

a bacillus.” Under all their theorizing we can discover But after careful consideration of all known the prevalent idea that the disease is not merely

facts, and also the theories deduced, it was ala local affliction.

lowed to be an unsolved question whether the In accordance with the bilious humor theory, hypothetical specific contagium acted primarily they prescribed in the beginning of an attack on the tissues where it entered the body, or on emetics and cholagogue cathartics.

the general circulatory and nervous systems. Topically they used cooling (i. e. narcotic) Also whether the said hypothetical specific conherbs, vinegar, clay, lead preparations, verdigris, tagium entered the system through some lesion of

, sulphur, alum, etc. And if these failed, and the integument or of mucous membrane, or through affected part became livid, they made incisions the normal respiratory mucous membrane, as do in the skin, and put on poultices and hot fo- the viruses of smallpox, measles and scarlatina. mentations.

Since that time it has been demonstrated to When the disease seemed to them to involve a certainty that the specific cause of erysipelas the brain, some favored venesection from the is the streptococcus erysipelatis, which very ranine arteries, and cooling applications to the closely resembles the streptococcus pyogenes. scalp.

In fact, for a time they were thought to be Certain conditions favor the development of identical, but there are slight differences in size erysipelas, such as cold, damp weather. Cold and in their manner of grouping, and further, alone can scarcely be considered a predisposing inoculation with streptococcus erysipelatis will cause, unless it be cold wind. Some cachexias cause erysipelas, but not suppuration. And on seem to act as predisposing factors, presumably the other hand, inoculation with the streptococby lessening the normal resistance of the body cus pyogenes will always cause suppuration but to the specific cause. Bright's disease is said by not erysipelas. some to be a predisposing cause.

The usual prominent lesion is an exudative On the other hand, the body seems some- inflammation of the skin, sometimes confined to times to acquire a tolerance of the specific the derma, and sometimes extending to the subpoison, as shown in those instances recorded of cutaneous connective tissue. The exudate conpersons being attacked with erysipelas immedi- tains a large number of white corpuscles, which ately on moving into an infected house, while are said, at least in some cases, to be increased those who preceded them as tenants had lived in proportionate number according to the rise in indefinite periods in the midst of the infection temperature. In severe cases the red corpuswithout harm.

cles run together, adhering in masses instead of In all times a certain specific cause or poison in rolls. The lymphatic vessels and glands, and has been deemed the only satisfactory origin of sometimes the veins are inflamed. Occasionally this disease. But it is only very recently that it the blood coagulates in the veins, forming a has been demonstrated that one particular thrombus. The coagulum may be washed on microscopic form of vegetation is the only cause and become an embolus, and thus determine a of erysipelas.

slough. Such accidents are most frequent Bacteria were discovered over 200 years ago, among those of impaired constitution. and were found in this and other diseases, but as The microörganism which is the cause of the late as 1881 Dr. Stille wrote: “Even if it were disease, the streptococcus erysipelatis is found true, which it is not, that one and the same bac- mostly in the capillary lymphatics of the skin, terium is uniformly found in connection with probably but very seldom in the capillary bloodthe same disease, the manner in which it occa- vessels. They are abundant in the spreading

was

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.

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 fætid 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, diarrhea, 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 diarrhea, 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 umbili

The inflammation first appears either at

cus.

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the umbilicus or on the pubes, and spreads both portion of cases need really only to be let alone. up and down.

Others are almost necessarily fatal. A middle Erysipelas of the peritoneum runs a rapid class is open for the judgment and skill of the course. The vital powers are overwhelmed; physician to show its benefit. Ordinarily, havcollapse and death usually speedily follow. ing isolated the case in a well ventilated room,

The diagnosis may at times be made before secure from drafts of air and dampness, having the eruption appears, on the evidence of the such persons only as are needed in attendance, swelling and tenderness of the lymphatic glands the inflamed part should be protected from of the part, especially if there is any known prob- strong light and from the air. Of local applicaable source of infection.

tions for protection, cooling and palliative effect, The eruption is a uniform pink or rose color. there are many in use, all more or less useful in In the throat it may be of a dusky hue. With the estimation of different practitioners. The the advent of the eruption the skin rapidly swells part may be dusted with lycopodium, starch, and there is a sense of burning. There is a flour, zinc oxide, etc., and then covered with a marked ridge at the edge of the inflamed area. layer of cotton. Vaseline alone, or as the base The temperature quickly rises quite high. It is with various medicaments, may be used, as zinc distinguished from simple lymphangitis by the oxide, lead preparations, belladonna, etc. The redness being uniform and not in streaks corre- white of egg, with or without alum, has been sponding to the lymph vessels. From erythe- used. Mucilages and mucilaginous poultices ma, which is more superficial, less elevated, and have been used, but do more harm than good. not so distinctly limited.

The weight of testimony has always been The common idiopathic form is rarely fatal. against blood-letting as routine treatment. At The epidemic and puerperal varieties most gen- present it is seldom, if ever, used. erally fatal. There are cases of all intermediate Dr. Stilè says that "apart from the surgical degrees of severity and fatality.

treatment of phlegmonous erysipelas, local apThe subject of prophylaxis is very important, plications have not the slightest influence upon yet I shall say but little on that head. As a the course or issue of the disease beyond that proper measure of precaution, persons having which they exert as protectives and palliatives. to handle a case of erysipelas should refrain from He goes on to say that as palliatives, various attending cases of obstetrics, or from ordinary astringent and stimulant applications are useful surgical operations, until they can cleanse them- by protecting the inflamed part from the irritaselves from all infection.

tion of the air, by repressing vascular action, or Each case of erysipelas should be isolated, overcoming stagnation. Of the astringent apand cared for in a well ventilated apartment, and

plications he mentions lime water liniment, cleanliness, surgical cleanliness, be observed alum, cream, lead, zinc, iron in solution or powthe care of the case.

der. In other cases collodion, solutions of gutta

. Hippocrates used cold water as a local dress- percha, and of sodium salicylate. Bandages ing, if there was no ulceration.

have been found to be dangerous, as they are so Paul of Ægina used blood-letting (if the liable to cause ulceration and gangrene. As strength of the patient would permit), chola- stimulants he mentions blisters applied over the gogue medicines, ointments and cooling lotions. entire inflamed part, or on the sound skin in a Also in some cases emollient poultices, with or ring around the infected spot, to prevent the without anodynes, and later, astringent lotions. spread of the inflammation. He recommended incisions when mortification Nitrate of silver has been used instead of the threatened to occur.

In the chronic stage, blister. Iodine, of which the compound tincwhich is observed in some cases, he used hot and ture is painted on the affected skin. Turpentine salt water.

liniment has been thought by some to have a There was quite a general agreement of opin- specific virtue in being destructive to the virus ion in those times against general or routine de- of the disease. A great many remedies might pletion by blood-letting, but in favor of chola- be yet mentioned, all of which have been used gogue cathartics

and thought to be of value, as applications, such As one follows the history of the treatment as calcium iodide, camphor, mercurial ointof erysipelas it is found to be founded on the ments, bromine solution, etc., etc. rational indications as they were then inter- I have before mentioned the use of catharpreted. We endeavor to work on the same gen- tics and emetics. These were and are good eral principles today.

remedies to begin with in many cases, especially Some cases need only local protectives and the cathartics, removing putrescible material palliatives. In some depletion may be tolerated from the alimentary canal, and quickening the or really indicated, and in a middle and much emuctories. In the typhoid state to which larger class of cases, a general supporting and many cases tend, alcoholics, turpentine and cartonic treatment is necessary. Again, a certain bonate of ammonia are of use, as in the same

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