Ways to Die: Erysipelas

Erysipelas:

A skin infection, typically caused by an acute streptococcal infection (typically Streptococcus pyogenes), characterized by hot skin, fever, infected dermis and lymphatics, and when the infection reaches deeper tissues, can lead to serious complications. Erysipelas can often lead to dissection of the dermis from the epidermis. Basically the skin gets removed from its base and forms a bubble. Erysipelas can also be present at the onset of gangrene.

The skin also takes on a peau-de-orange appearance where the infection has spread - it looks like the skin of an orange peel in texture.

[Illustration from A Manual of Pathology. Joseph Coats & Lewis K. Sutherland, 1900.]

In our age of antibiotics and prophylactics and cleanliness, it's very rare that erysipelas leads to severe complications, but it was a very dangerous condition to acquire in centuries past.

History of the term:

Erysipelas was originally used to refer both to the more superficial streptococcal skin infection, but more often was used to refer to classic cellulitis (a deeper and often more serious skin infection). The classic "butterfly rash" over the nose and cheeks wasn't used as a defining characteristic of the condition until around the turn of the 19th century, when classic cellulitis was beginning to be recognized as something different. However, only ~20% of erysipelas cases have the facial rash. Most are a fiery red and painful plaque on the limbs or torso.

As erysipelas can often occur as a secondary characteristic of a pre-existing disease (such as laryngitis or puerperal sepsis), it was often seen as a signal of a poor prognosis, since the infection had spread all the way to the skin. 

These days erysipelas more often occurs when the streptococcus bacteria enters the skin through a cut or trauma, or through a condition such as eczema.

Case Study:

[All info courtesy of The Burns Archive]

J.B. Shadle Co C 87 PA Wounded at Petersburg, April 2, 1865 Gun shot wound, right thumb, amputation. Hand/arm has erysipelas. Discharged June 1, 1865.

Shadle, aged 43, admitted to Harewood Hospital, April 12, 1865. Suffering from amputation of right thumb at metacarpal joint (bilateral flaps) result of GSW. Operation performed on field. The patient soon after admission, attacked with (phlegmonous) erysipelas. Large abscesses had formed in forearm, extending towards elbow joint, with great tumefaction of parts, but by deep and free incision and liberal internal use of ferric chloride and a nourishing supporting diet, the parts assumed a healthier appearance. Patient improving rapidly, parts entirely healed when patient was discharged.

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Also notable: when physicians of centuries past referred to "Saint Anthony's Fire", this was one of the three conditions that they could have been referring to. The other two are the classic cellulitis manifestation and shingles.

A manuscript by Dr. Cornelius Osborn (1722-1782), describing cures for the various forms of St. Anthony's fire.

Complications:

Erysipelsas can lead to such hideously bad outcomes as -

Though these complications are incredibly uncommon these days, even in developing countries, fatal complications were present in almost 30% of erysipelasas infections before antibiotics and preemptive vaccination. Often the fatal complications occurred after years of re-infection and apparent clearing of the disease.

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[100 years of erysipelas prophylaxis: significance and reduction of animal experiments] (Article in German). K Cussler, E Balks. Altex 2001; 18(1): 29-33.

Erysipelas in Emergency Medicine. Geofrey Nochimson, MD; Chief Editor: Rick Kulkarni, MD, 2011.

Early 20th-century ventilation testing device. It worked much the same as modern tank-type spirometers do today. In TB, asthma, bronchitis, emphysema, and other situations affecting lung function, ventilation testing can both help patients improve the function of their lungs, and let doctors know where a patient is at in terms of overall well-being.

While many aspects of inspiration and respiration were known and studied in the early 1900s, the most common lung test these days, peak expiratory flow (which measures the airflow through the bronchi and is especially important in asthma), was not on the scene until 1959.

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When Charles Schulz had a heart attack in 1982, his doctors realized that his poor lung function following his quadruple bypass would greatly prolong his recovery, and presented him with an incentive spirometer. When patients are recovering from rib damage (as in many people who have undergone CPR) or heart surgery that requires extended bed rest, use of an incentive spirometer reduces the chances of deadly fluid buildup in the lungs. Every day, patients breathe in through the device as slowly and deeply as possible, and balls or plungers inside the spirometer indicate lung function, by indicating sustained inhalation vacuum.

While hospitalized, a nurse put a black paint marker at Schulz' bedside. She didn't say much, except that if he could draw something on the wall before he left (this was after Schulz was off of bed rest, but not ready to leave), it would greatly cheer future patients who are going through the same things that he is. Though Schulz never before or after did "requests" using his Peanuts characters, the day before he left, he decided to draw a few quick panels on the wall (despite his hand tremors that developed after the quadruple bypass). 

The panels were of Snoopy in the hospital, with an incentive spirometer. He tries and tries to get the three balls to where they have to be, over and over, and when he finally does, he collapses with exhaustion. Schulz commented that the frustration and agony at getting the spirometer balls in place was what impressed upon him the most at the hospital. It wasn't an "upbeat" strip, it wasn't a "happy" strip, but it was one that showed that even Snoopy, the Red Baron, had a hard time with what they were going through. He could commiserate. And in the end, he could do it...but he knew how hard it was.

Try as I might, I can't find a photograph of that strip he drew. The story of it comes from the official 50th Anniversary Peanuts collection.

1844 hand-tinted photograph of a dentist. This is thought to be the earliest extant studio photograph of a medical professional. From the Burns Archive

Photograph of an emergency lung ambulance from 1937. From the Burns Archive.

Close-up of iridectomy, from the first book about eye surgery to use photographs demonstrating procedures. 1870.

Iridectomy was one of the first eye surgeries that actually helped (at least after aseptic technique was used). Iridectomies were used in removing cataracts, and later were used to treat closed-angle (acute) glaucoma by relieving dangerously high intraocular pressure.

One of three active bloodletting photographs known to exist, in the Burns Archive. I love the tinting of the blood on this.

Bloodletting has been used medicinally for over 3000 years.

Lupus vulgaris with corneal leucoma, from 1860s