The Surgical Treatment of Erysipelas in Children. BY A. SEIBERT, M. D., PROFESSOR OF DISEASES OF CHILDREN, NEW YORK POLYCLINIC, AND PHYSICIAN TO THE CHILDREN'S DEPARTMENT OF THE GERMAN DISPENSARY. REPRINTED FROM Cie Nelli ¥ortt JWeWcal journal for October 7P, 1889. Reprinted from, the Rew York Medical Journal for October 19, 1889. THE SURGICAL TREATMENT OF ERYSIPELAS IN CHILDREN. By A. SEIBERT, M. D., PROFESSOR OF DISEASES OF CHILDREN, NEW YORK POLYCLINIC, AND PHYSICIAN TO THE CHILDREN'S DEPARTMENT OF THE GERMAN DISPENSARY. To open the inflamed skin in erysipelas by means of numerous small incisions made all over the diseased surface, and deep enough to draw blood, has been practiced for some time, and not without success, provided antiseptic lotions (five-per-cent, solutions of carbolic acid, or sublimate, 1 to 2,000) were frequently poured on the dressing. Hypoder- matic injections of a two-per-cent, solution of carbolic acid into the healthy skin surrounding the inflamed part have also been in use with varying success. The object in both methods was to bring Fehleisen's coccus of erysipelas, wan- dering in and along the lymphatics, in direct contact with germicidal fluids. The idea was correct, but its execution deficient in both methods. The incisions in the inflamed cutis closed up too rapidly to admit sufficient antiseptic fluid into its lower layers, and the fluid, brought into the healthy skin bordering on the erysipelas by the hypoder- matic needle, found its way too rapidly into the circulation, thus doing no good locally, but often harm constitutionally. Kraske's method was the first step in the right direction. 2 THE SURGICAL TREATMENT OF He made regular incisions on the border of the erysipelas, extending into the healthy skin, and, by crossing these diagonally with others, the incised surface (diseased and healthy) presented an appearance not unlike a rail fence. The object here was to give a good chance to the cocci to get to the surface, and the antiseptic fluid to get to the cocci in the lower layers of the skin, at the same time dis- infecting the healthy ground most likely to be invaded next by these germs. To this end the dressing was constantly moistened for the next few days. The results of this method were excellent. Riedel and Lauenstein (" Deutsch, med. Woch.," March 14, 1889) proposed to improve Kraske's method by locat- ing this fence of incisions entirely in the healthy tissue, about one or two inches away from the border of the ery- sipelas. This was to avoid possible infection of yet aseptic tissue, and this modification has given better results than any other method as yet practiced. The patients were usu- ally put under an anaesthetic and the whole operation was performed strictly according to the rules of antiseptic sur- gery. In three cases of genuine erysipelas in children I have been able to employ this method, and in each case with such success that I may be pardoned for relating them in detail: Girl, five years old, in private practice. Child had an erup- tion (varicella); had scratched its legs, causing open sores, and in one of these on the left calf erysipelatous inflammation was set up, beginning with a severe chil] ami nausea, continuing with high temperature (104° to 105° F.) and other signs of severe ill- ness, and spreading rapidly downward and upward. 1 saw the child eighteen hours after the chill, and, recognizing it- cause immediately, proposed the Kiedel-Kraske method. This was flatly refused, because of the anesthetic. Next day I brought a new vaccination lancet with me, and proposed to make the bloody ERYSIPELAS LN CHILDREN. 3 fence with the little harrow attached to it and without the anaesthetic. This was consented to. The erysipelas had mean- while spread upward to about an inch above the knee and down- ward to the ankle joint. I decided to make a fence only around the thigh. After carefally cleansing the whole thigh with soap, water, ether, and a five-per-cent, solution of carbolic acid, and covering the en sipelatons region with a carbolized towel, I firm- ly grasped the leg, and with long strokes of the harrow managed to open the skin around the thigh to the width of about an inch, and about an inch and a half away from the erysipelas. The longitudinal scratches (which were all deep enough to draw blood) were carefully but quickly crossed diagonally with mani- fold strokes of the harrow, so as to be sure that all of the surface operated upon was opened. A solution of corrosive sublimate (1 to 2,000) was then rubbed into the wound, and a layer of ab- sorbent cott> n applied and fastened with gauze bandages. This dressing was moistened freely with the same solution every fif- teen minutes. whole operation lasted no more than two minutes. The child's temperature at the time was 105° F., it had vomited all food for two days, and had been awake and delirious most of the previous night. The "fence " was made at 11 p. m. I. did not see the child until the next day, when I found it sitting up in bed smiling, with a temperature of 100 5° in the rectum, due to the erysipelatous infiltration remaining in the limb be- low the "fence." The erysipelas had evidently reached the wounded ring, for on the lower border of the dressing the skin disappeared under it in a red and swollen condition, with a num- ber or blisters spread over it, while on the other side it was as white and cool as could be, and it remained so untd seven days later, when I removed the dressing. The temperature never rose again, the appetite returned, the child had slept well, and the subsiding of the severe symptoms had set in about six hours after the little operation. But I found another patient on that day also sick with the same complaint. The younger sister of the first patient, a very nervous, somewhat anaemic child three years and a half of age, had been attacked the evening before with erysipelas of the 4 IRYSIPELAS IN CHILDREN. right leg, beginning also at a scratch. As the parents con- sented immediately to the treatment, I was able to make the bloody ring just below the knee, and to thus stay the advance of the erysipelas in that direction. The temperature cf the child fell from 104"5° to 101° F. within four hours, the erysipe- las traveled down to the toe-nails, but never crossed our fence, the child meanwhile feeling perfectly well. The third case was that of a baby but thirteen months old. 1 first saw the child at the children's department of the German Dispensary, on September 10th, when it was brought there for a severe attack of cholera infantum. As it was collapsed, I washed out its stomach. This had the effect of checking the vomiting and of virtually curing the case. But two dajs later erysipelas began just above the knee, showing great tendency to spread rap- idly upward, thus threatening the child's life. I resolved to oper- ate the next day in spite of the child's weak condition. When 1 did make the fence the child's condition appeared almost hope- less, the temperature registering 105-5° F., and the strength of the baby being almost exhausted. As the inflammation had spread anteriorly nearly to Poupart's ligament, I had to make the ring just below it, coming up from behind half way over the buttock. The mother being a Bohemian and quite unable to understand me, I had to make myself intelligible more by signs than by words, and yet our combined efforts resulted in a complete suc- cess, for the next day the baby's temperature was normal and the child made a speedy recovery. I had the satisfaction of being enabled to present the three children to my class at the New York Polyclinic, and there removed the dressings for the first time, showing ex- actly the line of demarkation and its remarkable action. I am positive that this method will check and'cure every case of erysipelas if employed in time. My three cases demon- strate that my modification of operating with the vaccina- tion-harrow and without an anaesthetic can be easily made use of in children, its advantage being that parents will more readily consent to this treatment. 122 East Seventeenth Street. ft REASONS WHY Physicians Should Subscribe The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,i Published by D. APPLETON & CO, 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE: Its contributors are among the most learned medical men of this country. 4. BECAUSE: Its " Original Articles " are the results of scientific observation and research, and are of infinite practical value to the general practitioner. 5. 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