History

Antiquity Through the Eighteenth Century

Early accounts of erysipelas are often confusing because they lumped purulent and gangrenous afflictions under this rubric. Thus Hippocrates distinguished between "traumatic" erysipelas, which accompanied wounds, and a myriad of other skin lesions that had no known external cause. Galen in turn distinguished between "phlegmon," including suppurative ulcers and gangrene, and nonnecrotic cellulitis — but viewed both as forms of erysipelas. Celsus, in the first century A.D., considered septic ulcers, "canker," erythematous wound infections, and Ignes Sacer to all be types of erysipelas.

Such confusion has continued into the modern period, with some historians interpreting epidemics of Ignes Sacer (sacred fire) or Saint Anthony's fire as ergotism, whereas others have viewed these scourges as recurrent erysipelas. Before the modern period, however, physicians tended to embrace the distinc tions made by Galen, and consequently included a wide variety of ailments including diseases of the uterus and lungs among the varieties of erysipelas.

Nineteenth Century

During the nineteenth century, physicians began giving greater attention to the causes and prevalence of erysipelas because, on the one hand, the disease seemed connected to wound infection, and, on the other hand, because epidemics of erysipelas were occurring simultaneously with peak years of puerperal sepsis, or "childbed fever." Their investigations eventually led to the discovery of streptococci and the distinctions that have provided us with our current definitions of erysipelas.

In 1795 Alexander Gordon of Aberdeen became the first clinician formally to associate erysipelas with puerperal fever (Loudon 1987). Then around the middle of the nineteenth century, two seminal studies appeared. In 1842, Oliver Wendell Holmes published an essay on the contagiousness of puerperal fever, and in 1861 Philip Ignaz Semmelweis published his classic study of The Etiology, Concept, and Prophylaxis of Childbed Fever. Both men blamed physicians for carrying infective particles to the bedsides of parturient women. Holmes stated specifically that puerperal sepsis could be caused "by an infection originating in the matter or effluvia of erysipelas" (Carter ed. 1983). The great French clinician Armand Trousseau, writing during this same period, regarded even trivial skin injuries as precursors to erysipelas.

In 1882 following the discovery of streptococci, Frie-drich Fehleisen published a study of the etiology of erysipelas, which he associated with S. pyogenes. In addition, he reported using his cultures on human subjects, justifying the production of iatrogenic infection as a means of combatting some forms of cancer -a procedure in vogue in Germany at the time. In follow-up studies, another German surgeon, Frie-drich Julius Rosenbach, described the ability of the erysipelas-causing streptococci to spread through host tissues without causing suppuration. This research was of paramount interest to surgeons concerned with controlling the omnipresent infections -occasionally called "hospitalism" - that killed survivors of otherwise "successful" operations.

Twentieth Century

Although the use of aseptic and antiseptic techniques led to dramatic reductions in postsurgical mortality rates, maternal mortality still remained high. During the 1920s and 1930s, the research of Leonard and

Dora Cook and others permitted the identification and typing of strains of streptococci. This, in turn, led to irrefutable evidence that puerperal fever was an exogenous infection, usually transmitted from a physician, midwife, or nurse attending a parturient woman (Loudon 1987). Yet even family and friends could communicate the streptococci that caused puerperal sepsis in women in labor, for these were the same streptococci that caused erysipelas. Consequently, maternal mortality from puerperal fever declined only some time after effective antibiotics became available. Indeed, Irvine Loudon (1987) has shown that despite well-known changes in the virulence of streptococcal organisms historically, no sudden and spontaneous decline in the virulence of the organism can account for the abrupt decline in mortality from erysipelas, scarlet fever, and puerperal fever. Instead, credit for moderating these ancient scourges belongs to the beginning of the antibiotic era and, in particular, to the use of sulfonamides.

Ann G. Carmichael

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