Erysipelas In The Medical Casebook

"Confidential report into an outbreak of 26 cases of erysipelas, in patients admitted for other reasons, resulting in 5 deaths.” [23]

 

This Week

We are continuing our look at rarer diseases which feature in the book, and having a look at erysipelas. This is quite an old-fashioned diagnosis, but I still occasionally use the term for specific skin infections.

 

News

The book is now published and is fully available, which is a very exciting moment for me as a first-time author.

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.

 

Erysipelas

Erysipelas + Sherlock

We continue the plot of “The Adventure Of The Illustrious Client” with our look at erysipelas. In our Leprosy chapter, we left Holmes and Watson, along with Kitty Winter, failing to convince Violet De Merville that her fiancée, Baron Gruner, is manipulating her.

Two days later, Watson is walking along the Strand when he sees a newspaper billboard announcing: “Murderous attack upon Sherlock Holmes”.

“We learn with regret that Mr. Sherlock Holmes, the well-known private detective, was the victim this morning of a murderous assault which has left him in a precarious position. There are no exact details to hand, but the event seems to have occurred about twelve o’clock in Regent Street, outside the Cafe Royal. The attack was made by two men armed with sticks, and Mr. Holmes was beaten about the head and body, receiving injuries which the doctors describe as most serious. He was carried to Charing Cross Hospital and afterwards insisted upon being taken to his rooms in Baker Street. The miscreants who attacked him appear to have been respectably dressed men, who escaped from the bystanders by passing through the Cafe Royal and out into Glasshouse Street behind it. No doubt they belonged to that criminal fraternity which has so often had occasion to bewail the activity and ingenuity of the injured man.”

To make Baron Gruner think he has won, Holmes decides to exaggerate the seriousness of his injuries, via an early example of fake news.

For six days the public were under the impression that Holmes was at the door of death. The bulletins were very grave and there were sinister paragraphs in the papers. My continual visits assured me that it was not so bad as that. His wiry constitution and his determined will were working wonders. He was recovering fast, and I had suspicions at times that he was really finding himself faster than he pretended even to me. There was a curious secretive streak in the man which led to many dramatic effects, but left even his closest friend guessing as to what his exact plans might be. He pushed to an extreme the axiom that the only safe plotter was he who plotted alone. I was nearer him than anyone else, and yet I was always conscious of the gap between.

On the seventh day the stitches were taken out, in spite of which there was a report of erysipelas in the evening papers.

Holmes hatches a rather desperate plot to use Watson to distract Gruner, whilst Holmes searches his study. Watson disguises himself as Dr Hill Barton, an expert on Ming dynasty pottery, and distracts the Baron just long enough for Holmes to steal his “lust diary”. Gruner gives chase.

Two steps took me to the open door, and my mind will ever carry a clear picture of the scene within. The window leading out to the garden was wide open. Beside it, looking like some terrible ghost, his head girt with bloody bandages, his face drawn and white, stood Sherlock Holmes. The next instant he was through the gap, and I heard the crash of his body among the laurel bushes outside. With a howl of rage the master of the house rushed after him to the open window.

And then! It was done in an instant, and yet I clearly saw it. An arm—a woman’s arm—shot out from among the leaves. At the same instant the Baron uttered a horrible cry—a yell which will always ring in my memory. He clapped his two hands to his face and rushed round the room, beating his head horribly against the walls. Then he fell upon the carpet, rolling and writhing, while scream after scream resounded through the house.

“Water! For God’s sake, water!” was his cry.

I seized a carafe from a side-table and rushed to his aid. At the same moment the butler and several footmen ran in from the hall. I remember that one of them fainted as I knelt by the injured man and turned that awful face to the light of the lamp. The vitriol was eating into it everywhere and dripping from the ears and the chin. One eye was already white and glazed. The other was red and inflamed. The features which I had admired a few minutes before were now like some beautiful painting over which the artist has passed a wet and foul sponge. They were blurred, discoloured, inhuman, terrible.

In a few words I explained exactly what had occurred, so far as the vitriol attack was concerned. Some had climbed through the window and others had rushed out on to the lawn, but it was dark and it had begun to rain. Between his screams the victim raged and raved against the avenger. “It was that hell-cat, Kitty Winter!” he cried. “Oh, the she-devil! She shall pay for it! She shall pay! Oh, God in heaven, this pain is more than I can bear!”

  

Erysipelas In Victorian Times

Most readers likely won’t have heard of erysipelas, but we do still make the diagnosis occasionally. It is a form of cellulitis, which is a much more commonly used and understood medical term for skin infections.

The Rose or St Anthony’s Fire. [5]

The malady has been claimed as an infectious disorder, due to specific bacteria; but this is not certain. [3]

Some great alternative names for the condition. I found erysipelas still referred to as St Anthony’s Fire on some modern websites. The name seems to refer more commonly to ergot poisoning [LSD is an ergot derivative], but in this case refers to the fiery appearance of the rash. It was also historically used as a name for shingles. There are a range of interesting St Anthony’s. This one was St Anthony the Abbot, a 3^rd century monk, and patron saint of both fire and farm animals.

Erysipelas is indeed caused by a specific bacteria – group A beta-haemolytic streptococci. The streptococci are a complex group of bacteria, causing a range of diseases, such as rheumatic fever, tonsillitis, meningitis and pregnancy infections [we will cover several of these diseases in later chapters].

It is certain that wherever there is abrasion of the surface the skin at this point is likely to be attacked by erysipelas if the patient be exposed to unhealthy conditions – such, for instance, as a current of air escaping from a foul water-closet, or contact with decomposing matter. When once generated the inflammation spreads by extension to contiguous surfaces, and is easily conveyed by the hands of the attendants to other patients. [18]

Which is a pretty good understanding of how bacterial disease spreads, even if a scientific understanding of bacteria was in its infancy. 1876 was the year that Conan Doyle started medical school. It was also the year that Robert Koch published his work on Bacillus Anthracis causing anthrax – the first time that a specific bacteria had been conclusively proven to cause a specific disease.

The disease begins with a chill, followed by a fever. Soon a portion of the face is noticed to be red and hot. The redness spreads, a clearly-defined edge marking its onward march; and generally it does not stop until it has occupied the whole of the face and a considerable portion of the scalp. The features are then so tumefied as to be hardly recognisable. [3]

There is considerable desquamation after its subsidence. [5]

Suppuration, ulceration or gangrene and their consequences may occur. [5]

Occasionally the inflammation attacks the throat, producing oedema of the glottis, and such cases are very apt to terminate fatally. [6]

The first part of the description seems exactly as we would still see. Thankfully, all the complications are largely a thing of the past. It must have been a terrifying time when the risk of death accompanied simple bacterial diseases.

In all cases it is necessary to give rest to the inflamed part, and to keep it in such a position as will favour the return of the venous blood from it. Venesection and leeching are now generally abandoned. And you should support the action of the heart instead of depressing it. As the stools are usually dark and offensive, you may commence your treatment by freely evacuating the bowels, either by a dose of calomel or some other active purgative. [6]

Wherever there is a very feeble pulse or a brown tongue alcohol should be administered; the amount of stimulant ought to be in proportion to the depression. [6]

Perchloride of iron is looked upon by many writers as a specific for erysipelas. The local remedies that have been proposed are innumerable. In slight cases it is sufficient to apply cotton wool, so as to exclude the air from the inflamed part, or to dust it over with a powdered starch or flour, or with a mixture of oxide of zinc and starch. [6]

Where the pain is excessive relief is often afforded by fomentations with a decoction of poppy heads, or by covering the part with spongio-piline soaked in hot water and sprinkled with laudanum. [6]

This is a disease where there is no correlation at all between Victorian and modern medical practice, bar potentially elevating the affected body part. The Victorian doctor saw himself as terribly modern for shunning leeching in favour of a healthy bowel cleansing. The concept of aiding a skin disease by covering it with flour to exclude the air is rather quaint.

These days, erysipelas is not a big issue. It is a great example of a disease where the development of antibiotics changed a scary disease to an easily treatable disease. It is also one of the few diseases we still use good old-fashioned penicillin to treat. Most bacteria have developed resistance to penicillin, but oddly not group A streptococci.

Thus the plot of “The Adventure Of The Illustrious Client” doesn’t work so well these days. No longer could erysipelas be used as a reason why Sherlock is much too poorly to foil the evil plots of Baron Gruner.

 

Next Week

We’ll return to “The Adventure Of The Blanched Soldier” and conclude the story by covering the rather obscure dermatological diagnosis of Ichthyosis. Fascinating fact from the chapter – Vaseline [under that name] existed when Conan Doyle was practising.