Points in the Etiology and Clinical History of Erysipelas. Read in the Section of Practice of Medicine, at the Forty-fourth Annual Meeting of the American Medical Association. BY J. M. ANDERS, M.D. PHILADELPHIA, PA. Reprinted from the "Journal of the American Medical Association," July 22, 1893. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 1893. Points in the Etiology and Clinical History of Erysipelas. Read in the Section of Practice of Medicine, at the Forty-fourth Annual Meeting of the American Medical Association. BY J. M. ANDERS, M.D. PHILADELPHIA, PA. Reprinted from the "Journal of the American Medical Association," July 22, 1893. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 1893. POINTS IN THE ETIOLOGY AND CLINICAL HISTORY OF ERYSIPELAS. BY J. M. ANDERS, M.D. PHILADELPHIA, PA. In discussing the predisposing causes of erysipe- las, authors are greatly at variance as to the influ- ence of age, sex, seasonal effect, etc., among other well recognized factors. It must be confessed, how- ever, that no statistical inquiries have heretofore been instituted to show the exact effect exerted upon the disease by these supposed etiological elements. In a recent paper on "Seasonal Influence in Erysip- elas, with Statistics," the writer has shown, by care- ful analysis of 2,010 cases collected from different sources, the relationship existing between the var- ious seasons of the year and this affection; and he ventures to hope that he may be pardoned for calling attention briefly to some of the tabulated data con- tained in his former paper. Table 1 demonstrated clearly that the cases increase month by month in slightly varying ratio, from August to April, which latter month gives the greater number; and that there is a rapid decrease in the percentage of cases from April to August, the latter giving the smallest number. Again : "one-half of all the cases occurred 4 during the months of February, March, April and May, and i5.9 per cent, during the month of April alone. It would appear that the winter and spring months, though more particularly the latter, influ- TABLE I.-Ages. Representing 781 cases occurring from 1852 to 1892, inclusive. ence the susceptibility to this disease." To account forjjthis augmentation of cases during the winter and spring seasons no satisfactory explanation has been found. That it is not due to the increase in sickness 5 in general which, as pointed out by M. J. Lewis, occurs in the spring season, may be readily shown. Erysipelas gives the greatest percentage of cases in April, whilst on the other hand, the greatest percent- age in the aggregate of human illness, when com- puted month by month, occurs in March. Researches were also instituted with a view to showing any relationship that might exist between the mean relative humidity, the mean barometer, and the appearance of cases of erysipelas. Suffice it to re-state here a few of the deductions which may be found in my former paper relative to the rble played by certain leading climate elements in the causation of this affection. 1. That a low barometer and mean relative humid- ity invariably correspond with the annual period in which the greatest number of cases occur, and the highest percentage of relative humidity with the months affording the fewest cases. 2. Among the meteorological factors, temperature has the least, and relative humidity the most, inti- mate connection with the disease. Erysipelas is not to the same extent as chorea and rheumatism related to the seasonal variations in the totality of human illness.1 That the foregoing conclusions are based upon adequate data will be seen by a glance at the accom- panying table. It however will also be observed that, Jor the months of September, October, November and December, the tracings do not maintain the same resemblance to one another as during the months from January to September, hence the effects of the various meteorological factors alone are inadequate to account for the steady rise, in the percent- age of cases, throughout the cold months and more especially the quite considerable April augmenta- tion. The interesting fact, however, remains proven, i For a more complete discussion of the points raised, the reader is referred to the original article-Proceedings of the American Climato- logical Association, for 1893. 6 even though not explicable, that the disease is to a considerable extent dependent upon seasonal influ- ence. PREDISPOSING INFLUENCE OF AGE. The period of life at which persons are most liable to erysipelas has not, up to the present, been defin- itely determined, though there appears to be a prettv general impression among medical writers that it is most commonly met with in the young. Dr. J. A. Glaser (Therapeutic Monatshefte) reports 148 cases of erysipelas, in part from his. private practice and in part from cases observed in the hospital. "These did not include any but his severe cases, and were scattered through fifteen or sixteen years. The patients varied in age from three-fourths of a year to seventy-five years. The largest part of them were between twenty and forty years old." With a view to ascertaining with some approach to exactness the influence of age as a predisposing factor, I have obtained notes in 1,894 cases. Of these, 1,754 were acquired from the records of the various hospitals of Philadelphia and 143 from my private practice and the practice of others, who kindly fur- nished me with reports of their cases.2 In a small proportion of the cases only, the age of the patient was not given. The records of Blockley Hospital, Philadelphia, furnished 1,113 cases. It should be pointed out, relative to the lat- ter statistics, that I can do nothing more at present than to give the average age of the patients. During the years from 1857 to 1870 inclusive, there were 234 cases whose average age was 45 years. In 879 cases which were admitted into Blockley Hospital during the years from 1870 to 1890 inclusive, the average age was 43 years. On the other hand, the average 21 desire to express anew my grateful acknowledgment of the services kindly rendered, in the collection of these cases, by Drs. G. H. Crabtree, Wm. Osler, George Booth Miller, L. S. Bromley, Weiser and Litchfield and by numerous professional friends for cases from their private prac- 7 age of the cases derived from all other sources (781 in number) was 29 years. The average age of the 143 cases reported from private practice was 29.5 years. The explanation of this apparent great dis- crepancy in the ages is to be found in the fact that TABLE II. Jan. Feb. Meh. Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Meh. Apr. May June [Explanation of Table.-A-1163 eases occurring from 1871 to 1890, inclusive. B- Mean barometer from 1871 to 1890, inclusive. C- Mean relative humidity froin 1871 to 1890, inclusive. The eases increase in increments of 10. Barometric pressure reck- oned in inches. Mean relative humidity given in percentages.] the average age of all patients admitted into Block- ley Hospital is much greater than the average age of those admitted into other institutions or those met with in private practice. The patients cared for in 8 the wards of Blockley Hospital come from the pau- per element of the population in Philadelphia and elsewhere-an element composed in great part of middle-aged and old persons. With this brief reference to the statistics obtained from Blockley I dismiss them, but desire to call attention to some interesting as well as practical points growing out of a further analysis of the 781 cases previously mentioned. In order to indicate the proportionate percentage of cases for the differ- ent periods of life the subjoined table has been care- fully prepared. Since this chart is quite simple and really self- explanatory, it will be unnecessary for me to do more than to call attention to a few facts, which are of sufficient importance to be emphasized. The tracing in the table represents the whole series of cases and increases in increments of ten. It will be observed that more than one-half of all cases occur before thirty years of age; that the period of greatest lia- bility is from twenty to thirty years; that from thirty to fifty years the cases slowly decrease, and after fifty years quite rapidly. It should be noted especially that under ten years the disease is ex- tremely, and between ten and twenty comparatively rare. The period of greatest frequency-from twenty to thirty years-furnishes 35.8 per cent, of the aggre- gate number of cases. No attempt has been made to separate the idio- pathic from the traumatic form of the complaint, and chiefly for the reason that in most instances the distinction was not noted in the records. The Effect of Sex. The influence exerted by the sexes was also shown by the results of these investi- gations. The sex was noted in 1,767 cases. Of these, 1,219 were males and 548 females. It remains to be stated, however, in reference to the hospital statis- tics, that, in proportion to the whole number of cases of all complaints among the males as compared with those among the females, admitted into the 9 institutions named, the preponderance of the former over the latter would not be so great as indicated by these figures. And yet, after making due allowance for all modifying conditions, the ratio would be as three to two in favor of the male sex. The same thing may be shown by considering separately the 143 cases gleaned from private practice, of which eighty-five were males and fifty-eight females. Of the 148 cases of erysipelas reported by Dr. J. A. Glaser (loc. cit.), fifty-one were women and ninety- seven men. That the disease is more frequent in the male than the female sex is thus definitely shown. This dictum may excite surprise in view of the fact that by most authors erysipelas is stated to be more common in women than in men. The fact is rapidly becoming recognized by the profession that slight abrasions and fissures, either in the mucous membrane of the nose or in the skin of the face or the ear, as well as all forms of slight injuries, are liable to furnish a path of ingress to the specific poison. This point has also been corrob- orated by the results of our researches. In 643 cases which were examined with reference to this question, slight injuries and abrasions were noted in 113. Doubtless in many of these instances the examiner omitted to search for such lesions as we are considering. In most of the instances (here enumerated) the character of the changes was par- ticularized as follows : slight contusion of forehead, in six cases; small wounds of forehead, six cases; slight scalp wounds, seven; trifling lesions of the ear, four; slight wounds of skin of nose, six; syph- ilitic erosions of nasal bones, four; wounds of eye- brow, three; wounds of eyelid, three; slight injuries to leg, three; slight wounds of cheek, wounds of thumb, two each; vaccination, excoriation of elbow, toe rubbed by boot, corn cut, caries of tooth, small sty, excoriation of foot, dog bite, one each. It is interesting to note that, out of a total of 301 histories examined for me, by Dr. M. Booth Miller, 10 :acute coryza preceded the attack in thirteen instances. Doubtless in these, slight lesions of the Schneiderian mucous membrane favored specific infection. Testimony confirmatory of the well known fact that certain chronic diseases, such as chronic Bright's, phthisis etc., increase the susceptibility to the complaint, was also brought to light by these inquiries. The chronic affections in the course of which ery- sipelas occurs most frequently are shown by the fol- lowing analysis of 1,665 cases, viz: in the course of chronic leg ulcers, sixty-seven occurred; in chronic pulmonary tuberculosis and chronic nephritis, fif- teen each; in rheumatism, fourteen; in organic heart disease, ten; in urethral stricture, six; in syphilis and synovitis, five each ; in asthma, chronic pleurisy and chronic alcoholism, four each; in bone necrosis, malaria, locomotor ataxia, senile debility and puerperal state, three each; in typhoid fever and sciatica, two each. Instances in which single cases occurred secondary to other chronic affections were numerous, but need not be detailed here. According to these figures the proportion of exam- ples in which erysipelas is secondary to chronic dis- eases is not formidable, the percentage being 7.8, if we include those diseases that furnish but a single case of erysipelas. Individual predisposition to the complaint was shown in some instances, though not as frequently as some writers would have us believe. Of 450 in- stances previous attacks were noted in thirty-nine, or in 8.06 per cent. One patient had had seven previ- ous attacks; another, four; several, one, two and three attacks respectively. Family predisposition was noted in four instances. One of these patients stated that he had had many previous attacks and that his father and two brothers were also very sus- ceptible. As to the chief seat of the local manifestations POINTS IN THE CLINICAL HISTORY. 11 exact figures cannot be given since, in numerous in- stances, no mention of the locality was made; and yet the data obtained on this head were full of in- terest. The notes of the cases examined gave the result here stated. The locality was ascertained in 712 cases; of which 517 or 72.6 per cent, were facial; 127 or 17.8 per cent, affected the leg and foot; seven- teen cases or 2.3 per cent., the arm; eight cases or 1.1 per cent, the hand ; while five cases or .7 per cent, implicated the scrotum. The cases in which the in- flammation occupied portions of the body other than the head could not all be classified as idiopathic. For instance, as before stated, sixty-seven cases were secondary to leg ulcers. Here the ulcers served as a gate of entrance for the specific virus. After a careful elimination of cases in which there seemed to be any doubt, we have 586 as the aggregate number belong- ing to the idiopathic variety. Of these, 517 or 88.2 per cent, were facial; 50 or 8.5 per cent, occurred on the leg and foot; ten or 1.7 per cent, on the arm; five or .85 per cent, on the hand ; and four or .68 per cent, on the scrotum. It is seen that nearly all cases of idiopathic ery- sipelas attack the face-a fact previously well known. The next most favorite seat of this disease is the leg -a fact not heretofore demonstrated. Course and Duration.-Both the clinical course and duration of erysipelas were found to be quite varia- ble ; and this was owfing largely to the presence of complications (which are numerous), the previous condition of the patient, age, etc. I regret that the limits of the present article will not permit me to discuss the various complications that were noted as occurring in this complaint. The average duration of the affection was computed in 1,880 cases and found to be (including relapses) 25.13 days. At any period of life, according to these observations, the stay in a hospital, or the duration of a case in pri- vate practice, was lengthened almost indefinitely when the patient had been previously in an enfeebled 12 condition on account of chronic disease, and when complications existed. The average course was found to be much less in uncomplicated cases occurring in persons under 40 years, which is the time of life cor- responding with a preponderating proportion of cases, viz., about fourteen days. These results point strongly to the important prac- tical facts. that erysipelas in a typical form is a self-limited disease; that the length of the attack is greatly influenced by the age of the patientper se, its average duration in persons of 50 years or over being considerably longer than in younger subjects. Sex has no influence in this direction. That relapses are rather common in this disease is a fact long since learned by the profession. Among 476 cases recorded, relapses occurred in 54, or 11.3 per cent. It is interesting to note that in one pa- tient five relapses occurred ; in two others, four; and in three patients, three. First and second relapses were still more common. Single relapses were fre- quently observed, in typical cases, in otherwise healthy subjects. On the other hand, multiple relap- ses occurred most frequently in persons whose general health had been previously impaired.