THE OHIO MEDICAL RECORDER. editors: J. W. HAMILTON, M. D. J. F. BALDWIN, M. D. Vol. I. DECEMBER, 1876. No. 7. fiflmimnnnriiw. IS DIPHTHERIA A FORM OF ERYSIPELAS ? BY H. CULBERTSON, M. D.. PROFESSOR OF OPHTHALMOLOGY, COLUM- BUS MEDICAL COLLEGE. Read before the Zanesville Academy of Medicine. Whether diphtheria be, de novo, a local or constitutional disease, it and erysipelas present so many features in common, that it may not be amiss to consider if they are similar, or possibly identical in nature. In investigating this question it may be viewed under several propo- sitions : 1st. Diphtheria may affect the skin alone. " Diphtheria may be confined to the skin alone."-Meigs & Pepper, Dis. Child., page 660. Trousseau has seen the cutaneous form when no throat affection ex- isted.- Ibid, page 666. See also a case given by Bretonneau, in which a boy affected with frost-bite of used a foot-bath, the water of which had been bathed in by who had diphtheria, and the disease appeared in the wound.- Lancet, 1859, Vol. 1, page 288. 290 Communications. 2nd. Diphtheria may begin in the throat and spread to the face, and vice versa. " The disease may extend on to the denuded skin, or into the oesoph- agus."-Meigs & Pepper, page 660. Gross states he lias seen cases of diphtheritis of the tongue without the throat being involved, and where the mucous membrane of the gums and cheeks were coated with the deposit.-Gross' Surg., Vol. 2, p. 518. He also adds, a diphtheritic state of the tongue may be produced from salivation. Maunder's case, in which a man thirty-five years of age received a lacerated wound on the fore-arm, which became covered with a diph- theritic deposit, and subsequently diphtheria of the fauces appeared.- Lancet, 1864, page 640. Guersant's three operations for phymosis, diphtheria appeared in the wounds, and subsequently in the throat.-Lancet, 1859, Vol. 2, p. 557. Mackenzie's case of diphtheritis of the rectum, in which false mem- brapes were discharged peranum,and paralysis of the left lower extrem- ity resulted.-Lancet, 1860, Volume 1, page 157. The membrane may be found deposited in the nostrils, mouth, lar- ynx, trachea, oesophagus, conjunctiva, lining of the ear, the lungs, va- gina.-Smith's Dis. Child, page 231. It may appear in the bronchi, at the base of the tongue, in the mouth, oesophagus, upon the conjunctiva, the borders of the natural outlets, upon the nipple, at the union of the skin and mucous membranes, or in folds of the integument, or upon the denuded skin.-Lorain & Lepine, Nouv. Diet, de Med. et de Chirwrg. Pract. T. XI, page 603. It may communicate to others, pseudo-membranous angina, orcroup, or the cutaneous form, or any other form of pellicular affection.-Trous- seau, Nouv. Diet, de Med. et de Pract. T. XI, page 595. 3rd. Diphtheria may begin insidiously. It may begin as a redness of the throat with a feeling of fulness, be- fore general symptoms come on ; as in the case of a clergyman of the Pacific coast, whose disease was so insidious as to be beyond the hope of recovery when the magnitude of the throat affection was discovered.- Smith, Dis. Child, page 238. 4th. Diphtheria may develop rapidly. Case of Vaillex, in which some of the diphtheritic matter was receiv- ed in his throat, and he died in forty-eight hours of faiveiul diphtheria. See Smith, loc. -tit. page 238. Vx Case of Gendrin, in which the matter got on to the lips and Schnei- Culbertson, Is Diphtheria a form of Erysipelas ? 291 derian membrane, the diseas spread to the throat, and gave rise to the constitutional symptoms.-Lancet, 1859, Vol. 2, page 288. Case of Herpin, in which the matter reached the mucous lining of the nose, the disease spread to the throat, with constitutional symptoms. -Loe. cit. Case of Molloy, who sucked the tracheal tube in a diphtheritic pa- tient, and took the disease soon after in the throat.-Lancet, 1859, Vol. 2, page 132. 5th. It may arise in the throat (diphtheria). The cases given under the fourth head show this. Bretonneau and Trousseau maintained its local origin ; see Memoirs and Practice in Trans. Syd. Soc., and Meigs and Pepper, Dis. Child, page G53. At the last named page this authority says: "It must be admitted that the cases now on record, in which the disease has been so (locally) transmitted, are too clear and well authenticated to admit of doubt." Bochut believed that there was a local infecting, and a local non-in- fecting diphtheria.-Ibid, page 656. Niemeyer says the diseaseis generated from the false membrane, and the patient's breath.-Pract. Vol. 2, page 615. Cohen believes it arises from cryptogami deposited in the throat, there developing and producing inflammation of the mucous membrane, and subsequently poisoning the system.-Dis. Throat, page 97. Luscha has shown that a very early symptom of the disease is the en- largement of the lymphatic glands at the division of the carotid, and that this takes place first on the side first affected.-Niemeyer, Volume 2, page 616. 6th. The membrane in diphtheria is not pathognomonic of the dis- ease. Meigs and Pepper state the deposit cannot be distinguished, micro- scopically or ocularly, from the deposit in scarlatinous angina.-Dis. Child, page 660. The deposits in diphtheria and scarlatina resemble each other.-West, Dis. Child, page 324. Scalds of the throat may produce these diphtheritic deposits where there is no specific cause at work.-Holmes, Surg. Dis. Child, pages 291, and 301. Rokitansky classes the diphtheritic deposits with the croupous exu- dates, and states that these are found in diathetic diseases, as diphthe- ria, croup, etc.-Path, volume 1, page 112. 292 Communications. Again, he says, the exanthematous erases may all induce such croup- ous exudates and puerperal fever also.-Ibid, page 294. Williams says pellicular inflammation frequently produces a charac" teristic diphtheritic deposit, and is found in inflammations of the ton- sils and in scarlatina, and it sometimes extends into the larynx and trachea.-Pathol, page 483. Cohen says the membrane is similar to that formed in croup, and to that resulting from vesicants, ammonia, cantharides, and hydrochloric acid.-Dis. Throat, page 97. Rindfleich says that anatomically the membranes of croup and diph- theria are identical. See volume 54, New Syd. Soc. Trans, page 424. Zuegler says the anatomical changes not distinctive. See Ziemssen's Cyclop. Med. volume 2, page 444. The disease, diphtheria, arises as follows: "Immediately upon the invasion of the disease a redness is observed upon the faucial membrane as a faint blush, and rapidly extends. The mucous membrane is thick- ened and softened, its follicles tumified and actively secreting, with sub-mucous infiltration. Within a day, sometimes a few hours, mem- brane forms, which at first is quite firmly attached to the mucous mem- brane, often causing bleeding on separating it. In a few days it sepa- rates. This membrane is composed of fibrillae, nuclei, pus cells, and amorphous matter."-Smith, Dis. Child, page 231. Rindfleich says : " That at first the false is intimately united with the mucous membrane. The discharge is so thin that it transudes .the membrane'"-See volume 54, New Syd. Pub. page 424. Wood says: "The causes of ordinary angina will give rise to the pseudo-membranous variety in those predisposed to it."-Practice, vol- ume 1. page 496. Again he says: "From its resemblance (speaking of diphtheria) to f.he malignant sore throat of Frothergill, Huxham, and others, with which it is by some writers maintained to be identical, and from the simultaneous occurrence of both these affections with epidemic scarla- tina, and from the close analogy of their local symptoms with the throat affections of that disease, the inference is not without plausibility, that they may all be produced by the same cause, in those cases in which they have an epidemic or contagious character."-Loc. Cit. page 497. Steiner, volume IV, Ziemssen's Cyclop. Med. page 257, says: " Ac- cording to E. Wagner, whose numerous and thorough investigations have shown that there is no sharp dividing line between diphtheria and croup, an opinion in which I entirely agree, * * » Culbertson, Is Diphtheria a form of Erysipelas? 293 7th. Diphtheria may attack the substance of organs, and not devel- op as a membrane. Diphtheria may attack the substance of organs, as the spleen, kidneys and nervous system.-Niemeyer, volume 2, G15. In diphtheria maligna the substance of the throat, tonsils and glands of the neck are involved. See Cohen's description of this form. In which form is observed gangrene, ulceration, suppuration, effusion of serum and lymph, and other terminations of erysipelatous inflamma- tion. Ata meeting of the Clinical Society of London, Dr. Semple showed the parts from a diphtheria (maligna) patient, in which there was only a slight effusion into the larynx, tonsils, and surrounding parts which were intensely congested, thus presenting the precise symptoms of black tongue.-Lancet, 1859, vol. 1, page 420. 8th. The blood in diphtheria is modified. It may be thickened, the albumen diminished, the red globules in- creased or defective, and albuminuria may be present.-Rokitansky, volume omitted, page 292, et. seq. The heart clots observed in diphtheria are an evidence that the fibrin of the blood is affected by the disease. Dr. Rajewskey, of St. Petersburg, has lately examined a number of cases of intestinal diphtheria. He concludes, 1st. This inflammation is always preceded by a catarrhal state of that organ. 2d. Its com- mencement is always characterized by the formation of a fibrinous exu- dation, which collects in the substance of the mucous membrane, and on its surface. 3d. The next stage consists in the death of the mucous membrane, and its transformation into a granular albuminous mass, which dissolves in acetic acid. The work of destruction extends to the surrounding parts, and at the same time a hyaline metamorphosis of the blood-vessels occurs in the diseased tissues. 4th. He finds micrococ- ci and bacteria are infiltrated in the tissues, and in the lymphatic ves- sels. Thus while he believes parasites are at the bottom of the disease, it is necessary that the soil should be previously prepared by irritating substances.-Med. Times and Gazette, Dec. 11, 1875, page G59. It may attack the glands.-Trousseau, Nou. Diet, de Med. et Chirurg Pract. T. XI. page 595. The nerves may be altered, the heart and pharyngeal muscles under- go fatty degeneration.-Ibid, page 603. See Loraine & Lepine. The same writers say: " The kidneys are frequently altered in the parenchyma, the cellules being less transparent, and increased in vol- 294 Communications. ume. Frequently the parenchymatous nephritis is very marked. The spleen is not generally modified in an appreciable manner. Quite rare- ly it presents the enlargement common to infectuous diseases.-Loe. Cit. T. XI. 608. Ibid, page 614. Same authors say its malignant form may induce sphacelus. 9th. Erysipelas may arise locally upon the skin. Erysipelas is inoculable from instruments and vaccination.-Ziem- ssen's Cyclop, volume 2, page 436. A large proportion of cases of erysipelas areapt to begin at some local point of irritation, as a pimple, vesicle, or a wound.-Smith, Dis. Child, page 286. Niemeyer states the origin of erysipelas is in an inflammation of the lymphatic vessels of the skin which extends to the tissue of the integu- ment. He also speaks of the absorption of putrescent materials from abscesses and sores, engendering the erysipelatous form of inflamma- tion. See Pract. volume 2, page 412. Billroth says : " I consider erysipelas traumaticum, not as a symp- tomatic inflammation of the skin, but as a capillary lymphangitis of the skin, which is always due to infection." See Path, page 259. Williams states : " But it is also pretty certain that bad ventilation, and a crowded, uncleansed state of surgical patients, is capable of ren- dering common inflammation erysipelatous." He adds, this is proba- bly produced by the products of inflammation becoming poisonous.- Path, page 268. Trousseau maintains the local origin of a large class of cases of erysip- elas. See New Syd. Trans. Lorain and Lepine state, in diphtheria, "Sometimes the skin cover- ing the swollen parts takes on an erysipelatous inflammation, which has already been noticed by Bosieri."-Nouv. Diet, de Med. et de Chi- rurg. Pract. T. XI. page 615. 10th. Erysipelas may begin in the throat and spread to the face, and vice versa. Frazer's case, in which erysipelas began in the throat and spread up the nose and over the face and head, and involved the larynx.-Lancet volume 6, 1847, page 251. This disease may spread from the throat to the skin, and vice versa. -Da Costa, Diagnosis, page 405. " It may spread from the throat to the skin, or from the skin to the throat." See Zuegler, Ziemssen's Cyclop, volume 2, page 450. Culbertson, Is Diphtheria a form of Erysipelas? 295 Bayer's case, in which erysipelas spread from the upper part of the nose over the forehead.-Loe. Cit. Gallard and Ragal's cases, in which the disease spread from the throat to the nose, conjunctiva and face. See Cohen, Dis. Throat, page 111 and 112, and Hartshorn's Prine, page 305. 11th. Erysipelas may be attended with the deposit of false mem- brane, either on cutaneous or mucous surfaces. Da Costa says : " Erysipelas may attack tlie throat with the deposit of false membrane." "In one of these cases a layer of false membrane had coated the tonsils and half of the arches and uvula." See Diagnosis, page 406. Again he says : " I have seen a number of cases of erysipe- las of the fauces in which a membrane appeared, followed with all the constitutional symptoms of diphtheria."-Ibid, page 405. Showing at least the possibility of diphtheria and erysipelas being identical. In that form of erysipelas known as hospital gangrene, and called by Billroth " diphtheria of wounds," there is a deposit of false membrane, and this authority adds, there is a striking resemblance to diphtheria in this disease.-Path, page 308. Niemeyer says: Erysipelas may give rise to croupous or catarrhal inflammation of the mucous membrane of the intestines and the tubuli uriniferi, and that this deposit cannot be distinguished from that of scarlatina, by the eye or microscope.-Pract. volume 2, page 415. Paget says : such membranes may form on serous membranes.-Path, page 251. Croupous pneumonia may be a result of erysipelas.-Ziem. Cyclop, vol. 2, page 443. Cases by Trousseau, Thoinnet, Ritzmann, and others. Smith in puerperal peritonitis, a form of erysipelas, says: false membranes are found.-Dis. Child. 291. And again, at page 292, same work, he says in erysipelas, post-mortem examinations show that the intestines are glued together, and covered with inflammatory exudation, exactly similar to that seen after puerperal peritonitis. Rokitansky says, the exanthematous erases may each present such croupous exudates and puerperal fever the same.-Path, volume 1, page 294. " Cases of puerperal fever develop false membranes on the peritoneum and are without doubt due to erysipelas." Four cases are given, two of puerperal fever, and two others (all in the same family) of erysipelas following the former cases.-Lancet, 1849, volume 10, page 81. The editor of the Lancet says, in the discussion of puerperal fever in the London Obstetrical Society, 1875: " That puerperal fever may be 296 Communications. caused by erysipelas, and that the two diseases may be interchangeable was unanimously held."-Lancet, January 15, 1876. Gross,speaking of erysipelas of the throat,says: " The affected struct- ures are of a crimson or bright scarlet color, cedematous, incrusted with patches of lymph, etc."-Syst. of Surg. volume 1, page 579. 12th. Erysipelas may attack the substance of organs and not be at- tended with the deposit of false membrane. In the epidemic of erysipelas which prevailed in Vermont and Vir-* ginia in 1842-3, which was commonly called black tongue, and which has been so well described by Hall and Peebles, in the Am. Jour. Med. Set., the post-mortems clearly revealed a deposit of fibrin in the mucous membrane of the fauces and larynx, but not upon the surface of these membranes. Post-mortems also demonstrated that in this disease the in- testines, the mucous membrane of the bronchi, the spleen, and tlie membranes of the brain were affected and infiltrated with the same fluid. Zuegler says that the spleen may be enlarged, softened, or liquified, and the parenchyma of the kidneys inflamed from erysipelas.-Ziem. Cyclop, volume 2, page 444. In the same work, page 461, this authori- ty states the urine may contain albumen in erysipelas. The cellular tissue, the glands, and the tonsils were inflamed, infil- trated, and often exhibited ulceration and gangrene, as the effect of black tongue.-Am. Jour. Med. Sch.Loc. Cit. Erysipelas of the throat induces paralysis of the pharyngeal muscles, which cannot be excited to action by pressure with the finger or instru- ments, and regurgitation takes place principally through the mouth.- Lancet, 1849, volume 10, page 81. 13th. The blood in erysipelas is modified. Zuegler says the anatomical changes are not.distinctive, being the same as in simple inflammation of the skin without specific cause.- Ziem. Cyclop, volume 2, page 446. Rokitansky says in erysipelas the blood may be thickened, the albu- men diminished, the red globules increased or diminished, and albumi- nuria may be present.-Path, volume omitted, page 292, et. seq. Zuegler says; " The blood in erysipelas is sometimes thickened, and bright red, and again dark colored and thinned, and according to Vir- chow the proportion of fibrin is increased."-Ziem. Cyclop, volume 2, page 444. The same authority adds at page 446, same volume, "The anatomical changes are not peculiar, but are such as attend all febrile affections." Culbertson, Is Diphtheria a form of Erysipelas > 297 Blood clots may result from erysipelas. SUMMARY. Having presented the foregoing data,a comparison may be instituted betweeen diphtheria and erysipelas as follows: 1. Diphtheria may appear upon the skin alone, and so may erysipe- las. 2. Diphtheria may be located in the throat alone, and so may erysip- elas. 3. Diphtheria may spread from the throat to the skin, and so may erysipelas. 4. Diphtheria may spread from the skin to the throat, and so may erysipelas. 5. Diphtheria may spread to the respiratory organs, and so may ery- sipelas. 6. Diphtheria may spread to the intestinal tract, and so may erysipe- las. 7. Diphtheria may attack the substance of organs, and so may ery- sipelas. 8. Diphtheria may induce ulceration of the mucous membrane of the throat, gangrene and suppuration of the tonsils, and gangrene of the cellular tissue of the throat, and so may erysipelas. 9. Diphtheria may increase or diminish the albumen and the red glo- bules of the blood, it may thicken or thin the blood, it may render the blood darker or brighter red in color, or albuminuria may be present,as in erysipelas. 10. False membrane may be found in the respiratory passages, in the throat, on the skin, in the vagina, and in the rectum, in diphtheria, and so may such membranes be found in erysipelas. 11. Both diseases may induce emboli and thrombi. 12. Both diseases may produce paralysis. 13. Both diseases may induce a typhoidal state of the system. 14. Diphtheria may be attended with the merest show of fibrinous ef- fusion on the surface of mucous membranes, and a free deposit of lymph in the substance of the mucous membranes, as in diphtheria maligna, as is so nearly the case in black tongue, a form of erysipelas. 15. Both diseases may begin locally. 16. Both diseases may be mild or malignant. 17. Diphtheria may be successfully treated with the same remedies as erysipelas. 18. diphtheria and in erysipelas, the occult cause of either disease 298 Communications. has not been discovered, and hence we cannot know if they are dissim- ilar. 19. Diphtheria does not give immunity from another attack, (Loraine and Lepine, Nouv. Diet, de Med. et de Chirurg. Pract. T. XI. p. 602,) neither does erysipelas. 20. Statistics show a difference of but 1.84 per cent, in the mortality of the two diseases. Thus during the war of the rebellion there were reported 23,276 cases of erysipelas, with 1,860 deaths ; and 7,277 cases of diphtheria, with 716 deaths; showing a mortality for the former disease of 7.72 and for the latter of 9.56 per cent.-Med. and Surg Hist. War Rebellion, part 1, page 637. 21. The duration of erysipelas is eight or nine days, (Wood's Pract. volume 1.) and the false membrane separates in diphtheria in eight or nine days. (Ibid) and the active period of the disease is generally over in that period. CONCLUSION. 1. Diphtheria and erysipelas are similar diseases. 2. Diphtheria and erysipelas may posisbly be indentical in nature. Zanesville, Ohio, Sept. 1876.