THE COMPLICATING CONDITIONS, ASSOCIATED DISEASES, AND MORTALITY-RATE IN ERYSIPELAS. Read at the Pan-American Medical Congress, Section of Medicine, September 6, 1893. BY JAMES M. ANDERS, M.D., Ph.D., Professor of Medicine and Clinical Medicine at the Medico-Chirurgical College ; Physician to the Philadelphia Hospital, etc. Reprinted from the International Medical Magazine for October, 1898. THE COMPLICATING CONDITIONS, ASSOCIATED DISEASES, AND MORTALITY-RATE IN ERYSIPELAS. During the year just past I have been engaged in conducting an inves- tigation into the disease erysipelas. A portion of the results obtained from these researches were given in a recent paper on " The Seasonal Influences in Erysipelas, with Statistics."1 More recently I read an article on "Some Points in the Etiology and Clinical History of Erysipelas, with Statistics," before the Section on the Practice of Medicine of the American Medical Association, at its last meeting, in which article additional results were re- ported. To some of the conclusions reached in the latter paper I desire to make brief reference presently. While collecting data with a view to de- termining the duration of erysipelas, I had occasion to inquire into the effect of complications on the general course of the disease. Upon this point the following inferences may be found in my last paper : " The average duration of the affection was computed in eighteen hun- dred and eighty 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 private practice was lengthened almost indefinitely when the patient had been previously in an enfeebled 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 forty years, which is the time of life corresponding with a preponder- ating proportion of cases,-viz., about fourteen days." These results also point strongly to the important practical 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 patient per se, its average duration in persons ovei' fifty years being considerably longer than in younger subjects. Sex has no influence in this direction." I have directed attention to the influence of age upon the course of the disease-a factor that is especially operative at a period of life when cases are relatively infrequent-for two reasons: first, because it is an interesting and novel fact; and, secondly, that the other and more notable factors, as complications, etc., shall not be overrated. 1 Read at the meeting of the American Climatological Association, 1893. 2 JAMES M. ANDERS, M.D., PH.D., ON Respecting those associated diseases that are not to be classed as true complications additional data will in this connection be adduced. In my published article, before alluded to, may be found an analysis of sixteen hundred and sixty-five cases, and the data show which affections predispose most potently to erysipelas, as well as the comparative frequency of their occurrence, as follows. In the course of chronic leg ulcers sixty-seven oc- curred ; in chronic pulmonary tuberculosis and chronic nephritis, fifteen each ; in chronic 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, these being 7.8 per cent, of the total number of instances. The result just narrated fitly corroborated the broad fact-one long since appreciated by the profession-that certain conditions and diseases increase the liability to the complaint. I purpose to present, in the next place, the results obtained from a study of a series of sixteen hundred and seventy-four cases which were analyzed with particular reference to complications. Of the latter there were: abscesses, one hundred and five (of which the following only were classified: of eyelids, five; abscesses with ulcers, two; of leg, three; of foot, three; of finger, scalp, elbow, glands at angle of jaw, one each); rheumatism, twenty; pneumonia, seven; catarrhal pneumonia, two; pleu- ritis, seven ; delirium tremens, ten; delirium, seven; albuminuria, eight; acute nephritis, six; synovitis, five; phlebitis, seven ; diarrhoea, five; ton- sillitis, three; otitis media, pharyngitis, acute bronchitis, oedema of larynx, two each; angina pectoris, iritis, epistaxis, scurvy, hemiglossitis, neuralgia, sciatica, mastoiditis, pyaemia, endocarditis, eczema, jaundice, paralysis, men- ingitis, carbuncle, hysteria, apoplexy, insanity, arthritis, diphtheria, fol- lowed by leg ulcer and repeated hemorrhages, one each. Not a few of the complications which are mentioned by authors of modern text-books and other recent writers as being leading ones are, according to the results of these observations, actually rare. On the other hand, certain complicating conditions not emphasized in medical literature occur relatively frequently, notably acute articular rheumatism. With reference to this latter affection it should be pointed out that the attention of the profession has not hitherto been directed to the fact that it is quite frequently associated with erysip- elas. It is seen that, according to the above table, it ranks next to ab- scesses in point of frequency, and that it is present twice as often as delirium tremens, which stands third as to frequency of occurrence. In only three instances did the rheumatic attack precede the appearance of the erysipelas by two or three days. The symptoms of rheumatism usually came on several days after the onset of erysipelas. I will not at this time venture an opinion to explain why acute articular rheumatism should de- velop in the course of an existing erysipelas as often as would be indicated THE MORTALITY-RATE IN ERYSIPELAS. 3 by these researches. So long as the specific agent on which rheumatism depends is not known, so long must we remain in ignorance of the true explanation of this combination of diseases. It might be argued with considerable show of reason that the arthritic disturbance is purely symptomatic of a pysemic condition, and hence non- rheumatic in nature; but this latter view cannot be correct relative to at least one half-dozen instances in which a detailed description of the symp- toms was given. Moreover, I have endeavored to eliminate what might be regarded as doubtful cases, classifying them as "synovitis," etc. In connection with this, the fact before stated, that in fourteen instances chronic rheumatism preceded the attack and most probably operated as a predisposing factor, should be borne in mind. From these statistics it may be seen that pneumonia and pleuritis complicate erysipelas in a small pro- portion-less than one per cent.-of the cases. In some instances pneu- monia appeared early, hence it was due most probably to a special localiza- tion of the specific streptococcus. To such the term " pneumo-erysipelas" is here applied. The cases-two in number-in which acute nephritis developed during the first few days of the attack should be termed "nephro- erysipelas." I do not doubt that pneumonia, both lobar and catarrhal (the latter probably always), and acute nephritis, as well as pleuritis, may also occur as secondary results. It should be pointed out that acute endocarditis was present in but a single instance, and,1 since this complaint is held to be a relatively common complication by most recent authors, the present results may excite considerable surprise. Meningitis, which was formerly thought to be quite frequent, but is believed to be rare by a few recent writers, was present in one instance only, thus corroborating the latter view. Active delirium in this disease points to a severe type of infection, and not, as a rule, to meningitis. Precisely what is implied by "a complicating syno- vitis" it would be difficult to determine, unless we believe it to be a pysemic manifestation,-a not unlikely theory, I think. Perhaps certain other con- ditions, supposed to be complications, are to be regarded as pyaemic indica- tions, such as jaundice, etc. Mastoiditis, otitis media, tonsillitis, and oedema of the glottis are to be looked upon as secondary developments. Some interesting facts relating to the mortality-rate of this disease were also brought to light by these researches. In the opinion of all authors the death-rate is exceedingly variable, ranging, according to some writers, from one to fifty per cent. That it does exhibit great variations in this respect cannot be reasonably denied, but the limits of its diversities have been by many too widely separated. The correctness of this latter assertion will be evident after a glance at the accompanying table, which gives the number of cases from the different institutions separately, in which the terminations were recorded, with the number and percentage of deaths for each hospital, as well as the same points with reference to the cases derived from private practice. 4 JAMES M. ANDERS, M.D., PH.D., ON TABLE I.1 Source of Cases. Number of Terminations Recorded. Number of Deaths. Percentage of Deaths. General Aver- age Mortality Blocklev Hospital 1095 73 6.29 Pennsylvania Hospital 523 27 5.1 Episcopal Hospital 71 9 12.6 Johns Hopkins Hospital 16 3 18.75 German Hospital 9 3 33 3 Private practice 96 4 4 16 Total 1810 119 6.57 6.57 It will be observed that the variations in the percentage of deaths are not so great in the larger individual series, which are composed of sufficient cases on which to base reliable inferences. The general average mortality- rate, it is seen, is 6.57 j)er cent. The cases from private practice gave a lower death-rate, or 4.16 per cent. In the female sex it is 1.5 per cent, lower than in the male, according to these statistics. Surgical or traumatic erysipelas has a higher ratio of deaths than indicated by the general aver- age. There were one hundred and one cases classified as purely traumatic, and for these the percentage of deaths was 14.5. A careful study of the cases which were preceded by chronic illness shows that they swell the general average mortality-list, the increase being not less than twenty-five per cent. When occurring in the course of chronic Bright's disease the percentage of deaths was as high as forty, while in pulmo- nary tuberculosis (first and second stages) it was thirty. The disease proved fatal in two cases that occurred during convalescence from typhoid fever. The effect of complications upon the frequency of deaths is a question of lively interest and primary importance. This point also was investigated. The comparative gravity of the leading complicating conditions and diseases is shown by the following table. Complications. Instances. Deaths. Percentage of Deaths. Abscesses 105 8 7.6 Acute rheumatism 20 2 10 Pneumonia 4 57.1 " catarrhal 2 Delirium 4 57.1 Delirium tremens 10 8 80 Pleuritis 7 1 14.3 Acute nephritis 6 3 50 Phlebitis y Synovitis 5 Diarrhoea 5 (Edema of larvnx 2 2 100 Pyaemia 1 1 100 TABLE II. 1 Table VII. of former article. THE MORTALITY-RATE IN ERYSIPELAS. 5 It will be seen that while abscesses are common they do not to any ex- tent augment the mortality-rate. Pneumonia, delirium, delirium tremens, and acute nephritis are among the graver complications. Acute rheumatism, AGES. on the other hand, stands second in frequency, but is comparatively harm- less. To account for the increase in the percentage of fatal cases due to acute articular rheumatism we possess no positive knowledge. The opinion is and long has been prevalent that erysipelas benefits and even cures acute articular rheumatism and other affections, including carcinoma and sarcoma. Age, modifies the mortality. Above may be found a tracing which rep- resents the percentage of deaths in erysipelas, for the different decades, from the time of birth to eighty years of age. The line rises in increments of five. The mortality, it will be seen, is much less than the general aver- age,-i.e., 6.57 per cent.,-from birth to forty or forty-five years, and then it gradually becomes greater until we reach sixty years. After sixty each year increases considerably the percentage of deaths, while after seventy the percentage rises rapidly to forty-six. While age, per se, as has been stated, influences the death-rate quite materially, it does so only in persons over forty-five years of age. Other factors must not be overlooked. It 6 THE MORTALITY-RATE IN ERYSIPELAS. was among middle-aged and old persons that, comparatively speaking, most of the cases occurred in which chronic affections were associated. These latter, as previously shown, exert considerable influence upon the mortality. The various complications before mentioned did not prevail more exten- sively during the later than during the earlier periods of life. In conclusion, I would submit a few deductions which may serve not only to reiterate some of the leading demonstrated facts, but also to facili- tate a discussion of the same : (a) In typical cases erysipelas is a self-limited disease, the average duration in persons under forty years of age being fourteen days. (6) The course of the disease was greatly lengthened when complica- tions were present or chronic affections pre-existed, as well as when occur- ring in persons over fifty years of age. (c) Certain chronic affections, notably pulmonary tuberculosis, chronic nephritis, chronic rheumatism, and organic diseases of the heart, increase the susceptibility to the complaint,-having been present in 7.8 per cent, of the total number of cases. (d) The most common complications were abscesses and acute rheuma- tism ; the rarest meningitis and ulcerative endocarditis, pericarditis not having furnished a single instance. (e) The general average mortality was 6.57 per cent., while in the cases from private practice it was 4.16 per cent.; in persons under forty years it was only 3.5 per cent., in those over seventy years 46 per cent., and in the traumatic cases 14.5 per cent. (/) The mortality-list was augmented as much as twenty-five per cent, by the presence of coexisting chronic affections. (^) The numerous complications also increased the percentage of deaths, and certain of them in an especial degree, notably lobar pneumonia, acute nephritis, delirium tremens, and active delirium. (A) Age has a decisive influence upon the mortality after the forty-fifth year, this effect becoming more pronounced after the sixtieth year. International A MONTHLY Medical it < SURGICAL SCIENCE. Magazine. 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