THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT Dr. 3mil Bocen Q= t" J 1, ( bl n Vr^ i !ll L_^ V ^WAtLNlVtK'VA ^LUVAiNI ^i £3^ <P ^ y^-^N- S J '^^^ ^ ^ /^> i ^ ^^ 9 BSB!^^ '-4\)l ^^ - — -^^xs a ^ ;'TinK'\.'.vr\TH^ -7^/0 vr ^^Si^^^^SI i^^^ im 3Z5V0 u_ JX — 1 ^ s ';ai;\6^/ .'Lilt'^KA b b Thyroid Cartilage Crico-Thy oid Membran.3 - V- V\ and Artery. L_ \\ ; Cricoid Cartilaga— ^^h Superior Thyroid vein Infer, Thyroid V- Arteria imiorainat; A TREATISE ■ON — DIPHTHERIA Historically and Practically Considered; — INCLUDING — Croup. Tracheotomy and Intubation. By a. SANNE, Docteur en Medecine, Ancien des Hopiinux de Paris, Memhre de tu Societe Anatomigue, Des Societes de Medecine de Nancy, de Genhve, etc. Chevalier de la Legion d' Honneur. Translated, annotated AND THE SURGICAL ANATOMY ADDED; ILLUSTRATED WITH A FULL-PAGE COLORED LITHOGRAPH. AND MANY WOOD ENGRAVINGS. By henry z. gill, A.m., m. d., l l. d., Late Professor of Opera.fire and Clinical Snrgcry in the Medical Department of the Uniuersity of Wooster. at Cleveland. 0. ; Manber of the American Medical Association, Etc. St. Louis. Mo. : J. II. CHAMliERS & CO., 1887 COPYRIGHTED 1 887. By J. H. CHAMBERS. ALL RIGHTS RESERVED. mi TO PROFESSOR EDMUND ANDREWS, M.D., LL.D., AS A TRIBUTE OF RESPECT FOR HIS MORAL WORTH, LITERARY ATTAINMENTS,* AND DISTINGUISHED RANK IN THE MEDICAL PROFESSION, AND IN ACKNOWLEDGMENT OF PERSONAL FAVORS AND ENCOURAGEMENT IN THE PROSECUTION OF THE WORK, IS THIS TREATISE, IN ENGLISH DRESS, SINCERELY DEDICATED, BT HIS FRIEND, THE TRANSLATOR. INTRODUCTION. Since the period at which the immortal work of Bretonneau on diphtheria appeared numerous investigations have been made, and publications of great interest have issued from the press. The most celebrated, those 'which came from Trous- seau, have supplemented the description of the disease by ac- cessories which had escaped his predecessor. The labor of these two illustrious physicians has remained standing in its truly original portion — in that which concerns the doctrine of specificity. Their theories have undergone the test of time ; they have resisted powerful attacks, but now see returning to them a medical generation, shaken for a moment by specula- tions prematurely erected upon controvertible data. But the disease has continued its career, and has extended almost to the entire world ; its study has been pursued with perseverance ; new views have been enunciated, and certain important phenomena have been carefully examined if not fully explained. These elements, scattered through science, must be col- lected, classified, the approved acquisitions noted, the state of our knowledge upon points still in dispute set forth and, at the same time, must indicate the results of personal research, and, finally, present diphtheria in its complete entirety. I have undertaken"this task ; I have felt myself irresistibly attracted to it. For a long time my thoughts were directed in this channel ; being a student of Barthez and of Trousseau, two teachers who have contributed largely to the progress of this branch of pathology, I have been able to study diphtheria very closely. As early as 1869, I undertook to investigate a part of the subject, quite limited in appearance, that of the sequences of tracheotomy ; and we have seen by the develop- ments into which I have entered, what a conspicuous place it should occupy. The materials, so extensive, which I had barely touched, so to speak, at that time, offered me in pro- (5) VI INTRODUCTION. fusion the desirable resources. They have since been in- creased by an immense number of observations made by my- self at the Sainte Eugenie, or coming from my private prac- tice in the city; I have been able to add, also, notes taken of all the cases of diphtheria entering the service of Barthez, from 1869 to 1875, notes which this eminent teacher has placed at my disposal as he had already done those of the pe- riod from 1854 to 1869. The work which follows is, therefore, the substance of about fifteen hundred observations. Numer- ous facts, extracted from several theses and memoirs on diph- theria, have also been placed under contribution. I have en- deavored to make known the state of the question in France and abroad ; one will find a brief statement of the principal epidemics which have occurred in the old and in the new world, and the statistics will set forth the results of tracheot- omy in many of these countries. To have produced accurate accounts of the invading march of this plague in France, and of the track over which it has traversed annually, would have been very instructive. The reports of the committee on pre- vailing diseases, edited by E. Besnier, and the mortality tables published by the prefecture of the department of the Seine, have furnished me positive data of the course of the disease in Paris for some years past. The provinces have furnished me information much less definite ; the unfortunate interrup- tion which one observes in the reports of the epidemics pre- vents establishing complete statistics. I, therefore, join with authorized physicians who have demanded the reorganization of this service. I may not close without thanking MM. Barbosa, of Lisbon ; d'Espine, of Geneva ; Henriette and Warlomont, of Brussels, and Letourneau, of Florence, for the valuable documents which they have so kindly transmitted to me with equal promptness and liberality. A. SANNE. Paris, July, 1876. TRANSLATOR'S PREFACE. About eighteen years ago the question of the nature of diph- theria and of membranous croup — its oneness or duaUty — at- tracted my special attention and study. Having become ac- quainted with the German view from the personal instruction of Virchow, and then examining the subject as held by the French, and those two views so diametrically opposed as divid- ing the suffrages of the English and American authors and teachers, the subject grew upon my thought both in interest and extent. Was there no way of solving the problem — no way of reconciling the differences ? To adopt the views of the one class of observers was to reject the clinical facts, and teachings deduced therefrom, of the other equally competent and of equal experience. Having observed in discussions before medical societies the vagueness in many practising physicians as to the reasons for the use of certain remedies, as well as the positive dicta of others as to the difference between the membranous manifes- tations in the pharynx on the one hand and in the larynx oit the other, and especially in the only treatment in many casei (tracheotomy) which could possibly afford any chance of reliel or of hfe, I read everything regarded of high authority that 1 could command, either in German, French or English, which had for its object the investigation of the nature of the mem- branous diseases of the throat and air-passages. Very soon after its appearance in the original I imported Sanne's work. Its fullness, taking every feature of the subject under consider- ation, tracing its history down through the centuries, the clinical observations, the pathological manifestations, micro- scopical and clinical examination, and its inoculation — I con- fess the whole question grew in interest until it became almost a charm. At the same time, or a little before, operating on (7) VIU PREFACE. some cases for laryngeal obstruction (croup) with very encour- aging success, I set about investigating the status of the question, including the operation of tracheotomy, for the lar^mgeal form of the disease, in the entire state of Illinois, aiming to obtain the doctrines held, and the treatment, medical and surgical, adopted by the profession there, and to collect every case of tracheotomy that had ever been performed in the state for this disease (croup), with details of the operation. After most dili- gent investigation and extensive correspondence, continued until 1 88 1, the number of operations reported reached 151, of which 38 recovered — a number sufficiently large to encourage, certainly, the repetition of the practice in all suitable cases. In the above correspondence I was particularly impressed with the confused, limited and erroneous views held by many on the natui-e of, as well as the practise in, this very important disease. When we recall the fact that every year thousands die in the United States of diphtheria either with or without the laryn- geal complication (in 1880, according to the United States census, 38,398, or 52.32 to the 1,000 of all deaths with cause re- corded), it becomes every general practitioner to fully inform himself of the established facts of the disease, as well as of the questions still under investigation. A passage here from Prof. Jacobi's article in " Pepper's System of Medicine," will be in point : " It is a matter of regret that the limited space allotted to this subject should exclude much historical detail of the etiol- ogy, pathology and therapeutics of diphtheria. If history of any disease is interesting, and the neglect of its study has ever punished zVi'^//' [italics ours] it is diphtheria. Particularly would the treatment have been more successful if the knowledge of former times had been available and more heeded." In this volume, that regret may not arise, if the reader will have the industry to read, and exercise the intelligence to ana- lyze the material herein presented, both theory and practice, may we not confidently hope, will be greatly advanced, and in the result many lives be saved. I have used the metric sys- PREFACE. IX tern of weights and measures, not, however, omitting the one in more common use, though with the hope of aiding in the early general adoption of the former. The Arabic has, in both cases, been used rather than the Roman numerals. For this I make no apology. I had prepared a bibliography, chronologically arranged, of over thirty fools-cap pages, but upon farther considering the matter, it occurred to me that, for the general practitioner, it would be of little interest ; and because any one making an ex- tensive investigation of any of the questions connected with this subject would have access to " The Index-Catalogue of the Library of the Surgeon-General's Office," to be found in nearly all public libraries ; and for the farther reason that it seemed necessary to bring the limits of the work within some reasona- ble bounds. It is fitting and a pleasure to acknowledge the promptness and courtesy of my friends who have aided in various ways in carrying forward the work which, under the circumstances of delivering two annual courses of lectures on clinical and oper- ative surgery at the college, and acting as registrar and treas- urer, has been no easy task. Nothing short of the conviction of the intrinsic value of the work would have held me to its prosecution. The addition of the surgical anatomy of tracheotomy was an original thought with the translator ; and Prof. E. Andrews consented and prepared some matter for it. But an unforeseen and unavoidable delay occurred in the carrying out of the original plan; and the Professor, in the meantime, assumed other duties which made it, at a later date, impossible to complete the former purpose. Other arrangements had to be made. My friend, Dr. Lewis S. Pilcher, of Brooklyn, N. Y., most gen- erously placed at my disposal his article and the accompanying illustrations on the anatomy of the " Pretracheal Region." I have used much of it literally and liberally, and for it he has my warmest thanks. Dr. Harry K. Bell, of the " Sanitarian," very kindly prepared for me a " Report of the Mortality from Diphtheria and Croup X PREFACE. in the United States, during the year 1883," including nearly all the larger towns and cities, for the several weeks reported. But as, in many cases, several weeks were omitted, I could not use the report. I have, therefore, selected a number of the larger cities of the Union, and have given the mortality from diphtheria and croup for the years 1883 and 1884. This one table, if no other reason were given, would be justification for the publishing of the following pages. The translation has been made in the intervals of other work. It was very difficult to obtain assistance. Teachers of French do not always understand idiomatic English, and but few of those who do are familiar with medical language ; hence, it became necessary for me to reread and correct nearly all the work. Miss Annie B. Irish, Professor of the German Lang- uage and Literature in the University of Wooster, revised a portion of my first chapters, but distance and her engagements made it impracticable to further continue that assistance. Dr. L. B. Tuckerman kindly aided me in the latter part of the translation, other duties requiring so much of my time. Finally, the whole was reread by me with M. Lejeane, a Frenchman by birth and education. Did time permit, it would be a pleasure to read even again the entire volume, and in some cases to transpose, and to abbreviate in many cases ; but believing that the facts and sentiments are set forth in sufficiently clear terms to be understood it must now go to the reader, fully aware as we are that some mistakes may still be found. The author kindly gave me full permission to make the trans- lation, and has, since the first permit, also sent me his article on Diphtheria to be found in the Cyclopoedia Medical of a still later date of which I have availed myself I have added very recently some pages on hitubation, a pro- cedure now re-attracting the attention of the profession. In all over 50 pages have been added to the original work. Cleveland, O., Oct. i, 1886. TABLE OF CONTENTS. Frontispiece. Pseudo-Membranous Cast. Preface. Surgical Anatomy, - - - - - - - -- - i — 32 Introduction. Definition. History. Pathological Anatom/, -- -------52 FIRST CLASS. Primary Lesions of the False Membrane, ------ 53 Supports of the False Membrane, ---.----76 SECOND CLASS. Lesions of Apparatus, _...---.-- 81 Symptoms, -------------129 General Description of Diphtheria, - - - - - - i;,i — 188 Localizations of Diphtheria, ------- 1S9 — 264 Course. Duration. Termination, _-.-.-- 265 Recurrence. Diagnosis, -._ 267 Etiology, ----- 303 Epidemics, ----------- 304 — 358 Nature of Diphtheria --------- 359 — 374 Prognosis, ------------ 375 — 386 Treatment. ------------ 387 General Treatment, ---------- 457 Surgical Treatment, --------- 458 — 555 Sequences of Tracheotomy, ------- 536 — 635 Complications 574 Intubation of the Glottic, -------- 635 — 641 Prophylaxis, ----------- 652 — 656 LIST OF ILLUSTRATIONS. Fig. 2. Fig. 3- Fig. 4. Fig. 5- Fig. 6. Fig. 7- Fig. 8. Frontispiece, Membranous Cast from the Air-Passages. Fig. la. The vessels of the pretracheal space, natural size ; from a child of three years, 4 Fig. i^. The deep layer of the superficial fascia with the anterior jugular ve- nous plexus — typical arrangement, 5 Single median anterior vein, 6 Anterior jugular venous plexus, 6 Anterior jugular venous plexus, 6 The anterior cervical muscles, 8 The pretracheal space with typical arrangement of vessels and of thyroid gland, from nalure, 8 Larynx and trachea of child of six years, nataril size, isthmus ab- sent. Pyramid of Lalouette on left side. II Transvers'j anastomosing superior thyroid artery of large size; a'^- normal course of the crico- thyroid branch, 12 Fig. 9. Irregular course of the superior thyroid artery wijh anomalous sub- hyoid and crico-thyroid branches, 13 Figs. 10 — 11. Inferior thyroid venous plexus, 14 Figs. 12 — 13. Inferior thyroid venous plexus, 15 Fig. 14. Inferior thyroid venous plexus, 16 Fig. 15. Inferior thyroid veuous plexus, 17 Fig. 16. The pretracheal space. 20 Fig. 17. Innominate ariery crossing trachea transversely at a high point, 21 EiG. 18. The four great vessels arising separately from the arch of the aorta, 21 Fig. 19. The four great vessels arising separately from the arch of the aorta; the right subclavian and left carotid crossing in front of the of the trachea above the sternum, 22 Fig. 20. The four great vessels and the left vertebral arising separately from the arch of the aorta; right subclavian from left side of arch, passing behind others in front of trachea to its proper side, 22 Fig. 21. Carotids arising by a common median trunk between the origins of the subclavians, 23 Fig. 22. Carotids arising by a common trunk on right side, right subclavian from left side of arch, passing behind others in front of trachea to its prooer side, 23 Fig. 23. Right primitive carotid and subclavian arising separately from arch of aorta ; innominate on left side, 23 (12) LIST OF ILLUSTRATIONS CONTINUED. Xlll Fig. 24. Right subclavian arising from the arch of the aorta , both primitive carotids and the left subclavian by a common trunk on the left side, 23 Figs. 25 — 28. Anomalies in the arteries arising from the arch of the aorta, Figs. 29 — 34. C aliber of the larynx at different points, and at different ages, 32 Fig. 35. Dr. Packard's substitute for tracheotomy tube, 513 Fig. 36. Dr. L N. Himes' case of polypoid groA^th in the larynx, 614 Fig. 37. Dr. Hendrix's tracheotomy tube, 631. Figs. 38 — 40. Dr. O'Dwyer's instruments, A, B, C, D, for intubation. 636 Figs. 41 — 42. Dr. T. F. Rumbold's spray-producing instruments, 642 LIST OF AUTHORS AND WORKS REFERRED TO. Abeill*^. Acquapendente. Alaymo. Alexander. Albu. Allis. AndraL Andree, ^fi>in Annandale. Archaml-ault. Aretseus. Asclepiades. Aiibrun, Sr., Jr. Autenrieth. Avicenna. Ayers. Accetella. Adamson. Albers. Alibert. Albucasis. Amussat. Andre. Anger. Antyl us. Archer, Sr., Jr. Arron. Atlee. Aurelianus. Avenzoar. Axenftid. Babbington. Baillou. Baizeau. Balassa. Barbosa. Baron. Barry. Bartels. Barthez. Baudry. Baumbach. Bazin. Beau. Beaup. Becker. BecquereL Beherns. Bache. Bailly. Balzer. Barbeu. Bard. Barrier. Bartels, Max. Bartholin. Bastion. Baudelocque. Bayley. Beau, Verdeny. Beaupoil. Beclere. Behier. Bell. (14) LIST OF AUTHORS. XV Bellini. Bergius. Beringuir. Besnier. Bienfait. Bigelow. Binder. Bisnard. Bisson. Blache. Billroth. Blanclvt. Bland 1 1 . Bloom. Bogue, R. G. Boldyr . w. Bond. Bonley. Borden. Borsieri. Bousedo. Boudillat Bourdon. Bousuge. Bowman. Boeckel, E. W. Brassavolo Branco. Bridger. Briddon Brown, B. Broussais. Burgess. Burrow. Bergeron. Bernard, CI. Bernheim. Bichat. Biermer. Billard. Bischof. Bissel. Bitdeheim. Blachez, Blanchetiere. Blondeau. Broeck. Boeckel. Boinet. Boiling. Bonisson. Bonnet. Boruscut. Bouchut Boudet. Bouillon Lagrange. Bourgois. Bouvier. Braidwood. Brasch. Brenner. Bricheteau. Broncoli Brown-Sequard. Buchanan. Buhl. Burns. Buck. Cabot. Caillau. Calligari. Camlierlin. Carnevale. Carvalho. Cascalez. Casseri. Chantourelle. Charcot Chatard. Caldwell, C. P. Caillault. Calvet. Camuset. Caron. Casalds. Caspary. Chailly. Chapman. Chassaignac Chaussier. XVI LIST OF AUTHORS. Chavanne. Cheever. Cheyne. Cinni. Clemens. Coelius Aurelianus. Cohnheim. Colin. Colson. Corcelle. Cook. Costi has. Crawtord. Cruickshank. Daguillon. Damonette. Decker. De la Berge. Delacoux. Delthil. Demme. Deslandes. Ditzel. Double. Donders. Droste. Duch6. Duchenne. Duhomme. Dumontpallier. Durham. Duval. Diitersburg. Chedevergne. Chevalier. Chomel, Sr. Classen. Cleveland. Cohen. Colden, Cadwalader. Collin. Constantin. Cornil. Cortesio. Courty. Crequy. Curtis. D Damaschino. Daviot. Dehee. Delbert. Delens. Demarquay. Desault. Dickinson. D'Espine, Sr. Jr. Dobson. Dillie. Drysdale. Duchamp. Dufresse. Dujardin. Duplay. Durr. Dupuy. Easton. ^gineta, Paulus. Eisenschitz. Engstrom. Erb. Evans. Eberth. Eisenmann. Em pis. ^tius. Ebpine. Fabre. Faralli. Felix. Ferrand. Fagge. Fenger, Chr. Fenner. Fergeot. LIST OF AUTHORS. XVll Fehrmann. Figueiras. Fischer. Flammarion. Fock. Fontheim. Foncher. Formad. Foster. Fourgeaud. Foville. Frcebelius. Ferrier. Finaz. Fisher. Fleishmann. FoUin. Foglio. Forest, Peter. Foster. Fothergill. Fouris. Francisco. Fuller. Gairdner. Galentin. Garnier. Gavarret. Gendron. Gerlier. Germain. Gherli. Giacchi. Gibert. Gingiber. Gilette. Giron, Sales. Giurleo. Goltwald. Gosselin. Goupil. Green. Graefe. Gregory. Grove. Grandvilliers. Gubler. Guersant. Guinnier. Guyet Habicot. Hachler. Hallenius. Hallier. Manner. Harless. Galen. Garengeot. Gaupp. Gay. Gee. Gerdy. Germe. Ghisi. Gibbon. Gigot- Gigon. Giovanni. Girtanner. Goddard. Gombault. Gottstein, Gree. Greenhow. Graf. Grisolle. Griinberg. Grandboulogne. Guerard. Guillemaut. Gustin. H Hache. Hagner. Haller. Hamilton. Harder. Hatin. XVUl LIST OF AUTHORS. Haughton. Heister. Henle. Henroz. Henoch. Heral. Herard. Herrera. Herville. Ilewson. Hillier. Hilton. Hirsch. Hoffmann. Home. Holmes. Howse. Hufeland. Hiillmann. Huxham. Hayem. Hemey. Hendrick. Hendrix. Henriques. Henriette. Heredia. Hervieux. Herpin. Heslop. Hippocrates. Hodge. Holden. Homolle. Hueter. Hunt, E. M. Hulke. Hutchinson. Huttenbrenner. Ingals, E. F. Isnard Isambert Jaccoud. Jacobi, A. Jenner. Johnson. Juan do Soto. Jugand. Keen. Klaproth. Klee. Kohnemann. Korturn. Krackowitzer. Kiichenmeister. Jackson, V. Jaffa, Max. Jodin. Johnson, H. A. J urine. K KeeteL Klebs. Kieser. Korting. Kraft-Ebing. Krishaber. Kiihn. Labadie Lagrave. Laboulbene. Labat Lacaze. Laignez. Lallemand. Landeau. Labric. La Board. Laennec. Lallement. Lancereaux. Lange. LIST OF AUTHORS. XIX Langenbeck. Larue. Latour. Lauton. Layaut6. Ledran. Le Fort LegrOiX. Lespine. Letourneau. Lepine. Lepois. Leyden. Lionville. Loffler. Lorain. Louis. Lusitanus. McKenzie. Magne. Mair. Malichecq. Malouin. Marjolin. Marmisse. Marsb. Martin. Maunoir. Meigs. Menezes. Mesue. Michon. Millar. Minor. MiqueL Molloy. Morath. Morax. Monneret Monckton. Mounert. Muron. Napier. Nekton. Langbans. Lasegue. Laugier. Lavergne. Lecorche. Lee, E. W. Legros. Lemaire. Lespiau. Letzerich. Levis. Lewin. Lincoln. Littre. Loiseau. Loreau. Lunin. Liitz. M Malavicini. Maingault. Malgaigne. Maissonneuve. Rtaisord. Marchal. Marotte. Marteau de Grandvilliers. Maugin. Mazotto. Mellvain. Mercado. Michaelis. Middleton. Millard. Minowsky. Molendzinski. Mollereau. Moreau. Moriseau. Mortlake. Moiiremans. Moynier. Muller, Max. N NasilofF. Neubauer. XX LIST OF AUTHORS. Neumann. Niemeyer. Nola. Nunez. O'Dwyer, J. Oertel. Oppolzer. Ormerod. Oulmount Newcourt. NiveU Nonat- o Oelschlager. Onimus. Orillard. Otrobon. Ozanam. Packard. Paget. Pantaire. Parise. Paterson. Pean. Pelvet P6rat6. Perchant Perrin. Peter. Philippeaux. Picard. Pilcher, L. S. Pletzer. Polan. Prentis. Prosimi. Quinquaud. Raciborsky. Radcliff. Ranse. Ranvier. Rapin. Ravn. Raynaud. Rechou. Regnard. Reiffer. Reveil. Ridard. RillieL Page. Pancoast Parker, R. W. Parrot. Passavant. Pelletier de Chanbure. Pepper. Perier. Perron. Petit. Physick. Picot. Pinel. Plouviez. Potain. PouUet. Pouquet Prosper Faucher. Q R Racle. Ranney, S. W. Ransom. Rapp. Raser. Rayer. Reboullet Regate. Reil. Revilliout Richardson. Richardson, J. R, \ Rindfleisch. Robert Robinson. Rodrigues. RokitanskL Rosati. Rosenthal. Rothe. Rouziez-Joly. Rudberg. Rumsey. Ruysch. •LIST OF AUTHORS. Rippley, J, H. Robin. Roche. Roger. Rollo. Rosen. Roser. Roux. Royer Collard. Rumbold, T. F, Rush, Benj. XXI Sebatier. Saint Laurent Santy. S6e. Schobacher. Schrotter. Schiitz. Scoutetten. Seeligmiiller. Senator. Senf. Severinus. Signini. Smith, Henry. Smith. Solomon. Starr. Steiner. Stephenson. Stoeber. Stoll. Strong, A. B. Sylva. Symwrhid. Saint Germain. Santorio. Satterthwaite. See, Germain. Schlier. Schmidt. Schulz. Schwilgu6. Sebastien. Sellerier. Sendler. Serlo. Sgambati. Simon, Jules. Smith, H. H. Soglia. Soule. Squire. Stelzner. Steudener. Steppuhn. Stokes. Stolz. Tait. Tavignot. Teixeira. Thomas. Thompson. Tiedemann. Tilld. Tobanon. Tamajo. 'J'ardieu. Tenderini. Thore. Thomson. Tillaux. Titanus. Tommasi. XXll LIST OF AUTHORS. Toulmouche. Traube. Trousseau. Uhde. Ullersperger, Townsend. Trideau. Tuefferd. u Uhlenburg. Underwood. Vallantine. Valerani. Van Capelle. Velpeau. Vicq d' Azyr. Vidal. Villreal. Vogel. Vulpian. Voss. Wade- Wagner, E. Warimann. Warmont Weber, H. Wedel. Werner. iVhalbom. Wiedash. Wilson. Winkler. Wreden. Wynne. Valleix. Van Bergen. Van K5pl. Verneuil. Vieuseux. Vigla. Virchow. Voltolini. Von Roth. w Wadel. Waldeyer. Warlomont. Waxham, F. E. Wecker. Weirus, John. West. Wichmann. Wiederhoier. Wilke. Wood. Wundeilich. Zenker. Zorgo. Zobel. Zurkowski. INDEX. Abscess, . 83, 289. 576, 647 Anoesthetics, • 517 Acids, . . . .70 Angina, 34, 74, 149, 416 acetic, . . 71, 431 benign. 437 boracic, . . . 435 croupal. 35 carbolic, . . 410, 433 explosive. 199 chromic, . . 70 gangrenous. 54, 194 citric, . . 71, 431 maligna, 35, 199, 437-8 gallic, . . . 409 pestilential. 38 hydrochloric, . 70,417 Anorexia, 212 1 lactic, . . 71,431,438 Antimony, sulph., 40s ' nitric, . . 70,417 tartrate, . 395 oxalic, . . 410, 425 Antiphlogistics, . • 389 salicylic, . 410, 4", 435 Antispasmodics, 453 sulphuric, . . 70, 417 Antiseptics, 407,411,432 Adenitis, . . .81, 82, 644 Apomorphia, 450, 455 Age, . . . 350,377,445 Aphonia, 172 Air, in veins, death from, . . 26 Aphthae, 279, 298, 399 Albuminuria, 50, 124, 140, et. seq., 200 Apparatus, see Diphtheria. 212, 294 Asphyxia, 496-98, 537 Alcohol, 70,411-13,425,439,543,649 Aspirator tube, . 514, 550 Alimentation, . . 8, 412, 571 Astringents, 424 Alum, . 73, 392, 419, 424, 438 Atomizing, 444 Ammonia, . . 427, 444 Auscultation, 500-2 Anatomy, surgical, . i et seq. Autopsy, 113 Bacillus, 373-4 Bacteria, . 57,66 Balsamics, . 37-8, 51, 392 Beaty, David E., Jr., 612 Bite, causing diphth. . . 337 Bladder, . 124, 166 Bleeding in diphth.. 389 Blisters, 369, 390, 440, 649 Blood in diphth.. 41, 115, 121,390 Borax, . . . 424 Bromate of potass., . . 427 Bromide of potass., . 72,427,438 Bromine, 39, 70, 80, 406, 426, 432, 438, 445, 449, 454 Bronchitis in children, . 231, 243 capillary, . . . 290 pseudo-membranous, . 642-4 Broncho-pneumonia, 92-8, 232, 234, 502 (23) XXIV INDEX. Calomel, . 73. 391 Constipation, 212 Cartilage, cricoid, see Anatomy. Constitution, medical e, • 375 thyroid, 27 Contagion, 325 Catarrh, 283 Contro-stimulants, 5o> 435 laryngitis. . Convulsions, 161,620 pneumonia. 403 Copaiba, 401 Cause, see Etiology Copper, sulph.. 418 Catheterization ol larynx, 446-8, 454, 635 Corium, lesions of, 59. 75 Cauterization, 75, 365,417-423,449.454 Corrosive sublimate. 406 Children, 33, 38, 39 Coryza, 203, 241, 295, 641 Chinolin, 406 Croup, 439 Chloral, 433-34 and diphtheria, identity, . 48 Chlorate, see Potass, and Sodium. cure in. 497 Chorine water, 400 diphtheritic, 48, 62, 291, 363-s Cicatrization, • 593 duration of, 76, 221, 225 premature, 594 forms of, 217, 221 Climate, . 320 membrane, 305 Clots in heart, III, 116 paroxysms in, 497 Coal tar. • 443 periods of. 204-8,225,451-4 Coffee, . 413. 437-8 primary, 201 Cold, . 414 secondary, 504 Cold cream, . 580 symptoms, 203-9, 230 Collapse, 438 treatment, 497. 573 Collodion, 554, 562 Cubebs, 401, 402 Complications, . 226, 230-8, 621, 646 Cyanosis, 501 Conjunctivitis, see I iphtheria. D Deaths among physicians. 327 Degeneration, amyloic i, 123 fatty. 127 Diarrhoea, 151 Diphtheria: definition, . . 33 et seq., 52 diagnosis. . 268 et seq. etiology. 303 in tracheotomy, . 590 ofanusj 40, 57, 85. 172, 258, 300 of bladder, 124 of connective tissue. 83 of ear, 53, 128 251, 297, 644 of eye. . 57, 127 167. 171 247, 296, 644 of fauces. 39, 416 of glands. 81-2, 198, 644 Diphtheria 0/ apparatus, nervous, 125 skin, . . . 261 German view of, 47, 58, 59, 360, 363 a parasitic disease, . 66, 372 a specific disease, 47, 51. 359, 369, 370 conditions favoring, . 349 conditions unfavorable to, 353 contagiousness of, 39, 326, 367 course of, . . 265 duration of, . . 265, 624 following other diseases, 354 forms of, 62, 131, 1F9, 387 fungus in, 64, 372-4 gangrene in, 77, 80-1 incubation of. 355 nature of. 359 INDEX. XXV of intestines, . 85, 258 of larynx, 282 of liver, . 86 of lungs, . • 94 of mouth, 83, 253-7, 297, 646 of nose, 39, 41,86, I 29, 203, , 206, 295 symptoms. • 129, 192 synonyms of, . 33 of apparatus : circulatory, . no digestive, 83, 253, 647 genito-urinary. . 124, 259 glandular. 81 -2; , 198, 644 locomotor. 128 primary, . 78, 130 secondary, 78, 185-8, 353 termination of. . 265 transmission of. 325-6 typhoid, • . 8s without diphtheria, 62, 175, 282, 369 Diphtherite, . . 45-7, 37 1 Diphtheroid, . . 37° Drinks, . . . 416 Dropsy, . . . I44 Dull knife, ... 9 Dysphagia, . • . I97 Dyspnoea, . . 35,213-16 E Ear, see Diphtheria. Ecchemosis, . . . 164 Electricity, . . 166, 181-2 Emboli, . . . 106 Emetics, . 390-8, 435, 449, 452 Emigration of blood globules, 61-7, 73 Emphysema, . 105, 236, 550-4 Endemics, . 303 et seq., 380-2 influence of other, . 324 Endo-carditis, . . 156 et seq. Endocardium, . . 113 Entrance of infectious material into the system, mode of, see Trans- mission. Epidemics, . 36-49, 304-324 Epidemics, influence of other, 324 Epiglottis, Epistaxis, . . . 154"^ Epithelium, transformation of, 58-69 Eruptions, 40-1, 148 et seq., 212 Erysipelas in tracheotomy, . 581 Eschar, . . . 56,67-8 Etiology, ... 303 Eustachian tube, . . S3, 253 Expectorants, . • 4^4 Experiments, Curtis and S., Wood and Formad, . 339-41 Extravasation of blood, . 83 Exudates, . . . 72,403 Eye, see Diphtheria. False Membranes : adherence of, characteristics of, chemical characteristics of, color, . . 41 destruction of, detachment of, dimensions of, . expelled, extension of, exudative nature of, forms of, 41, 53, 62, 131, I { from bronchi, False membranes, from larynx, 57 S4 nature of, . . . 67 45-78 prevention of, . . 389 45-9, putrefaction of, . . 363 69, 70 structure and seat of, . 52-77 I 53-55 theories of, . . 58-62 388 False principle, . • • 75 76 Fascia, . . . 5-10 . 53 Fauces, . . . . ^4 35 Fever, . . 209,415,495 74-5 Fibrin, exudation of, . 61-9, 78 67 Food, see Alimentation. I9, 387 Fumigation, . . 440, 443 57 XXVI INDEX. Gangjrene, 42, 56, 77-9, 81-3, 108, 152 Gland, thyroid, isthmus, 2,9-11,18,21,527 et seq., . . 171, 582 623 lymphatic. , 81 Gargles, . . 416,423-4, 435 suppuration of. 647 Geni to-urinary organs, see Diphtheria. Glottis, diameters of. 32 Genius epidemicus. 375 intubation of, . 446, 635 Germs, 354 Glycerine, • 70, 423 German views, see Diphtheria. Goat, operation on, , 459 Gland, thymus, . . 2, 19 Grog, • 439 H Haemorrhage, 154, 197, 199, 623, 647 Heart, clots in. . 117 fatal, ... 22 Hemiplegia, • • 166 into trachea, . . .18 Herpes labialis, . 2S0 in tracheotomy, 18, 29, 30, 155, 537 Herpetic pharynpi -, 279, :62 Haemostatics, . . 533, 543 Hospital gangrenj. . 370 forceps of Pean, . 515,542 Hygiene, defecti\ , 349, 570 Hearing, . . . 168 Hyoid bone. . 27 Heart, . . . 112,165 Hyperinosis, 121, 145 Ice, . . . 408, 415-16 Identity of all forms of diphtheria, 68 Illumination, . . . 516 Impotence, . . . 166 Incubation, . . 315, 355-8 Indications for treatment, . 387 Infection, . • 359, 363, 37° deaths from in physicians, 327 Inflation tube, . . 550-3 Inhalations, . . . 443 Injections, . . . 445 Inoculability, . . 326 et seq. Inoculability, accidental. • 331-3 by false membranes, 337 Insufflation, . 423-5, 440 Intelligence, . 169 Intestines, . . 85,258 Intubation, . 446, 635 Iodine, 70, 401, 410, 441 Ipecac, . 450 Iron, 414 perchloride of. 7 :, 406-7, 418 Irrigation, . • 438 Isolation, • 652 Jaborandi, Jews, 405 Jugular veins, 33 16 K Kermes mineral. Kidneys, 405 122, 145-6 Kidneys, loops of Henle, 123 INDEX. XXVll Labarraque's sol. 409-14, 433 Leeches, . . . 390 Lactic acid, see Acid. Lemon juice, . . . 430 Landmarks, suigical, I Leptothrix buccalis, . . 66 Laryngeal diphtheria. 282 Lesions, primary, secuiula.y, . 52 lesions. 625-6 Leucocytes, ... 78 Laryngitis, . 283 Light, .... 516 Laryngocentesis, 459 Lime, saccharate, . . 428 Laryngoscope, . 609 water, 399, 427, 438, 444-5, 454 Laryngotomy, 34, 460 " Line of safety," . . 3, 26 Laryngo-tracheotoni) , 10, 29 Listerine, . . . 435 Larynx, 27, 87, 170 Localization, . 315, 376, 416 foreign bodies in. . 289 Locomotor ataxia, . . 303 intubation of. • 635-40 Lymphatics, . . .81 M Malignant pustule, . . 361 Martyrology, . . . 327 Measles, 185, 238, 254, 495, 504 Mediastinum, . . 109 Medulla, . . . 169 Membrane, see False Membrane. mucous, . . -77 serous, ... 62 Mercury, Mercury, salts of, Micro-organisms, Milk, Morbus strangulatorius, Mortality, see Statisiics Mortification, Motility, Mucin, . 319, 406, 432, 442 Muguet, N 73 51, 57, 64-6 408 38 So 163, 166 69, 76 279 Necrosis, . . .67, 76 Nephritis (see also Kidneys), 58 Nervous system, see Paralysis, and Diphtheria of apparatus. Neurin, . . . 644 Nitrate of silver, . . 73 Nurses, trained, see Tracheotomy. Nutrition, see Alimentation. CEdema, glottidis, pulmonary, CEsophagus, 109, 124, 144, 156 82, 88, 92, 241, 286 237 Ontology, Origin, Oxalic acid, see Acii 75. 84, 554 Oysters, 407 303 412 Palate, . 37-9, 79, 84, 161, 179 Papayotin (papaine), . . 644 Paralysis, 37-9, 40-3, 51, 89, 126, 16), 161 et seq., . Parasites, see Micro-organisms. 302, 650 Pharyngitis, herpetic. 279, 362 Pilcher, Dr. L. S., 504 Pilocarpine, . Plasma, 120 Pleurisy, . 103, 236 XXVUl INDEX. Paresis, see Paralysis. Pathological, see Anatomy. physiology, Penis, Pepsin, . . . . Pericardium, Pharyngitis, 175, 189, 272 et seq benign, diphtheritic, duration of, 73. 213 124 112 366 190 193,272 197 Pneumonia, broncho-, 92, 232, 502 croupal, 58, lOl, 403, 503, 622, 649 pleuro- Polypus of larynx, Position of patient. Prevention, Prize, Prognosis, Prophylaxis. 104 613 515.650 . 239, 652 44, 397. 460 . 375.377 239, 652-6 Quinine, 412,437-8,455 R Railroads, 320 Resorcine, Rectum, 165 Respiration, Recurrence (recedive). 265, 377 Rete mucosum, Relapse, 315 Rhinoscopic, Remedies, numerous, 4" Rubeola, 406 • 244 . 81 206, 295 80 Salicylic acid, see Acid. Salivation, . . 292, 392 Scarlatina, 124, 144, 149, 186-8, 239, 354, 377. 495. 504 Scoutteten, . . 481,448 Season, . . 316, 320-1, 378 Self limitation, ."-enega, . . • 404 Sensation, . . . 167 Sepia blood, see Blood. Sequelae, . . • 240, 379 Sex, . . . 351.377.492 Spasm, . . . .161 Skin, diphtheria of, . . 646 Skin, mobility of in tracheotomy, 4, 5 Small-pox, . . . 504 Smell, . - . .168 Sodium, benzoate, bi-carbonate, . 3934, 427 chlorate of, . . 72, 426, 430 chloride of, . . 73 hypobromite, . . 73 Soda, caustic, . . 418 Spasm of glottis, of larynx, Speech, . Specifics, Spray, Statistics, . Steam, Sternutatories, . 289, 617 421, 428 . 168 50,411,416,443 . 445, 642 380, et seq., 456, et seq. . 441 452 Stimulants, see Alcohol, Stomach, . . 85-6, 15 1-7 Stomatitis, . 84, 257, 298, 392, 429 Strabismus, ... 39 Stricture, of larynx, of pharynx, of trachea. Strychnia, Suffocation, Sulphur, Sulphites, Swabbing of larynx, Symptoms, Syncope, Syphilis, . 82 82 . 93, 607-8 • 35. 47 407, 424, 438 410 443 129, 192, 201 537 33^> 377 INDEX. T Table, operating, 515 Tannin, . . 424,438,454 Tartar emetic, • 395.449 Taste, . 168 Teeth, • 35, 392 Temperature, 209-11, 502, 571 Temperament, • 352,378 Thermo-cautery, 30 Throat, 416 Thrombosis, 116 etseq., 158 Tirage, 206 Tonics, 413, 439, 455 Tongue, 84 Tonsillitis, 273, 422 Trachea, see also Surg. Anatomy, 90 aspirator, . . 550 collapse of walls of . . 563 diameters of, . . 31, 32 fistula of, . . .619 impertect incisions of, . 544-7 movements of, . . 2, 27 polypus of, • . 93, 608-16 retraction of, . . 29 rings of, . 12, 29, 92, 489 ulceration of, . 51, 91-3, 601-7 Tracheotomy, .... 34, 38, 42, 47, 50, 451. 458, et seq., 638 age, . . 481, 488-92 accidents of, . 497, 525, 537, 547. 555. 575. et seq. after-treatment of, . . 557 bloodless, . . 30 causes which influence the results of, . . . 487 causes which prevent, 568, 624-34 dangers and difficulties in, i, 2, 19, 26, 30, 489, 497-8, 525, 544-7, 551; day-light for, . 500, 516 XXIX dilators in, . . 508, 513 dressing after, 5i3-'4. 525, 5^0 early operation, . 495 eruptive fevers, . • 495 final removal of cannula in, 565, et seq. gangrene in, . 582, 623 hemorrhage in and treatment of, 537-44,621 indications for, and contra-, 495-506 in extremis, . . 496-8 land-marks in, . I, 2, 528-30 measles, . . 495» 5°4 methods, "high, low, crico-trache- otomy," . . 519, et seq. period for, . . 495"9 pioneers of, . . 460 previous health, . . 492 " treatment, . 494 preparation for, . 506-13 process, slow, and rapid, 527-34 season of year, . . 494 sequelae of, . . 556 statistics of, 50 et seq ,471 et seq. steps of, . . . 520 temperament, . • 493 tenaculum, use of in, . 528-30 thermic, . . 534-37 tubes, . 32. 5 »o, 513, 634 without dilators, . 508, 513 " tubes, . . 513 Transmission ol diphtheria, . . 325-6, 345, et seq. Treatment of diptheria, 387, 416, 573 period for, . . 451 Tubercle, cricoid, . 528-30 Tuberculosis, 187, 303, 377, 505 Turpentine, . . 406, 443 Typhoid fever, . . 377,405 u Urine, 183-4, 195 Ulceration, 35, 77-80, 88, 92, 579, 601 XXX INDEX. V Vibrios, . . • 57 variations of, . . 2-17 Veins, plexus of in neck, . 1-16 Vichy water, . , 392, 427 innominate, . . 21 Vomiting, . . 152,212 thyroid, . . .13 Ventilation, • . -571 Whooping cough, 186-7, 240. S04 Wine, . . 413, 437-8 z Zinc, sulph., • • 45° Zymotic, ... 51 SUMMARY OF A REPORT OF A CAST. BY DR. H. GRAFF, OF EAU CLAIRE, WISCONSIN. [Ill stration opposite Frontispiece.] Case. A girl aged i6 years was taken sick on October lO, 1883. The doctor was called October 14. Found the patient with fever and pain in the throat, and considerable swelling about the neck. Both tonsils were covered with a greyish membrane. Diagnosis : Diphtheria, of which there was a "violent epidemic" prevailing in the locality. On the 15th, condition about the same. On i6th, the doctor was called early and found the patient suffering most "violent dyspnoea and slight asphyxia." This condition had been growing worse during the night. At noon when making his next visit he found the patient sleeping, her respiration almost normal, and the surface bathed with perspiration. He had at the last visit given her 0.04 (Ys gr.) of sulphide of calcium. About an hour after the previous visit the patient had occasion to get up and was siezed with a violent paroxysm of coughing, and after ex- treme efforts she shot up a "white rag" which the mother showed him in the spitoon. This ivhite rag — the false mem- brane — the doctor took to the office, and on examination it was found to be a complete cast of the trachea and bronchial tubes down to the smaller ramifications, and all in one piece. See frontispiece. A photograph was taken of it while fresh, and then the specimen was dried and varnished. The doctor has it in his possession. The relief was of short duration ; after about eight hours dyspnoea returned, and she gradually grew worse until she died, at 9 o'clock the next morning. No post mor- tem examination could be obtained. How much this is like the first case/eported by Dr. Stephenson, of Leesville, O., only a more perfect specimen (p. 305). Also the case reported by Marteau de Grandvilliers more than a century ago ; as well as cases described by the early writers, as Galen, who saw a pa- tient expel a thick viscid membrane supposed to be the epi- glottis. [SURGICAL ANATOMY OF THE PRE -TRACHEAL REGION WITH SPECIAL REFERENCE TO TRACHEOTOMY IN CHILDREN. Without desiring to magnify the difficulties which may be met with in the operation of opening the trachea for the reHef of dyspnoea in croup, but with a purpose to give them their true weight and to aid in recommending measures by which they may be avoided or surmounted, I have deemed it not un- important to add to what^has been said by the author, even at the risk of repetition, some remarks and illustrations which may be of service (at least to beginners) in this operation. Having heard remarks from those who may have operated once or twice or, at most, but a few times, indicating their opinion of the operation for croup, even in quite young chil- dren, as being rather a simple operation and not dangerous, I feel bound to say that, in my opinion, it is one of the most un- pleasant, if not dangerous, as met with binder the usual circum- stances, of all the operations which the surgeon is called upon to perform. In other words, I entirely agree with Dr. John H. Ripley, of New York, that there are probably more patients die on the table in or after the operation of tracheotomy for croup than in any other established operation in surgery. I would myself prefer to amputate at the hip-joint, or perform ovariotomy ; though I have never refused the operation, but, under proper circumstances, always urge it. A few sections (25, 26 and 27) from Holden's excellent work on " Land-Marks, Medical and Surgical," will here be inserted : 25. Cricoid Cartilage. — The projection of the cricoid carti- lage is a point of great interest to the surgeon, because it is his chief guide in opening the air passages, and can always be felt even in infants, however young or fat. [In some cases I have found it very obscure indeed]. It corresponds to the interval (I) 2 DIPHTHERIA, CROUP AND TRACHEOTOMY. between the fifth and sixth cervical vertebrae. The commence- ment of the oesophagus Hes behind it ; here, therefore, a for- eign substance too large to be swallowed would probably lodge, and might be felt externally. Again, a transverse line drawn from the cricoid cartilage horizontally across the neck would pass over the spot where the omo-hyoid crosses the common carotid. Just above this spot is the most convenient place for tying the artery. 26. Those who have not directed their attention to the sub- ject are hardly aware what a little distance there is between the cricoid cartilage and the upper part of the sternum. In a person of the average height, sitting with the neck in an easy position, the distance is barely one inch and a half. When the neck is well stretched, about three-quarters of an inch more is gained [1V2+V4 in. =2^/4]. Thus, we have (generally) not more than seven or eight rings of the trachea above the stern- um. None of these rings can be felt externally. The second, third and fourth are covered by the isthmus of the thyroid gland. The trachea, it should be remembered, recedes from the surface more and more as it descends, so that, just above the sternum, in a short, fat-necked adult, the front of the tra- chea would be quite one inch and a half from the skin. 27. Trachea. — In the dead subject nothing is more easy than to open the trachea ; in the living, this operation may be attended with the greatest difficulties. In urgent dyspnoea you must expect to find the patient with his head bent for- ward, and the chin dropped, so as to relax as much as possi- ble the parts. On raising his head, a paroxysm of dyspnoea is almost sure to come on, threatening instant suffocation. The elevator and depressor muscles draw the trachea and lar- ynx up and down with a rapidity and a force which may bring the cricoid cartilage within half an inch of the sternum. The great thyroid veins which descend in front of the trachea are sure to be distended. There may be a middle thyroid artery. In children the lobes of the thymus may extend up in front of the trachea, and the left vena innominata may cross it unusu- ally high. Thus the air-tube may be covered by important TRACHEOTOMY IN CHILDREN, 3 parts which ought not to be cut. Considering all these possi- ble complications, the least difficult and the best mode of pro- ceeding is to open the trachea just below the cricoid cartilage, and if more room be requisite, to pull down the isthmus of the thyroid gland or, in children, to divide the cricoid itself. It is important that all the incisions be made strictly in the middle line, the " line of safety." With the free and generous consent of my friend. Dr. L. S. Pilcher, of Brooklyn, N. Y., I shall make use of the illustra- tions and much of the text of his able article in "Annals of Anatomy and Surgery," April, 1881. The description of the plates scarcely admits of abbreviation, hence I shall insert the most of it entire, and will make free use of the main por- tion of the article. The colored plate I have had prepared expressly for this part of the work. It is enlarged from Gray,, with a few changes. That part of the neck interesting to the surgeon in the op- eration of tracheotomy is comprised between the hyoid bone above, the sternum below, and the sterno-cleido-mastoid and anterior belly of the omo-hyoid muscle on each side. The space thus bounded has been designated by Dr. L. S. Pilcher,. " The Anterior Median Region of the Neck." DIPHTHERIA, CROUP AND TRACHEOTOMY. FIG. I a. THE VESSELS OF THE PRETRACHEAL SPACE, NATURAL SIZE FROM A CHILD OF 3 YEARS. A, Great transverse vein. BB, Internal jugular veins. CCC, Inferior thyroid venus plexus. D, Lateral thyroid vein. E, Left common carotid arteiy. F, Isthmus of the thyroid gland. G, Crico-thyroid space with arter>'. H, Superior thyroid ar- tery with accompanying vein. The structures met with in this operation are : The ski)i in this region is thin, soft and very movable ; in- deed, so great is the mobiHty that it is well for the operator, unless his experience in the operation under consideration is large, to mark out on the skin the line of incision before com- mencing the operation, otherwise, in the end, the lines of in- cision in the skin and in the muscles may be found not to cor- TRACHEOTOMY IN CHILDREN. respond. While the first division of tissue is being made, the skin should be either drawn tense, or it may be transfixed. FIG. I b. THE DEEP LAYER OF THE SUPERFICIAL FASCIA WITH THE ANTERIOR JUGULAR VENOUS PLEXUS — TYPICAL ARRANGEMENT. The Siipe^'ficial Fascia of this region may be separated into the superficial and the deep layers. The former, together with the skin, forms \h& first layer in this region. — Pilcher. In the latter are to be found spread-out nerve filaments and arterial twigs of no special importance ; but between this layer and the deep cervical fascia lie the venous trunks of the anterior jugular plexus. Fig. i a gives the most frequent arrangement, from which there are very frequent variations. " In this the venous radicles below the chin with, perhaps, communicating branches from the facial, or external jugular, unite to form two trunks which run downwards parallel with each other, a 6 DIPHTHERIA, CROUP AND TRACHEOTOMY. little to the outside of the median line on each side ; as they approach the sternum they sink beneath the deep cervical fas- cia, and each, turning sharply outwards, passes behind the sterno-cleido-mastoid, along the upper margin of the clavicle, to the outer border of the muscle, where, in common with the external jugular, it empties into the sub-clavian. A transverse branch unites the two lateral trunks above ; and again, just above the sternum, under the deep fascia, a similar communi- cating transverse branch is usual. "A frequent variation is the presence of but one trunk, which lies directly in the median line as shown in Fig. 2, and again at A, on Fig. i6. FIG. 2. SINGLE MEDIAN ANTERIOR VEIN. 'Other arrangements are shown in Figures 3 and 4, in which FIG. 3. ANTERIOR JUGULAR VENOUS FLEXUS. FIG. 4. ANTERIOR JUGULAR VENOUS FLEXUS. TRACHEOTOMY IN CHILDREN. 7 the absence of one of the usual lateral trunks is compensated for by a large obliquely transverse branch which comes from the external jugular and crosses the neck in its lower third to join the lateral anterior jugular of the other side." Some of these trunks may be divided either in the early or in the latter part of the operation, and may produce very embarrassing or even dangerous haemorrhage. " In the median line the deep layer of the superficial fascia is practically blended with the deep fascia proper, the points where they are separated by the anterior jugular venous plexus alone excepted. This deep fascia, which is the cervical aponeurosis proper, is of great in- terest and importance in this region. Stretched from the hyoid bone, over the thyroid cartilage above, to the upper border of the sternum below, this aponeurosis, at a point mid- way between the cricoid cartilage and the sternal notch, di- vides into two well-marked, dense fibrous layers, the more su- perficial of which is inserted into the anterior border of the sternum, and the deeper one into its posterior border, the in- terval between them being filled by connective tissue and fat." The fact of this union or separation should be borne in mind, else embarrassment may arise in the operation by sup- posing that both layers have been divided when it may be only one has been. The two layers should both be nicked, then the director will pass easily beneath, either upwards or downwards, and the venous trunks may thus be frequently avoided. DIPHTHERIA, CROUP AND TRACHEOTOMY. FIG. ANTERIOR CERVICAL MUSCLES. a, Sterno-cleido-mastoid. l>, omo-hyoid. r, sterno-hyoid. d, stemo-thyroid. h, hyoid bone. "This aponeurosis, with' the deeper layer of the superficial fascia, constitutes the second layer, and their incision the second step in the operation of tracheotomy." — Pilcher. The next structures met with are the sterno-hyoid and the sterno-thyroid muscles on each side. They are intimately connected by their sheaths to the cervical aponeurosis; their inner margins, varying as to proximity, are connected by a more or less dense layer of fibrous tissue. These, with the connective tissue layer, form the tJiii'd layer to be recognized in the operation. The dividing line between these muscles may not always be readily distinguished. By rendering the parts tense in the median line, the separation may be readily made by using a TRACHEOTOMY IN CHILDREN. blunt-pointed or dull knife. The separation having been ef- fected, tJie pre-tracheal space proper is opened ; and its struct- ures form thQ fo2(rth layer. " This space is divided into two nearly equal parts by the isthmus of the thyroid gland, which parts differ greatly as to their accessibility, and as to the possible complications with which operations in them may be accompanied." FIG. 6. PRETRACHEAL SPACE WITH TYPICAL ARRANGEMENT OF VESSELS AND OF THYROID GLAND FROM NATURE. A, Great transverse vein. BB, Internal jugular veins. C, Median inferior thyroid vein. D, Innominate artery. E, Left common carotid artery. F, Thyroid isthmus. G, Crico-thyroid space and arteiy. H, Superior thyroid artery. I, Lateral inferior thyroid vein. lO DIPHTHERIA, CROUP AND TRACHEOTOMY. " The inter-muscular connective tissue layer at the level of the isthmus of the thyroid is closely applied upon its anterior surface, and furnishes a sheath for it which is reflected outward upon the lateral lobes and affords a distinct fibrous envelope for the whole gland." It also unites intimately with the sheath of connective tissue surrounding the trachea ; thus con- necting the two organs closely, and securing their conjoint movements. By separating the muscles above the isthmus we expose the thyroid and cricoid cartilages. " Between the isth- mus and the latter there is found the fascia laryngo-tJiyroidea of Hueter, which covers the trachea. By tearing through this fascia transversely until the first ring of the trachea is ex- posed, it is quite easy to get under the fascia thyro-trachealis and separate the isthmus from the trachea to an extent suffic- ient to permit its depression so far as to expose the two rings next below." Thus tracheotomy may be performed above the isthmus without encroaching upon the cricoid cartilage. If more room should be required the cricoid may be divided — laryngo-tracheotomy — the dilatation of this cartilage in the very young being easily accomplished. "The structures just described, including the thyroid isth- mus, the fascia laryngo-thyroidea, and the fascia thyro-trach- ealis, compose \h& fourth and final layer into which the su- perior pretracheal structures are practically divisible — the identification and removal of which in their order is desirable. The isthmus of the thyroid may vary greatly in volume. The series of drawings from my own dissections, which illustrate the anatomy of the pretracheal space. Figures 6, 8, 9, 10, 11, 12, 13, 14 and 15, show the ordinary variations in the shape and volume of the isthmus. In one of my operations (Mary Sandford, aet. 10 years) there was present a very broad isth- mus which descended nearly to the upper border of the TRACHEOTOMY IN CHILDREN. II FIG. 7. LARYNX AND TRACHEA OF CHILD OF 6 YEARS, NATURAL SIZE, ISTHMUS ABSENT. PYRAMID OF LALOUETTE ON LEFT SIDE. sternum. By holding it up with a retractor, I was, however, enabled to expose the trachea and incise it without other complications. In a recent dissection upon the body of a girl, set. 6 years, I found the isthmus entirely wanting, an interval of four millimetres separating the inner borders of the lateral lobes in front of the trachea ; from the superior border of the left lobe there is prolonged upwards and inwards a glandular slip which is attached to the body of the hyoid bone — the pyramid of Lalouette. Fig. 7 shows the preparation the nat- ural size. Usually the second, third and fourth rings of the 12 DIPHTHERIA, CROUP AND TRACHEOTOMY. trachea are covered by the isthmus. The vascularity of the isthmus is also the subject of great variations. In addition to the vascular network in its interior, there is usually a small arterial loop which runs along its upper border (See H, Fig. 6) connecting the superior thyroid arteries on either side. This may be of considerable size, as in the case from which the drawing that constitutes the Fig. i a was taken, and as again in Fig. 8. FIG. 8. TRANSVERSE ANASTOMOSING SUPERIOR THYROID ARTERY OF LARGE SIZE ; ABNORMAL COURSE OF THE_^CRICO- THYROID BRANCH. D, Innominate arteiy. E, Left carotid artery. F, Isthmus of the thyroid gland. G, Crico-thyroid space. HH, Superior thyroid arteries. "An abnormal course of the superior thyroid artery, which may give to the isthmus arterial branches of unusual size, is not usual. In the case represented in Fig. 9, the anterior TRACHEOTOMY IN CHILDREN. 1 3 trunk of the superior thyroid artery passes as a vessel of con-- siderable size to the middle of the isthmus, where it breaks up into branches of distribution. A transverse vein, the compan- ion of the transverse artery, is regularly present at the supe- rior border of the isthmus, inosculating on either side with FIG. 9. IRREGULAR COURSE OF THE SUPERIOR THYROID ARTERY WITH ANOMALOUS SUB-HYOID AND CRICO-THYROID BRANCHES. the superior thyroid veins. (See Figure i a, and Figures lO, II, 13 and 15). The arrangement is more as if the superior veins from the upper border of either lobe had met and blended in the middle line ; from their point of union there is prolonged downward in the middle line of the anterior surface of the isthmus a perpendicular trunk, which is joined below by a varying number of branches which issue from the sub- stance of the lobes to form the inferior thyroid venous plexus. "Figure i a, and Figures lO to 15, inclusive, illustrate some of the varying conditions which these branches present as they lie upon the anterior surface of the isthmus. Of great importance to be borne in mind is the occasional pres- ence of a large venous trunk, which, having its origin in the 14 DIPHTHERIA, CROUP AND TRACHEOTOMY, FIG. lO. INFERIOR THYROID VENOUS PLEXUS. MEDIAN TRUNK CROSSING TO LEFT. FIG. II. INFERIOR THYROID VENOUS PLEXUS. The trunks uniting in the lower part of the space to form a single trunk which is deflected to the right. TRACHEOTOMY IN CHILDREN. IS FIG. 12. INFERIOR THYROID VENOUS PLEXUS. Lateral trunks only ; front of trachea clear. T, Large thymus gland. FIG. 13. INFERIOR THYROID VENOUS PLEXUS. Two lateral trunks united by oblique trunk crossing in front of trachea. i6 DIPHTHERIA, CROUP AND TRACHEOTOMY. sub-hyoid region above, passes down directly in the median line, deeply seated, between the third and fourth layers which I have described, covering the crico-thyroid space, and receiv- ing the superior thyroid veins at the upper border of the isth- mus, taking the place of the usual small perpendicular trunk, FIG. 14. INFERIOR THYROID VENOUS PLEXUS. Veins from left lobe crossing in front of trachea to the right ; veins from right lobe emptying by a short lateral trunk into right internal jugular vein. receiving the inferior thyroid veins below, and finally empty- ing into the great transverse vein. Such a large, deep anterior jugular trunk is seen in Fig, 16, in which case a large single superficial median anterior jugular is seen. An identical con- dition, both of the superficial and the deep vein, was met with by me in the case of a boy, set. 5 years (Thomas .Smith), in whom, however, I succeeded in opening the trachea without wounding either. In the subject which presented the abnor- mal course of the superior thyroid artery (Fig. 9), there was also TRACHEOTOMY IN CHILDREN. 17 a very large vein which accompanied the artery to the middle of the isthmus, and then turning directly downward ran in front of the trachea to disappear behind the sternum. The right internal jugular vein in this subject was impervious from the FIG. 15. INFERIOR THYROID VENOUS PLEXUS. Two lateral trunks connected by transverse branch in upper part of space. base of the skull to within four centimetres from the innomi- nate, a fibrous cord alone remaining in its place. Whenever this deep median anterior jugular vein is present, any method of reaching the trachea other than that of layer by layer would inevitably wound it and occasion dangerous haemor- rhage. " The transverse vessels of the isthmus, described above, are enclosed within the fibrous capsule of the gland, and when the fascia laryngo-thyroidea is scratched through transversely at the lower border of the cricoid cartilage, they are drawn down with the isthmus, and thus are secure from injury when this 1 8 DIPHTHERIA, CROUP AND TRACHEOTOMY. method of operating is adopted. Incision of the isthmus it- self, it is apparent, may be attended with a varying degree of haemorrhage and peril. Experience has shown that, though in most cases the bleeding from an incised isthmus stops spon- taneously after the introduction of a tube, and the restoration of respiration, yet repeatedly has impending suffocation been made complete by the flow of blood into the trachea with the first inspiration after it had been opened ; many cases also are on record in which fatal secondary hzemorrhage has occurred from an incised isthmus. Its division, therefore, is, when it is at all developed, always a perilous proceeding, and must pre- cipitate a crisis at a time when, especially, deliberation and caution are needed. In my own experience I have never been compelled to cut it. " The possible presence of a large crico-thyroid branch, or of the superior thyroid running abnormally across the crico- thyroid space is to be borne in mind if an incision is made in it. In Fig. 9, two small arteries running across this space are seen. Above the thyroid cartilage, immediately below the hyoid bone, another small transverse branch crosses the medi- an line of the neck, the hyoid branch of the superior thyroid, by means of which another anastomosis between these trunks is effected. I have seen an incision through the thyro-hyoid space prove disastrous by the unperceived escape of blood into the larynx and trachea until suffocation was occasioned. The case was that of an infant, aet. 19 months, who had in- haled the half of the body of a fish's vertebra into its larynx. The surgeon attempted to extract it through an incision which he made in the thyro-hyoid space ; a sudden collapse and ces- sation of breathing in the little patient caused him to abandon the attempt and to hastily incise the trachea below and insert a tube for the purpose of re-establishing the respiration. Fur- ther attempts to remove the foreign body were postponed un- til complete reaction should be obtained. At the end of two and a half hours the child made an attempt to cough, throw- ing out blood, and then suddenly expired. Upon post-mortem examination the air passages were found filled with blood. TRACHEOTOMY IN CHILDREN. I9 There having been no external oozing at the site of the trach- eal incision, which was filled by the tube, the inference, almost certainty, was that the haemorrahge had come from the sub- hyoid wound, having increased in amount as more perfect re- action had been obtained. The inferior pretracheal space, the space extending from the lower margin of the isthmus of the thyroid to the sternum, is much deeper than the superior space, in which, as has been seen, the superficial coverings are closely applied to the anterior face of the larynx and trachea. By the recession of the trachea, which follows the backward trend of the lower cervical and upper dorsal vertebrae, a continually increasing distance is produced between its anterior surface and the superficial coverings which roof it over. On either side, this space is walled in by the sheaths of the great ves- sels of the neck, above it is closed by the blending of the su- perficial layers with the envelope of the thyroid gland, its floor is the anterior face of the vertebral column, and below it is continuous with the anterior mediastinum. It is filled with loose connective and adipose tissues, containing some small lymphatic glands, and affording a bed in which ramify the vessels of the region. The thymus gland may still extend up into it from the mediastinum, and occasionally may be of suf- ficient size to embarrass attempts to uncover the trachea in this space. Fig. 12 is from a subject in which the thymus gland was found still large. In the course of an operation for tracheotomy in croup, as soon as this space is opened by the tearing of the intermuscular fascia and the retraction of the mus- cles, the alternate sinking in and thrusting up of the loose tissue of this space as the labored efforts at inspiration cause them to be sucked down behind the sternum and then projected again up into the wound at each exspiration, constituting a serious em- barrassment to deliberate and certain incision of the trachea ; a special retractor to depress towards the sternum this loose tis- sue greatly facilitates manoeuvres in this space. The vessels which are normally present in this space are the branches of the inferior thyroid venous plexus, the origins of which have been described on pages 13, 14, 15. But the abnormalities which 20 DIPHTHERIA, CROUP AND TRACHEOTOMY. occur here are numerous and important. The number, ar- rangement and size of the trunks of this plexus are subject to great variations. The typical arrangement is the one shown in the frontispiece, in Fig. i a, and again in Fig. 6, in which the radi- FIG. 1 6. THE PRETRACHEAL SPACE — FROM NATURE. A, Superficial median anterior jugular vein. B, Deep median anterior jugular vein. cles from the various parts of the thyroid gland converge to a common trunk which passes downward vertically in the median line in front of the trachea and empties into the great trans- verse innominate vein at its centre. Samples of the various modifications of this arrangement which I have found in my dissections are shown in Figures lO to l6 inclusive. Examin- ation of these illustrations will at once impress the lesson to be drawn as to the important variations of this plexus with reference to the middle line of the trachea. Fig. I2 shows the DIPHTHERIA IN CHILDREN. 21 middle line of the trachea not covered by any vessel, lateral trunks passing down on either side. In the subject (Fig. 7) in which there was no isthmus, the veins from the two lobes converge as usual to form a trunk in the median line below. The relations in this space of the large, deep anterior jugular trunk, described on pages 16-17, are shown in Fig. 16. "Just below the lower boundary of this space, crossing from left to right, is the great transverse or left innominate vein. Normally, its upper margin is on a level with the sternal notch, its lower crossing the origins of the arteries, which rise from the arch of the aorta. Its possible elevation above the sternal notch, particularly when the head is extended, should be borne in mind. The innominate artery so frequently rises up into the lower part of the pretracheal space that its presence there can hardly be considerd an abnormality. My own dissections have shown this to be of greater relative frequency in young children than in adults. Burns' observation was, that in early infancy the innominate artery seldom turns to the side of the trachea lower than a quarter to a half an inch above the chest. FIG. 17. FIG. 18. Innominate artery crossing trachea trans- The four great vessels arising separate- versely at a high point. ly from the arch of the aorta. He has seen it mounting so high in front of the trachea as to reach the lower border of the thyroid gland. Its usual point of origin from the arch of the aorta is in front of the trachea, 22 DIPHTHERIA, CROUP AND TRACHEOTOMY. which it crosses obliquely so as quickly to be found running up to its point of bifurcation along its side. Frequently its aortic origin is to the left of the trachea, as seen in Fig. i a, and in Figures 14 and 15, and in its upward course it does not FIG. 19. The four great vessels arising separately from the arch of the aorta ; the right sub-clavian and the left carotid cross- ing in front of the trachea above the sternum. FIG. 20. The four great vessels and the left ver- tebral arising separately from the arch of the aorta ; right sub-clavian from left side of arch, passing behind others in front of trachea to its proper side. EXPLANATION OF REFERENCES IN FIGURES 1 8 TO 20. a. Trachea and thyroid glands, h, Division of the bronchi, i, Arch of aorta. 2, Descending aorta. 3, Right innominate. 4, Left innominate. (Figures 23 and 24). 5, Right subclavian. 6, Right carotid. 7, Left subclavian. 8, Left primitive carotid. 9, Right vertebral. 10, Left vertebral. 11, Thyroid arter)'. 12, Pulmonaiy arterj'. reach the right of the trachea until it has ascended above the sternal notch. It may ascend vertically for some distance in front of or along the left side of the trachea, and then, turning abruptly, cross it transversely, as in the case shown in Fig. 17. The close proximity of this trunk has been often recognized by many operators during the operation of tracheotomy, being seen or felt pulsating at the lower angle of the wound. It has repeatedly been opened by ulceration from the pressure of the canula upon it, causing fatal haemorrhage. Delay on the part of the innominate in crossing the trachea may bring the right carotid also in relation to its anterior surface. Burns records TRACHEOTOMY IN CHILDREN. 23 FIG. 21. Carotids arising by a common median trunk between the origins of the sub- clavians. FIG. 22. Carotids arising by a common trunk on right side, right subclavian from left side of arch, passing behind the others in front of the trachea to its proper side. that, in a boy, aet. 12 years, he found the right carotid ascend- ing in front of the trachea for two and a half inches above the top of the sternum before it passed to the side. Many varia- tions in the branches which arise from the arch of the aorta FIG. 23. Right primitive carotid and subclavian arising separately from arch of aorta ; innominate on left side. FIG. 24. Right subclavian arising from the arch of the aorta ; both primitive carotids and the left subclavian by a common trunk on the left side. 24 DIPHTHERIA, CROUP AND TRACHEOTOMY. have been met with, some of which cause the front of the trachea above the sternum to be crossed by large arterial trunks. Figures i8 to 26, inclusive, from the work of Tillaux, " Anatomic Topographique," in which they are copied from Tiedemann, show some of the most important of these. Such a graphic presentation of these will convey a more perfect idea of the anomalies than any description. "A middle thyroid artery, arteria thyroidea ima, ascending vertically in front of the trachea up to the thyroid gland, is found, according to Neubauer, in one out of every ten cases. It is derived from the arch of the aorta, or the innominate usually. Irregular origins from other of the great vessels at the root of the neck have been noted. Fig. 27 shows two such vessels of small size, from one of my own injections. Fig. 28, from Tiedemann, shows a large median trunk arising from the FIG. 25. Left primitive carotid arising from right innominate. FIG. 26. Left primitive carotid arising from right innominate, left vertebral from arch of the aorta. aorta which took the place of the usual inferior thyroid ar- teries. Blandin states that he has seen a middle thyroid ves- sel as large as the radial artery. Burns records four cases in which the innominate artery, when on a level with the sternum, just before bifurcating, gave off from its left side a branch about the size of a crow-quill, which soon divided into two TRACHEOTOMY IN CHILDREN. 2$ main branches, and then broke up into a number of twigs which ascended along the front of the trachea to the thyroid gland in such a manner that there was hardly a single point of the trachea into which an incision could be made without di- viding some of the pretty large twigs of the vessel. The in- ferior thyroid arteries occasionally take an abnormal course, in which one of them crosses in front of the trachea. Norm- ally these arteries having passed up on either side from the subclavian, behind the sheath of the great vessels, to a point opposite the first ring of the trachea, pass horizontally inwards, then downwards, then upwards again, having made thus two curves in opposite directions, and finally penetrate the gland from behind. One of the inferior thyroid trunks is sometimes wanting, in which case its place is supplied by a branch from FIG. 27. FIG. 28. Arterias thyroidea; imie, double. Arteria thyrodea ima, single large aortic branch replacing the lateral inferior thyroids. the other side, which crosses to its destination in front of the trachea. Burns describes a preparation in the possession of Dr. Barclay, in which the two inferior arteries arise by a com- mon trunk from the right subclavian artery, the vessel, passing to the front of the trachea ; the left also ascends till within two tracheal rings of the cricoid cartilage. The replacement 26 DIPHTHERIA, CROUP AND TRACHEOTOMY. of both inferior thyroids by a common median trunk from the aorta (Fig. 28) has already been noticed. From this presentation of the varying vascular conditions in the pretracheal space, it is evident that the greatest caution should be used in attempting to approach the trachea through it. There is no line of safety to be preserved. Whatever freedom from other complications may be present, the presence, at least, of an important venous plexus, covering the trachea in the middle line, will demand special precautions for its avoid- ance, except in occasional instances. In addition to the dan- gers and difficulties which the haemorrhage from the wound of this plexus occasions, the additional peril of entrance of air into the heart through them has been found to be no chimera. The case which occurred in the experience of Professor H. B. Sands, in 1868, in which, while performing tracheotomy upon an adult, immediate death resulted from the rushing in of air through an incision in an inferior thyroid vein which had been prevented from collapsing by the fact that the tissues in which it was imbedded were indurated by recent inflammatory^ exu- dates — this case cannot be considered as germane to the con- sideration of the dangers to be apprehended from operations in which the tissues of the pretracheal space are healthy. But the case reported recently by Professor Parise, of Lille, France, in the "Archives Generales de Medecine," 1880, p. 571, illus- trates perfectly this danger. While doing tracheotomy for diphtheretic croup in a girl, set. 5 years, after having made the usual incisions, wishing to uncover more fully the trachea, which was covered by an unusually large thyroid isthmus, this surgeon wounded the left branch of the middle thyroid vein near its junction with that from the right side ; copious haem- orrhage resulted. In the effort to seize the trunk of the vein to tie it, the superficial wall only was seized and raised up, which rendered the vein patent for the moment, during which a strong inspiration took place, a sharp hiss was heard, and in- stant death followed without a cry or struggle. Upon autopsy, air was found in the right cavity of the heart. " The looseness of the peritracheal connective tissue permits TRACHEOTOMY IN CHILDREN. 2/ the trachea to be Hfted up from its bed and brought near to the surface when once it has been exposed. If a pair of catch- forceps, hke the pinces hcemostatigttes of Pean, be fastened on either side into the layer of fascia that has been torn aside from the front of the trachea, and then be permitted to fall outward to the side of the neck, by their own weight they will lift up the trachea, and depress the side walls of the pretracheal space so that the trachea is rendered quite superficial, and its incis- ion, and exploration greatly facilitated. " Some points as to the laryngo-tracheal tube itself remains for consideration. In the child, the thyroid cartilage is, rela- tively, little developed, and its upper border rises up behind the body of the hyoid bone, which obscures it except when the head is extended. This is well shown in Fig. 7, which is a life-size representation of the parts taken from a girl, set. 6 years. The outlines of the thyroid cartilage can not be clearly made out through the overlying tissues. The resistant outline of the cricoid cartilage, however, can always be recognized through the skin in children [?], a point of which Cassaignac made much in his method of tracheotomy. The distance be- tween the hyoid bone and the cricoid cartilage, in a child three or four years of age, is about i centimetre ; in the six-year old specimen, Fig. 7, the distance is i\/., centimetres. This space may be more than doubled by bending the head strongly back- ward. The relatively small size of the larynx in children per- sists until the time of puberty, so that the differences in size between the larynx of a child of three years and of twelve are small, and can not be estimated by the differences in stature. The result of this is that the cricoid cartilage is always placed relatively high in the neck of a child, and, as its position de- termines the position of the isthmus of the thyroid, the space between the lower border of the gland and the sternum is rel- atively large. As the larynx, however, begins to evolve at puberty, the cricoid cartilage is depressed, the thyroid gland descends along with it, and the comparative distance between the gland and the sternum is lessened in the adult. These points are especially noted by Burns in his work on " The Sur- 28 DIPHTHERIA, CROUP AND TRACHEOTOMY. gical Anatomy of the Neck," who drew from them inferences in favor of incising the trachea in children below the isthmus. Tillaux gives a table of distances between the cricoid cartilage and the sternum in thirty-one children between the ages of two and a half and ten years. The average for those between two and three years is 3\/2 centimetres ; for those between three and six years, 4 centimetres ; for those between six and ten years, about 5 centimetres ; while the average distance in twenty-four adults was but 672 centimetres, the lowest being 4^.,, and the greatest 8^/,. I have myself often felt surprised to find in very young children upon whom I have had occasion to operate, quite as much room in the pretracheal space as in children much older. As far as the trachea itself is concerned, an incision below the isthmus is certainly favored, for the younger the subject the less room there is above the thyroid isthmus and the more below it for gaining access to the air- tube. The greater depth and the varying vascular networks that are found in front of it in the pretracheal space, however, increase materially the dangers of attempts to reach it here. If, however, these difficulties can be met by skillful and deliber- ate [!] manipulation, the question of what particular point should be chosen for the incision ought to be decided less on the score of operative difficulties than on that of therapeutic value. Whichever will best secure the good aimed at by the operation ought to be chosen. In my own experience, I find that my earliest operations were through the cricoid and the first ring ; then followed a series in which, by depressing the isthmus, I incised the upper tracheal rings. In my last fifteen operations I have performed the low operation. My experi- ence has been sufficient to assure me that, as a rule, the ana- tomical difficulties which the low operation involve may be so controlled as to make it safe and facile, while if, on exposure of the contents of the pretracheal space, it is apparent that great peril would be incurred by persevering in the attempt to reach the trachea through it, prolongation of the incision up- wards so as to expose the space above the isthmus is always possible. * * * TRACHEOTOMY IN CHILDREN. 29 " If laryngo-tracheotomy, or tracheotomy through the upper rings by depressing the isthmus is chosen, the cricoid prom- inence should fall midway in the incisions ; if the low opera- tion is to be done, the incision, beginning above the cricoid, should extend downward from it to the sternum. "The elastic and compressible nature of the tracheal rings in young children may be the occasion of a serious complica- tion, embarrassing the last steps of an operation for tracheot- omy. In conditions of laryngeal stenosis the force of the at- mospheric pressure upon the parts at the outlet of the thorax is extreme, and is supported by the musculo-aponcurotic cov- ering which is stretched over the trachea from cricoid to stern- um, secured, as it is, along the sides to the sterno-cleido-mas- toid muscles. After this protective covering has been incised, the tissues beneath are exposed to the force of the atmos- pheric pressure. The sucking downward behind the sternum of the loose pretracheal connective tissue has already been noted ; the trachea is affected by the same pressure, and in children, in whom the walls of the tube are much less resist- ant than in adults, it may be so flattened by the retraction or insucking of its anterior wall that the already scanty supply of air to the lungs is materially diminished and the symptoms of impending asphyxia become alarmingly aggravated. The more intense the obstructive symptoms previous to the operation, the greater the liability to peril from this cause, and the more likely to occur a crisis in which instantaneous opening of the trachea at any hazard is demanded. " The mucous membrane of the trachea receives from the inferior thyroid arteries vessels which may acquire in the adult some development and, even in children, afford a vascular sup- ply to this membrane that requires notice in a surgical point of view, in consequence of the haemorrhage which they occasion, in tracheotomy, when the trachea is incised. However per- fectly bleeding may have been arrested before the trachea is opened, some haemorrhage will follow the opening of the trachea, the blood flowing into the tube and occasioning the violent spasm of coughing which occurs when the trachea is 30 DIPHTHERIA, CROUP AND TRACAEOTOMY. Opened. The impression has been usual that this paroxysm of cough is caused by the stimulating effect of the sudden free access of the air to the interior of the trachea. The idea that it is, in fact, caused by the entrance of blood into the tube is advanced by Tillaux, who supports it by an observation, com- municated to the Surgical Society of Paris, in 1874, of a case in which, having opened the trachea in an adult by the use of the thermo-cautery, there was not a drop of blood shed ; when FIG. 29. Aperture of glottis when fully dilated. Actual size from nature in child 2 years and 8 months. — Holmes. FIG. 30. Transverse section through cricoid car- tilage. Same subject as Fig. 29. Natural size. FIG. 31. FIG. 32. Same parts in child of 3 years and 10 months. ' the trachea was opened no cough followed, and those present, not hearing the characteristic sound, could not believe the op- eration finished. Burns quotes a case in point from Sabatier, in which a soldier, having suffered tracheotomy for the relief of suffocative laryngitis, was so tormented by a convulsive cough produced by blood falling into the trachea that it was impossible to keep the canula in place. Relief was finally ob- tained by turning him upon his face until the blood ceased to flow. The patient ultimately recovered. Haemorrhage from TRACHEOTOMY IN CHILDREN. 31 this source is usually insignificant in its amount, and is speedily arrested by the pressure of the canula when inserted. The di- ameter of the interior of the tube is of importance to be considered with reference to the size of the canula to be used after trach- eotomy. The diameter of the orifice of the glottis is always much less than that of the trachea proper. The relative di- mensions of the entrance to the air tube, and of the tube it- self, are well shown in Figures 29 to 34, copied from Holmes on "The Surgical Diseases of Children." The inference has been drawn from this that the tube to be used after tracheoto- my need not be of the full size that the calibre of the trachea FIG. 33. FIG. 34. Same parts in child of 9 years and 9 months. would admit. The special conditions which children present after tracheotomy for croup, by the continual accumulation in the tube of tenacious mucus, make it desirable, however, that in such cases tubes of as large calibre as possible should be used. Tillaux gives measurements of the diameter of the trachea in nine children between two and five years, and Marsh, in the " St. Bartholomew's Hospital Report," Vol. HI., 1867, of eighteen children, of the same age. From these measure- ments it appears that, while there is a gradually increasing aver- age diameter, there are many individual variations in those of the same age, and a diameter in the older ones smaller than in some of the younger ones is not uncommon." "Boy, 1 6 months, <( 27. years, <i 3 n 4'/. Girl, 5 it 5'/. (( 6 (< 7 <( 8 Boy. 9 Girl, 13 32 DIPHTHERIA, CROUP AND TRACHEOTOMY. [Table of the distances which separate the posterior wall of the trachea from the anterior wall, at a level with the fourth ring. — Boiirdillat : Distance — Millimetres. - 7 8 9 10 - 9''. 10 I0'/2 II 12 - I2V, - I3VV' The diameter of the trachea varies according to age, as well as with the subject, as follows: Age — Years. Variation — mm. in. 17,— 4 - - - between 6— 8=7,-73 2 — 4 - - - " 8—10=73—75 4 — 10 - - - from 10 — 12=75 — V2 10 — 20 - _ - " 12 — 19=72 — 7^ As a rule, all ages up to 3 years can wear a tube one-fourth an inch in outside diameter — 6 mm. (^/^ in.); of course over 2 years, a little larger. From 3 to 5 years, - - 8 mm. (73 in.) " 5 to 10 " - - 10 " (78 in.) " 10 to 20 " - - 12 " (75 to 72 in.) Dr. Pilcher has used the same size — 772 mm., outside diam- eter — in all his cases (31 cases in 1881), from 13 months to 10 years old]. DIPHTHERIA. DEFINITION.— HISTORY. Diphtheria is a specific, infectious, general disease, trans- missible by inhalation, by contact and probably by inocula- tion, the principle characteristic of which is the production upon the mucous membranes, or upon the deep layer of the epidermis, of fibrinous exudations commonly called false mem- branes. Known from the most remote antiquity but differently un- derstood by numerous authors who have observed it, it has re- ceived in the course of the ages names which recall either one of its principal symptoms, or the idea which has been formed of its nature, or the country in which it has prevailed. Hence, the names ulcus Syriacuni, ulcus Egyptiacimi, garrotillo, morbus suffocajis, morbus or affectus strangulatorius, pestilentis gutturis affectio,peda7tcho maligna, angina maligna, anginosa passio, mal de gorge gangreneux, ulcere gangreneux, angina polyposa, croup, angi?ie maligne, up to the time when Bretonneau gave it that of diphtherite, then diphtheria, derived from the greek word litfOipa membrane. Diphtheria, a disease unique and specific, will be described in accordance with the method ordinarily applied to well- defined pathological types. The treatise will form several chapters in which will be reviewed the history from the most remote periods, the pathological anatomy, symptoms, diagno- sis, etiology, nature of the disease, prognosis and treatment. By pursuing the annals of science one may assure himself that diphtheria is not a new disease and that the different forms observed in our day existed already in antiquity. The Jews fasted, it is said, the fourth day of the week for the sake of children succumbing suddenly under an attack of (33) 34 niPHTAERIA, CROUP AND TRACHEOTOMY. angina. It is believed that the proof is found in the works of Hippocrates, that diphtheria was not unknown at that period. But by examining the quotations produced in its support one cannot refrain from entertaining doubts as to the interpretation which has been given them. The words angina and cynanchc did not signify among the ancients a disease Hmited to the throat or to the upper portions of the air passages ; they meant all those which occasioned dyspnoea; to-wit: Diseases of the lungs, phthisis, etc. " However," says Liltre, "it is not un- reasonable to imagine a membranous inflammation, seeing that the Hippocratic writings attribute to certain anginas a very pe- culiar expectoration." About a hundred years before our era, Asclepiades of Bith- ynia, the writings of whom, though lost, are known by the quotations taken from them by Aretaeus, Coelius Aurelianus, and Galen, seems to have known diphtheria, because he prac- ticed, according to these authors, laryngotomy. Had this operation been tried previously? There is doubt on this sub- ject, for Ccelius Aurelianus says in one place in speaking of Asclepiades: " Dehinc a veteribus probatam, approbat arteriae divisuram, ad respirationem faciendam, quam laryngotomiam vocant." And again, " Est etiam fabulosa arteriae ad respira- tionem divisura et quae a nu/lo sit antiquoruvi tradita, sed cadu- ca atque temeraria Asclepiadis invcntionc afifirmata." At best, CceHus formed an indifferent idea of tracheotomy ; he also em- phasized his reprobation : " Ne tantum scelus angusta ora- tione damnemus, lebris quos de adjutoriis sumus scripturi, re- spondebimus." The first description of agina gangrenosa is given by Aretaeus, of Cappadocia, who lived in the time of Vespasian. We find there indicated the varieties of diphther- itic angina discrete and benign, as well as the gangrenous and malignant forms. The author signalized also the extension to the respiratory passages and death by suffocation. This de- scpiption, given by a master's hand, deserves to be reproduced : " Ulcers appear upon the tonsils, some are benign others pes- tilential and fatal ; the pestilential ones are broad, deep, and tumefied, covered over with a white, livid or black concrete DIPHTHERIA. 35 product. But if this concretion gains in depth it becomes what is called in Greek an eschar, or in Latin a crust. A vivid in- flammatory redness surrounds this crust; discrete, small pus- tules arise around, then others supervene, and uniting with the former ones form a large broad ulceration. By continuing its destructive action this may extend into the mouth and reach the uvula; it also invades the tongue and the gums, by which the teeth become loosened and blackened. * * * "Phg [^_ flammation extends also to the neck. * * * Yj^g patients die at the end of a few days. * * * And, if the malady invades the chest by the trachea, it causes suffocation on the same day. Children up to the age of puberty are the most exposed to this disease." It is necessary to read afterwards the startling description of croupal angina : " A cough occurs with the dyspnoea and death is produced under the most pitia- ble conditions. The pale or livid countenance expresses suf- fering whenever the tonsils are compressed. When the pa- tient lies down he immediately arises, not being able to toler- ate the horizontal position ; if he sits up the fatigue soon com- pells him to lie down again, and most of the time he walks restlessly to and fro, the prey of violent agitation. Inspirations are long, the expirations short, the voice is hoarse, then be- comes extinct. These symptoms grow rapidly worse until the exhausted patient succumbs." Everything tends to the be- lief that the physician of Cappadocia considered angina mal- igna and croup as two phases of one and the same disease. He mentions also that these anginas raged principally in Egypt and in Syria, whence the name u/cus Syriacuui or Egyp- tiacum. Tournefort, traveling in these countries in the eight- eenth century, found the same disease, which he designated as charbon du fond de la gorge. Galen, who wrote in the second century, made mention of the pseudo-membranous expectora- tion : " A fragment of expelled membranous tunic denotes the existence of an ulceration, but in what part is it found ? This is what will teach us the seat of the disease. * * * If it is produced by coughing, it is an affection of the larynx, of the trachea, or of the lungs ; if it is expelled by spitting (hawking) it is an affection of the pharynx." 36 DIPHTHERIA, CROUP AND TRACHEOTOMY. Coelius Aurelianus, after Galen, gives the description of grave anginas and describes certain symptoms which corre- spond to croup and to diphtheritic paralysis. He speaks of disturbance of phonation, defective articulation, extinction of the voice, and of its sounding like the barking of a dog, of the laryngo-tracheal wheezing, the lividity of the face, the re- jection of drinks through the nose, etc. He mentions the practice of Asclepiades, consisting of scarifications of the ton- sil and even of performing laryngotomy. After Coelius Aure- lianus, silence existed for a long series of ages, and was only broken by ^tius, of Amida, in the fifth century, who, com- menting on Aretaeus, added to the description of his predeces- sor the results of his own experience : " The crusty and pesti- lential ulcers of the tonsils are usually not preceded by any discharge. They are principally observed in children ; * * they are at one time white-like spots ; at another of an ashy or rusty color j * * * putrefaction follows then, * * * there are patients in which the throat becomes corroded when the ulcerations have persisted for a long time and gained in depth ; their voice becomes hoarse, and they are in danger up to the seventh day." The author continues by blaming those who apply energetic remedies to the disease and tear away the patches. This, he says, should not be done before they are about to separate. His practice, we shall see further on, ap- proaches very closely to that which I shall defend. Paulus ^gineta has the reputation of having spoken of diphtheria. It is not true. To make amends, he transmits to us the opera- tive procedure by Antyllus for tracheotomy. Here ends the testimony from antiquity. The chain is broken, the tradition is lost ; we must traverse all the middle ages and come to the middle of the sixteenth century to find new documents. At this period fatal epidemics passed over Europe and found numerous historians. These authors confound diphtheria with gangrene ; everything is ascribed to this latter. The first is Peter Forest, who observed in 1557 an epidemic of angina at Alkmaer in Holland ; he was attacked with it himself. He pointed out propagation into the air-passages and suffocation. DIPHTHERIA. 37 In 1563 another epidemic extended over the kingdom of Naples and Sicily; in 1564 it reached Constantinople and Al- exandria. Its historian is Anthony Soglia, of Naples, quoted by the elder Chomel. In 1565 an epidemic of the same na- ture was reported by John Weirus, who informs us that Dant- zig, Cologne and Augsburg were infected by it at the same period. He gave to the disease the name of angina pestilen- tia. In 1576 Baillou gave the description of an epidemic which prevailed in Paris. For the first time since ^Etius he describes the false membrane, which was in reality observed not by himself but by a surgeon whose name he does not give : "A surgeon declared he opened the body of a patient who had died of dyspnoea in connection with an unknown dis- ease. He found a thick, resistant humour stretched like a membrane over the orifice of the trachea in such a manner that the external air could neither enter nor escape freely, and that it had caused sudden suffocation." In 1583-87-91-96, and from 1600 to 1605, then in 161 3 epidemics showed them- selves in Spain. The disease was designated by the name ano del garrotillo, derived from the instrument called garrot which was used to execute criminals by strangling. Some in- teresting accounts are due to Mercado, physician of Philip III, (1608); he reported among others the fact of a child who communicated the disease to his father by biting the finger of the latter while he was removing from its throat a piece of false membrane; and to Francis Perez Cascalez (1611), who recognized the false membranes and employed for them gargles of alum and sulphate of copper. Christobal Perez Herrera describes diphtheria and notes its production upon the skin and upon wounds ; he observed in autopsies the presence of false membranes, and made them the anatomical characteristic of the disease. Miguel Heredia distinguished two forms, one suffocative and the other asthenic ; he observed paralysis of the velum palati, the pharynx and the limbs ; he believed in a secondary infection by resorption of the products and recom- mended the use of caustics from the first with the view of pre- venting it. He mentions also the pseudo-membranous pro- 38 DIPHTHERIA, CROUP AND TRACHEOTOMY. ductions which cause the death of children because they could neither cough nor spit out the products. Antonio Maria Bar- bosa, in his remarkable memoir on croup again cites the works — too little known — of several Spanish and Portugese physi- cians, among whom should be mentioned Juan de Villareal, Juan Alonzo de Fontecha, Ildefonso Nunez, Thomas de Agu- jar, Andre Tamajo, Alonzo Nunez de Pereira, Ildefonso Mene- zes, Juan de Soto, Francisco de Figueiras who wrote at Lima, in 1616, Lorenzo de San Millan and Geronimo Gil del Pina. Bar- bosa has found some documents of the sanitary police which attest the existence of an epidemic of diphtheria in Portugal (1626). In them is found an account of corroding and malig- nant ulcers of the throat which destroyed children in large numbers while adults recovered. In 1668 Thomas Rodrigues de Viga, professor at the University of Co'imbra, proposed tracheotomy ; he is imitated by Francisco da Fonseca Hen- riques. Another Portuguese physician, Manoel Joaquin Hen- riques, speaks of an epidemic which took place in 1755- Soa- rez Barbosa gave, in 1789, the account of an epidemic which raged at Leiria, in Portugal. This able and conscientious ob- server, who was himself attacked, describes the white false membranes. Blood-letting, which he employed at first, was abandoned by him ; he had recourse to emetics with advant- age, giving the preference to ipecacuanha over tartar emetic. Having been led forward by the important works of the Spanish physicians too far in advance, I now return to the Seventeenth century. From Spain diphtheria passed into Italy. It was found at Naples in 161 8. It called forth the descrip- tions of Sgambati (1619), Carnevale (1620), Francis Nola (1620), Foglia (1620), Broncoli (1622), Alaymo (1625), at Palermo; Cortesio (1625), Prosimi (1635), at Messina; Signini (1636), at Rome ; Zacutus Lusitanus and Marcus Aurelius Severinus at Naples (1641). We should place by the side of these authors, Rene Moreau, in France, and Thomas Bartholin, who com- mented on Severinus. The disease which they describe under the name of morbus strangulatorius, and angina pestilentia, is in nearly all respects DIPHTHERIA. 39 like that of the Spanish physicians. It appeared first at Na- ples around the Chiaja, then it extended to the other quarters and to the provinces. It commenced by slight inflammation of the throat ; very soon the affected parts became white ; the breath assumed a fetid odor, deglutition became impossible, the voice became extinct, respiration was embarrassed and the children succumbed as if they had been strangled with a cord. Its tendency to generalization, and its contagious properties, without distinction of age or sex, are noted by all authors. It attacks especially, says Cortesio, persons who attend the pa- tients. Sgambati speaks of diphtheritic coryza. Severinus witnessed certain cases of adynamia, and a kind of imbecility followed the disease ; perhaps he had in view diphtheritic paral- ysis ? In this period, pathological anatomy remained stationary; the question on all sides was concerning the gangrenous ulcers but nothing definite about the false membranes. Autopsies were wanting; a single one, however, which was made in 1642, demonstrated, according to Severinus, the existence of a false membrane in the larynx. In 1718, Wolfgang Wedel, of Jena, spoke of the greater frequency of contagious angina in children in Italy when compared to the children of the countries in the north of Europe. He gave the first document on the utility of isolation in the proph\'laxis of diphtheria by reporting the history of a father who, having already lost five children by this disease, only saved the sixth by quickly removing it. In 1735, seventeen years after the epidemic of Naples, Cadwalla- der Colden, Esq., announced another at Kingston, fifty miles from Boston, in the United States. The disease attacked children especially ; changes similar to those in the back part of the throat were often observed behind the ears, upon blistered sur- faces, and on the genital organs. Symptoms of croup often supervened and terminated the scene. We find, therefore, in this account a formal mention of cutaneous diphtheria. France did not escape the epidemic scourge ; it prevailed at Paris from 1743 to 1748, and had for its historians Malouin and Chomel. The latter described clearly paralysis of the velum palati, and a case of diphtheritic strabismus. At about the same period 40 DIPHTHERIA, CROUP AND TRACHEOTOMY. Other epidemics arose in England and at Cremona, where it was studied by physicians of merit : Fothergill, Starr and Ghisi. The angina observed by Fothergill, at London, was secondary, and connected in an evident manner with scarlatina ; this was probably scarlatinous diphtheria. What seems to confirm this view is the extreme rarity of its extension to the air passages. This author proved the inefficacy of blood-letting, and recom- mended deturgent injections and aromatic gargles. The dis- ease appeared to him, moreover, as to his predecessors, of gan- grenous nature. This epidemic,- of which Starr gave an ac- count, raged in the county of Cornwall. It was much more severe than that of London, although the angina was primary. All the characteristics of malignancy were encountered ; cervi- cal oedematous swelling, petechias, generalization of the false membranes, anal diphtheria, extension to the respiratory pass- ages, and pseudo-membranous expectoration. Ghisi made the same observations, but in addition he signalized the first case of primary croup without angina ; at the same time he showed grangrenous angina alone, then these two affections united in the same patient, and considered the second as the propagation of the first. Like his predecessors he termed the disease of the posterior part of the mouth and throat, ulceration or gan- grene. Moreover he, like Chomel, witnessed certain disturb- ances which corresponded to diphtheritic paralysis. " There is," said he, " return of the food through the nose and a nasal tone of voice, persisting for a shorter or longer time after re- covery." In 1743, Molloy observed an epidemic in Ireland, reported by some as croup, by others as gangrenous angina. In 1752, diphtheria appeared in New York; and it is described by Peter Middleton, who mentions, among other lesions, false membranes in the trachea. It was noted at the same time at Zurich by Langhans. From 175 1 to 1753, Huxham observed an epidemic which prevailed at Plymouth. The angina of which he speaks was secondary in a large number of cases ; possibly he even con- fused simple scarlatinous angina with diphtheria of the same origin ; but he pointed out some cases which evidently be- DIPHTHERIA. 4I longed to diphtheria : there were present, the fetid breath, the rough, hoarse voice, dyspnoea, laryngo-tracheal wheezing, ejec- tions of pseudo-membranous patches, and diphtheritic coryza. From 1755 Sweden was invaded in its turn. These epidemics are reported by Bergius, Rudberg, Schulz, Hallenius, Wilke, Wahlbom, Bloom, and Engestroom. In several of the epi- demics just spoken of, it is proper to remark, with Deslandes, that the false membranes soon lost their whitish appearance and became brown, black and fetid. In these cases one would observe adynamia, nervous phenomena, offensiveness of the stools, and eruptions of the skin ; the blood furnished by bleeding was slightly, or not at all, coagulable. In other epi- demics the false membranes remained white, and the disease assumed a decided benignity. In France, Marteau de Grandvilliers gave an excellent de- scription of the epidemic at Aumale. He described, in detail, a case in which, without doubt, the diphtheria was com- plicated with gangrene. The tracheal and laryngeal false membranes were described by this author with great precision. He gave the detailed report of a case of bronchial diphtheria without angina; the patient ejected ramified false membranes, which were illustrated in drawings. We also mention Dupuy de la Porcherie, who published a work on an epidemic of gan- grenous angina, which raged at Charon in 1762; Van Bergen who observed, at Frankfort-on-the-Maine, in 1764, an epidemic which appeared to correspond with simple croup ; and Planchon, who described an epidemic occurring in 1765 at Peruwelz, in Hainaut, which appeared to exist especially in pultaceous scar- latinous anginas. In the same year appeared the celebrated work of Home ; the suffocative affections of the larynx took the name of croup, by which it has ever since been designated, and was minutely described. Several preceding authors had signalized the laryngeal symptoms consecutive to angina and even primary croup, but it devolved upon the Scotch physician to accurately describe what the others had vaguely indicated. He delineated very accurately the laryngeal and tracheal false membranes. This lesion failed in but one of his patients. He 42 DIPHTHERIA, CROUP AND TRACHEOTOMY. located the seat of the disease in the cavity of the air pasages, and attributed the production of the false membranes to con- cretion of the mucus. Besides, it is impossible to express one- self more clearly than Home has done on the absence of gan- grene in croup. " The practitioner," said he, " who has had several opportunities for post-mortem examinations in this dis- ease, will be much more inclined to the belief that what has been regarded as gangrene of the internal membrane of the trachea, is only a false membrane become black in consequence of a morbific affection." He recognized that croup attacked principally children from two to twelve years old ; that it pre- vailed ordinarily in the winter, and that it was more common in damp localities. After having described the symptoms with accuracy, and having given a physiological explanation of them, based upon the structure and functions of the larynx and trachea, he closed by speaking of the prognosis, which he based upon the age of the subject, and the period at which the treatment was commenced. According to him, the medica- tions should be almost exclusively antiphlogistic ; lie advises in desperate cases the operation of tracheotomy. Home is, there- fore, the real inventor of the word croup. Nevertheless, it is to be regretted that, while seeing solely in the object of his description a new disease, he separated croup distinctly from the angina maligna described by Aretaeus, Mercado, Sgambati, Huxham and Marteau. He could not recognize that croup and angina are only different localizations of the same disease. Moreover he incurs the severe censure, from Bretonneau, of having arrested the progress of observation, and hidden the traces of ancient traditions. The omission of Home, expli- cable by the imperfection of science at his time, and by the in- fancy of pathological anatomy, is compensated for by the def- inite addition, to the nosological list, of a disease but imper- fectly apprehended by the ancients. It had the unfortunate re- sult of separating croup from diphtheria for a long time ; the efforts of Bretonneau succeeded in uniting them again, not without opposition on the part of a certain number of physic- ians. It served, again, as a pretext to the recent attempts made DIPHTHERIA. 43 in Germany to renew the divorce between these two morbid conditions. On the other hand, while croup was better studied, gangrenous angina remained where Marteau de GrandvilHers left it. Deslandes shows us at what point the chaos occurred in this matter. " The separation of croup and angina gangrenosa did not, however," said he, " remove from the latter the symp- toms of croup ; it preserved them all until now, so that the works on pathology describe them twice under two different titles." In 1769, Millar endeavored to distinguish laryngeal asthma from croup ; he showed that this asthma is not accom- panied with plastic expectoration nor with swelling of the neck. In the midst of this agreement but two protestations are heard, that of Keettel and that of Samuel Bard. The former, in 1769 and 1770, observed an epidemic of angina which he named strangulatoria : at one time this disease is limited to the phar- ynx, at another it extends into the trachea. In 1771, Samuel Bard, of New York, who was the true forerunner of Bretonneau ; like Ghisi and as, later, the celebrated physician of Tours, had the good fortune to observe angina alone, angina in unison with laryngitis, and laryngitis alone. He reported observations of the different forms which he considered as all three being of the same nature. He established the identity of the affection which he observed with that of Home, and with the epidemic disease which Aretaeus and the Spanish and Italian physicians described. For him, angina was not a gangrenous affection ; and he regarded the patches as formed of concreted mucus produced by an alteration of the glands of the naso-pharyn- geal space and of the trachea ; they remain white, or become putrid, according to their age or the nature of the patients. He found in one of his autopsies, inflammation of the lungs " such as follows peripneumonia." Cutaneous diphtheria was also seen by him ; several of his patients were attacked with it be- hind the ears. Consecutive paralysis was signalized also by him ; in one patient it produced dysphagia, aphonia, and diffi- culty in walking. The ideas of Bard found no response except some authors, such as Solomon and Boeck, who made obser- vations at Stockholm, in 1772; Zobel, at Werth, near Ratis- 44 DIPHTHERIA, CROUP AND TRACHEOTOMY. bonne, and Bayley (1774 — 79); with the exception of these au- thors, all those who wrote after Bard saw or believed they saw only simple croup. Besides, we should mention Crawford, of Scotland (1771), and Michaelis (1778), who reproduced the ideas of Home and gave the disease the name of angina poly- posa seu membranacea. In 1783 the Royal Society of Medi- cine of France offered a prize on the subject of croup, and re- warded the memoir of Vieusseux of Geneva. This author de- scribes three varieties of croup : the inflammatory, the nervous and the chronic. From this time until the prize awarded in 1807 by Napoleon I., a great number of authors wrote on croup; Borsieri, Stoll, Reil, Girtanner, and Schwilgue, to whom science is indebted for the editing of the materials collected by the Ecole de Medicin, for the grand prize of 1807. The result of this contest is known. Of the seventy-nine memoirs only five were rewarded : Jurine, of Geneva, and Albers, of Bremen, di- vided the premium ; Vieusseux, Caillau and Double received honorable mention. Royer-Collard, in a report which remains a scientific monument, analyzed and criticised the works of the successful candidates. Jurine distinguished himself over his contemporaries by recognizing that croup often complicated malignant angina of children. Moreover he expressed the most decided doubts upon the gangrenous nature of this angina. The following passage, borrowed from his manuscript and al- ready cited by Barthez and Rilliet, furnishes the proof of it : " There is another disease, epidemic and, perhaps, contagious, with which croup is ordinarily complicated, and which, in some respects, resembles ordinary gangrenous angina, while it differs from it, sensibly enough in others, to claim the attention of physicians; the disease is angina gangrenosa of children. When one reads the works of authors who have described the symp- toms of this disease, and reflects upon the predisposition that children have to take the disease, the promptness with which the concretion is formed in the trachea, the nature of the spots or ulcers which cover the tonsils and the walls of the pharynx, and, finally, upon its termination, one experiences a feeling of uncertainty concerning the existence of gangrene in the major- DIPHTHERIA. 45 ity of cases of angina, so that one would be tempted to sup- pose that it is only croup itself, disguised by the putrid in- fluence of the epidemic, and, consequently, to name it putrid, malignant, or aphthous croup." These ideas passed unheeded and were held as null and void like those of Bard. After the prize of 1807, a certain number of works were published, among which we may cite those of Vallantine, Royer-Collard, Desruelles, des Essarts, Blaud, of Beaucaire, Double and Brich- eteau. These authors continued, as was formely done, to re- gard angina and croup as two distinct diseases. More than ever, the gangrenous nature of angina was entertained when Bretonneau appeared. The illustrious physician of Tours gave his support to the ideas of Samuel Bard ; he proved, in the most positive manner, the identity in nature of the different pseudo- membranous inflammations of the mucous and cutaneous structures designated up to that time by the names angina gangrenosa, croup, ulcers, etc. He taught that these different morbid states were only different manifestations of one and the same disease which he introduced into nosology under the name of diphtherite, from dofOipa, membrane. He demon- strated irrefutably the absence of gangrene in the form of an- gina called gangrenosa. He separated distinctly from croup an affection which was generally confounded in France with pseudo-membranous laryngitis, viz., the disease first described by Millar under the name of asthma ; it received from Breton- neau the name of laryngitis stridulosa, then from Guersant that of pseudo croup, and that of spasmodic laryngitis from Bar- thez and RiUiet. To crown his work, Bretonneau had the dis- tinguished merit of restoring tracheotomy to repute. The ep- idemics of Tours (1818), of Ferriere (1825) and of Chenusson (1826), furnished him the materials for his work. The novelty of the work of Bretonneau appeared in the methods which he adopted. Contrary to his predecessors, to begin with, he based his arguments almost exclusively upon pathological anatomy. Adopting the ideas of Laennec, he recognized that diseases can be definitely distinguished only by their anatomical character- istics. He omitted nothing, neither the chemical analysis, nor 46 DIPHTHERIA, CROUP AND TRACHEOTOMY. even the microscopical examination. These researches led him to the conclusion that the so-called eschar was nothing other than the product formed at one time from thickened mucus, at another from fibrine exuded by the inflamed mucous membrane; he proved, what had never been clearlyestablished, the continuity of the false membranes of the larynx and of the trachea with those of the throat and nasal fossae. It was not enough to show these productions as the result of an inflammation of the mucous membrane, Bretonneau had the inspiration, so prolific, of the specificity. It is with the following announcement of principles that the book begins : " The illustrious author of Philosophical Nosography [Pinel], in taking for a basis of his classification of phlegmasiae, the modifications which inflamma- tion undergoes in the diverse organic tissues, has certainly shed new light on a large number of diseases and given a new impulse to the spirit of observation. Still, one is forced to acknowledge that the diversity of the inflammatory alterations, and that of the phenomena with which they are accompanied can not de- pend upon this single condition. The specific character of in- flammation, rather than its intensity or the nature of the tissue of which it is the seat, influences the disturbance which every inflammatory lesion produces upon the functions. It is the spe- cificity of the inflammation with which the duration, the grav- ity and the danger of the majority of fevers correspond. No tissue, perhaps, is susceptible of a single form of inflammation; but the diverse inflammations with which the external tegument- ary envelope may be affected, present, without doubt, the most manifold and remarkable differences. Should one direct the least attention to it he will also be convinced that the mucous tissue — the internal tegumentary organ, is also the seat of in- flammations extremely diversified." And, further, " I should not express all my thoughts if I did not add, that I see in this membranous inflammation a specific phlegmasia as different from a catarrhal phlogosis as malignant pustule is from zona, a disease more distinct from scarlatinous angina than scarlatina itself is from chicken-pox ; finally, a morbid affection sui ge7ie- ris, which is no more the last expression of catarrh than squam- DIPHTHERIA. 4/ ous dartre is the last termination of erysipelas. In the impos- sibility of applying to a special inflammation so decided, a sin- gle one of the improper names which has been given to each of its shades, I may be permitted to distinguish this phlegma- sia under the name of Diphtherite, derived from ^KfOipa, "pel- Its, exuviuni, vestis coriacea, whence St<fOtii<'io>, corio obtcgo." Immediately on their appearance the ideas of Bretonneau found numerous supporters : Guersant, Louis, Tobanon and MacKen- zie added also their testimony. But the most powerful cham- pion to Bretonneau, the most eloquent popularizer of his doc- trine, beyond question, was Trousseau, his pupil and friend. Not only was Trousseau the successor of Bretonneau, but he completed the latter's doctrine, improved it, and brought it to the point where we find it to-day. Investigating the idea of specificity, he showed that if diphtheria is a specific, it is so not only so far as the inflammation producing the patch is con- cerned, but as a general disease, totius substantice, unique in its nature, infectious, and possessing the property of causing at different points of the economy, inflammations the result of which is false membranes. To his mind the inflammation was no longer an initial but a secondary phenomena. Bretonneau thought that diphtheria destroyed by suffocation. Trousseau, however, showed that this condition was not necessary, but that the disease itself produced death, by infection of the organism, without intervention of asphyxia. To express this conception, he modffied the nosological term created by Bretonneau : from diphtheritis he formed diphtheria. Finally, he gave a strong impulse to tracheotomy by improving the operative procedure and the after treatment, and by rendering the recoveries numer- ous, which until then were exceptional. From this time on, the works on this subject, as well in France as abroad, became very numerous. In France, the views of Trousseau were universally accepted, except upon some points, of which we shall speak hereafter. England has given up (or renounced) the views of Home ; deadly epidemics of infectious diphtheria gave to the disease, according to West, a form very nearly similar in the two countries. Portugal, Spain, Italy, nearly all the countries 48 DIPHTHERIA, CROUP AND TRACHEOTOMY. of Europe, and of the New World, have adopted Trousseau's views. It is not so in Germany. Regarding diphtheria from a purely anatomical standpoint and holding the results of clinical observations as valueless (null and void), Virchow, Wagner, Rokitanski and their school caused science to relapse into the chaos from which Bretonneau rescued it. Returning to the theories of Home, they separate angina and croup in the name of pathological anatomy. The former was again regarded as a gangrene ; the latter only was regarded as of an exudative nature. The first was held to be infectious ; the last as simply inflammatory. The succession of croup to angina was explained by saying that the two diseases so differ- ent, might exist side by side in the same patient. This dis- tinction appeared even so fortunate that the two names, diph- theria and croup, employed up to that time to designate the morbid totality, was applied exclusively to anatomical processes. Diphtheria was applied to every lesion consisting in fibrinous infiltration of the tissues ; while croup was used to signify all anatomical alterations characterized by a superficial fibrinous exudation. Thus it is that ulcero-membranous stomatitis, which has absolutely nothing in common with diphtheria, understood in its correct acceptation, is a diphtheria in the German sense, and that a croupal pneumonia has been instituted, on the pre- text that this disease had, as its anatomical product, an exuda- tion of fibrine on the surface of the pulmonary vesiculae. I shall enlarge more fully upon these speculations in order to combat them, aided besides in the task by several German au- thors who seem to have gained anew a glimpse of the truth. In spite of these divergencies, the dogma of specificity, and of the unity of diphtheria is confirmed ; the contagiousness of the disease has been demonstrated, its complications and its se- quences have been studied ; the treatment has been improved, and tracheotomy is now largely practised in many countries where it renders every year increased service. For a moment led astray by these Germanic notions, the physicians of all countries are returning to the doctrine of Bretonneau and Trousseau. Numerous works have thrown light upon differ- DIPHTHERIA. 49 ent parts of the subject. At the head of the list, I should men- tion that of Deslandes, which appeared in 1827, a remarkable work, in which the history of diphtheria is treated from its ori- gin very fully and in the most judicial spirit of criticism. I have been fortunate in finding a guide so safe on a question so complex. Bretonneau went too far in excluding absolutely gan- grene from diphtheria ; protestation arose : de la Berge, and Monneret, Becquerel, Barthez and Rilliet, Gubler, Isambert, Crequy, Millard, Axenfeld and others cited indisputable exam- ples of the coincidence of gangrene with diphtheria, and showed that while diphtheria was not gangrene, these two pro- cesses might co-exist. Recent epidemics have been observed by Guimier (1826-7), ^.t Vouvray; Gendron (1829), at Ven- dome and at Artlns (Loir-et-cher) ; Lespine (1830), at la Fleche; Ridard (1832), at Bohalle; Bourgeois (1827-8), at St. Denis; Boudet (1842) and Becquerel (1843), at Paris; Daviot (1841-2), in the department of the Saone-et-Loire and Nievre ; Gibbon (1845), at Salem, U.S.; Lespiau (1854), Oulmont (1855), at Paris; Besnard, Fourgeaud (1856-7), in California; Forgeot (1857), at Vignory; Bouillon Lagrange (1857-8), in the department of the Saine-et-Oise; Peter (1858), at Paris; Robert (1859), in the Lower Charente; Saint-Laurent (i860), at Paris; Jugand (1856, 7, 8-9), at Issoudun ; Landeau (1861), in the vicinity of Bordeaux ; Bricheteau (1859), at Paris ; Brown (1862), in United States; Radcliffe (1862), in England; Wynne, from 1855 to 1861, in England; Kohnemann (1862), in the island of Baltrum ; Wiedash in 1862 in the island of Nordeney; Forster, from 1862 to 1864, at Prague; Uhlenburg, at Leer, Germany; Tuefferd, of Montbeliard (1864), at Etupes; Nivet, from 1849 to 1865, in Clermont — Ferrand; Guillemant, from 1863 to 5^1865, at Louhans; Van Capelle (1864), in Holland; Demme (1868), at Berne ; Marmisse, from 1858 to 1866, at Bor- deaux; Dillie (1866), at Arnemuiden, in Holland; Becker (1866) in Hanover; Bartels (1866), at Kiel; Henroz, at Bihain, Bel- gium; Lange (1865), Ditzel (1869), in Denmark; Graf (1868), at Munich ; Felix (1868), at Bucharest ; Gaupp (1868), at Schorn- dorf, Wurtemburg; Mair (1871), in Middle Franconia ; Flam- 50 DIPHTHERIA, CROUP AND TRACHEOTOMY. marion — Haut-Marne (1871-2); Nesti, from 1862 to 1872, at Florence; Binder, at Agnetheln, in Transylvania (1873); Otrobon, from 1870 to 1873, in Transylvania. The structure of the false membranes and their chemical composition, sketched by Bretonneau, then indicated more fully by Thompson, have been the subject of very important studies, especially in Germany. Albuminuria, diphtheritic ex- anthemata, pulmonary complications and, quite recently, lesions of the circulation, as well as consecutive paralysis, have furnished material for numerous works, as well in France as in other countries, and for important discussions at sessions of learned societies. The treatment of diphtheria has been examined in all its phases ; local applications by caustics and astringents, submit- ted to a severe control, have lost much of their importance. Persons have been much occupied in seeking for agents capa- ble of dissolving the false membranes without injuring the healthy tissues. Controstimulants, then tonics have been applied to diphthe- ria; efforts have even been made to find a specific for it. Trach- eotomy especially has been subjected to violent attacks. The discussion on catheterism of the glottis, prolonged in 1858 be- fore the Academy of Medicine, and before the Societe des Hopi- taux of Paris, will remain memorable. Defended, notably by Trousseau and by Bouvier, with extraordinary talent, the oper- ation (tracheotomy) repulsed victoriously the unjust attacks. At this debate, the periods of croup were defined by Barthez, who insisted upon the part which the infectious element played in the failures of tracheotomy. He pointed out the impropriety of plac- ing side by side in the statistics the cases of infectious croup and cases without apparent infection, showing that the comparison between analogous cases alone can furnish precise results. Numerous modifications have been proposed for the opera- tive procedure, and numerous instruments have been invented ; the expeditious method has been recommended as more advan- tageous than the slow method, advocated by Trousseau. Can- ulas of all sorts have been constructed, while certain authors DIPHTHERIA. 5 1 have proposed to dispense with this instrument. The indica- tions and the contraindications of the operation have been ex- amined at different times, and gave rise, especially in 1807, to an interesting discussion before the Societe Medical des Hopi- taux, of Paris. The contraindications have diminished. The after treatment of the operation, brought into prominence by- Trousseau, has attained, in the minds of physicians, the im- portance that it merits. Millard has treated this question in a remarkable work. I have in a previous work set forth this part of the subject as well as the accidents following the oper- ation. We note also the ulcerations of the tracheal tube, on which Roger presented an important communication to the Societe des Hopitaux. In his last clinical lectures. Trousseau completed his conception of the unity and the specificity of diphtheria. Barthez, in different writings, entered into the same ideas. The current which has impelled science for the last few years to seek, in diseases, and particularly in epidemics, for low or- ganisms should have like results in respect to diphtheria. We have demanded of a parasite the secret which the disease still keeps of its origin and of its mode of propagation. Advanced by Jodin, this idea was not slow in finding partisans, principally in Germany. According to Hallier, Biihl. Jaffe, Hueter and Tommasi, and Eberth, diphtheria has become a zymotic disease. Recently, Letzerich has built upon this principle a complete theory. Other observers. Senator in particular, have demon- strated the error of the former authors, and showed that the so- called diphtheritic parasites are only developed on false mem- branes already old and altered. A great number of foreign works have been published on diphtheria. Germany has re- served to itself principally the pathological anatomy ; England has been occupied particularly with diphtheritic paralysis, and Portugal has furnished us some very remarkable clinical works. These researches will be brought into prominence when I shall examine the part of diphtheria to which they belong. I shall, however, mention the principal ones, those of Antonio Maria Barbosa, of Lisbon ; Bartels, of Kiel, and Senator. PATHOLOGICAL ANATOMY. Diphtheria, a general, septic aisease, even in its mildest forms, leaves its impression upon every part of the economy — no apparatus escapes its attacks. The lesions which it pro- duces are multiple, and should be sought for in every organ. There is one lesion, however, which attracts attention and ex- ceeds all others. (To that alone, which characterizes the mal- ady and gives it its special stamp, I give the name of false membrane). The other alterations, though important and in- teresting in so many respects, pass to the second rank ; they are no longer essential. One or more of them may fail from the picture, then it looses some of the additions, but the prin- cipal subject stands out in no less distinctness and strength. It, therefore, follows that the lesions of diphtheria should be di- vided into two general classes : The first will comprehend \\\& fundamental ox primary lesions, that is, the false membrane and the alterations of the tissues which underlie it. This will be the general pathological anato- my of diphtheria. The second will comprise lesions of apparatus which, aside from the false membranes, are met with in subjects attacked with diphtheria, and may be attributed to the influence of this disease. These are the secondary lesions. FIRST CLASS — PRIMARY LESIONS. Section I. The False Membrane. The diphtheritic pellicle presents for study: Its external characteristics, its structure, chemical composition, and its evo- lution. (52) PATHOLOGICAL ANATOMY. 53 I. EXTERNAL CHARACTERISTICS. Seat. — All the mucous membranes and the entire cutaneous surface are liable to become the seat of false membranes. An exception may be made of mucous membranes protected from the air ; the presence of diphtheritic exudations on their surface is very rare, and it has even been positively denied, but incorrectly. Form. — The product of diphtheria is spread upon the sur- faces in the form of patches or pellicles of variable appearance, but roughly resembhng adventitious membranes, hence the name, false membrane. The exudation is limited, occasionally, to a single patch ; ordinarily several exist, occupying at one time the same region, at another different points. In the same locality their number often corresponds with the period in the disease ; small, and separated in the beginning by healthy tis- sue, they increase and become united later. Usually they are somewhat round and their borders regular. These characteristics, however, are not constant. The age of the disease and its seat affect the form of the product ; it is es- pecially in the throat and in the mouth that it is rounded in the beginning; later, the edges are irregular, and excavated into irregular flaps. The form varies also according to the regions. Upon the skin they are large patches with sinuous margins ; in the Eustachian tube the false membrane is accurately moulded to this duct ; in the nasal fossae it conforms to the tur- binated bones ; in the respiratory passages it presents irregular patches, and incomplete or complete straight tubes, or dichoto- mously ramified (see plate of cast opposite the frontispiece); in the oesophagus and stomach it forms long strips ; and about the anus it is found in patches, remote or near, and sometimes it ascends into the rectum. Dimensions. — They vary infinitely from a millet-seed, or ves- icles of guttural herpes, or tonsilar concretions, to those of broad patches occupying the posterior surface of the trunk from the nucha to the sacrum. They increase as the disease becomes older. Sometimes, however, the punctiform false membranes 54 DIPHTHERIA, CROUP AND TRACHEOTOMY. persist in these limited dimensions during the entire period of their evolution. Surfaces — Superficial and Deep. — The superficial surface is smooth, moderately elevated at the centre and becomes atten- uated at the margins, which appear to be continuous with the substratum when the patch is small and recent. When it is older and beginning to be detached, the margins retract and become elevated. If the exudate covers a wide surface, the central prominence disappears. The surface is sometimes ridged and grained, mainly when the false membrane is old. The deep surface is less even, it is often ridged or villous and velvety ; it receives the impression of the parts which it covers. Sometimes it gives rise to filaments which correspond to the orifices of the mucous glands. When the exudate is recent it is very adherent to the subjacent tissue, and is detachable only in particles, and causes bleeding of the parts ; when older, its adherence diminishes and the membrane falls off of itself. Color. — From white at first to opaline, then often to yellow- ish, the superficial surface contrasts strongly with the red color of the inflamed mucous membrane and the ulcerated surfaces ; not infrequently it becomes grayish. It may assume a tint deep gray or brown, which gives it the aspect of an eschar. Ancient authors, struck by this appearance, believed in the ex- istence of a gangrenous process, hence the name, gangrenous ulcer and angina gangrenosa. Brettonneau opposed with all his influence this identification ; he maintained the constant in- tegrity of the mucous membrane, and refused to regard the deep discoloring of the membrane as anything more than the result of sanguineous imbibition, a common occurence in diph- theria. He was wrong, however, in excluding gangrene en- tirely ; under some circumstances it really does accompany diphtheria. The deep surface is usually, in the beginning, of a rather deeper shade than the other, and has little bloody, reddish, or ecchymotic spots, which subsequently disappear. Thickness. — In thickness it is variable, at one time reduced to a thin white, semi-transparent pellicle, having quite the ap- pearance of the vitelline membrane of the Qgg\ at another, PATHOLOGICAL ANATOMY. 55 quite considerable, formed of several stratified layers, and may- exceed two millimetres. Then it is that it has that resemblance to the membrane or skin of lard which attracted the first ob- servers. Generally speaking, the thickness attains its maxi- mum in the throat and in the larynx, especially in the ventri- cles; it diminishes to its minimum in the bronchial tubes. It is especially upon the tonsils that the false membrane becomes abundant ; in the bronchial tubes it becomes attenuated and terminates in thin strips. Nevertheless, I have seen croup patients expel pseudo-membranous fragments, very thick and consistent, coming from the trachea. In these cases, the dis- ease had existed for a long time, and several fibrous layers were super-posed. Consistence. — This is in proportion to the thickness. Ordi- narily compact and elastic, it may acquire a firmness and re- sistance almost cartilaginous. Such is the false membrane in its acme, at the moment of its complete development. At the beginning, the stage of formation, it is soft, dififiuent; later, when it reaches the end of its evolution, it may soften and be- come pulpous. Odor. — The false membrane is odorless by itself; one must not attribute to it the exhalations which proceed from the al- terations of the epithelium and the buccal liquids, blood and mucus. One will observe that the stale and nauseous odor of diphtheritic angina is not perceived at first, but is in the course of a few days, when a bloody exudation occurs on the surface of the mucous membrane, and when the false membrane commences to disintegrate. In the infectious form of anginas, grave altera- tions of the mucous membrane as well as a strong disposition to putrefaction are occasionally added to the above causes. II. STRUCTURE. From Bretonneau down to the last few years the false mem- brane of diphtheria was considered as a pellicle produced by exudation on the surface of the inflamed mucous membrane by virtue of the same action as in the false membrane of the pleura, and leaving the subjacent membrane intact. While the ancients 56 DIPHTHERIA, CROUP AND TRACHEOTOMY. held to the existence of a gangrenous process in all grave cases of angina, Bretonneau, falling into the opposite extreme, de- nied emphatically all change in the mucous membrane. A re- action was not long in rising against this too exclusive opinion. Some observers, less prejudiced, Becquerel, Barthez and Ril- liet ; e'^en Trousseau, Laboulbene, Roger and Peter, and Isam- bert, 1 ^ognized the undeniable existence of lesions of the mu- cous nembrane in certain infectious or secondary anginas. While retaining for the false membrane of benign diphtheria the characteristics and mode of formation which Bretonneau assigned to it, they attribute the alterations of the mucous mem- brane to the secondary or infectious forms which are so fre- quently coincident. The work performed in recent years by the German school, under the direction of Virchow, goes still further. Denying to the diphtheritic false membrane its exu- dative character, these authors have been principally engaged in demonstrating that it was solely constituted by a morbid transformation of the mucous membrane which formed of it a veritable eschar. This theory reigned supreme for several years, but its halo is beginning to fade. Opponents have arisen, and by a singular revolution their researches have restored to light the old theory of Bretonneau, modifying it, however, a little. These vicissitudes I shall now examine. Writers, previous to Samuel Bard, regarded the false membrane as only an eschar ; the subjacent membrane as always ulcerated. He, however, considered the false membrane as formed by the thickened mucus, and he thought the mucous membrane remained intact. Laboulbene, who has studied the diphthe- ritic false membranes with much care, assigns to them two prin- ciple elements : 1, An amorphous material, a sort of matrix, sprinkled with fine molecular granulations which, when set free, become agi- tated with a lively molecular movement. 2. The fibrin presents the appearance of slender fibrillae, thin, straight, and sometimes parallel, sometimes intersecting in every direction ; more rarely it is composed of very small PATHOLOGICAL ANATOMY. 57 granules, placed in juxtaposition in a linear series. One finds also leucocytes, granular bodies, numerous fat globules, epi- thelial elements in various degrees of development, blood glob- ules when the membranes are ecchymosed, crystals of various forms, very rarely vegetal forms, consisting of spores, and of mycelium, as well as vibriones belonging to the genera .Bacte- rium and Vibrio. jg- The locality which produces the false membrane impresses it with a particular character, as Laboulbene recognized from the debris of epithelium which adhered to the membrane. In those membranes from the larynx the epithelium is cylin- drical, provided with cilia at the large extremity of the cell; there may be, moreover, some rare cellules from nuclear or pavement epithelium. Those from the trachea, and large bron- chi are composed especially of fibrin and ciliated epithelial cells. In the bronchi of smaller calibre, the diphtheritic con- cretions, recognizable from their small volume and from the form of the bronchi upon which they are moulded, present pavement epithelium. In very rare cases Laboulbene observed pigmentary granules. In diphtheria of the conjunctiva, examined in the beginning, the fibrin was in a fibrillar state ; later it had become granular. In diphtheria of the genitals, and of the anus, one finds principally fibrin and (pavement) epithelium. Cutaneous diphtheria presents an amorphous especially fibri- nous stratum mingled with pavement cells of different degrees of development. Roger and Peter describe the false membranes as passing through three stages. They are at first soft and diffluent, then concrete and, finally, pulpous. In the first phase they are formed of a stroma of amorphous granular matter, in the midst of which one observes a series of parallel lines which are nothing but fibrin in a fibrillar state. In the second phase, they are formed of the same stroma of granular fibrin, in the thickness of which exist very numerous free nuclei, rarely round cells, epithelium cells and, finally, straight fibres, sometimes compacted but never united into 58 DIPHTHERIA, CROUP AND TRACHEOTOMY. bundles of connective tissue. In no case does one discover any vessels nor even red striae as indicating the formation (nisus) of vessels. In the third phase, the period of detritus, the fibrillar ap- pearance has disappeared, one finds no longer only granular fibrin, free nuclei and leucocytes. These authors say this is evidently in the retrogressive state. Jules Simon gives a similar description. When we pass to the examination of German works, we en- counter from the first a confusion of words which contributes singularly to the complication of the question. By a deplora- ble abuse of language, applying to anatomico-pathological processes, terms which serve to designate diseases, the authors beyond the Rhine, after the example of Virchow, called croup- al inflammation a phlegmasia, which, without touching the structure of the mucous membrane, deposits upon its surface an exudate, a false membrane ; and diphtheritic inflammation an interstitial phlegmasia, characterised by a sero-fibrinous ex- udation, which infiltrates the tissues and causes their mortifi- cation. Diverting the word cronp from its true acceptation, which is that of an acute, suffocative and pseudo-membranous disease of the larynx, they have created the singular terms, cronpal pneumonia, croupal 7iephritis, etc., under the pretext that, in these pathological cases, the fibrinous exudation is formed on the surface of the pulmonary alveoli, urinary tubuli, etc. Be that as it may, the German work may be summed up under two opinions, which I shall now present in detail : According to the first, set forth originally by Virchow, and continued by Wagner, Biihl and Rindfleisch, the false mem- brane is a production of the epithelium of the mucous mem- brane with or without infiltration of the mucous corium. The second approaches the French idea of exudation, ex- cepting some details. The false membranes are formed essen- tially of emigrated leucocytes (Cohnheim) and a fibrinous sub- stance transuded through the diseased walls of the vessels of the mucous membrane (Steudener, Boldyrew, Senator, etc.). PATHOLOGICAL ANATOMY. 59 First Theory. — The work which presents and develops this theory the best is that of E. Wagner. This author has exam- ined the false membranes, both in the fresh state and after hardening in alcohol. The following are his conclusions : In the pharynx arid the upper part of the larynx the mucous corium presents lesions as well marked as those of the epithe- lium. The inflammation there is always diphtheritic, that is, interstitial. a. Lesio7is of the Epithelium. — The epithelial cells undergo a special transformation, which he calls fibrinous ; in reality they grow by an infiltration of fibrin into their interior. Then are developed, especially at the periphery, small, clear spaces, round or oval, which, by increasing, displace the protoplasm. This becomes deformed, elongated, and projects ramifications which soon become united with those of the neighboring cells, A characteristic network is thus formed in which one can no longer recognize a nucleus. b. Lesions of the Corium. — At first the mucous membrane is simply congested, later it becomes the seat of a quite active new formation of young cells which one may sometimes fol- low even into the sub-mucous tissue. This author regards these two processes as distinct, and as not being connected necessarily one with the other. At one time the epithelial lesion predominates, at another the cellular neoplasia. In the liypoglottic portions of the larynx and in the trachea the net work of the false membrane is formed of thinner threads and of more compact lamellae, but it has, as in the pharynx, an epithelial origin. It is constituted by the union [so?(dure) of cylindrical cells which have undergone fibrinous transform- ation. But the young cells are much more abundant in the meshes of the network, and much more rare in the corium. Biihl, while admitting, as does Wagner, the fibrinous trans- formation of the epithelium, assigns to diphtheria a character- istic lesion which consists in the infiltration of the tissue of the mucous membrane with cellular or nucleolar bodies {cyt'did Kbrper), now isolated, now united to the number of from two 6o DIPHTHERIA, CROUP AND TRACHEOTOMY. to six upon a single mass of protoplasm. Quite close in the superficial layer of the mucous membrane, they are more scat- tered in the deeper layers. Their formation at the expense of the connective tissue cells is scarcely demonstrated. This new formation of elements of the mucous membrane was found not only in all the false membranes but in the mucous membranes which were not covered by it. From this fact, Biihl deduced an argument in favor of the general nature of the disease. In a case of diphtheritic paralysis, he found the nurilemma thickened at a point corresponding to the spinal ganglions ; there again, the new formation is said to have ef- fected its work and produced the paralysis. This process would recall, to a certain degree, that of syphilitic lesions. Rindfleisch also describes separately, croupal (pseudo-mem- branous) inflammation and diphtheritic (membranous) inflam- mation, at the same time recognizing that there is only a dif- ference of degree and not of nature between the two pro- cesses. The false membrane is composed of two principal elements : 1. A special transformation, called vitreous, of the epithe- lium. 2. A fibrinoid exudate coming from the vessels. One sees that this theoiy lends support, on one hand, to that of Wag- ner, and on the other to that which the most recent German works have set forth. According to Rindfleisch, croupal inflammation differs from catarrhal inflammation of the mucous membrane only in the specific nature of the product — a body analogous to fibrin becoming clear by the action of acetic acid. In the pharynx the greater part of the false membrane is formed of cells which have undergone the vitreous transformation. The pro- cess develops in islets and recovers without producing any cicatrix of the mucous membrane. In the larj'nx there can be no doubt of the presence of fibrin; the false membrane is formed of stratified layers of young cells alternating with layers of fibrin. The submucous tissue is more or less infil- trated with young cells. In diphtheritic inflammation there PATHOLOGICAL ANATOMY. 6l arises in the thickness of the corium an exudation so intense that it entails the necrosis of the tissue, hence the production of eschars which detach themselves and leave after them cica- trices. Second Theory. — By one of those reversions so common in histology, the most recent researches concur in returning to honor the works of ancient observers, which were for a mo- ment contested, by supporting them with the influence of the modern means of investigation. Boldyrew, Steudener and Senator established clearly that in the genesis of the false membrane, vascular exudation is the principal fact, and that the epithelial alteration presents an importance entirely second- ary. Boldyrew verified in the false membrane the presence of the following elements : 1. Fibrin, deposited in parallel layers which one may some- times succeed in separating like the concentric layers of an onion. The fibrinous network is very rich. One finds accum- ulated mucus in certain parts of the false membrane, particu- larly in proximity to the excretory canals of the glans of the mucous membrane. 2. Pus in great abundance in the thickness of the false mem- brane, especially at first. The epithelium has totally disap- peared, and the mucous membrane is infiltrated with leuco- cytes. One finds neither congestion in the capillaries nor haemorrhage. Steudener in examining the false membrane of the larynx and of the trachea gave nearly the same descrip- tion. He insisted upon the fact of the total absence of the epithelium and upon the infiltration of the corium and often even of the submucous tissue with round cells. He admits with Cohnheim an alteration of the walls* of the vessels (po- rosity of Rindfleish) which permits the emigration of the white globules and the exudation of fibrin. To the assertions of Wagner he offers the following objections: 1. The threads of the network of the tracheal false mem- brane are too thick for it to be possible for them to be formed at the expense of the little pre-existent cylindrical cells. 2. The number of the cells is too considerable to arise from the epithelium. 62 DIPHTHERIA, CROUP AND TRACHEOTOMY. 3. One cannot explain by his theory the rapid formation of new false membranes after the falling off of the old one, since there is no longer any trace of epithelium there. 4. He never observed, neither in the larynx nor in the trachea, the fibrinous transformation described by Wagner. 5. The lesions observed in the inflamed serous membranes by Cohnheim resemble so closely those met with in croup that they may be inte preted in the same manner. These very weighty objections, added to those researches which we have just analysed and those which remain for us to present, give to the theory of Wagner a blow from which it will with difficulty recover. Senator, in a remarkable work, made a decided step toward the ideas of Brettoneau. In a more philosophical spirit, more of a generalizer than his predecessors, he no longer held to the single anatomical nature which had inspired in them the separation of the croupal and the diphtheritic affections. He preserved, it is true, these denominations, but he applied them to anatomical varieties which enter into a common whole, and this he called diphtheria after the example of Trousseau. He described four anatomical forms of diphtheria : 1. Catarrhal form. One frequently meets during an epi- demic cases of simple catarrhs of the air passages, which may degenerate into true diphtheria, of which they are evidently the first stage or a slight attack. The author thus gives an anatomical sanction to the purely French idea of diphtJicria without diphtheria, that is, diphtheria without the false mem- brane, of which I shall show later the reality. 2. The croupal form of which the type is found in the pseu- do-membranous inflammation of the larynx and trachea. The fibrin stratified in lamellae and the leucocytes chiefly consti- tute the false membrane ; underneath, the mucous membrane is strongly hperaemic and infiltrated with young cells. This anatomical form is never met with pure in the pharynx. But, says Senator, no person will deny to-day that true anatomical croup maybe developed under the influence of diphtheritic con- tagion, that is to say, there is a diphtheritic croup coincident with diphtheritic inflammation of the pharynx. PATHOLOGICAL ANATOMY. 6$ 3. The pseudo-croupal form which is characterized by grey or milky membranes scattered in patches or bands upon the mucous membranes of the soft palate, and the tonsils, and more rarely upon the buccal mucous membrane. They may be easily separated, and underneath one finds the mucous membranes perfectly healthy. They are composed essentially of epithelium easily recognizable on the spot, and of low forms of fungi (leptothrix, etc.), which are probably the cause of the alteration and putrefaction of the epithelium, as in aphthaii^ but with this difference: there is, in this later case another kind of fungi. There is neither pus nor fibrin. This form, often quite benign and purely local, may appear during an epidemic and be followed by true diphtheria. This description seems to resemble very closely the form called catarrh of the author ; and it seems that he might have united them with advantage. 4. The diphtheritic for»i properly so-called is that in which the process is gangrenous and not pellicular. The description which Senator gives of it accords with that of Rindfleisch. From an anatomical point of view his work presents nothing especially new ; but on the part of nosography a grand advan- tage is realized over other German authors by recognizing that the different anatomical forms all arise from the same cause, namely, diphtheritic contagion. How different this from Wag- ner, who, fashioning the pathology to suit his ideas of the anat- omy maintains that the same patient may have at the same time, but by simple coincidence, two different diseases; one a diphtheria of the pharynx and of the larynx above the glottis, and later a croup of the hypoglottic portion of the larynx and of the trachea. Niemeyer, while preserving the distinction between the croupal and the diphtheritic processes, and recognizing simple croup, differs formally from physicians who confound this sim- ple croup with croupal laryngitis dependent upon diptheritic infection. He says, " I cannot sha^e in this view. The divi- sion of diseases according to the anatomico-pathological mod- ifications which they entail in their train is but a last shift. 64 DIPHTHERIA, CROUP AND TRACHEOTOMY. Whenever it is possible to demonstrate, as occurs in primary- croup and diphtheritic croup, that two disturbances of nutri- tion anatomically alike have an essentially different origin, we are no longer allowed to confound one with the other. * * *" Diphtheria is seen, finally, in its true light by Warimann and Hagner, who consider it as one process susceptible of taking on distinct anatomical forms according to the organ on which it is localized. The works of the French school experience, during these latter years, the German influence. The princi- pal are those of Lorain and Lepine, Cornil and Ranvier, ]\Iath- ias Duval, and RebouUet. Let us note, however, a memoir of Homolle, in which the author demonstrates that the exudate is formed of a coagulable liquid in which are imprisoned the young cells deposited in large quantity on the surface of the mucous membrane. The Parasitic Element. The fibrin, the leucocytes and the epithelial transformations are not the only products which are met with in the false mem- brane of diphtheria. Several observers have also discovered in it fungi or inferior algae. Laboulbene has mentioned vibri- ones. I have already reported his description. Other authors have gone still farther; they have been disposed to make these organisms the specific lesion of diphtheria. Hallier found the spores of an undescribed fungus which he called the diplospo- runn fuscmn. Letzerich, who has made some thorough inves- tigations and formed from them an entire theory, admits, to the exclusion of all other fungi, the zygodesmiis fuscus which he has followed as far as into the lymphatic ganglions, the mus- cles, and into the kidneys where it formed a true layer {^pilz- ladeii). Penetrating into the mucous net-work of Malpighiand into the connective tissue, the fungus provoked the formation of patches of exudate ; at the same time it corrodes the walls of the neighboring blood vessels and lymphatics, and penetrates into their cavity, where it forms parasitic emboli. Once entered into the circulatory system, the spores have the faculty of es- caping thence by a kind of transudation and extending into the PATHOLOGICAL ANATOMY. 65 surrounding tissues, where they constitute new foci. In this way- are produced the lesions of the lungs, the heart, the kidneys the nerves, the muscles, etc. The theory is complete, as we see, and plausible ; it has led as- tray several German authors, Biihl and Neumann among others. B. Napier has found these fungi, but also in children perfectly healthy. Many other pathological anatomists have sought without finding the fungus of Letzerich. Among them we may mention Max Jaffe. This author has observed accidentally in diphtheretic false membranes low vegetable forms : oidium albi- cans and leptothrix biiccalis ; but he accords to them no specific significance. Rud, Demme, of Berne, holds the same opinion. Classen, of Rostock, has never met with the zygodesmus fuscus, but he de- scribes little, round, brilliant, mobile bodies analogous to those observed by Hallier in variola and in other diseases. He sup- poses that these organisms exert a special action upon the epi- thelium, which induces upon the latter the alterations such as Wagner insists upon. Hueter and Tommasi have observed, in the blood of persons attacke 1 with diphtheria, small round, shining, very mobile points, which they have also seen in the false membranes and in the diphtheritic inflammations produced experimentally. But Bittleheim has demonstrated that these points are not specific, since they are found also in the blood of persons in good health. In the view of Nassiloff, Oertel, Classen and Eberth, the spe- cific parasite is a micrococcus of which they have recognized large quantities in the false membranes, in the interior of the cells of the mucous membrane, in the neigboring vessels and lymphatic ganglions and in the viscera. They have found it in the cases of inoculated diphtheria (diphtheritic inoculation) and Oertel has made the remark that it always fails in experi- mental croup caused by ordinary caustic substances. These authors therefore conclude that the false membrane is, at the beginning, a local affection caused by the presence of the mi- crococcus and that the general infection is produced by tiie penetration of the parasite into the organism. 66 DIPHTHERIA, CROUP AND TRACHEOTOMY. Senator refutes peremptorily these conclusions. He has never observed the fungus described by Letzerich. He has constantly found in the false membranes of the throat (i.) small round bodies with sharp outlines, from one (i) to two , a (2) (1/25000 in.) in diameter, resisting the action of ether and of caustic potash, sometimes stationary, sometimes movable, which he regards as spores of lepothrix buccalis or of monas cre- pusculum\ (2.) vibriones; (3.) leptothrix buccalis. But these round bodies are obsers^ed in the aphthous, ulcerous and mer- curial inflammations of the mouth. Senator was able in these cases to obtain the same figures as Oertel had, by leaving a small piece of meat for some time in the mouth of the patient. He saw distinctly the spores in the muscular tissue. The pre- ferred seat of these organisms is found in the false m.embranes of the throat ; they are wanting or are very rare in those which come from the respiratory passages. These microphytes are, therefore, not necessary to the development of the false mem- branes ; they are carried by the air, deposited upon the first ex- udates which they meet and are there developed as they are usually upon organic matters exposed to warm moist air and consequently exposed to putrefaction. It is in fact upon the old false membranes already more or less altered, that they are observed. We may add, that the numerous experiments to which persons have applied them- selves with the object of inoculating these vegetable growths have given only negative results. From what precedes it fol- lows that the spores set forth as the morbific germs of diph- theria do not merit such a title, and that new observations and solid proofs are needed to establish diphtheria as a parasitic disease. Conclusions. — What must we conclude from the preceding views ? The whole question reduces itself to two points : Is the false membrane a fibrinous exudate ? Or is it, on the con- trary, a product of epithelial transformation ? The second opinion admitted in whole by Wagner and Buhl, and in part by Rindfleisch, is combatted by Boldyrew, Steu- dener and Senator, who return to the theory of Bretonneau by PATHOLOGICAL ANATOMY. 6/ perfecting it and bringing it up to a level with modern science. The arguments with which the latter authors combat those of their opponents have been presented in detail. There is a point on which all the world is now agreed : that is, the exud- ative nature of the false membrane in the sub-glottic portions of the larynx and in the remainder of the respiratory passages. On this subject modern observers hold common ground with the ancients. When we come to the pharyngeal false membrane diverg- ences arise, but more apparent than real. According to Senator, the necrotic process is the almost constant rule ; on the other hand, when he describes the laryn- geal false membrane he is careful to tell us that this anatomical form is never found pure in the pharynx. Upon this latter point he is entirely correct, the more so as this proposition rectifies that in which the first was too absolute. Certainly the gangrenous (necrotic) process is observed in the pharynx, and much more frequently than the school of Bretonneau thought ; but we fall into error by supposing that all the diphtheritic false membranes of the pharynx are eschars. It is evident that the authors who formulated this latter opinion made their examinations in only one cf the forms of diphtheria, the grave form which resembles gangrene or is accompanied with it. But the product of diphtheria presents itself under the most varied forms. While there are some false membranes which are thick, firm, adherent, grey or brown, others, on the contrary, are thin, transparent, white, slightly adherent, and become detached in a very short time. It cannot be a ques- tion, in these latter cases, of eschars and of the gangrenous process. [The question is so strongly in the negative that there is no ground for disagreement.] This difference did not escape Rindfleisch, who, though a partisan of the epithelial transformation, described the croupal inflammation of the pharynx. Niemeyer did the same thing, but he considered croup of the pharynx as foreign to the diphtheritic infection. Disregarding the interpretation as insignificant, let us only 68 DIPHTHERIA, CROUP AND TRACHEOTOMY. establish the anatomical fact — a superficial fibrinous exudation may be produced on the surface of the pharynx. Therefore, while affirming that the false membranes of the pharynx and of the larynx are of the same nature and proceed from the same cause, I am prepared to recognize that these morbid products offer certain differences of aspect To present these diverse characteristics in their true light, to exhibit their real nature: this is the important point in the question. It is not to different processes that these pellicular varieties owe their existence. The morbid action is the same, only its effects vary with the intensity of this same action and with the structure of the mucous membrane on which it is developed. That is a principle of general pathology applicable to diph- theria as well as to other diseases. The question thus brought back to its true terms, let us see the influence that these two factors exercise upon their products. The inflamed mucous membrane presents among others the well-known alterations of the vascular walls, lesions which, according to the generally re- ceived opinions of Cohnheim, permit the emigration of leuco- cytes and the exudation of fibrin. That settled, we easily see how the product may vary under the influence of the intensity of the cause. When the inflammation is slight an exudation is formed on the surface of the mucous^membrane which is itself infiltrated with young cells. But the lesion is superficial, slightly intense and recovers without cicatrix. At a higher degree the exuda- tion is more profound, and the vitality of the mucous membrane suffers, and a slight loss of substance follows the elimination. Finally, in the grave cases which correspond to what the Ger- mans call the diphtheritic form the inflammatory impetus is energetic, the exudation of fibrin and of young cells is pro- found and dense, and it chokes the circulation in the invaded parts. These latter mortify, assume an ashy grey color or brown, and from that time on follow the course of eschars. The structure of the mucous membrane leaves, no more than the first, any special character upon the product of its inflam- mation. In the pharynx and in the hyper-glottic portion of PATHOLOGICAL ANATOMY. 69 the larynx, the epithelium is thick and composed of pavement cells ; it adheres intimately to the mucous corium. This an- atomical condition favors the profound infiltration of the tis- sues ; it explains why the pharyngeal false membrane, while remaining superficial and slightly adherent in the cases in which the process is moderate, becomes thick and tenacious under opposite circumstances, and how, without having the gangrenous appearance, it may leave, after its separation, a loss of substance in the mucous membrane. In the hypo-glottic portion of the larynx, on the contrary, as well as in the remainder of the air passages, the epithelium is composed of cylindrical cells much thinner; but what changes principally the anatomical conditions, is the, existence of the basement vicvibrane of Bowman, an amorphous layer which separates the epithelium from the corium and forms a difficult barrier to cross. By studying this disposition, we explain the generally superficial character and feeble adher- ence of the false membranes which are produced at these points. Chemical Characters. From all time fibrin has been considered as the funda- mental element of the false membrane. The school of Vir- chow itself, while no longer according to this substance but a secondary place, has not been able to exclude it completely, and admits its existepce in the false membrane, or at least, the presence of an analogous material, a fibrinoid substance. The most recent works published in Germany (Steudener and Senator) have assigned to fibrin its predominant part ; we are able to establish by all observers that the chemical composition of the diphtheritic product is represented by the following elements: i. Fibrin; 2. An amorphous material; 3. Fatty matters in considerable quantity ; 4. Mucin. According to Robin, the false membrane is formed by an exudation of plasmine which separates into two parts, a liquid part which escapes (flows off), and another part which, coag- ulating in the form of fibrin, gives rise to the membranes. yO DIPHTHERIA, CROUP AND TRACHEOTOMY. But it is not sufficient to know the chemical composition of a body, it is important also to know how it behaves in the presence of different reagents. This part of the history of false membranes has been considered as very important, thanks to that opinion which has prevailed for a long time, namely : that the false membranes being the disease itself and not its product, it is important above all to remove a pathological element the presence of which would favor the entrance of morbid principles into the economy. It is with the hope of discovering an agent capable of rapidly destroying the diph- theritic exudate that the latter has been brought into contact with a large number of reagents, of which some give theoret- ically hope of the more or less easy solution of the fibrinous exudate. In a former work I have examined this question principally from a therapeutical point of view; I will now repeat it in its ensemble. Water has upon the false membranes only an insignificant action; at the end of three or four hours of immersion, the diphtheritic pellicle is separated into parts (desagrege) but without there being any solution. Alcohol, by dissolving the fatty exudate, hardens and shriv- els it. Glycerine swells it and makes it transparent. Among the metalloids iodine and bromine have a certain action. Iodine employed in the form of tincture colors the false membranes yellow and hardens them. A zvatery solution of bromine hardens them and renders them friable and destroys their aggregation. The acids nearly all produce a decided action upon the pseudo-membranes. Mineral Acids. — Sulphuric acid diluted with water shrivels, darkens, softens and dissolves them. Nitric Acid colors yellow and separates by feebly dissolving them. Hydrochloric acid concentrated softens and swells the false membrane. Chromic acid hardens it and turns it yellow. PATHOLOGICAL ANATOMY, 7I Organic Acids. — Tannic acid shrivels and slightly contracts it. Acetic acid acts in the same manner as hydrochloric acid, but more completely ; it swells and softens the false membrane. Citric acid attenuates without dissolving it entirely ; a thin net-work remains in the liquid. Lactic acid studied by Adrian and Bricheteau has, ac- cording to these authors, a more decided action. Two drops of this acid diluted in five (5) grammes (seventy-five minims) of water in a few seconds reduce the false membranes to a state of translucent net-work ; at the end of ten minutes there re- main in the liquid only a few fragments, scarcely perceptible, of a gelatiniform substance like scum or dregs. The addition of a few drops of the acid removes every trace of solid sub- stance, but there always remains a slight cloud. I have re- peated these experiments with the solution recommended by these authors, viz., lactic acid five grammes, to water one hundred grammes. The thinning of the false membrane was effected very rapidly, but the fibrous net-work remained, though I brought, by degrees, the quantity of lactic acid to fifteen grammes to the same quantity of water. I operated upon false membranes of three-fifths of an inch (d'un centimetre et demi) in width. This disagreement has, however, but a sec- ondary importance. The principal fact is admitted ; lactic acid reduces a false membrane in a few minutes to a net-work so thin that it becomes insignificant so far as a local lesion is concerned. Alkalies. — The solutions of potassa, of soda and of a'}nfnonia act upon the diphtheritic products by causing them to swell and softening them. Lime-zvater, above all the preceding bodies, is the best, and acts the most rapidly in dissolving the false membranes. Its solvent power was signalized by Kiichenmeister; I have ob- served it very many times, and have proved it by experiment. Take a false membrane half an inch or more in size, throw it into a graduated tube containing six cubic centimetres of lime-water, and the water will immediately be seen to become 72 DIPHTHERIA, CROUP AND TRACHEOTOMY. clouded and the exudate to become rapidly thin. At the end of ten minutes there remains only a transparent net-work which itself disappears in about half an hour, possibly less. The liquid becomes cloudy, but it always remains sufficiently transparent easily to show what remains of the false membrane. By the next day the liquid has again become clear, and a white sediment is deposited at the bottom of the tube. This reaction, like all those which have for their object the false membranes, do not always act with the same rapidity. Some- times five minutes suffice for the complete solution ; but it may occur that the fibrillary net-work will persist and remain insoluble ; and finally, in other cases, the false membrane re- mains refractory. The explanation of this variety of action is found in the differences in structure of the diphtheritic product. One which is furnished by a gangrenous angina and which contains within the fibrin fragments of mortified tissues remains in large part insoluble, or at least but little sensible to the in- fluence of the reagent. Exudates, themselves purely fibrinous, do not behave entirely in the same manner. They are at- tacked the more easily in proportion as they are thinner and more recent. When they are old, thick, compact, and, more- over, composed of stratified layers, they resist obstinately. We will yet notice a substance which possesses a great analogy to lime-water and of which the properties are similar, I mean the saccharate of lime, as it is obtained by saturating simple syrup with slaked lime. I have already called attention to its affinities for the false membrane, [In a former work.] Neiiti'al Salts. The chlorate of potassium studied by Isam- bert possesses incontestibly a solvent action, but mild. The chlorate of sodium pointed out by Barthez exercises a solvent power twice as strong as its congener. Alkaline Salts. — The bicarbonate of soda in solution acts but feebly. Applied in powder its action is more manifest. The bromide of potassium, to which Ozanam attaches great importance, gives about the same results as the preceding salts; but these results are obtained still more slowly. PATHOLOGICAL ANATOMY. 73 The hypobromite of soda is, of all the bromine compounds, the most active in reference to its influence upon the false membranes. After having studied the action of a solution of bromine and that of the solution of bromide of potassium, I was led by accident to try the hypobromite of soda, which I employed with a very different object. I made examinations of the variations of urea in specimens of urine by the method of Regnard, a method which consists in treating urine with a solution of hypobromite of soda, a substance which is ob- tained by mixing sixty (60) cubic centimetres of lye or so- lution of caustic soda with seven cubic centimetres of bro- mine, to which is added one hundred and forty cubic centi- metres of distilled water. Finding that I had a compound of bromine not yet tried in its relations to the product of diph- theria, I thought I would make a trial of it. I witnessed a very powerful solvent action, equal to that of lime-water. The chloride of sodium is indifferent to the plastic products. Metallic Salts. — Nitrate of silver does not dissolve the false membrane, it contracts and condenses it. The perchloride of iron has no direct action upon it. Aubrun has shown that this salt, in the presence of organic matters, is decomposed into hydrochloric acid, which is set free, and into oxyde of iron, which is precipitated and can be removed by scraping. The mcrcmial salts, calomel, red precipitate, einabar, etc., pro- duce in a state of powder a slightly solvent action. Before closing this list of reagents, alieady long, I should mention alum, a substance the action of which is analogous to tannin. Evolution. — Pathological Physiology. The mucous membrane in the formation of the diphtheritic false membrane becomes the seat of an inflammatory action which is peculiar in its origin and course, yet presents all the known characteristics of phlegmasia of the mucous mem- branes. The capital point of this elaboration is the transuda- tion through the vessels of a fibrinoid substance to which is added quite a considerable number of emigrated leucocytes. (Cohnheim.) 74 DIPHTHERIA, CROUP AND TRACAEOTOMY. At first the false membrane is thin, soft and semi-transparent. The German school has maintained and still maintains that this kind of false membrane is peculiar to the respiratory- passages and is never, or almost never, observed in the throat, the necrotic process being limited to the latter. I have given the reasons which convince me of the inaccuracy of this view. At the end of a very short time, a few hours generally, the exudation continuing, the false membrane becomes thicker, harder and reaches its full development. At the same time it increases in surface. It is rare that it assumes from the first its full dimensions ; it makes its appearance as a round patch, often quite circumscribed, even punctiform, which develops eccentrically. This mode of extension is sometimes quite re- markable ; there exists at the outset but one or more little points which have the greatest analogy to herpetic vesicles or to the concretions of the tonsils ; they enlarge, unite if there be a certain number of them, and end by forming one or more diphtheritic membranes well marked, such as we meet in grave angina and in croup. I have often seen infectious angina, fol- lowed or not by croup, begin in this manner. Pseudo-mem- braneous inflammation, when it begins on a single point or on several at a time, extends by contiguity, and quite frequently assumes a remarkable tendency to propagate itself from above downwards. Bretonneau, who had apprehended this peculiarity, admitted as an explanation that the parts first affected furnished an acrid, virulent, epispastic liquid which, escaping towards the dependent parts, irritated the latter and communicated to them pseudo-membraneous inflammation. This hypothesis could not stand before a careful examination of the facts. The existence of this acrid liquid is more than doubtful. More- over, the descending progress of the diphtheritic exudate is much less general than Bretonneau thought; the cases of croup ascending and those of coryza and otitis, consecutive to angina, are common. We do not see what action the acrid liquid, if it did exist, could exercise under these circumstances; without considering that gravity and the movements of deglu- PATHOLOGICAL ANATOMY. 75 tition bring it into the oesophagus, the mucous membrane of this tube should figure among the points most affected ; now, nothing is less true ; this organ is so rarely attacked by diphtheria that the presence of the concretions on its surface has been emphatically denied. This theory had produced a special plan of treatment, which consisted in cauterizing extensively, unmercifully, with a sauv- age energie, the points attacked with diphtheritic exudation, with the object of concentrating and destroying the morbid principle on the spot. A false principle leads necessarily to a defective practice ; and the talent of Trousseau was able to save neither the one nor the other from the discredit into which they have both fallen. However that may be, the false membrane is constituted and follows the cycle of its evolution. But it happens some- times that the disease not having exhausted its efforts, forms in the diseased mucous membrane a new action which is itself followed by a second exudation and which insinuates itself under the patch already formed and lines it with a second layer. When several times reproduced these impulses produce new fibrinous layers, which are superimposed and give to the false membrane the stratified appearance. In the gangrenous form the inflammatory action, much more intense, results in a profound infiltration of the mucous or cutaneous corium with fibrin and young cells, an infiltration which compromises the nutrition of the tissue invaded and stamps it with death. Like all inflammatory products the false membrane, after having obtained its acme, proceeds towards its end. It may end in one of two ways : it separates, or it disintegrates. The separation of the false membrane is ac- complished under the following circumstances : the inflamma- tion of the mucous membrane declines, the vascular walls be- come strengthened ; the altered portions of the epithelium are restored ; the mucous secreted anew interposes itself between the exudate and the mucous membrane ; the filaments which united the two surfaces are broken; the false membrane grad- ually loses its adherence and is detached. At the same time 76 DIPHTHERIA, CROUP AND TRACHEOTOMY. some important changes are established in its composition. At first decidedly fibrillary, like the clot after venesection, the fibrin of the false membrane loses its fibrillary character, as occurs in all coagulated fibrin after a considerable time. At the end of four or five days the fibrillary condition has com- pletely disappeared or is found only imperfectly and on very limited points. It is replaced by the granular condition. More- over, the fibrin may also be transformed, partially at least, into mucin; but the most important change that it undergoes is the return to a fatty condition. These modifications explain how the false membrane may soften, become pulpous, wear away, disintegrate and disappear before reaching a separation en masse. When the inflammation has reached a degree sufficiently violent to produce necrosis (gangrene) the morbid product is eliminated as eschars are. The facility with which the false membranes separate varies also according to the region. In the pharynx the thickness of the epithelium and its con- nection with the corium enable the two parts to be invaded at once ; there is therefore deeper penetration, and also a greater adherence of the plastic product to the subjacent tis- sues. In the hypo-glottic portion of the larynx and in all the res- piratory tract, the false membrane is more superficial, it is never intimately united to the corium from which the amorphous lamella or membrane of Bowman separates it. Hence it is much more easily detached. The detachment occurs in a period of time varying between two and fifteen days. It commences from the second to the tenth day and ends from the ninth to the fifteenth. But successive exudations may be produced. It is thus that I have found false membranes in an autopsy made on the thirty-first day from the outset. I have seen a patient attacked with croup expel false membranes up to the thirty-second day. pathological anatomy. 77 Sec. 2. — Supports of the False Membrane. I. The Miico2is Membrane. — I have shown in the preceding chapter the divergences which appear among authors on the subject of the condition of the mucous membrane: some re- gard it as always healthy or admit only slight lesions ; others regard it as profoundly affected, always degenerated and often mortified. The ancients, believing in a gangrenous process, looked upon the false membrane as an eschar ; Bretonneau showed that it was only an inflammatory product coming from the mucous membrane. Opposing too strongly the doctrines of his predecessors, he affirmed the absolute integrity of the mucous membrane in all cases. " Most frequently," said he, "the mucous membrane preserves its polish and its ordinary consistence." Elsewhere, he insists in this language : "In no case, even when malignant angina had assumed the most repulsive character, have I ever been able to discover anything which resembles a gangrenous lesion. Ecchymoses of limited extent, as well as a slight erosion of the surfaces on which the duration of the malady was prolonged, were the gravest alterations that I succeeded in establishing." He was careful to secure the observer against possible anatomical er- rors. Tumefaction of the mucous membrane and of the sub- mucous tissue which surrounds the pseudo-membranous patch- es might, he said, if one was not on his guard, cause the latter to be taken for ulcerations. The opinion of Bretonneau, founded, no doubt, upon the special characteristics of the epidemics which he observed, has found numerous opponents. Bequerel, Isambert, Bouillon-Lagrange, Barthez and Rilliet, H. Roger, Laboulbene and Trousseau have proved by numerous facts that the gangrenous and ulcerous process might coincide with diphtheria. The fact was well established when Germany, returning to the ideas which prevailed before Bretonneau, undertook to give them currency once more. More recent works emanating from the same country have shown wherein this attempt was extreme. The mucous membrane, in my opinion, behaves differently 78 DIPHTHERIA, CROUP AND TRACHEOTOMY. in simple cases and in those in which the infectious element predominates. French authors have written that the condition of the mucous membrane and the appearance of the false membrane varied according as the diphtheria was priviary or secondajy; they have consequently adopted this division as the basis of their description. I have not admitted this view, for the reason that these differences hold essentially, not to the primary or secondary character of the disease, but to the degree of intensity and to its simple or its infectious nature. In fact, while certain grave local characteristics present them- selves often and in a high degree in secondary diphtheria, they are not inseparable from it, and we see them but too frequent- ly in the primary form. It is, therefore, rational to examine the modifications which the mucous membrane and the sub- mucous tissues undergo in the simple cases as well as in those in which the disease is intense and infectious. In the begin- ning the mucous membrane is red and hypersemic ; in some eases, according to Daviot, it presents a transparent oedema- tous aspect. The capillaries are dilated, arborescent or form small dotted spots. Their walls become altered and permit the leucocytes and fibrin to transude. The leucocytes im- pregnate the mucous membrane to a considerable depth and upon a surface extending beyond that occupied by the false membrane. The fibrin is distributed according to the case, and especially according to the intensity of the process. In the mild forms it is deposited on the surface of the epithelium in the form of a white pellicle, which becomes thickened and hardened. In the grave form, and according to the region, it is infiltrated, superficially or profoundly, into the structure of the corium, suspends nutrition in these parts, mortifies them and forms with them an eschar which is eliminated by the ordinary process. When the false membrane is constituted, the mucous membrane remains for a certain time congested, but smooth, rarely uneven. The mucous membrane and its morbid product adhere strongly to one another, they are separable only with some difficulty, and only at the expense of a slight escape of blood. PATHOLOGICAL ANATOMY. 79 Little by little the congestion diminishes, the mucous mem- brane returns to its normal state and the false membrane sep- arates, carrying with it a large part of the epithelium. The latter is replaced at the end of a short time. In the more intense cases of the disease, the congestion is accompanied with tumefaction, infiltration of the mucous membrane and of the cellular tissue in a certain zone around the false membrane ; the latter appears to be situated at the bottom of a depression. The mucous membrane is rugose, roughened, and there are formed on its surface ecchemoses which discolor the false membrane and spot it with brown. Ulcerations of various forms and dimensions may appear on the surface. Sometimes round, sometimes sinuous, which makes them resemble, according to the comparison of Barthez and Rilliet, moth-eaten cloth, they show clean-cut margins, not separated or detached. The base is constituted of mus- cular fibers frequently changed, as modem investigations show, contrary to ancient opinion. In the violent and infectious forms, the tumefaction and oedema become considerable, the ecchemotic discoloration more pronounced and the infiltration of fibrin and leucocytes increase in the structure of the mu- cous corium. The mucous membrane becomes uneven, rough- ened (shagreened); it softens, mortifies and becomes covered with large grey or brown ulcerations, with the margins de- tached, coated with a greenish gray detritus, the whole exhal- ing the fetor characteristic of gangrene. The tonsils, uvula, soft palate and its pillars are the parts most frequently morti- fied. The mucous membrane of the larynx and trachea is affected much more rarely. The gangrenous process varies in proportion to its intensity. Most frequently it attacks but a part of the thickness of the mucous membrane; but in others it goes beyond the limits of this membrane, invades the subjacent cellular tissue, and even the neighboring muscles. In a patient attacked with diph- theritic angina of the gangrenous form, the detachment of the eschars revealed several perforations of the soft palate. The disease not having been either preceded by nor accompanied 8o DIPHTHERIA, CROUP AND TRACHEOTOMY. with rubeola or any other morbid condition impelling to gan- grene, diphtheria could be alone chargeable with the un- usual intensity of this gangrenous process. The mortification has also been seen to progress, step by step, to the vicinity of the large vessels. In the cases less grave the ulcerations heal, but they leave in their place a cicatricial tissue, the retraction of which causes deformities and strictures which may produce obstacles to the action of the pharynx, the larynx and the trachea. The sub- vmcous tissue is also affected by extension of the lesions of the mucous membranes. In the simple cases it is infiltrated with young cells. In the grave cases it participates in the inflam- matory and gangrenous processes of which the mucous mem- brane becomes the seat. 2. The Skin. Like the mucous membrane, the skin serves as a substratum to the diphtheritic pseudo-membranes. I shall not occupy myself in this chapter with the appearances of the disease, but shall confine myself to the description of its anatomical alter- ations. The exudation presents itself most frequently upon the skin deprived of the superficial layer of the epidermis and upon ulcerated and excoriated surfaces, and those covered with eruptions. The dermis which supports the false membranes is indu- rated, thickened, red, uneven and granulated on its surface. The margins of the injury are quite prominent and of a vio- let red ; the subcutaneous connective tissue is infiltrated and tumefied. These alterations affect the surrounding skin to a certain ex- tent. Upon this inflamed surface the epidermis rises, vesicles and bullae form, filled, most frequently, with a milky serosity. By incising this epidermis the deep surface appears covered with a false membrane in process of formation or completely formed, according to the period. It is by this mechanism and by the agglomeration of these phylctenulse that the diph- PATHOLOGICAL ANATOMY. 8 1 theria extends. In some cases the disease assumes a greater intensity and takes on the gangrenous form ; and to the false membranes are then added the lesions peculiar to gangrene, viz., eschar, fetor and a peculiar discoloration. The histological part presents nothing new. The alterations of the skin are analogous to those of the mucous membrane. The rete nmcosuni of Malpighi and the superficial layer of the corium, which present so much correspondence with the epi- thelium and the corium of the mucous membranes, serve as the seat of the process and present lesions of the same kind. The mode of formation of the false membrane is the same, as well as its structure. SECOND CLASS— LESIONS OF THE APPARATUS- LOCALIZATION OF THE FALSE MEMBRANE- SECONDARY LESIONS. Section I. Lymphatic Glands. It is very rarely in diphtheria that the neighboring lym- phatic ganglions or glands remain in a state of integrity. All superficial ganghons are amenable to adenitis, but especially those of the neck, among which, in a pre-eminent degree, are the submaxillary and the parotid. It is to these that the dis- ease extends most frequently and with the greatest intensity. In certain regions the deep ganglions may become afTected after the superficial ones; in the neck this is the case especially with those following the course of the sterno-mastoid. Lesions of the cervical ganghons have been pointed out by numerous authors, but there are other ganglions of which the morbid condition is less known ; I refer to the bronchial and also to the mesenteric glands. In a large number of cases, dead of croup, I have seen at the autopsy the tracheal and bronchial ganglions present lesions varying from simple tumefaction to suppuration. These cases of adenitis present nothing peculiar; their anatomical 82 DIPHTHERIA, CROUP AND TRACHEOTOMY. characteristics are the same as those of adenitis in general. Increase of volume and redness on section are the most com- mon conditions of the ganglions. At a more advanced period the redness becomes darker and the parenchyma becomes like that of the spleen, and later becomes infiltrated with a some- what abundant milky serosity. Finally, when the diphtheritic manifestation is very intense — it is almost invariably in angina that this termination is observed — the gland suppurates. In its tissue are formed purulent nodules isolated or united into a single focus. When the ganglions are affected in large number they some- times form, by agglomeration, tumors of considerable size of which their importance depends upon the relation they sustain to the neighboring organs. Among the possible consequences may be, projection into the pharynx and stricture of its cavity; compression of the larynx, the trachea or the bronchi; or strangulation of the vessels ; these are their possible conse- quences. I have published the case of a patient in whom an enormous double, submaxillary adenitis, accompanying a scar- latinous diphtheria, gave rise, in consequence of the obstructed circulation which it produced, to an oedema of the glottis which necessitated tracheotomy. The surrounding connective tissue which envelops the gan- glions does not remain indifferent to their morbid condition. It participates in it at times with a surprising intensity. In the simple cases, it is only hyperemic and tumefied. In cases more grave there occurs a true inflammatory oedema which gives to the part a doughy consistence, but hard at the same time. The skin assumes that shiny aspect which it acquires when it is strongly distended ; and it pits on press- ure. When the adenitis is very intense the connective tissue suppurates and we find in it scattered points or large purulent pouches in which the diseased glands float. One thing re- markable is, that the lesions of the ganglions are frequently more tardy than those of the connective tissue. While the lat- ter is in complete suppuration, it may happen that the glandu- ular inflammation may have been arrested in its course. W'hen PATHOLOGICAL ANATOMY. 83 suppuration occurs in both tissues it forms two collections of unequal volume, the superficial one is of much the greater ex- tent. They are united by a quite narrow track, and constitute In their entirety the variety known by the name of abces en bouton de chemise. Section II. General Connective Tissue. The general sub-cutaneous connective tissue is most frequently healthy ; however it must be noted that an anasarca may oc- cur, though very rarely, in the train of albuminuria. Sangui- nolent effusions also occur in its substance. In a patient tra- cheotomized on account of croup, in whom the flaps were attacked with gangrene, I recognized the existence of a small subcutaneous bloody effusion situated behind one ear. Bou- chut has quite frequently witnessed these extravasations ; in forty-six autopsies he saw them twenty-six times, as well in the connective tissue as in the muscles. Section III. Digestive Apparatus. The throat is, beyond qusstion, the site of election of diph- theria; and of all the manifestations of this disease, angina is the most common. We must not suppose, however, that the other parts of the digestive tube are always free. The ana- tomical lesions of which I shall speak in this section are not numerous. The general remarks upon the false membranes and upon the mucous membrane and the neighboring tissues, having been given, it remains only to speak of loca.' oeculiari- ties. Now, the most important regions of this apparatus being visible, the pathological anatomy is blended largely with the description of the local symptoms. To avoid repetition I shall reserve the latter part of this description for the chanter on symptoms, where it will find its proper place. I shall limit myself, for the present, to some brief indica- tions. Diphtheria of the Mouth exists beyond doubt. It occurs in much less relative frequency, however, than was supposed by Bretonneau and Trousseau, who confounded with it that path- 84 DIPHTHERIA, CROUP AND TRACHEOTOMY. ological species so different, known under the name of tdcero- nionhranons stomatitis. Any part of the mouth may become the seat of false membranes ; the Hps, upon their borders, their commissures and their posterior surfaces; the cheeks, and the tongue. Gangrene of these parts is rare ; the mucous membrane is attacked superficially. The tongue, however, is an exception. Upon this organ the mucous membrane is often invaded, and recovers with a cicatrix. Hayem insists correctly upon this point. The istlinms of the fauces is indifferently attacked at all points. The tonsils, the soft palate with its pillars, and the pb^rvnx, may be separately, simultaneously or successively covered with diphtheritic exudates. The different forms, sim- ple, ulcerous and gangrenous, are there met with in all their varieties. The latter two concern the pathological anatomy by the deep destruction of which they are the cause. The false membranes form, with the subjacent tissues, a sloughy pulp. The uvula and the tonsils are ragged, infiltrated with pus, and are on the point of being detached ; the soft palate itself may be perforated, as the observation cited on p. 79 may prove [and as I have seen]. In another case one tonsil contained a large purulent sac. In a third, the tonsils had disappeared, nothing remaining in their place but a brown consistent sac enclosed between the pillars, containing in its cavity a semi- liquid, greenish substance, with gangrenous odor. From the point where the mucous membrane ceases to be exposed to the external air the false membranes become very rare, so ex- ceptional, indeed, that their existence in these regions has been .doubted by Empis and Isambert. However, some observers of high repute having described de visit these lesions, we are obliged to admit their existence, however rare they may be. Let us then examine them in the various divisions of the digestive tube. In the a;sophagiis they present themselves under different forms; at one time like bands, lining the posterior wall of this tube, part of or its en- tire length, even extending into the stomach ; at another they are in the form of complete or incomplete tubes ( Vidal). To PATHOLOGICAL ANATOMY. 8$ these cases I can add a personal observation. In a child dead of diphtheria of the throat and tongue, the autopsy revealed a yellow false membrane, thick and cylindrical, lining the su- perior half of the oesophagus. In the stomach they are still more rare, forming in this cavity thin filaments or even bands, running from the cardia to the pylorus. In the intestines they are mentioned by Roche, who observed them twice ; in each case the patient was attacked with mem- branous angina or croup. Guersant, Bretonneau, Guibert and Louis have also cited examples observed under the same cir- cumstances. Finally, diphtheria of the anus is mentioned by I'Espine, who observed it during an epidemic which prevailed at the military hospital of La Fleche. I have also seen two cases of it. The exudate is disposed in separate or in conflu- ent patches which may ascend into the rectum. Anatomical lesions, independent of the false membrane, have their seat in the digestive tube or its appendages. Redness and tumefac- tion of the patches of Peyer are quite frequently encountered. But these alterations are of little importance. They have been found, in children, independently of typhoid fever, and in many morbid conditions, such as scarlatina, measles, etc. On the other hand, they do not attend, in primary diph- theria, a collection of special symptoms. They are discovered frequently at the autopsy without any morbid phenomena hav- ing attended them. In a case in which they existed with mes- enteric adenitis there had not been, during life, any abdomi- nal symptom or typhoid fever. These cases do not appear to enter, in any manner, into whatTraube calls typhoid diphtheria, a form which is characterized, among other symptoms, by tumefaction of the spleen and a roseolar eruption. On the contrary. Dr. Blanchetiere found in two cases altera- tions of Peyer's patches ; but in these two patients diphtheria had appeared in the course of an attack of typhoid fever, on the twentieth or twenty-third day. It was not, therefore, ty- phoid diphtheria, but secondary diphtheria with typhoid fever. In an observation by Parrot, cited by Beau Verdeny, it was the case of a child attacked with croup, which suffered at the 86 DIPHTHERIA, CROUP AND TRACHEOTOMY. same time with severe diarrhoea, accompanied with rose spots and duhiess (submatite) on percussion in the right iHac fossa. SwelHng and redness of Peyer's glands were found. Wilson believes that diphtheria of the throat is always consec- utive to a disease of the stomach (?). In New Zealand he ob- served gastric symptoms before angina. At the autopsy he found lesions of the stomach. The liver is often altered. In many autopsies I have found a certain degree of fatty degeneration of this organ. Most frequently we find some superficial patches ; in other cases they are in the form of foci, occupying the depth of the organ, the surface escaping or not. In two cases the hepatic tissue was completely fatty ; one of the two livers was very large. In another patient a perihepatitis of the convex surface of the liver, with diaphragmatic adhesion, existed. Blanchetiere observed in the practice of Labric a case of fatty alteration in islets. In the thesis of Beau Verdeny it is also stated that fatty degeneration of the liver, more or less profound, was found in nine observations out of twenty-six. These transformations of tissue have nothing in them peculiar to diphtheria; they are common to all maladies which pro- foundly affect the economy, namely, fevers and certain kinds of poisoning. Section IV. — Respiratory Apparatus. The entire respiratory tract may be, primarily or secondarily, affected by diphtheria; primarily, by the false membranes which extend upon the respiratory mucous membrane ; sec- ondarily, by the lesions which, without being pseudo-membran- ous, are closely connected, by virtue of complications, with the diphtheritic process. Every part of the respiratory appar- atus is subject to these morbid manifestations. I. The Nose and the Nasal Foss^. Barthez and Rilliet have given an excellent description of pseudo-membranous coryza. Bretonneau, Isambert and La- boulbene have also touched uqon this question. The exudate PATHOLOGICAL ANATOMY. 8/ occupies a variable extent ; it forms patches, at one time small and scattered, at another broad and extended, which are molded upon the turbinated bones and into the meatuses, penetrating into the sinuses, especially the upper maxillary, and covering the entire extent of the Schneiderian mucous membrane. It exceeds the limits, also, of the nasal fossa, of the side which it invades, either posteriorly or anteriorly. Often but slightly adherent, but thick and resistant, it is of a yellowish white. Its under surface is sometimes ecchemosed and beset with papillae like those on the end of the tongue (Bretonneau); these are prolongations which penetrate into the orifices of the muciparous glands. The mucous membrane is inflamed, red and thick ; but in no case has it been proved to be ulcerated. A fetid muco-prurulent fluid bathes the parts. Diphtheria is rarely limited to the nasal fossae, false membranes appear almost always upon other points, to-wit, the pharynx, larynx, bronchi, etc. 2. Larynx. Some peculiarities of disposition only deserve to be men- tionen. The diphtheritic pellicle which is met with in the larynx may be isolated, but more frequently it is prolonged into the pharynx or into the trachea. The epiglottis and the aryteno-epiglottic ligaments are its favorite sites. When in con- tact with both surfaces of the epiglottis, it completely covers this organ, and then extending upon the aryteno-epiglottic lig- aments, it forms at their margins swellings which contract the orifice of the larynx. It is rare to find the false membranes acquiring such a thickness as to completely obstruct the larynx. However, asphyxia does not require an absolute occlusion of the passage ; it appears when the disturbances of haematosis #have acquired, at length, a sufficient intensity. But though the pseudo-membranous coating rarely suffices to close the larynx, it does occur that fragments, falling from above, act the part of a plug. The age, and consequently the dimensions of the larynx, greatly influence the permeability left by the diph- theretic coating. An adult larynx is but seldom filled up even 88 DIPHTHERIA, CROUP AND TRACHEOTOMY. by thick false membrane, while a thin one, relatively, is suffi- cient to close hermetically that of a young child. From the aryteno-epiglottic ligament, the pseudo-membrane reaches the true larynx, passes round the vocal cords, extends into the ven- tricles and penetrates the trachea. The larynx is not always lined throughout its entire extent with false membrane, the hypo-glottic portion is more frequently attacked. The degree of adherence and of thickness of the false membranes differs in many cases. However, those of the hypo-glottic portion adhere more firmly to the subjacent parts. Upon its free sur- face the false membrane is most frequently of a whitish yellow, but it may present all the varieties indicated in the general description. Its deep surface sends numerous projections into the mucous membrane ; sometimes it is ecchymosed. The mucous membrane is at times red and inflamed, at others tumefied and softened, but seldom ulcerated or morti- fied. Ulceration is more common in the hyper-glottic portion ; it is, however, to be seen also in the hypo-glottic part ; it gen- erally coincides with a similar lesion of the trachea or with gangrene of the wound resulting from tracheotomy. I have showed it, however, of the size of a half dime, and situated below the vocal cords in a patient who had died of croup with- out having been operated on. In one case it was located on a level with the inferior vocal cords ; on one side it was super- ficial, but on the other it had destroyed the mucous membrane and left the thyro-arytenoid muscle exposed. The tumefac- tion may be considerable ; I have seen it sufficiently devel- oped, on a level with the inferior vocal cords, to greatly dimin- ish the calibre of the glottis. Under certain circumstances, very rare by the way, one observes, instead of simple tumefac- tion, infiltration of the mucous membrane and of the subjacent tissues, the oedema of the glottis. One case has been mentioned s by Messrs. Barthez and Rilliet, and another by Bouchut. Five cases came under my observation, the first being a case of croup without angina. While a false membrane covered uni- formly the larynx, the epiglottis and the aryteno-epiglottic lig- aments were oedematous. In the second, the laryngeal oedema PATHOLOGICAL ANATOMY. 89 followed a diphtheritic angina without croup. One could still find some pseudo-membranous remains upon the tonsils, but the air-passages were free of them. The aryteno-epiglottic ligaments and the margins of the epiglottis formed thick, dense and tremulous swellings. By pressure a few drops of turbid serosity would exude from the incised surface. The third was discovered sixteen days after the commencement of an operated croup case. The patient died of albuminuria, with anasarca, pulmonary oedema, and bronchitis. Whenever an attempt was made to remove the canula, violent attacks of suffocation compelled its replacement. The epiglottis and the aryteno-epiglottic ligaments presented the same appear- ances as described above. Another case occurred, after an abscess, anterior to the larynx, developed as the result of tra- cheotomy. The muscles of the laryjtx often present alterations in their structure; unrecognized by most authors they are pointed out in a general way by Niemeyer. Rokitanski states that these muscles are pale, softened, infiltrated, and consequently incapa- ble of efficient contraction. Zenker, while admitting the paralysis, doubts the changes in the muscular tissue. Charcot and Vulpian, while examining a case of diphtheritic paralysis, found local changes of the laryngeal nerves and partial fatty degeneration of the muscles. It is not only at a period remote from the commencement that these muscular lesions are discovered, but they are also met with in the acute stage. They have been stated by Quin- quaud and by Callandreau Dufresse. The extrinsic muscles of the larynx are rarely attacked, or in a slight degree. The pos- terior arytenoid muscles are rather more frequently attacked than the preceding ones ; but the most frequently and the most profoundly affected are the thyro-arytenoidii. Pale or of a dark brown (dead-leaf), these latter are tumefied, oedematous and friable. The fibrillae have augmented in volume, and the striation has disappeared ; all the characteristics of fatty de- generation are revealed, viz., granules strongly refracting the light, and crowded together, rendered more apparent by the 90 DIPHTHERIA, CROUP AND TRACHEOTOMY. action of acetic acid, but diminishing and disappearing under the action of ether or of chloroform ; and in some fibres there is multipHcation of the nuclei of the myolemma. It looks as if one was dealing with phosphorous fatty degeneration. (Callendreau Dufresse.) All the fibrillae are not so pro- foundly changed ; every intermediate degree, even to a healthy state, may be met with, but the muscle always presents in its totality numerous lesions. The elucidation of this anatomical point is fertile in pathological applications; it facilitates the explanation of certain symptoms in croup following, early or later, the attack, and gives valuable data upon the action of the larynx in this disease. Cartilages. — The cartilages of the larynx occasionally par- ticipate, by extension, in the inflammation and lesions of the parts which cover them. They are found more or less eroded. Delbet speaks of a child attacked with gangrenous angina who spat up his epiglottis. Blanchetiere describes a case of exten- sive necrosis of the cricoid and the thyroid cartilages follow- ing gangrene of the wound in tracheotomy. 3. Trachea. Primary diphtheritic lesions of the trachea are encountered in every form and degree. The false membranes are here de- veloped either in patches of various dimensions with fre- quently irregular margins, or are in the form of cylinders which occupy a part or the whole of the tube. In the latter case the cylinder often extends into the bronchi. But com- plete pseudo-membranous tubes lining the trachea in its entire length are sufficiently rare; [see plate of a cast opposite frontispiece] ; it is particularly in the superior part of this passage, and following that of the larynx, that the false membrane is deposited circularly. Further down, its edges are fringed and projected into points more or less ex- tended, which often terminate in filaments. The most common variety of these latter follow the posterior wall of the passage and divide, at a level with the bifurcation, into two secondary bands which penetrate deeply into the bronchi. The false I PATHOLOGICAL ANATOMY. 9I membrane of the trachea is dense, thicker in the superior por- tions than in the inferior, and moderately adherent. The mu- cous membrane is seldom altered, at least to the naked eye. It is susceptible to the same lesions as that of the larynx. But there is a class of ulcerations, peculiar to the trachea, of trau- matic origin, produced nearly always by the retention of the canula after tracheotomy. They demand a separate descrip- tion. Ulceration of the Trahcea. — Mentioned by Vidal, Goupil, and Barthez, their history has been written by Roger. I have de- voted one chapter of a former work to this interesting part of pathology. The most common site of this ulceration is the anterior wall of the trachea below the inferior angle of the incision, at a point which, during hfe, corresponded to the lower end of the canula ; a healthy mucous surface generally separates these two points ; and more rarely the posterior wall is also compromised ; finally, sometimes the entire circumfer- ence is implicated. The color varies from grayish white to yellow, sometimes it is brown or greenish. The form, in sim- ple cases, is round or oval, but may become irregular. The size, which often does not exceed that of a lentil or of a half- dime or dime piece, becomes much extended under some cir- cumstances. Roger cites a case of ulceration which occupied two-thirds of the length of the trachea in its entire circumfer- ence. The depth varies between a simple erosion of the mu- cous membrane and a perforation of the trachea. Frequently it corresponds with the intensity of the lesions of the sur- rounding mucous membrane, that is, deep ulcerations are ob- served in the midst of serious destruction. This rule has ex- ceptions. One finds deep ulcerations, even perforations, which appear excavated as with a punch in the apparently sound tis- sue ; on the other hand, we find superficial erosions upon tis- sues seriously injured. But aside from these deviations from the rule, the surrounding mucous membrane is yellow and roughened when it is not of a dark gray or greenish. It is friable and comes off in fragments. The bottom of the ulcer- ation is covered with mortified debris and leaves exposed the 92 DIPHTHERIA, CROUP AND TRACHEOTOMY. denuded cartilages. These lose their elasticity and resistance, become attenuated, sometimes to complete destruction, leav- ing no protection to the trachea but the fibrous coating. This latter barrier itself may yield and the perforatio7i be ef- fected. In nearly all cases the perforation is made in the an- terior wall at a point which was in contact with the lower extremity of the tube. The relations which this portion of the trachea holds with important organs add much interest to the seat of this lesion. I have cited a case observed at the Hospital St. Eugenie, in which two large perforations existed, of which the innominate artery formed the base. In another the perforation was not complete, but a very thin cellular layer alone intervened be- tween the end of the canula and the same vessel on a level with its bifurcation. In the third patient three perforations of the trachea opened communication between this organ and the lower portion of the wound of the integument, itself quite large. One of the patients of whom Roger speaks had, as an exception, a perforation of the posterior tracheal wall, and the ces®phagus was in contact with the opening. The starting point of the ulceration is not always the one which I have de- scribed ; for example, it may be formed on a level with the tracheal incision. Around it are found the same lesions ; the cartilages are worn off, eroded and jagged on their cut surface. In one case they were destroyed in the anterior third of their circumference. This class of ulcerations coincide nearly al- ways with those of the inferior part. Others, finally, are found beyond reach of the canula and just within the larynx ; this is what may be seen in the patient of whom I described above the laryngeal ulcerations affecting the vocal cords. The ul- cerations of the trachea always coincide with other lesions of the respiratory passages. In twenty-three autopsies redness of the tracheal mucous membrane is described fifteen times, in which eleven cases of broncho-pneumonia are mentioned. More rarely one finds pseudo-membranous bronchitis, pulmon- ary apoplexy, oedema of the glottis, and tubercularization. It is no less interesting to know the condition of the wound in the PATHOLOGICAL ANATOMY. 93 integuments. In twenty-three cases of tracheal ulceration the wound was attacked with : Gangrene, 1 1 times. Diphtheria, 2 times. Simple ulceration, 2 times. Was healthy, / times. Condition not noted, i time. The frequency of gangrene of the wound is striking; the tracheal ulceration appears to be frequently only the extension of the necrotic process. The loss of substance of the mucous membranes and of the cartilages may be followed, after cica- trization and recovery, by Strictures of the Trachea. — They are the consequences of ul- cerations (especially of those located on the ' margins), cauter- izations and of losses of substance at the expense of the carti- lages, caused during the operation. Their site varies with that of the ulceration ; in one case cited by Blachez it was found on a level with the vocal cords. The degree of narrowing is not very marked, at least in the few cases which have been ob- sei'ved in autopsies. Polypus of the Trachea. — N. Gigon of Angouleme, and Ber- geron have called attention ■ to this interesting incident. A communication made by Krishaber in 1874 to the Societe de Chirurgie was the occasion of discussion in this society as well as in the Societe Medicale des hopitaux, and in the Societe de Medecine of Paris. Since that period Bouchut and Calvet of Castres have reported examples. I myself observed one case of it in 1871, of which I shall give later a brief history. The anatomical examinations, still few, do not permit us to re- gard the question as sufficiently known. These tumors as- sume the form of vegetations, fleshy swellings, pink, round, soft and having the size of hemp seeds or peas ; they are sessile, or pedunculated, and floating, isolated or multiple. They sensi- bly diminish the caliber of the trachea. Their structure is cellular. The histological examination has been made in a single case, that by Krishaber. Ranvier saw in this tumor large fleshy nodules analogous to those which are developed 94 DIPHTHERIA, CROUP AND TRACHEOTOMY. around drainage tubes or even a papillary polypus, primarily clothed with epithelium, but which, under the influence of trau- matic laryngitis, may have assumed the characteristics of fleshy tumors. According to Verneuil this would be in reality a papilloma. The location or seat of these tumors added to the discussion. It was first thought that they were implanted upon the cicatrix. In all cases in which autopsy could be made they were found appended to the neighboring mucous membrane. Moreover, their likeness to fleshy tumors, and their structure, which, in the only case of known examination, was that of papilloma, makes their derivation probable from mucous membrane rather than from the cicatrix. Rupture of the Trachea. — Latour reports the case of a child in which a rupture of the first two rings of the trachea occurred during a violent paroxysm of suffocation. IV. The Lungs. The pulmonary lesions encountered in diphtheria are very various ; some of them are so frequent as to be regarded as almost the necessary accompaniment of the disease ; others are more rare. They have been mentioned by several authors, among whom are Barthez and Rilliet, Hache, Trousseau, Mil- lard, etc., and they have been studied with care by Peter. This learned author having recourse to elaborate statistics has proved the frequency of these morbid conditions, until then but little known. And he was so fortunate as to show that they were not simple complications due to accident or to external influ- ence, but were especially local manifestations of the same gen- eral condition. I. Simple Bronchitis. — This is the most common lesion in diphtheria. There are few autopsies following croup in which it is absent, whether it be alone or accompanying other altera- tions. But, however frequent it may be in croup, it is not ex- clusively confined to this variety of diphtheria, what appears also natural, since every morbid action would seem, in this case, to be concentrated upon the respiratory apparatus. I have seen it in fact coincide with diphtheritic angina alone. It may be PATHOLOGICAL ANATOMY. 95 limited to the large bronchi, or extend to the small bronchial divisions. Its intensity is in proportion to its extent. But even in the cases in which it becomes generalized, the parts most severely attacked are the last invaded, that is, the most dependent. The inflammation rarely attacks at once the entire bronchial surface, it descends gradually from the trachea to the bronchi of small caliber. In the majority of cases it preserves the catarrhal inflammatory form ; but there is produced at times, upon the surface of the air-tubes, a thick muco-purulent exudation which may be quite abundant. This it is which fur- nishes an expectoration of the same nature, ordinarily so co- pious, which is often observed to follow tracheotomy. I have seen, during an operation, a gush of muco-pus escape at the moment when the bistoury opened the trachea. Simple bronchitis is often found in company with other path- ological conditions of the lungs, viz., pseudo-membranous bronchitis, broncho-pneumonia and pneumonia. In one case the redness started from an ulceration of the trachea situated below the incision, and extended as far as the smallest bron- chial ramifications ; above the incision the mucous membrane was sound. Should the bronchitis and the ulceration be re- garded in the relation of cause and effect ? Without ascribing too much importance to a single fact, one may imagine that in a disease in which the danger of bronchitis is constant, inflam- mation produced at an ulcerated point might determine a gen- eral attack. Pseiido-Dicuibranoiis Bro7ichitis. — From the catarrhal, the bronchitis becomes exudative. The mucous membrane is strongly injected, red or dregs-of-wine colored, glossy or rough, and on its surface are developed false membranes. At first the exudate is thin, pellucid, friable and slightly adherent ; later it assumes a dull white color and increases in consistence. At a period still more advanced, it becomes movable, dense, resistant, almost cartilaginous, and of a greyish brown. On the tenth day after tracheotomy, a patient ejected from the tracheal wound a compact, coreaceous fragment of a cylinder measuring three millimetres in thickness. According to the 96 DIPHTHERIA, CROUP AND TRACHEOTOMY. duration and the intensity of the disease, the false membranes occupy a limited point or a broad extent of si'rface. At one time spots of variable size are scattered in the bronchi ; at an- other there are fibrinous cylinders which introduce themselves into the bronchial tubes. These cylinders may be complete or incomplete ; in the large bronchi particularly, they are hollow, their circumference presents solutions of continuity. It is in the medium sized bronchi that the best cylindrical appearance is observed ; in the smallest, the central canal often disappears and only solid cylinders are seen, or even little white shreds, quite thin and narrow. The ribbon form is not, however, the one peculiar to the small bronchi, it is observed also in those of large or medium caliber ; the band occupies the anterior part of the tube, and divides, and at the same time becomes attenuated and ends in the terminal branches by a kind of out- line. At the same time of meeting these adherent false mem- branes, debris is seen floating or free, mixed with pus or muco- pus. The mucous membrane of the air-passage is inflamed throughout its extent, even at those places where no false mem- brane is seen. All the pulmonary lesions may be met with at the same time as pseudo-membranous bronchitis. But there is one much more frequent than the others, almost inevitable when the disease has continued several days ; I speak of bron- cho-pneumonia. Nevertheless, pseudo-membranous bronchitis appears at the beginning still more frequently than broncho- pneumonia. In subjects who die in the first two or three days bronchial diphtheria is observed more frequently ; at a more advanced period these two conditions are found united, or the broncho-pneumonia exists alone. In 165 autopsies in which pseudo-membranous bronchitis appeared it coincided with broncho-pneumonia 60 times, with pneumonia 17, with pleurisy 8 times, with pulmonar}^ apoplexy 7 times, and simple bron- chitis was present in all the cases. When pseudo-membranous bronchitis invades the small bronchi, one fact interesting to note is often produced. The fibrinous cylinders completely obstruct the bronchial canaliculi and restore the pulmonary lobules, situated below them, to the foetal condition, just as PATHOLOGICAL ANATOMY. 97 broncho-pneumonia does. The mechanism is the same, the lesion is identical ; though the plug is fibrinous in one case, and purulent in the other. According to Peter, bronchial diphtheria will be met with most frequently on the fourth day. The abstract which I have made from my observations indi- cates the fifth day as that on which the extension of the false membranes to the bronchi has been noted the most frequently at the autopsy. The following table shows how these cases are proportioned : Date of Death. 1st day of the disease 2nd (< (( 3rd « « 4th (( (( 5 th (( <( 6th (( (< 7th <( <( 8th << (< 9th (( (( loth (( (( nth <( (( 1 2th <( (( 27th <( (( No. of Cases. 16 21 24 37 13 10 4 9 6 3 5 I Total 151 The result of this table is to show that pseudo-membranous bronchitis is most frequently observed from the second to the sixth day. The increase is rapid from the second to the fifth, there it is abruptly arrested and the decrease is rapid during the following days. From the eighth day bronchial diphtheria is only an exception. One may remark that while pseudo- membranous bronchitis may be anatomically proved at a per- iod so near the commencement of the disease, its onset at this 98 DIPHTHERIA, CROUP AND TRACHEOTOMY. Stage has, a fortiori, the preference. At the same time that diphtheria prevails in the bronchial tubes it manifests itself in the immense majority of cases in other organs, particularly in the throat and larynx. Twice, however, the bronchial tubes alone were attacked. 3. Bronchial Pneumonia. — All forms and all degrees of bronchial pneumonia, from atelectasis and splenization to pur- ulent granules and pulmonary vacuoles, are met with in diph- theria. These lesions present no peculiarity except their ex- tremely frequent coincidence with this disease, but in them- selves there is nothin^" special ; their description agrees en- tirely with that of broncho-pneumonia in general, which I need not give here. Of all the manifestations of diphtheria pseudo- membranous laryngitis, which accompanies bronchial pneu- monia, is the most frequent. In 121 cases of broncho-pneu- monia found at autopsy, in subjects attacked with diphtheria, 119 were coincident with pseudo-membranous laryngitis. In one of the other patients, the diphtheria occupied the pharynx only, while in the second it was limited to the nasal fossae. Next in order of frequence comes pseudo-membranous bron- chitis. In 121 cases of broncho-pneumonia, 60 co-existed with bronchial diphtheria. Other localizations of diphtheria are encountered quite frequently with broncho-pneumonia, but almost never alone. As one of the above statements proves, they are nearly always associated with laryngeal diphtheria. Other pulmonary lesions are observed concurrently with broncho-pneumonia, but more rarely ; they are simple bron- chitis, pneumonia, pleurisy and, speaking generally, nearly all the anatomical alterations which may attack the lungs. It is particularly during the first few days that bronchi-pneumonia, as shown by autopsy, exists ; in some cases, however, it has been found at a more remote period. The following table will indicate at what period it has been discovered in 121 au- topsies: PATHOLOGICAL ANATOMY. 99 Date of Death. No. of Cases. 1st day of diphtheria - - - - 2 2nd " " " - - - - 12 3rd " " " - - - - II 4th " " « - - - - 15 5th " " « - - - - 19 6th " " « - - - - 14 7th •' " " - - - - 5 8th " " « - - - - 6 9th " " " - _ - . 7 lOth " " " - - - - 7 nth " " " - - - - I I2th " " «. - - - - 4 13th " " « - . - - 5 14th " " " - - - - I 15th " " « . . ... I i6th " " « - . . - I 19th " " «' - . _ - 2 20th " « « . - . _ I 23d " " " - - - . 3 27th, 30th, 31st and 41st, each i - - - 4 Total - - - - - 121 From this table one important fact becomes conspicuous, viz., the great frequency of broncho-pneumonia in the early days of the disease. Peter had already insisted upon this point in his remarkable work; he showed that pulmonary lesions could be proved anatomically the third day. By prov- ing its presence from the second day, and even from the first, the above figures demonstrate positively that it is not absolute- ly dependent upon tracheotomy, but that it is produced spon- taneously, as simple or as pseudo-membranous bronchitis. One may still more fully convince himself of this by studying the following table, in which is set forth the interval which has separated tracheotomy from the verification of the broncho- pneumonia at the autopsy: lOO DIPHTHERIA, CROUP AND TRACHEOTOMY. Date of Death 1st day of the tracheotomy 2nd " ( <( << 3rd (( (( (( (I ^ 4th (( (( (( <i _ 5th (( (( ti _ 6th (( ( (( (< _ 7th <t ( (( « _ 8th It ( <( ft _ 9th ti ( <( (( nth li ( « (t _ 13th (( ( <( (I _ 15 th it ( (. (( 1 8th (( ( ( (< « _ 26th <( ( ( (( <c _ 27th (< < ( (( 11 _ No. of Cases. 20 13 6 6 4 3 2 2 I 2 I I I I I Total 64 The results are identical. The maximum coincides with the same day as the tracheotomy. It is probable that at least the greater part of these cases of broncho-pneumonia existed be- fore the operation. The second day they are still quite fre- quent, the process scarcely diminished. Then it rapidly dimin- ishes on the third day as we depart from the onset, and the violence of the first shock diminishes. Moreover, croup cases, not operated on, furnish their share of bron- cho-pneumonia. In 121 autopsies of broncho-pneumonia 21 were in cases of croup without tracheotomy. Finally, one case of diphtheritic angina, and one of pseudo-membranous coryza, both exempt from other localizations of diphtheria, were accompanied with broncho-pneumonia, recognized at the autopsy. • 4th. Puhnonary Congestion. — This is another of the frequent complications of diphtheria, whatever may be the localization of this latter. It occupies one only of the lungs or both or- gans simultaneously. Its seat of predilection is the base of PATHOLOGICAL ANATOMY. lOI the posterior border. Its color is red, or dregs-of-tvine, or nearly black. I do not insist upon its other anatomical char- acteristics which are not peculiar to diphtheria. They most frequently coincide with diphtheria of the larynx, bronchitis, and with other pulmonary lesions, such as simple bronchitis, bronchial pneumonia, and pneumonia, pulmonary apoplexy, oedema of the lungs and pleurisy. In those cases it corre- sponds with the intensity of the respiratory embarrassment. When asphyxia has arisen to a sufficient degree the lung be- comes engorged with dark blood. Sometimes this exists to the exclusion of every other pulmonary alteration. This con- dition is met with as well in the autopsies of diphtheria as in those of subjects dead of infectious diseases of diverse nature. Its frequency and intensity are in proportion to the preponder- ance of the infectious element. Finally, in certain cases every trace of false membrane has disappeared, but the diphtheria has left behind it a general paralysis which has reached the respiratory muscles. The dyspnoea which results from this condition again produces pulmonary congestion. 5. Pneumonia. — Less frequent than the preceding lesions, hepatization of the pulmonary parenchyma is not, however, so rare as it seems at present to be supposed. Authors are, in fact, much more interested with the importance of broncho- pneumonia than with simple pneumonia. Barthez and Rilliet think that pneumonia appears always in the lobular form. Bouchut speaks of the latter form only. Peter, who places pneumonia and broncho-pneumonia in the same chapter, cites but one example of frank hepatization. Jules Simon places these two anatomical conditions together among the pulmon- ary complications of croup. Vogel does the same. I find, in my observations, 48 cases of simple (franche) pneumonia, of which 32 are confirmed by autopsy. In these anatomical forms, pneumonia, developed under the influence of diphtheria, presents nothing special to note. It is single or double, and occupies the base or the apex of the lung. It remains in the second degree or passes to gray hepatization. One point, how- ever, deserves to be placed in evidence, that is the frequency, I02 DIPHTHERIA, CROUP AND TRACHEOTOMY. in diphtheria, of this third degree of pneumonia, usually so rare in children. In 32 cases of pneumonia, verified by autop- sy, I found 9 cases of gray hepatization. The following table will show that the largest number of these cases of pneumon- ia have been found, at the autopsy, at a date approximating the attack : Date of Death. No. of Cases. 1st day of diphtheria - - - - o 2nd " " " . - - - 2 3rd " " " - - - - 5 4th " " " - - - - 2 5th " " " . - _ . 7 After this one a day only except the 13th day, on which there were 2. Date of death not known - - - - 6 The interval which separates tracheotomy from the anatom- ical verification of the pneumonia no longer fails to be of in- terest. As in broncho-pneumonia, so here the greatest number coincides with the first and second days of the operation; there is, therefore, reason to adopt tlie same conclusions and to admit that the complications, far from resulting from trache- otomy, as a sole cause, are principally due to the original in- tensity of the disease. The table below proves what I assert. Date of Death. No. of Cases. 1st day of tracheotomy - - - - 8 2nd " " " - ... 5 3rd " " " _ - - - 3 4th " " " - - - - I 5th " " « - ... 3 6th " " " - - - - I 8th " " " - - - - 2 loth " " " - - - - I I2th " " " - - - - I i6th " " " ... - I 51st " •' « . - - . I Total - - - ... 27 PATHOLOGICAL ANATOMY. IO3 We may still add that pneumonia did not destroy solely the operated cases of croup. The five remaining cases of the 32 autopsies are divided as follows : Croup not operated - - _ ' - 4 cases Diphtheritic angina without croup - _ i " In the last patient, pneumonia was found at the autopsy, the fifth day. The preceding figures are conclusive : tracheotomy is not the sole cause of the pneumonia any more than of the other pulmonary inflammations. Of all the diphtheritic manifestations, pseudo-membranous bronchitis is the one which coincides most frequently with pneumonia. Respecting the pulmonary inflammation, pneu- monia may be circumscribed, but that is the exception. But how shall we comprehend the origin of pneumonia in a case of diphtheria, if it be not by the propagation to the pulmonary parenchyma of the bronchial inflammation so common in this disease. The results of autopsies justify this view of the case; and they show us the almost constant co-existence of pneu- monia with intense bronchitis, purulent or not, with pseudo- membranous bronchitis and bronchial pneumonia. In 32 au- topsies pneumonia was found : With pseudo-membranous bronchitis - - 16 times " broncho-pneumonia - - - lO " " bronchitis - _ _ _ 6 " In three of these patients broncho pneumonia and bronchial diphtheria united, were concurrent with pneumonia. In eight of the observations the condition of the air passages was not noted. We see how frequent the cases are in which may be comprehended the diff'erent phases of the inflammatory action which commences in bronchitis and ends in hepatization. Other lesions of less importance are also observed with pneumonia ; they are pleurisy, pulmonary oedema and pulmonary apoplexy. 6th. Pleurisy. — Still less frequent than pneumonia, this takes a lower rank among the thoracic complications of diphtheria. Peter is the only author who mentions it, and he found 9 cases I04 DIPHTHERIA, CROUP AND TRACHEOTOMY. in 121 autopsies. I have met with it twenty times, sometimes single, sometimes double. It is characterized in the greater number of cases by a severe effusion, and sometimes by ad- hesions. In one case the liquid was purulent. Eleven of the twenty cases occurred from the third to the ninth day inclusive. The interval in relation to the tracheotomy is given in the following table : Date of Death. No. of Cases. 1st day of the tracheotomy - - - 5 2nd " " " « - - . 2 4th " " « " . - - - I 5th " " « « - - - 3 6th " " " " - - - I nth, I2th and 13th, i each, " - " 3 Total - - _ - - 15 [There was well-marked pleuro-pneumonia. in one of my recovered cases of tracheotomy.] The results furnished by these statements do not differ sen- sibly from those respecting pneumonia and broncho-pneumon- ia ; it is also in the first days that the highest numbers are found. All the forms of diphtheria, but particularly croup and pseudo-membranous bronchitis, are to be found with pleurisy; with these two principal forms are associated, more rarely, an- gina, coryza, and others which are never found isolated. Pleur- isy always accompanies some other pulmonary phlegmasia. We may in fact consider it as the final termination of the in- flammatory process, which, beginning at the bronchial mucous membrane, is propagated to the pulmonary parenchyma. Most frequently this process stops in its course, a circum- stance which explains the relative infrequency of pleurisy. In 20 autopsies pleurisy co-existed : With broncho-pneumonia - - - 13 times " pseudo-membranous bronchitis - - 9 " " pneumonia - - - - 4 " " bronchitis - - - - . 2 " PATHOLOGICAL ANATOMY. IO5 In seven of these cases broncho-pneumonia and pseudo- membranous bronchitis existed simultaneously. In nearly all, several of these lesions were united. That which we found most frequent is broncho-pneumonia ; that it is which connects the bronchitis and the pleurisy and directs the inflammation to the pleura. 7th. Pulmonary Emphysema. — This is one of the most common complications of diphtheria, but especially that of the air-pas- sages. There is scarcely an autopsy after croup in which alve- olar dilation is not found. This fact has attracted the atten- tion of observers. Barthez and Rilliet have emphasized the extreme frequency of emphysema in croup. Roger, Peter and Simon have observed the same results. My researches confirm in every particular those of the above authors. In all the cases of croup, emphysema, in all degrees, is found and in all forms. Most frequently it is vesicular, but it may be inter-lobar and sub-pleural. In some cases, finally, it reaches the mediastinum and the sub-cutaneous cellular tissue. It usually occupies the anterior border and the apex of the lungs, and thence extends to the anterior surfaces. The difficulty with which the air en- ters the chest, and the relative facility with which it escapes does not allow of the admission that the emphysema is pro- duced directly by excess of intra-alveolar pressure in inspira- tion and expiration. On the contrary, everything tends to the belief that it pertains to the class of compensatory emphysema. In fact, as Gairdner has shown, whenever certain parts of the lungs become impermeable to air, and consequently retract, it happens that the thorax, continuing or even increasing its movements of amplification, the sound parts, compelled to fill the vacuum left by the first, dilate energetically. If this con- dition continues a certain time, in the least degree, the vesi- cules which are forcibly dilated return no longer to their form- er condition, and emphysema is produced. This is why alve- olar dilatation is so often encountered as a sequence of pneu- monia, chronic bronchitis and of all the pulmonary diseases. Barthez and Rilliet have mentioned its frequency in broncho- pneumonia. The pulmonary lesions so frequent in croup, 106 niPHTHERIA, CROUP AND TRACHEOTOMY. from simple bronchitis and pseudo-membranous bronchitis to gangrene, are they not all-powerful predisposing conditions to its production ? When it becomes general it arises from trau- matic causes, and is frequently produced by inflation of the lungs without care, through the wound, in case of apparent death during the operation. The effort exerted in this way causes also rupture of the pulmonary vesicles, and consequent- ly sub-pleural emphysema. These are really accidents result- ing from the operation. 8th. Pulmonary Apoplexy. — Pulmonary apoplexy was pointed out by Millard, then by Peter and by Bouchut. It is one of the more rare complications of diphtheria, and I have collected eighteen observations. It is located particularly at the poster- ior part and at the base of the lungs. At one time it presents itself under the form of sub-pleural ecchymosis, attacking sometimes a part the size of a dime, but ordinarily smaller, resembling petichiae, or presenting only a point of quite lim- ited extent. At another time it is a true infarctus, or apopletic foci are disseminated in the pulmonary structure. Most fre- quently these two forms are associated ; the spots may exist alone ; the infarctions are rarely met with without the spots. The composition of these foci is purely hematic. Still, in the case reported by Bouchut some of the dark foci enclosed in their centres a grayish portion of purulent infiltration, some- times a real sac containing pus ; others were converted entirely into abscesses. It is in the cases of croup and pseudo-mem- branous bronchitis, in which asphyxia predominates, that pul- monary apoplexy is found. However, I have shown its exist- ence in a patient attacked with diphtheritic angina and with coryza without laryngeal or bronchial manifestations. Besides, it should be stated that it appears to prefer the generalized « diphtheria of the infectious form, accompanied with consider- able adenitis and albuminuria. Other pulmonary complications exist at the same time, viz., broncho-pneumonia, pneumonia, pulmonary congestion and bronchitis. In one case there was observed at the same time with it a granular condition (sable) of the cerebral substance, and considerable engorgement of PATHOLOGICAL ANATOMY. IO7 dark blood in the sinuses of the dura mater. Finally, I have seen it co-exist with general diphtlieritic paralysis extending to the respiratory muscles, from which the patient succumbed, after the false membranes had disappeared, and in the absence of other pulmonary complications. Hence, apoplexy in diph- theria appears to proceed from two causes, viz., asphyxia and infection. The patho-genetic role of asphyxia is known. Now, if there is a disease capable of producing asphyxia, it is croup, especially and particularly that form of it which accompanies bronchial diphtheria or broncho-pneumonia. All the cases of apoplexy, except one, coincided with croup. The influence of asphyxia indicated by theory is therefore verified anatomically and appears indisputable. But this is not the sole cause ; we find proof of it in observation which shows us apoplexy arising in a case of diphtheria limited to the throat and nasal fossae and exempt from other respiratory disturbances. It is averred, on the other hand, that pulmonary apoplexy has a tendency to form in grave fevers, in black small-pox, and in haemorrhagic scarlatina and measles, in typhoid fever, in purulent infection and in anaemia. Diphtheria by its infectious character being assimilable to these different conditions, one may admit that it may, by this sole cause, favor the production of pulmonary apoplexy. In the case of general diphtheritic paralysis, the cause of death was asphyxia from the immobility of the res- piratory muscles ; there is no necessity to examine whether or not one has had to do with a case of pulmonary heemorrhages which arise under the influence of the nervous system, such as were observed clinically by Barthez and Rilliet, as well as by Barrier, and experimentally by Claude Bernard and Brown Sequard. Another cause has recently been referred to by Bouchut and Labadie Lagrave, I mean capillary emboli and interlobular thrombosis. The role of emboli in the production of pulmonary apoplexy is too well known to require discussion. But these two learned authors, having admitted the frequency of endocarditis and cardiac thrombosis in diphtheria, were obliged, very naturally, to suppose that pulmonary embolism was frequent in this malady. One will see later what restric- I08 DIPHTHERIA, CROUP AND TRACHEOTOMY. tions must be placed upon these assertions, and how much the importance of endocarditis and thrombosis in diphtheria should be diminished. Moreover, in some of the observations which Labadie Lagrave presented as examples of infarctus by em- bolism or by thrombosis, there were found in the heart only the clots of simple coagulation. 9, Pulmonary Gangrene. — Only three cases of this condition have been described, two by Garnier, who observed them in the service of Barthez, the other by Callandreau Dufresse. I can, on my part, report still another example. In three of these four cases the gangrene occupied both lungs. In all, the seat of it was the base. It, in every case, presents itself in the form of a focus (one or more) which was in one case accom- panied with superficial patches. The greenish color of the tis- sues reduced to a detritus, the peculiar odor and all the char- acteristics of the process of mortification, correspond to the name. The lungs were engorged with a dark, fetid liquid. The conditions under which pulmonary' gangrene is produced are not the same in all cases. Twice it occurred in a case operated upon for croup; once in a case of croup not operated, and once in a case of diphtheria limited to the throat. Three times in four there was broncho-pneumonia, and the gangrene appeared to be developed by the increase of inflammation of the parts already diseased. Angin? without croup is of this number. In only one case did the question of other pulmon- ary lesions not arise, but the report of the autopsy is very brief, and perhaps only the most prominent phenomenon was noted. In three cases gangrene occupied other organs. In the two tracheotomized, the integumentary wound was gangrenous ; in the patient attacked with angina without croup there was very extended gangrene of the uvula, the soft palate and the ton- sils. Diphtheria was primary in three cases ; in the fourth, the one by Callandreau Dufresse, it was a case of croup tracheot- omized after measles. This exanthema being quite often fol- lowed by gangrene, without it being necessary that diphtheria should intervene, the case loses much of its importance and may, when speaking accurately, be excluded. PATHOLOGICAL ANATOMY. IO9 10. CEdenia. — This accident has as yet been httle studied. Barthez and Rilliet, however, intimate that they have seen sev- eral cases of oedema of the lungs ; and they attribute them to obstruction of circulation and to violation of hematoses re- sulting from the obstruction to the passage of air into the lungs. Fischer reports one case of it observed at the clinic of Traube. In no other case is oedem^ of the lungs set forth in diphtheria. I have met several examples of it. The infil- tration occupies both lungs, especially towards the bases and to a variable extent, which is not always the same for each lung. The cases which I have observed are divided into two categories. In those of the first, which are most numerous, the oedema is accompanied with extensive and serious pulmon- ary lesions, such as broncho-pneumonia, pseudo-membranous bronchitis, pneumonia and pulmonary congestion. Several of these pathological conditions are nearly always combined. CEdema appears, therefore, very clearly to proceed from the embarrassment which is produced in the circulation of the lung. In those of the second category the pulmonary lesions are much less important ; sometimes they fail entirely, but oedema exists in other organs, and the existence of renal alter- ations is observed. Twice oedema of the glottis coincided with that of the lung, in subjects in which the diphtheria had presented an infectious character, very marked, and which, among other symptoms, had presented albuminuria. Cases of this categoiy seem therefore principally connected with altera- tions of the blood. Section 5. Mediastinum. This region is sometimes the seat of abscesses which nearly always have for their cause operation-accidents arising during tracheotomy. Abscess of the mediastinum has been brought to notice by Millard, Crequy, Pellitier of Chambure, and Boeckel, and I have reported ten cases of it. It is not my intention to give a complete description of the anatomical lesions which characterize abscesses of the mediastinum, I shall only indicate the varieties which have been encountered, succeeding trache- no DIPHTHERIA, CROUP AND TRACHEOTOMY. otomy. The pus was sometimes collected into a purulent focus of which, the dimensions attained the size of an egg; in other cases there were purulent tracks, starting from the tegu- mentary wound, penetrating more or less deeply into the med- iastinum, or simple purulent infiltration of this region. In one case the pus was not yet apparent, and there was found only a sero-gelatinous streak, Vhich followed the same direction. Suppuration is met with in all parts of this region, viz., on the anterior surface of the trachea, on its posterior part, and in the planes which separate it from the oesophagus ; the latter itself might be surrounded by this suppurated centre. In all the autopsies the lesions started from the wound in the integument. I have seen the pus-center communicate, by a perforation of the posterior tracheal wall, with a second collection seated under the laryngeal mucous membrane. The relations of the abscess with important organs of the mediastinum may par- ticipate in producing the phenomena of dyspnoea, which some- times accompanies the development of the swelling. In two cases the sternum was denuded and there was commencing ne- crosis. Emphysema of the mediastinum, of the neighboring sub-cutaneous tissue, and of the lung, frequently coincides with the abscess. Section 6. Circulatory Apparatus. For a long time disturbances of the circulation have been observed in patients attacked with diphtheria. The alterations so remarkable, of the blood, the existence of clots in the cav- ities of the heart, and cases of sudden death, have attracted the attention of observers. It is particularly within the last fourteen years that these questions have been studied. The progress made in cardiac pathology, the discovery of endocar- ditis in fevers and in septic diseases, have inspired some able authors with the thought of searching for endocarditis in diph- theria. The results reached have given to these lesions quite an importance ; but they were not long in being refuted by an observer whose works in pathological anatomy have justly ac- quired an authority by reason of the precision he gave to them PATHOLOGICAL ANATOMY. 1 1 I and the careful guarding to which he submitted them. This part of the pathological anatomy of diphtheria, being as yet little known and still contested, I shall say something of the principal works which relate to it. Richardson pointed out the existence of fibrinous concretions in the right heart during the course of diphtheria, and described the symptoms which correspond to them. Barry, of Tunbridge Wells, reports three cases of clots in the right cavities. Beau relates a very inter- esting observation of sudden death in diphtheria, which he at- tributes to the same cause. An autopsy, unfortunately, could not be made. John Bridger of Coltenham says he has treated more than three thou^nd cases of diphtheria! Among the complications which he has encountered figured pleurisy, peri- tonitis and endocarditis. In many autopsies he has found the mitral valves uneven, red, thickened, especially at the centre, by an interstitial deposit. He has observed loi cases of diph- theritic endocarditis. Meigs publishes three observations of cardiac thrombosis supervening under the same circumstances. There were found in both cardiac cavities clots, adherent, dis- colored and already old. In one case this verification was made on the twenty-first day of the disease. Gerlier analyzed several observations of Beau, Bergeron, Meigs, and others of his own. He proved the existence of clots in the heart and sought the part which belongs to them in the production of sudden death. Beverly Robinson assigns an important place to cardiac thrombosis; it is a frequent complication of diph- theria and a very common cause of death. The polyp-forms of clots are the origin of fatal accidents and not their results. Bouchut and Labadie Lagrave have insisted upon the great frequency in diphtheria of vegetative endocarditis, and as a sequence cardiac thrombosis as well as pulmonary emboli. Callandreau Dufresse criticises very judiciously Beverly Rob- inson, Bouchut and Labadie Lagrave, and shows that they have accorded a place too important to cardiac lesions. Beau Ver- deny in his thesis written under the inspiration of Parrot speaks in the same way. Parrot, in a remarkable memoir, combats vigorously the work of Bouchut and Labadie Lagrave. 112 DIPHTHERIA, CROUP AND TRACHEOTOMY. He shows that these authors have described under the name of endocarditis lesions of an entirely different nature. To these works may be added others of less importance, such as those of Werner, Smith, Thompson, RoUo and Winkler. I shall consider in order the different parts of the circulatory apparatus. I. Pericardium. The alterations of this serous membrane are very rare. We find it sometimes spotted by the ecchymoses which are found in the subjacent connective tissue. It is ordinarily in the cases in which asphyxia has played an important part ; and then we find at the same time analogous lesions in the lungs. We find also sometimes small yellowish translucent effusions in the ser- ous cavity, such as show themselves also in a great number of subjects dead of affections quite different. But as to pericar- ditis, strictly speaking, I have never observed it at the autopsy. II. The Heart. The cardiac muscle is sometimes altered. It is dilated, gorged with blood or clots, or contracted. In some cases one perceives in its substance sanguineous infiltrations analogous to those which are seen under the pericardium. Asphyxia is suf- ficient cause for these extravasations without it being necessary to attribute them, as Bouchut and Labadie Lagrave have done, to capillary emboli. The most common lesion is fatty degen- eration. It is observed in about one-fifth of the cases. Gen- erally it att?ccks only a small number of the fibres of the fasci- culi, but it may invade the organ to a large extent, or entirely. In the latter case the heart is pale, its color approaches that of the dead leaf, new leather, or coffee and milk. Its consistency has diminished, it is softened, preserves the imprint of the finger or becomes friable in places. The microscope reveals in it the characteristics of granulo-fatty degeneration, viz., molecular and fatty granulation, disappearance of the transverse striae of the fibrillze, globules or larger fat-globules. Every part of the cardiac muscle may be attacked ; at one time the wall exter- nally or internally, at another the columnae carneae. The origin I PATHOLOGICAL ANATOMY. II3 of these nutritive disturbances appears to be myocarditis. It is well to add that diphtheria has not the monopoly of these lesions ; they are observed in all infectious diseases, and even in diphtheria they are found in cases in which the pulmonary lesions are sufficient to account for death. III. The Endocardium. Ecchymoses, the presence of which under the pericardium has been pointed out, have sometimes been observed under the endocardium. Endocarditis, but lately reserved almost ex- clusively to articular rheumatism, has been recognized in a great number of morbid states. Fevers and septic diseases have, however, their endocarditis. It was, therefore, quite nat- ural to seek for it in diphtheria. That iswhat Bouchut and my friend Labadie Lagrave did. In the first memoir these two authors set forth that they encountered vegetative acute endo- carditis 22 times in 40. In the second Labadie Lagrave, sup- porting himself by 22 autopsies, confirmed the preceding re- sults and concluded that diphtheria, whatever may be its local- zation or its form, nearly always entails, though not constantly, an acute inflammation of the endocardium, and in particular of that part of the serous membrane which covers the auriculo- ventricular valves. This able work, presented and executed with ability, has not convinced me, and I find it impossible to accept the inferences of these two learned authors. Endocarditis is in fact much more rare than they admit. Desirous of veri- fying data so new and interesting I judged it expedient to con- trol my observations, fearing that these lesions may have es- caped while they were not carefully looked for ; I have applied myself to special investigations. In 65 autopsies made during the last two years, and in which the heart was scrupulously examined, endocarditis was found only in a number quite in- significant. In order to reach an understanding it is necessary to state precisely the lesions which should characterize endo- carditis. Now, what characteristics has Labadie Lagrave pointed out to us? They are : i. A general or partial redness circumscribing, in this latter case, the free margins of the 114 DIPHTHERIA, CROUP AND TRACHEOTOMY. valves by a zone of bright red. It often accompanies vegeta- tions disposed along the border. In all the cases, with one exception, it was uniform and diffused. Should this be con- sidered as proof of an inflammatory state ? Parrot has ans- wered the question in the negative ; and I believe he is entirely correct. Really, on the one hand, we know that inflammatory redness presents among its characteristics the existence of fine vascular arborizations. On the other hand, diffuse redness is encountered, in a great number of autopsies, following dis- eases of all kinds, but especially in cases in which the form of death, from asphyxia or otherwise, has been the cause of ac- cumulation of blood in the heart during the last moments of life. There is, therefore, every reason to believe that this col- oring is due to a cadaveric imbibition. Moreover, L. Lagrave presents an objection by observing that this origin might be admitted in a certain number of cases. As to the frequency of this coloring, it should be attributed t& the action of the external temperature, the autopsies of L. Lagrave having been made in the hottest months in the year, viz., June, July and August (Parrot). 2. Mammillated projections, which he regarded as vegetations produced by endocarditis. These projections are bright red at their base, pink in the middle, and often whitish at their summit. They are often, also, pearly, glisten- ing and fibrous, and occupy the upper surface of the valve some millimeters from its free border, forming a single or double festooned band ; more rarely they extend over a wider surface. The mitral valves are their ordinary seat, rarely the tricuspid. In one case only was a similar projection found on an aortic valve. These primary lesions cause the coagulation of the fibrin which deposits on their surface, forming as many warty stalactites. The valve is thickened, tumefied, and ap- pears to have lost its delicacy and transparency. To make a few autopsies of children is sufficient to convince one of the trifling importance of these little projections. They are quite common and are met with after diseases of the most diverse kind. Hence they do not belong exclusively to diphtheria. Are they inflammatory products? Can they characterize endo- PATHOLOGICAL ANATOMY, II5 carditis? These questions have been answered by Parrot in a manner irrefutable that these recent pretended inflammatory- lesions were in reality the products of the fibrinous transfor- mation of the little haematoma developed upon the valves dur- ing the first months of existence and perhaps during in- tra-uterine life. The two anatomical peculiarities offered as proof of the frequency of endocarditis in diphtheria lose, therefore, all their significance, since neither of them belongs to the inflammatory process. Hence it results that, without denying the possibility of endocarditis, one should consider it as much less common than those authors affirm whose opin- ions I have just discussed. [Leyden claims to have discovered lately a typical myocar- ditis in diphtheria.] IV. The Blood. Alterations of th© blood are frequent in diphtheria. They affect its color, its consistency and its composition, A, Color. In a sufficiently large number of autopsies the color of the blood seemed modified. Most frequently one finds a dark coloring, which coincides with a fluid condition of the blood. In other cases, more rare, this liquid takes a brown tint pointed out by Millard ; it stains the fingers like sepia and communicates to the organs impregnated by it a characteris- tic bistre tint, it is turbid and slightly muddy; the coagula which it forms have, aside from their softness, a kind of re- semblance to over-cooked jam ; finally, the arteries, in place of being empty, contain as much of them as the veins. Peter has also pointed out this alteration, as likewise all authors who have written since upon croup and diphtheritic angina. Other tints are observed ; thus the blood has sometimes the appear- ance of currant-jelly, sometimes that of water-ice (wine and water). Finally, I have seen it grayish and of a deeper yellow than the sepia tint. These varieties belong to the asphyxic and infectious forms of diphtheria. Concerning the sepia blood, Millard and Peter have emphasized this coincidence. I can but affirm their assertions. In 50 cases in which I have Il6 DIPHTHERIA, CROUP AND TRACHEOTOMY. noted the alteration of the blood, the sepia tint existed 20 times. In this number it was coincident 17 times with the in- fectious form alone ; in three other cases the malignity was accompanied with asphyxia. The dark and fluid state of the blood was present 28 times. Of these 28 cases, 20 were co- incident with infectious diphtheria, accompanied or not with asphyxia. In 8 others asphyxia had predominated ; I ought to cite the one of a patient who succumbed to diph- theritic paralysis, although all the other manifestations of the disease had disappeared. The chemical and histological man- ifestations of the blood under the circumstances are still but little known. Nevertheless, in one case in which the blood was dark and diffluent the microscope showed that the blood globules presented nuclei very opaque, dark, varying in num- ber from one to three or four. B. Consistence. This may be diminished or increased. When asphyxia predominates the blood is nearfy always dark and fluid ; when infection assumes first rank the blood is often fluid, but it is sometimes thick, as occurs in the sepia tint. In other cases the blood loses its homogeneity, disintegrates, remains fluid in certain parts and coagulates in others. It is in the heart and in the large vessels that the coagulations are most frequently found. This subject having attracted a lively in- terest in recent times and given rise to important works, I shall devote one chapter especially to it. Heart Clots. Cardiac Thrombosis. — I have previously men- tioned the works of Werner, Beau, Richardson, Gerlier, Smith, Thompson, Winkler, Meigs, John Bridger, Beverly Robinson, Bouchut, Labadie Lagrave and Callandreau Du- fresse, upon the cardiac concretions in diphtheria. These authors, after having pointed out the presence of fibrinous clots in the heart of subjects dead of diphtheria, have attrib- uted to these concretions an important role in the mechanism of sudden death occurring during the course of, or the convalescence from, this disease. These coagula, therefore, may form during life and would belong to thrombosis. Amono- these authors Robinson and L. Lagrave have insisted PATHOLOGICAL ANATOMY. 11/ upon the importance of these productions. The former con- siders them as quite frequent and as often causing death. I shall have to make some exceptions. The capital point really is to know whether these clots are indeed formed during life. Before expressing myself I shall present the results which au- topsies have furnished me. I shall then pass in review the characteristics by which one recognizes, according to the most competent authorities, the clots formed during life. We may then be able to see without difficulty whether the facts invoked by the partisans of frequent thrombosis have all the value that they have been disposed to give them. And first, what do autopsies declare? The clots found in the heart of diphtheretic subjects are of tlirce kinds, some are purely co- agulant; these are soft, are of currant-jelly color, and are mostly lodged in the right cavity. On this point there is no disagreement; all consider them as formed after death. The second s.xt half-fibrinous and half-coagular ; the former in their antero-superior part, and the latter in their postero-inferior part. They may be seen especially in the right cavities, and send prolongations to a greater or less distance into the ves- sels, hence, their polypoid appearance. These are also pro- ducts formed during the last moments, or after death. Cornil and Ranvier explain the formation in the following manner: The right ventricle is distended with blood, which is explained by the fact that dying is most usually accompanied with as- phyxia. The auricles, by reason of their feeble contractibility, are found in the same condition. When the heart ceases to beat the blood contained in its cavities coagulates slowh^; the red globules, which are the heaviest, sink to the lowest part, while the surface, deprived of the globules, presents, by co- agulation, a colorless, fibrinous mass. This is the explanation of the decoloration of the clots on their antero-superior sur- face while they are in the condition of a coagulam on their postero-inferior surface. Cornil and Ranvier refuse to admit that these clots are active, that is, ibrmed during life. Rind- fleisch is of the opinion that cardiac thomboses recognize for their cause the double action of the rugosity of the walls and Il8 DIPHTHERIA, CROUP AND TRACHEOTOMY. the slowness of the circulation; the clots which result there- from are seldom observed on the surface of the valves even when roughened; and they are small and never attain the vol- ume of those large fibrinous coagula whose form and prolon- gations have caused them to be designated polypi, and which result from the slowing or the arrest of the cardiac circulation. We find in the observations of L. Lagrave several of these voluminous clots placed in the list of thrombosis. The tliird are purely fibrinous. They vary as to volume; are globular, entangled by their base in the tendons of the valves and then become thinner so as to send prolongations into the arteries or auricles. The imprint of the valves then remains upon their surface in the form of a constriction. They are resistant and sometimes quite hard. Most frequently they are like oede- mata ; by pressure they lose quite a quantity of the serum, and diminish perceptibly in volume. Their structure is fibrillar, but not granular. All parts of their substance appear to be of the same age; no intimate change was observed in it. Such are the clots that I, as all other observers, have observed in the heart of subjects dead of diphtheria. We find them not only in cases in which death has occurred from the heart, but in many others which have presented no cardiac symptoms. The autopsies of subjects having succumbed from lesions of distant organs, the brain, for example, furnished also numer- ous specimens of it. Let us now examine what are the char- acteristics of clots formed during life. Legroux, my lamented teacher, has given them in an excellent work. This de- scription remains classic. Bucquoy cites them in numerous extracts. Legroux does not admit that the masses of decol- ored fibrin which crowd the cavities of the heart are the re- sults of morbid action; they are products of dying (agonic); it appears to him that these fibrinous concretions could only be deposited in the heart with difficulty so long as the circubtion is not interrupted for a certain time. The signs which prove the age of the coagulum are: i. The condensation. 2. The ashy gray color. 3. Adherence to the walls of the heart and to the valves, adherence which need not be confounded with PATHOLOGICAL ANATOMY. II9 entanglement in the tendons of the columns carneae, but is formed upon an uneven surface, altered by endocarditis. 4. The structure is in concentric and stratified layers. An anatomical specimen presented to the Anatomical Society in November, 1875, by Balzer, showed the complete series of these essential characteristics. PouUet and Raynaud give as a proof of vital origin the constriction produced upon the clot by the valves. That is not, I think, a proof of contraction ex- erted by the walls of the heart, but rather the result of the moulding undergone in the cavity of that organ and in the vessels. In fact, when death occurs, the heart being in diastole and full of blood, the valves present no resistance, the blood contained in the heart flows into the large vessels, and when the mass has changed into fibrin it reproduces the contracted part of the mould which corresponds to the valvular openings. The arterial prolongations are no better proof of formation during life; and really one sees the concretions, purely coagu- lar, sending out also these polypoid ramifications. Aside from condensation and stratification which I have verified in a rather small number of cases, the other characteristics have failed me. Do they exist in the clots as Meigs, Robinson, and L. Lagrave show us as facts of thrombosis? Not posi- tively. Even in the observations of L. Lagrave, who believed in the frequence of endocarditis, there is no well-defined ad- herence of the clots to the internal surface of the heart. A few of these concretions are attached to the walls or to the columnae carneae, but in these points the endocardium is not altered. The only lesions indicated on the part of this mem- brane are the nodules or mammillary projections ; and this au- thor imputes them to vegetative endocarditis. We now know how to value this interpretation. I shall make the same objections to the statements of Meigs. It is not without interest to re- mark that in many of the observations made by these authors grave lesions of the respiratory apparatus exist at the same time as the clots, lesions which in themselves amply suffice to account for death. One may still add that these coagulations have been encountered in a large number of cases in which I20 DIPHTHERIA, CROUP AND TRACHEOTOMY. their presence was in no way revealed during life. From pre- vious considerations it follows that the anatomical facts pre- sented in cases of cardiac thombosis, as clots formed during life and before the dying (agonie), lack the characteristics which pertain to this class of concretions, and that concerning a large number of them various doubts should be raised re- specting the period of their formation. We shall see later whether the examination of the symptoms observed during life may cause us to retract these conclusions. Thrombi in the Vessels. — The heart is not the only point at which clots are found. In several parts of the venous system, and particularly in the sinuses of the dura mater, they may be found, but exceptionally. They are black, coagular, or mixed, without adherence to the walls, and of post-mortem formation. Others are contained in the pulmonary artery or in the aorta. These are nearly always prolongations from clots existing in the cavity of the heart, and are of recent origin. Bouchutand L. Lagrave regard capillary emboli and interlobular thrombi as intervening in the production of pulmonary apoplexy. They connect also the former with the small bloody effusions which occur under the skin. Nothing would be more simple if we should adopt the views of these authors on the frequence of endocarditis and thrombosis. But we have been able to con- vince ourselves to the contrary by the rarity of these lesions. From the exceptional character of pulmonary emboli in diph- theria the conclusion must be so much the clearer that upon this special point the observations cited in its support are no more convincing than the others. Composition. — The alterations of the blood in its intimate composition are still little known. Chemical analyses are wanting, and, consequently, certain data; and we are limited to indicate in a general manner the modifications which the elements of this fluid undergo. The plasma or the globules of the blood may be affected. The Plasma. — The tendency in diphtheria to the exudation of fibrin, often in abundance, has caused many authors to suppose that this disease may give rise to an increase of the PATHOLOGICAL ANATOMY. 121 fibrin in the blood. This tl:eoretical view has, as a conse- quence, been follo\\ed by alterative medication, viz., mercuri- als, alkalines, etc. Nothing is more fallacious, however, if, in absence of direct proof, one should judge by analogy. The blood in diphtheria presents that condition of dyscrasia desig- nated under the name of disintegrated blood [sang dissotis), which is also observed in certain general infectious maladies which have to it a strong analogy, viz., typhoid fever, the grave fevers, puerperal conditions, virulent diseases, etc. The analysis of the blood in these diseases made by Andral and Gavarret has shown a remarkable diminution of the fibrin. The similarity in the external aspect of the blood and in the general characteristics of these diseases authorize the suppo- sition that, far from producing hypcrinosis, diphtheria produces, on the contray, Jiypinosis. The formation of false membranes is, therefore, no evidence of an excess of fibrin in the blood, but of an anomaly in the conditions which maintain the plas- mine and other albuminoid materials in their physiological fluidity and prevent them from decomposing by reduction (dedoublement). The diphllieretic poison does not render the blood more plastic, it disintegrates it; it permits the plasmine to become reduced and to allow the fibrin and albuminoid products to escape in the form of false membranes, albumen, etc. The blood globules also undergo modifications. Bou- chut has called attention to leucocytosis. In fact it is not very rare that the lecocytes increase in considerable proportion. In several of the observations of L. Lagrave we find these bodies, which in the normal condition scarcely exceed the number of three, in the field of the microscope, rise to sixty. I have been able to verify these results. We may here say that leu- cocytosis has no special relation to diphtheria, and that we meet it in those pathological conditions which profoundly alter the organism. The red globules are evidently altered under certain circumstances, notably when the blood assumes abnormal colors. Must we consider in sepia-blood the ab- normal increase of the debris of the red globules, a debris sparse in the normal state, but considerablv increased by the 122 DIPHTHERIA, CROUP AND TRACHEOTOMY. injurious influence of the diphtheritic poison which rapidly produces the destruction of a great number of globules? I have above reproduced the results of a micrographic exami- nation made in a case of this kind ; researches more numer- ous, however, will be necessary. Section 7. Gemto-urinary Apparatus. Kidneys. — Since diphtheritic albuminuria was pointed out by Wade, of Birmingham, this question has been the subject of profound study by several authors. But it is in a theoret- ical and semeiological point of view, rather than that of the anatomical lesions, that these works have been conceived. Let us then examine the renal lesions which may be found in diphtheria. The opinion held by Lecorche and by Lancere- aux concerning the lesion which characterizes albuminuria, and of that of diphtheria in particular, is that it is superficial parenchymatous nephritis. This anatomical form may cer- tainly be counted among the most frequent. But it is not the only one. Others sufficiently numerous, very variable and equal in extent and intensity, are frequently observed. Pass- ing in review these pathological conditions, we find, first, sim- ple hypercBmia, which frequently is accompanied with increase in volume of the organ. The congestion may occupy the medullary (tubular), or the cortical substance, but it is usually limited to the former, while the latter has become pale. These characteristics are very apparent on section. At the same time the external surface of the kidney is pink and is sown with red points. Sometimes the impression is sufficiently in- tense to produce small ecchymoses on a plane with the straight tubes (Virchow). When to the hyperaemia is added the iji- flammatory process we observe desquamation and granular de- generation (rarely fatty) of the epithelium of the straight canaliculi. The cells undergo protein infilitration, which ren- ders them opaque, but they may recover their transparency under the influence of acetic acid. They adhere together and coalesce into a mass which moulds itself in the canaliculi, and are found in the urine in the form of epithelial cyhnders. The PATHOLOGICAL ANATOMY. I23 process may cease at the surface, but frequently the organ is attacked in its interior. The external surface of the kidney is yellowish, sprinkled with patches of a lighter yellow, and section shows an analogous color of the cortical substance. The latter is augmented in volume and sends exuberant pro- longations between the pyramids which strangulate the med- ullary substance. This latter is red, in consequence of the obstruction which the compression of the capillaries of the cortical substance offers to the returning circulation. Some- times this redness is scarcely observed, and the demarcation between the two substances is almost effaced. The consis- tency of the kidney is soft and friable. We find at this period the lesions of the straight tubes signalized in the above form, but one observes that they have extended to the tortuous ca- naliculi and to the capsules of the glomeruli. By virtue of a very curious anatomical peculiarity the tortuous canaliculi are larger than the loops (anses) of Henle which follow them. It follows, therefore, as Lecorche observes, that the epithelial de- tritus, easily expelled in the form of cylinders when they oc- cupy the straight canaliculi, are expelled only with difficulty when formed in the tortuous canaliculi ; and they here accu- mulate and undergo fatty degeneration. This anatomical form may be described in the following manner: Epithelial hyperplasia, cortical anaemia and fatty degeneration. The transformation is more or less important; sometimes it forms only a few small yellow patches, more frequently they are more extended, and rarely they occupy the entire organ. After the above we may mention the amyloid degeneration of which L. Lagrave cites one example. We know that this pe- culiar transformation has, as a characteristic, that the tissue thus affected acts in the presence of the iodo-sulphuric reao-ent in the same manner as does starch. Finally, at times the kid- ney presents the characters of simple fatty metamorphosis (steatose), non-inflammatory. In these cases other organs, the liver in particular, undergo the same degeneration. In these diverse pathological states the renal capsule is nearly always healthy and not adherent. Another very important 124 DIPHTHERIA, CROUP AND TRACHEOTOMY. fact deserves to be mentioned, that is, the non-symmetry of the renal alterations. In fact, quite frequently one kidney alone is diseased, and when the other is affected it is to a much less degree. It is extremely rare that both organs are attacked with the same intensity. One can thus explain the rarity of oedema and cerebral s)"mptoms in diphtheritic albu- minuria, while they are so frequent in that of scarlatina. In the latter both kidneys are most frequently affected ; now, however superficial may be the lesions, from the moment that both the glands are out of condition to act, the elimination of protein material is suspended. When a single kidney is at- tacked, even profoundly, the other suffices for the demands of excretion. The other organs which form part of the genito- urinary apparatus are only very exceptionally the seat of af- fections attributable to diphtheria. Cases of diphtheria of the vesical imicoiis vievibrane have been reported, but that is of German diphtheria, that is to say, the word is diverted from its true sense to be applied to a form of cystitis which we call membranous, and which has no relation with diphtheritic in- fection. Behier has reported some cases in which the false membrane developed itself in lying-in women upon the sur- face of the uterus at the place of the placental insertion. Trousseau has several times seen diphtheria of the vulvae and of the vagina ; he has also observed it on the prepuce. These pseudo-membranous localizations were accompanied with manifestations of the same nature seated on other regions. I have also met several cases of it. The extension of false membranes into the urethra and their existence on the glans, the prepuce and scrotum, have been pointed out by several authors. These manifestations are very rare. Moreover, they present nothing peculiar to themselves, and behave like all those of the skin or mucous membrane. Section 8. The Nervous System. The discovery of diphtheritic paralysis has had the effect of calling attention to the condition of the nervous system in diphtheria, and especially in the cases of paralysis. At pres- PATHOLOGICAL ANATOMY. 12$ ent the results obtainable are unsatisfactory, and we must wait till new researches make them more complete. The incom- pleteness is explained by the relative rarity of autopsies under circumstances in which diphtheritic paralysis is clearly estab- lished. Really the largest number of patients die at a period soon after the attack, under the action of infection or as- phyxia, before the paralysis has been able to develop itself in a positive manner. Many of those who escape these dangers recover. Those who succumb from the action of paralysis are few. Of this number how many autopsies remain unfinished because of the time, the investigations and the minute prepa- rations that they require. And yet, in spite of the use of the most advanced methods, there are cases in which the results are absolutely negative. Herman Weber publishes the report of two autopsies of diphtheritic paralysis in which the brain and spinal cord, examined with care and with the aid of the microscope, presented no appreciable alteration. In several of the observations which I have made use of in this work, analogous researches made with the greatest care, and the highest ability by D'Espine, of Geneva, and by Gombault, have reached the same conclusions. So the central nervous sys- tem appears, at the present, exempt. I do not speak of cere- bral congestion, turgescence of the sinuses of the dura mater, nor of meningeal ecchymoses, which have been noted several times ; they were in evident relation with asphyxia, which had determined death, and were accompanied with other lesions of asphyxia, such as pulmonary apoplexy. In a case in which a patient succumbed to convulsions a general granular con- dition of the white substance was found ; in others, in which there had been albuminuria, oedema and cerebral symptoms, I was able to verify serous effusions of the meninges and ven- tricular oedema. These lesions have only an accessory role ; they refer to grave cerebral symptoms which coincide with paralysis. The peripheral nervous system has several times presented notable alterations. Charcot and Vulpian, in ex- amining the soft palate (velum pendulum palati) of a female dead of diphtheritic angina with paralysis of this organ, found 126 DIPHTHERIA, CROUP AND TRACHEOTOMY some interesting lesions. A certain number of the muscular fibres had become fatty. In the muscular nerves, certain fibres were composed of tubes empty of medullary matter. Under the neurilemma granular bodies, with or without nuclei, were seen at certain places. Filaments of nerves so completely de- generated were rare; in the larger number the alteration was only partial; and then they were composed of two kinds of tubes, viz., one containing healthy myeline ; in the other this latter presented a sprinkling of fine fatty granules either between the tubes or under the common neurilemma ; lastly, under this neurilemma were observed, in several places, granu- lar bodies resembling those met with in certain foci of soften- ing. Authors regard it as possible that in the filaments con- taining some healthy tubes, and others altered, the former may have belonged to sensory, and the altered ones to the motor element. Lorain and Lepine speak of the autopsy of a simi- lar case made by one of them. In another of the same kind which he reports, Biihl found small bloody extravasations in the brain with peripheral softening; and at the point of union of the anterior and posterior roots of the cord including the spinal ganglions, they had a volume nearly double and were colored dark red by hemorrhagic infarctus, which already presented signs of yellow softening. This tumefaction was caused by infiltration of the nerve sheaths and of the inter- stitial connective tissue, by these neucleolar bodies which Biihl regards as the characteristic lesion of diphtheria, and which he found in the false membranes, in the mucous mem- branes covered by them, and even in those which appear healthy. These enlargements existed particularly in the lum- bar region ; they were less marked in the cervical, and still less in the dorsal. The cord was healthy; the nerve trunks were not examined. Oertel has found at the autopsy capil- lary hemorrhages in the cranial and spinal dura mater, as well as in the nerve roots and peripheral nerves. Leyden, cited by Senator, has shown in one case that it is a true case of mi- grating neuritis (neuritis migrans) starting from the diseased organ and ascending toward the centers as far as the medulla PATHOLOGICAL ANATOMY. 12/ oblongata, by encroaching upon the nerves step by step. Finally, in a subject who died of asphyxia in the course of diphtheritic paralysis, Liouville, quoted by Bailly, has found the phrenic nerves altered in the same way as the palatine nerves of the patient, who was the subject of the observation made by Charcot and Vulpian ; the degree of alteration was only a little less advanced. Section 9. Locomotor Apparatus. The muscles only, in the locomotor apparatus, should en- gage our attention. In the chapters which refer to the larynx and heart I have shown the changes which may affect the mus- cular fibres of these organs. We have seen, moreover, that the paralyzed muscles, those of the palate especially, undergo fatty degeneration. The general muscular system is ordinarily healthy, but docu- ments upon this subject are, however, rare. Authors who have treated of muscular pathology, viz., Zenker, Waldeyer, Hayem and Bernheim, have not mentioned the modifications made by diphtheria; those who have spoken of it have had in view only the lesions of muscles contiguous to the inflamed mucous membranes. However, we may establish the fact that certain muscles are sometimes attacked with fatty transforma- tion. In one of the observations of L. Lagrave the muscles examined by Damaschino presented the peculiarities of waxy degeneration. In all these cases paralysis was not noted. Section 10. Organs of the Senses. I. The Eye. — The ocular mucous membrane, like all the membranes of this order, is subject to be covered with diph- theritic productions. The different names, pseudo-membran- ous ophthalmia (Bouisson), conjunctival diphtheria (Laboul- bene), croup of the eyelids (Magne), diphtheritic opthalmia (Gibert), and (Raynaud), and palpebral diphtheria (Peter), have been applied to this diphtheritic manifestation by authors who have described it. The false membrane shows itself by pref- 128 DIPHTHERIA, CROUP AND TRACHEOTOMY. erence upon one or both of the divisions of the palpebral con- junctiva. More rarely it attacks the ocular conjunctiva. At first it is white, thin and very adherent, and can be torn off only in fragments, causing some bleeding. Sometimes it is more feebly attached, and may be separated all in one piece. At a later period it becomes gray and thicker. The con- junctiva is thickened and strongly injected at first; then it be- comes glossy, smooth, and of a pale gray or yellowish color, and the circulation then is imperfectly accomplished, there is a real ischaemia. The sub-jacent connective tissue is infil- trated and tumefied; the skin which covers it is glistening and tense. The conjunctiva may be attacked alone, but the cor- nea is often encroached upon, not by the diphtheria, but by a violent inflammation in the vicinity. Sometimes it is only abraded, but it may be ulcerated. This is the result of imper- fect nutrition, the consequence of ischaemia. In other cases still more grave I have seen an abscess develop in its sub- stance ; I have also witnessed its perforation ; the eye w^as then emptied of its aqueous humor, and the remaining layers of the cornea were greatly softened. It did not appear that the deep parts of the eye had suffered greatly. There are cases, however, the contrary of this, in which one meets all the lesions characteristic of suppuration of the globe. The mus- cles which preside over the movements of the eye and over accommodation of its various parts are certainly affected, since we observ^e strabismus, amblyopia, mydriasis and blepharo- tosis; but I believe they have not been examined anatom- ically. At the same time with diphtheritic conjunctivitis vari- ous localizations of diphtheria in other regions are met with, the most common of which is tliat of the integument. 2. The Ear. — When diphtheria attacks the ear grave lesions are produced in this organ. It is through the Eustachian tube that the disease is propagated from the pharynx to the middle ear. This duct alone is sometimes attacked, and the exu- date moulds itself upon its surface and takes the form of a trumpet. But frequently the process penetrates into the mid- dle ear, there produces irreparable destruction, detaches the PATHOLOGICAL ANATOMY. I 29 ossicles and perforates the membrana tympani, which permits the false membrane to extend to the meatus and auricle. Aside from the presence of the exudate which is deposited upon the entire surface of the middle ear and upon the exter- nal meatus, the disturbances met with are those of otitis media. But I need not describe them more in detail. The external parts of the ear, the pinna, and especially the groove which separates it from the cranium, are the seat of ulcerations cov- ered with diphtheritic concretions. These are lesions which really belong to cutaneous diphtheria. 3. The Nose and Nasal Fosses. — These parts have been treated in the chapter relating to the air-passages. SYMPTOMS. Divisions. — Like all general and infectious diseases, diph- theria reveals itself by local phenomena and by general symp- toms. The former are constant, with rare exceptions ; the lat- ter, very variable as to their intensity, are obscure, moderate, or predominant. Among the local phenomena the most im- portant, beyond doubt, is the false membrane. It is the al- most unfailing characteristic of the disease. All observers have verified its presence on different organs, and they have described the morbid conditions as well as the local deter- minations, whence the names membranous angina, croup, etc. To each of these names, in fact to each invasion of an organ, corresponds a totality of symptoms — a cry of the diseased or- gan which expresses the disturbances produced in the normal action of the latter. These different symptomatic aggrega- tions (complexus) form groups quite accurate and very dis- tinct. It is, therefore, expedient in the description of diph- theria to make divisions, each having as a caption the local- ization of the false membrane. Thus we shall have to present angina, croup, bronchitis, cutaneous diphtheria, etc. But aside from the false membrane and symptoms which are the direct consequences of it, general phenomena exist and derange- ments belonging to the several general systems, derangements 130 DIPHTHERIA, CROUP AND TRACHEOTOMY. which are common to all the localizations of diphtheria. These are the signs of diphtheritic infection. Thus there are two grand divisions of symptoms. One set are the expression of the general disease, and they belong to the general de- scription of diphtheria. The other take their characteristics from the situation of the false membrane, and they will find their place in the description of the localisations of dipJitheria. According to another classification, based upon etiology and adopted long ago, diphtheria is considered as different accord- ing as it is primary or secondary. This disease often being influenced in its course and in its gravity by its origin, this dis- tinction appears well founded. However, the modifications which result from etiological influences are not peculiar to the latter, and we find them frequently in the primary form. There is, therefore, no ground for admitting a secondary diphtheria different from the primary; it is proper only to make conspicuous the peculiar physiognomy assumed by the disease in each case in which it is engrafted upon a previous morbid state, and to show that though the course and general symptoms are not to be distinguished from those of primary diphtheria, it is no longer the same when we consider the lo- calizations. These nearly always recall in their arrangement the local manifestations of the original disease. In a prog- nostic point of view secondary diphtheria deserves also a sep- arate notice. For these reasons I shall preserve the classic division into primary diphtheria and secondary diphtheria^ while assigning much less importance to the latter. \ ARTICLE FIRST. — GENERAL DESCRIPTION OF DIPHTHERIA. Primary Diphtheria. Taking it in its simplest acceptation, diphtheria is a general, infectious and contagious disease, of which the local mani^ festations, presenting themselves on the part of the mucous membranes and the skin, are accompanied at one time feebly, at another strongly, with general sympoms, which latter reveal its septic nature. These two elements are associated in very variable proportions. At one time the local element appears to dominate exclusively, the septic element remaining in a latent itate; but while being predominant the former does not assume an extensive development. When it extends it always does so by contiguity; it does not appear simultaneously hor consecutively at distant points. In another, the local symp- toms are distinguished by their tendency to spread. Not only do they extend locally with a remarkable activity, but they soon appear upon the points more or less distant from the point of departure. At this time toxic symptoms suddenly appear, which are frequently absent at first. In a third class the local condition is nearly absent, but the intoxication domi- nates the scene from the beginning. These tliree forms (mo- dalites) represent diphtheria under its principal aspects; it pre- sents three types which, while conserving to the disease its unity, renders the description more easy of apprehension. They constitute, properly speaking, the symptomatic forms of the disease. I shall, therefore, assign to diphtheria three forms, each corresponding to one of the preceding models, viz., a benign, an infections, and a malignajit form. Each lo- calization of diphtheria may assume any one of these forms. From this relationship, taking angina as an example, there will follow angina of a benign, an infectious, or of a malignant form. 132 diphtheria, croup and tracneotomy. Forms. Benign Form. — We find this form most frequently in the throat ; and it occurs again primarily in the larynx, in the cases of primary croup (croup d'emblee). It commences by a febrile movement, sometimes imperceptible, more frequently quite marked, usually accompanied with a slight and repeated chill, an onset like one of the non-diphtheritic inflammatory an- ginas, provided they acquire a certain violence. At the same time there is anorexia, extreme lassitude and headache. The local condition varies greatly. Often the false membrane is quite limited; sometimes it is simply dotted, and assumes that form which Gubler has separated from diphtheria, giving it the name of herpetic angina. It maintains these dimensions or ex- tends superficially while still remaining confined to the pharynx. Finally, it may happen that it will extend from the pharynx and gradually reach the larynx. If in this case the patient runs certain dangers, these belong to the situation of the exudate, but the disease remains none the less benign as to diphtheria, and as soon as one has relieved the asphyxia by appropriate means the cure is effected without difficulty. This form of diphtheria is found almost entirely in angina ; and I transfer, therefore, to the description of the latter what remains to be said, so as to avoid repetition. Adenitis is often ob- served with the benign form, and it is never very considerable. Trousseau attaches great importance to the glandular swell- ing in angina ; it was to him a phenomenon pathognomonic of diphtheria. In accord with many authors, I shall be less posi- tive, so much the less so as adenitis is met with in certain cases of intense simple, yet inflammatory angina. While not common, albuminuria is still not very rare. Its duration is short, not exceeding six or eight days. Paralysis of the soft palate or other organs sometimes intervenes during conva- lescence. Infections Form. — The commencement is the same as in the above form, but at the end of a few days characteristic symp- toms appear. Most frequently the false membranes first ap- GENERAL DISCRIPTION OF DIPHTHERIA. 1 33 pear in the throat, but sometimes they show themselves there after having attacked other mucous membranes, or the skin at the point of an accidental wound, or on the surface of a blister or an old ulcer. Instead of occupying limited points of the throat they extend as a simple patch, which covers the soft palate, its pillars, and the tonsils (Barthez). Their color be- comes gray or dark gray, and they assume a gangrenous ap- pearance and fotid odor. The mucous membrane becomes tumefied, violet-colored, bleeds easily, and even, in some cases, mortifies. When the false membrane has attacked the throat first, it is seen to extend into the nasal fossae, the larynx and the bronchi; and it breaks out on wounds, at points of the skin denuded of epidermis, on the place of old cutaneous af- fections, upon the conjunctiva, the lips, and upon the genital organs; everywhere it assumes the same characteristics. The mucous membrane, even that of the larynx, and the skin may become gangrenous. The lymphatic ganglions, around the regions attacked, are considerably enlarged, and they often suppurate. The atmosphere of connective tissue which sur- rounds them participates more or less in the ganglionary in- flammation. The infectious character may still depend upon the generalization of false membranes without assuming the gangrenous character and without their development being accompanied with adenitis. Thus it is that one sees the dis- ease remain limited to the throat during several days, with all the appearance of benignity, and then extend suddenly to the larynx and bronchial tubes. There is usually fever; the pulse is small and feeble. The complexion, at first bright, becomes pale, livid, leaden, and the mucous membranes become cyan- osed without there being any predominance of asphyxia. The dejected countenance bears the imprint of sadness. The vital forces are considerably diminished. Haemorrhages appear from different passages, especially from the nose, sometimes from the mouth, the anus, or the bladder. A decided anaemia is the result of this condition, less, however, from the loss of blood than from the disease itself, which increases the genesis of white blood globules. We have seen in the pathological 134 DIPHTHERIA, CROUP AND TRACHEOTOMY. anatomy that the number of these bodies might be increased in considerable proportion. Intestinal symptoms are not com- mon when not produced by emetics ; however, P. Wilson and Eisenmann notice their frequency (?). Greenhow cites a fatal case of haematemesis in a case of diphtheria, the patient being a boy of 15. Albuminuria is more frequent than in the benign form. The cerebral phenomena are slight and intellection is perfectly clear. Convulsions, however, are sometimes ob- served, either at the beginning, as in many of the diseases of children, or at the termination. This form of diphtheria is grave, and often ends fatally. Yet recovery is not very rare, and it is more frequent in proportion as the false membranes are more localized and the general condition less compro- mised. When death occurs it is due principally to exhaustion and to the depraved condition (cachexia) into which the pa- tients sink. Death by asphyxia alone is less frequent; and carbonic acid intoxication, while arising under various circum- stances, when the larynx or bronchial tubes are covered with false membranes, is never only one of the factors in a product to which septicaemia largely contributes, Patients who do not succumb rapidly seldom escape paralysis of various or- gans. The duration is long. Of the three forms of diphtheria, the infectious is the most prolonged. It is to this form that belong those cases in which the false membranes are repro- duced with remarkable tenacity, and which Barthez has pro- posed to include in a fourth form, which he calls the chronic form. Isambert reports, in this class, the history of a house surgeon who, having been attacked with nasal diphtheria, con- tinued for several months to expel from his nose false mem- branes. The Malignant Form. This form is characterized by the predominance of the toxic element. It presents two varieties. In the first, which may also be called the explosive form (forme foudroyante), the symptomatic complex is the same as in the preceding form, and is distinguished from it only by the GENERAL DISCRIPTION OF DIPHTHERIA. I35 rapidity with which the symptoms follow, and death may su- pervene in twenty-four hours, or in forty-eight, as in the case of Valleix, or in three or four days at farthest. It is not propa- gation to the larynx which causes the fatal termination ; the false membranes have often not time to extend that far. It is a veritable blasting. In other cases false membranes arise on all sides with frightful rapidity; in a day or two the throat, the nose, the larynx, the bronchial tubes, different points of the skin, the conjunctiva, the genital organs, etc., may be in- vaded to such an extent that healthy mucous membrane is no longer to be found. Even in these local conditions the gen- eral state predominates. The local symptoms present nothing new, except it be an exaggeration of the gangrenous symp- toms, increase of the offensive odor, which becomes perfectly intolerable, the violet tint of the mucous membranes, and the greater tendency to hemorrhages. We must not suppose that the false membranes are always very extended; on the con- trary, one is often surprised to find them on one side only, and of little extent, or almost absent. But, however limited they may be, the neck always presents an enormous tumefaction ; this latter is the characteristic of this form. This swelling, which, according to the figurative expression of Trousseau, "sent sa peste;" pestiferi inorbi naturani redolens, said Mer- cado, is not formed alone at the expense of the inflamed cervical and parotid glands, it includes the surrounding connective tissue also. The general symptoms and the signs of cachexia are still more marked, viz., prostration, small and weak pulse, chilliness, and sometimes, at the close, de- lirium ; very often there is somnolence or coma, throughout the entire duration of the disease. This variety is always fatal. The second variety merits the name, insidious form. It leads, in the beginning, to the expectation of benignity, which, however, becomes painfully deceiving. The lesions are unim- portant, but they extend to the throat and nose ; their appear- rnce has not always the special characteristics above de- scribed; but the general condition is profoundly affected. 136 DIPHTHERIA, CROUP AND TRACHEOTOMY. The fever, it is true, is often absent, the pulse not very fre- quent, but weak and miserable, the countenance pale and leaden, the eyes with dark circles around them, the disgust for food insurmountable, depression of the vital forces com- plete, and the swelling of the cervical glands is enormous. However, at the .end of from five to eight days the local con- dition improves, even recovers, but the prostration continues, increases, the pulse becomes slower, and the patient cold, the prey of a constant agitation, or remains in an absolute quiet- ude, which contrasts with the gravity of the situation ; then he dies by progressive marasmus, or suddenly. In other cases the insidious character is still more striking. The local lesions are ill-expressed, the fever is absent, and the patient suffers but little ; he remains up, walks about, and appears not at all concerned about his condition. But the countenance is char- acteristic, and the cervical swelling is considerable. Then, at the end of a few days, the patient dies suddenly, while mov- ing, during an effort, or, indeed, sinks rapidly from general conditions which suddenly develop. The termination is al- ways fatal. Albuminuria is frequently met with in both ot these varieties. ANALYSIS OF SYMPTOMS. Among the symptoms which have just been enumerated, some are peculiar to certain localizations; they will be studied with them. Others are independent of forms and localiza- tions. Without being constant, they are found in forms most benign, as well as in those most severe, in localizations the most various, and in the most extended as well as the most circumscribed. Their place is noted in the general history of diphtheria. They are fever, albuminuria and eruptions. Others vary according to the different forms ; they are the inheritance (apanage) of the infectious forms on which they place their stamp of gravity. In this sense they may be described as complications. But admitting that they are the same grave accidents which characterize the forms of diphtheria, I do not hesitate to think that their description may enter into that of t GENERAL DISCRIPTION OF DIPHTHERIA. 1 3/ the symptoms of diphtheritic disease. I shall therefore study them after those of the primary group. One will there find gastro-intestinal disturbances, gangrene, hemorrhages, oedema without albuminuria, and derangements of the circulatory ap- paratus. Afterwards will come the nervous disturbances, con- vulsions and diphtheritic paralysis. After having devoted a few words to the variations which the urine undergoes in its quantity and in its composition I shall close by some consid- erations upon secondary diphtheria. FEVER. Fever is one of the most variable phenomena of diphtheria. In certain epidemics and in some sporadic cases it fails com- pletely, or almost so. In the most simple cases the fever is often intense at the onset. In malignant cases it may be at zero. If it be present it may rapidly diminish while the pulse is becoming small and the extremities cold. On the other hand, a persistent fever is not regarded either as a favorable omen. It is therefore not so much the presence or absence of fever which we must consider, but rather the period of its appearance, its persistence, and the symptoms which accom- pany it. An intense fever at the beginning is not of serious import when it disappears without the forces being depressed. If, on the contrary, it persist, or if after having disappeared it return; if it appear at a period somewhat remote from the in- vasion, it has more importance because it indicates the ap- pearance of an untoward complication. It should be examined in its three elements : Temperature, pulse, and respiration. The teniperatiire has been especially studied in croup. Not- withstanding the modifications impressed upon the course of the temperature, certain functional derangements, such as as- phyxia and inflammatory complications, there is a quite marked resemblance between the temperature curve of croup and that of diphtheria when the latter is exempt from those two perturbing causes. It is in the relatively slight elevation that this analogy is expressed most strongly. To the con- trary of what occurs in many diseases, the rise of temperature is 138 DIPHTHERIA, CROUP AND TRACHEOTOMY. not in direct proportion to the intensity of the process. This is the only important peculiarity revealed in the study of tem- perature in diphtheria. All authors have observed it. Wun- derlich demonstrated that there was no other acute disease in which the temperature is so little characteristic as in pharyn- geal diphtheria and in croup of the larynx. While admitting that a very high temperature constitutes an increase of danger, he adds that a moderate temperature, even normal, does not furnish the least guarantee of a favorable issue, and that the elevated temperature may descend while the disease pro- gresses with an excessive fever until the individual succumbs. Roger observes that animal heat is increased in croup, but much less than one might suppose from the rapidity of the pulse and from the acceleration of the respiratory movements. Lorain and Lepine teach that diphtheritic poison is not re- markably pyrogenous. The diphtheritic infection does not re- veal itsell by a febrile movement of any importance. The fever of an infectious angina may not exceed that of an an- gina without infection ; one may see, especially in children, the temperature the first few days sink below normal, and death occur in collapse. The results of my researches accord with these data. In the greatest number of cases, in the mild- est as well as in the most severe, the temperature from the be- ginning varies between 38°. 2 (101° F.) and 38°. 8 (102° F.); several times, among others in a case of generalized diphthe- ria, I have seen it mark 36°. 8 (98°. 2 F.). Under other cir- cumstances, finally, the invasion was marked by temperatures oscillating between 39° and 40^.4 ( I02°.4 F. and 105° F.). But then, complications, such as bronchitis, broncho-pneumo- nia, pneumonia or convulsions, had supervened, or were immi- nent. In speaking of the beginning I did not mean the real beginning or date at which the patient began to be indisposed. This moment nearly always escapes the observer ; it is rarely that the physician is called before the formation of false mem- branes. At least, with very exceptional cases, one is, there- fore, obliged to be content with this date. However, Squire, and Callandreau Dufresse, who cites him, appear to have been GENELAL DISCRIPTION OF DIPHTHERIA. 1 39 more fortunate, since they admit a period of incubation which reveals itself by an elevation of temperature, an elevation which they do not give precisely, and which may diminish when the local manifestations appear. I cannot admit, with- out farther information, this assertion, inasmuch as in two cases in which the patients could be observed during the initial pe- riod, these conditions occurred reversed. In the first patient the temperature was 38°. 5 (101°. 3 F.) when the throat pre- sented only redness, but rose to 38'^./ (101°./ F.), when the exudation appeared. In the second the difference is much more striking. Taken under the same circumstances the tem- perature rose from 38^.4 to 40^.4 (F. ioi°.i-i04''.7). When the disease is established the temperature curve rises accord- ing as the process advances towards recovery or towards death. In the former case the curve, if there be no complica- tions, falls to normal at the end of two or three days, either suddenly or after a few oscillations. If diphtheria reach the larynx, modifications arise which I shall present in detail when speaking of croup. If certain complications appear the curve rises, reaches a higher point than at the beginning, remains between 39° and 40° (l02° and 104° F.) during the time the complication continues active, then resumes its descent at a period varying with the nature and intensity of the complica- tion ; sometimes a local determination upon another point, a new impulse, or simply the appearance of paralysis causes it to ascend. In the /atUr case the temperature rises rapidly to 39° or 40° (I02°-I04° F.), and even above ; or, after a rapid ora progressive decline, to a little below normal, the patient dies in a kind of collapse. The temperature in this latter case no longer expresses the gravity of the situation, as it does in so many other diseases. Dr. Faralli has reached similar con- clusions. He admits, moreover, that in the infectious and malignant forms, the mercurial column continues to rise till the death of the patient. We have seen by what precedes that the latter proposition is not always verified. The details just given confirm what I advanced at the beginning of this chapter, viz., that the course of the temperature furnishes but 140 DIPHTHERIA, CROUP AND TRACHEOTOMY. imperfect and even negative indications of the course of the disease. The only interesting, and perhaps useful fact re- sulting from this study is the slight elevation of temperature developed by diphtheria when abandoned to itself. The pulse is, ordinarily, frequent in uncomplicated diphtheria; it rises to 120, to 140, or even higher, according to age. Relatively more elevated than the temperature, it follows, however, the latter in its ascent, then descends, but not always in the same ratio. It often continues frequent for a certain time after the temperature has returned to normal. When a complication supervenes it follows the features belonging thereto. In the malignant and in the infectious forms, when the latter termi- nates in death, the pulse sometimes becomes small, weak, sud- denly slow, and falls below 50 pulsations in the minute ; a decided reduction, especially so when it is the case of a young child. In the insidious, malignant form it often occurs that the pulse is not modified even at the beginning. It continues normal ; but when the signs of malignancy appear, when col- lapse supervenes, it sinks as in the former case. The respiratio7i generally follows pretty closely the tempera- ture and the pulse in their rise, from the beginning. It reaches from 36 to 38 respirations in the minute. If the fever cease or decline the respirations diminish at the same time. In case of fatal termination, even when the pulse may become slower, the respiration becomes accelerated and rises to 50 or 60, or even more, in the minute. The same occurs when a thoracic complication supervenes, and the frequency of respiration is often the best and even the only index of it. ALBUMINURIA. Diphtheritic albuminuria, signalized by Wade, of Birming- ham, has been the subject of study by many authors who have endeavored to throw light upon the cause and the symptom- atology. In persons attacked with diphtheria the color of the urine is variable; most frequently it is limpid, and of an am- ber yellow color. Sometimes it becomes cloudy on cooling, which is occasioned by the precipitation of the urates which it GENERAL DISCRIPTION OF DIPHTHERIA. I4I contains in sufificiently large quantity alone or together with albuminuria. After standing some days, and independently of all lithate sediments, the microscope enables one to discover often in the inferior strata of the urine altered histological ele- ments coming from the renal debris, such as blood globules, leucocytes, epithelial cells scattered or agglomerated into hyalin or fibrinous cylinders. The presence of albuminuria is revealed by applying, in the usual manner, heat and nitric acid. The quantity is quite variable. At one time the pre- cipitate is flocculent and quite abundant, at another but a slight cloudy aopearance is obtained. The sources of error are too well known to occupy my time in this work. There is one, however, which enters fully into the subject and which I cannot leave in obscurity, so niuch the less, as the rather ex- tensive use at this time of the balsams may make it more com- mon. In fact the resin of copaiba is climated by the urine in which it remains in suspension, but it is precipitated by nitric acid. The cloud produced by the addition of this reagent presents a strong analogy to that of albumen ; it is distin- guished from the latter by being soluble in alcohol. Thus when the urine of a patient, treated with the balsams, becomes cloudy by the action of nitric acid it is necessary to add to the fluid a little alcohol, which will remove the precipitate if it has arisen from resinous matter. The microscope also furnishes useful information. The albuminous precipitate is granular lamellar, but never crystalline. According to the statements of all authors, albuminuria is frequent in diphtheria. Accord- ing to Empis and Bouchut one should find it in two-thirds of the cases ; according to See, in half, and according to Mau"-in in the majority. My statements appear to confirm these data- in 410 cases of diphtheria, in which it was sought, it was found 224 times, that is, in a little more than half the cases. One comprehends that it may be difficult to fix exactly the fre- quency of this symptom ; albuminuria being frequently a purely transitory, evanescr-nt. phenomenon, statistics, compiled with the object of establishing its frequency, can be of value only on condition that the urine has been examined every day from 142 DIPHTHERIA, CROUP AND TRACHEOTOMY. the invasion to complete recovery. It is, therefore, possible that certain ones, among those which are known, are quite be- low the facts. The appearance of albuminuria does not occur at any fixed period ; it is from the second to the eleventh day that I have found it most frequently. The following table will give evidence of this statement. In 224 cases of diphtheritic albuminuria the first appearance was observed at the following dates : Date of Death. 1st ( Jay of the di 2nd (( <( 3rd ( (( 4th t( « 5th ( « 6th < « 7th t *( 8th t t( 9th t *( loth 1 ti nth t t( 1 2th t (( 13th ( " 14th < « 15th ( «( sease i6th, 19th, 23d, 26th, 29th, 37th, 38th, each, No. of Cases. 3 lu 30 30 22 26 13 33 12 14 10 I 2 I 4 I Total, - - - - - 224 Thus, generally speaking, its greatest frequency is found within the limits which I have drawn, and we may, to be still more precise, show that albuminuria has appeared most com- monly between the third and the eighth days ; the latter has been the period of preference. That this table is marred with some inaccuracies I readily concede. In hospital^ especially, patients being rarely subjected to observation from the begin- ning of the disease, the evidence of albuminuria on the day of entry does not prove that it did not exist before. Error is therefore possible, even probable, and it is proper to take it GENERAL DISCRIPTION OF DIPHTHERIA. I43 into account. But far from weakening the results deduced from this table, it confirms them, since it aids in bringing the appearance of the albuminuria near to the invasion of the dis- ease. Nothing is more irregular than the course of diphthe- ritic albuminuria. At one time the precipitate is sudden, abun- dant and flocculent; at another it commences with an opaque cloud, which continues with this characteristic till the time at which it disappears, or very rapidly becomes thick. In certain cases, continuing only a day, it may in others remain sta- tionary for a considerable time. While, in general, continu- ous, it is sometimes intermittent, disappearing, then reappear- ing at various intervals. In eighty cases of diphtheria terminating in recovery in which albuminuria had completely developed, I have obtained the following results: Duration of Albuminuria. No. of Cases. - - - - - 10 2 6 3 4 6 3 8 - - - - - 2 3 4 - - - - - 2 - - - - - 2 - - - - - I - - - - - 2 Total, - - - - - - 80 It appears that the most common duration is from one to three days, and in the next rank is that from one to ten days. I day 2 days 3 (( 4 (( 5 (( 6 « 7 « 8 u 9 It 10 « II (( 12 (( 13 (( 14 <( 15 « 16 ' 17 « 19 u 22 « 26 <( 57 « 144 DIPHTHERIA, CROUP AND TRACHEOTOMY. We see also that though albuminuria may continue for a longer time, fifteen, twenty, and even fifty-seven days, yet it is only in quite rare cases. I have not seen a single case in which it has become chronic. Yet Gregory and Rayer have cited several such. I think, in order to reckon them with diphtheria, one must be certain that scarlatina had no share in them. These cases, however, admitting them to be correct, would be ex- ceptional. The albuminuria of diphtheria is very rarely accom- panied by oedema, the reverse of that of scarlatina. The rea- son of this curious peculiarity is found in the fact which I men- tioned when treating of the pathological anatomy, namely, that in scarlatina the renal lesions occupy, most frequently, both kidneys, while in diphtheria there is ordinarily but one of them attacked. Wade has never noted dropsy ; G. See has met with it, but much more rarely than in scarlatina. According to Trousseau, one does not observe it once in twenty cases. For my part, I have assigned to it a still lower proportion, for in 224 cases of diphtheritic albuminuria I have collected but seven cases of dropsy. I need hardly say that I have deducted the cases in which albuminuria and cellular infiltration existed be- fore diphtheria. Dropsy did not appear before the fifth day. At one time it appeared in the form of anasarca, at another in that of oedema of the face. In one of the patients it was limited to the larynx. This was in a child attacked with infectious diphthe- ritic angina with coryza, adenitis, and albuminuria, in which laryngeal symptoms suddenly appeared on the fifth day, fol- lowed by suffocation; and it was supposed to be a case of croup. Tracheotomy, decided to be necessary, was performed, but the patient died. Instead of laryngeal false membranes, which one expected to find, the autopsy demonstrated the ex- istence of lesions most characteristic of cedema of the glottis. In another case, albuminuria and dropsy were accompanied with extremely serious cerebral symptoms, disturbances of vis- ion and repeated eclamptic attacks, which carried off the pa- tient. The post mortem examination revealed a considerable oedema of the meninges and ventricles. I shall add that in nearly all these cases dropsy and albuminuria arose simultane- GENERAL DISCRIPTION OF DIPHTHERIA. 145 ously ; in one case, on the contrary, dropsy preceded albumi- nuria for eighteen days. Upon the causes of albuminuria there is far from being an agreement. Empis and Bouchut, Germe, andHervieux give it as resulting from croupal asphyxia. According to Lorain, Charcot, and Lecorche, the cause is in re- nal congestion or in slight parenchymatous nephritis analogous to those visceral congestions which occur in fevers, in typhus, in typhoid, etc. According to Gubler it is the consequence of excess of protein materials contained in the blood. The first hypothesis should be discarded, for the reason that albuminu- ria occurs in cases of diphtheria in which respiration experi- ences not the least restraint, in the most simple angina, even in diphtheria confined to the skin. While in croup asphyxia may be an auxiliary cause in consequence of visceral con- gestion which it engenders, and from carbonization (anoxe- mia), which leaves imperfect the combustion of protein matter and nothing farther, yet it should not be removed from this secondary rank. The hypothesis of renal lesion combines many correct reasons. As in fevers and in infectious diseases, visceral congestions are common in diphtheria. Besides, in cases in which albuminuria was observed during life, autopsy revealed most frequently, on the part of the kidney, anatomical alterations which vary from simple hyperaemia to parenchyma- tous nephritis most perfectly marked. It is generally admitted, according to clinical and experimental data, that in albuminu- ria the kidneys are not limited to a passive relation ; their role, on the contrary, is active ; in other words, they do not permit the transudation of albumin only on condition of their being transformed or undergoing certain modifications in their struct- ure, often evanescent, sometimes more important, which are the instrumental conditions, sine qua non, of filtration. These modifications are, as Lecorche has demonstrated, congestion of the organ and degeneration of the epithelium of the canalic- uh. Excess of albumin in the blood does not suffice to de- termine albuminuria ; the proteinous matter remains inclosed in the vessels of the circulation, if the kidneys are not placed in the required structural conditions. One may object that in 146 DIPHTHERIA, CROUP AND TRACHEOTOMY. certain cases the kidneys appear healthy, but it is only from ex- ternal appearance that this opinion has been given ; histolog- ical examination has not been made. Moreover, the lesions necessary to albuminuria, besides being often slight, are in many cases essentially evanescent ; the congestion disappears rapidly, the epithelium is quickly regenerated, and the lesion may have disappeared if the patient has not died in the height of albuminuria. The theory which attributes albuminuria to congestions, frequently transitory, which arise in the kidneys as well as in other viscera, in diphtheria as in all general or in- fectious diseases, is, therefore, supported by ver}^ solid argu- ments. While recognizing the necessity of an organic change in the kidneys, Gubler thought that albuminuria should recog- nize as the proximate cause the hyper-albuminous condition ot the blood, and particularly in diphtheria, the membranous diath- esis characterized by the excess of albumino-fibrinous exuda- tion. Now, in the absence of exact analyses of the blood in diphtheria, there is nothing to prove that this disease is accom- panied with an exaggerated richness of proteinous material in the blood ; and I have already insisted upon the apparent cer- tainty of the contrary. Besides, experiment has proved that excess of albumin in the blood is not sufficient to determine albuminuria. The symptomatology and the prognostic val- ue of albuminuria have given rise to numerous contra- dictions. Maugin, Bergeron and Lewin give it great import- ance, in a diagnostic point of view. I have shown how often it fails, even in the most marked cases of diphtheria. If from its presence one may infer the diphtheritic nature of the dis- ease, he may not apply the converse and exclud,€ from diph-^ theria the cases in which the urine does not furnish a coagu- lum under the action of special re-agents. One would expose himself by this course to sad mistakes, and would see patients die with symptoms peculiar to diphtheria whom he iiad de- clared attacked with a simple herpetic angina. Barbosa is of the opinion that it aggravates the prognosis when it is not the result of renal congestion. See, on the contrary, has shown that in eleven cases of diphtheria with albuminuria he had ob- GENERAL DISCRIPTION OF DIPHTHERIA. I47 tained six recoveries, while in sixteen cases of diphtheria with- out albuminuria nine had terminated in death. I intended to verify, upon a large scale, the conclusions of See, which I readily accepted, having observed many times albuminuria quite intense in cases of benign diphtheria, and conversely, the absence of albuminuria in many cases of infectious or malig- nant diphtheria. I have arrived at results different in form, but analogous in substance. In 233 cases of diphtheri ac- companied by albuminuria, 142 died and ninety-one recov- ered. In 160 cases of diphtheria in which albuminuria was absent, ninety-seven patients recovered and sixty-three died. These figures show that in the cases of albuminuria the mor- tality has greatly surpassed the number of recoveries, and that in those in which albuminuria was wanting the reverse result was produced, though with a difference much less marked. It appeared, therefore, that albuminuria exercised in fact an un- favorable influence upon the course of diphtheria, or rather, that it was more common in the grave cases. However, I think it necessary to be guarded in accepting the results of statistical reports unconditionally as the expression of the truth. Many other causes of death are met with in diphtheria : croup, operations, pulmonary and other complications, which tend much more strongly to a fatal termination than albumi- nuria. In examining the total cases in which albuminuria was absent, one sees that other causes were sufficiently powerful to cause death in sixty-three cases of 160, that is, in a lit- tle less than one-half. In those in which albuminuria existed and which terminated fatally, there were at the same time other serious phenomena. No symptom peculiar to albuminuria ap- pear to have conduced to the fatal issue. In the cases which recovered its presence was revealed only by the examination of the urine, and its reaction on the economy was nil in spite of its intensity, occasionally quite marked. If to these con- siderations one add that in the fatal cases albuminuria is often found in very small quantity and but transitorily ; and if one still add that albuminuria never, so to speak, passes into the chronic state, except in the very rare cases in which it is ac- 148 DIPHTHERIA, CROUP AND TRACHEOTOMY. companied by oedema, recovery generally takes place, and that in the fatal cases in which autopsy could be made one never found those profound and generalized lesions which characterize diseases of the kidneys which induce death, we should, therefore, conclude that diphtheritic albuminuria is an epiphenomenon which in the vast majority of cases remains without influence upon the course of the disease. Eruptions. In 1858 G. See called the attention of the Societe Medical des hopitaux de Paris to cutaneous eruptions which he had observed in his service in a certain number of subjects at- tacked with croup and diphtheritic angina. They were almost analogous to scarlatina; some of them resembled roseola. See did not consider them as eruptive fevers running concurrently with diphtheria, but as emanations of the diphtheritic poison- ing, as cutaneous manifestations which would be the counter- part of those met with in other toxic diseases. Their fre- quency was relatively great ; they were present at least one time in four. Numerous objections to this interpretation arose ; certain members of the society declared that the so-called diphtheritic eruptions were unrecognized scarlatina. Others, while admitting the possibility of the rash in diphtheria, pre- sented very legitimate reservations upon the frequency of these phenomena. Indeed, while accepting as demonstrated the existence of diphtheritic eruptions analogous to those ob- served in typhus, typhoid, cholera, rheumatism, etc., it is nec- essary, in order to be correct in declaring the diphtheritic na- ture of an exanthema, to proceed by exclusion, and to exclude all other causes. Now, the age of the patients, when they are children, and their sojourn at the hospital, are conditions which strongly contend in favor'of eruptive fevers. The younger the patient the greater are the chances of an eruptive fever. And first, it is indispensable to exclude all eruptions which appear before the false membranes ; it is more legitimate to consider them as the primary disease of which diphtheria would be only a secondary symptom ; as to those which arise during the GENERAL DISCRIPTION OF DIPHTHERIA. I49 course of diphtheria, they, should, in order to be considered as manifestations of this disease, appear at a period as near as possible to the onset, or at least to the entrance into the hos- pital ; it is ordinarily in the ward of the hospital that patients contract eruptive fevers which complicate the disease for which they have been admitted. The incubation of scarlatina, for example, continues, according to Rilliet and Barthez, Guersant and Blache, from three to five days at the minimum, and from five to thirteen days on the average. The minimum of incubation in measles varying from six to ten days on the av- erage, one should have the right to exclude from the list of eruptive fevers the cutaneous manifestations which shall occur in the minimum of the space of time fixed for the incubation of these fevers, at least to admit that diphtheria and the erup- tive fever may have been contracted at the same time, as may be, strictly speaking, possible in the time of an epidemic. The eruptions which appear at a later date should not, any more than the others, present any of the symptoms which accom- pany measles and scarlatina: ocular, nasal, pulmonary and in- testinal catarrh for the former ; or redness of the throat, or cutaneous and lingual desquamation for the latter. The fe- ver, or at least the febrile paroxysm, should be absent at the time the eruption appears. While these conditions should not inspire absolute confidence, for scarlatina, especially, pre- sents in its appearance and course irregularities more or less unexpected, they are, nevertheless, quite important elements of probability. If one could establish the previous existence of the eruptive fever by which the exanthema shows itself, or if one knew that the patient had had later the fever in ques- tion, there would then be, at least respecting scarlatina, a cer- tainty almost complete. In one case cited by See, one was able to verify, six months after a diphtheritic scarlatiniform rash, the appearance of a veritable scarlatina. Conversely, in a patient attacked with diphtheria, supervening on the tenth day of a case of measles, I observed the same day of the for- mation of false membranes a rubeoliform eruption. Now, while the balsams are quite largely employed in the treatment of 150 DIPHTHERIA, CROUP AND TRACHEOTOMY. diphtheria, one should bear in mind, in patients so treated, the possibihty of a copaivic eruption. In taking account of these various causes of error we considerably reduce the number of eruptions really due to diphtheria. In the large number of observations which I have examined I have found the exan- themata in only one-fiftieth of the cases. They have assumed various types. The most common has been the scarlatini- form, the only one that See had first in view. Others follow which present all the physical characteristics of measles, eryth- ema limited to the trunk or the extremities, or generalized, urticaria, ecthyma, etc. Sometimes they are vesicular. These eruptions have appeared from the first to the seventh day of the disease, and from the second to the third day after admission to the ward, when the patients were observed at hospital. These limits have very rarely been exceeded. Their duration was always short, a day or two at most. They were never ushered in by general symptoms. The fever, or the increase of the febrile movement already existing, the vomiting, ano- rexia, pruritus and tumefaction failed. It is difficult to state the value of these eruptions respecting the prognosis. See admits that they exercise a favorable influence ; children who had them recovered in the proportion of two to three. It ap- pears really, at first thought, that they are observed most fre- quently in cases of benign diphtheria. Respecting the scarla- tiniform eruption the proportion is true ; the proportion of re- coveries was exactly two in three. In the erythematous form there was but one death in five cases. But in the rubeolar form the number of deaths was equal to that of recover>\ Finally, in the cases in which the exanthema assumed the form of urticaria, the termination was always fatal. The cutaneous manifestations, therefore, must be of favorable prognosis. While completely harmless of themselves, they accompany many of the grave cases, and their number would be much greater if the disease did not very frequently run such a rapid course as to leave no time for their development. One will approximate the truth more nearly by according to them a quite limited value in this respect. From what pre- GENERAL DISCRIPTION OF DIPHTHERIA. I51 cedes one may conclude that exanthemata are observed during the course of diphtheria which appear to be true cutaneous manifestations of the disease ; that these eruptions are rela- tively infrequent ; that they are met with as well in the grave cases as in the slight, and that their appearance does not modify the development of the process. Gastro-intestinal Disturbances. These are not common in diphtheria unless they should be the result of active treatment by emetics, and especially anti- mony. However, P. Wilson believes that diphtheria is always consecutive to a disease of the stomach ; Eisenmann, who re- produced his work, thinks he has observed in the great epi- demics of Paris, Boulogne and Crowfort, in England, that gas- tro-intestinal symptoms always preceded angina. To contend is useless. In a certain number of cases the appetite and thirst present nothing worthy of note ; they follow the course of the fever, but generally, in the course of angina, as in croup after trache- otomy, from the fact of the disease itself, as well as from the restraint of deglutition, anorexia is absolute, and the patients would die if not constrained to eat even by compulsion. Bre- tonneau and Trousseau especially have strongly insisted upon this aversion for nourishment and upon the necessity of re- lieving it. Diarrhoea is not very frequent, and very frequently it is found to arise from the excessive administration of emetics, es- pecially that of tartar emetic. It is not rare, under these cir- cumstances, that it assumes the choleraic aspect. However, it may exist without this cause. It is found in the prodromes and at the moment of invasion; but under these circumstances it appears to have not much importance ; but when it super- venes in the course of the disease it coincides nearly always with other signs of intoxication, and ends in giving to the pa- thological whole an unquestionable stamp of gravity. Under other circumstances, when the economy is greatly enfeebled and when the patient sinks into a complete cachexia, diarrhoea 152 DIPHTHERIA, CROUP AND TRACHEOTOMY. intervenes and is classed with the final phenomena. The ex- creted matters generally present nothing of special character. In cases in which the diarrhoea coincides with a well-marked state of poisoning, they are very fetid; sometimes, indeed, they are sanguinolent. Pseudo-membranous debris may be encountered in them without it being easy to decide their ori- gin. Do they indicate exudation of false membrane in the oesophagus, stomach, or intestines? Should they be consid- ered simply as swallowed after having been detached from the throat? The rarity of diphtheritic exudation upon the lower portions of the digestive tube would incline one to the second hypothesis. However, when they are very abundant, and especially when they are accompanied by sanguinolent ex- cretions per anum, one may suppose that they are formed in the intestine. Vomiting is quite common ; is noticed in the prodromes ; is seldom repeated, and is not of unfavorable prognosis. Sometimes, also, it is due to the treatment by tar- tar emetic ; and it is then associated with very serious diar- rhoea, and is sometimes uncontrollable. It is observed, also, during the course of the disease, especially in croup, a short time after the operation. It is nearly always, in this case, either the consequence of the administration of emetics or the indication of some impending complication : pneumonia, eruptive fever, etc. It then decidedly darkens the prognosis. Ormerod regards frequent vomiting as a serious symptom, particularly at the time when the throat begins to clear off. He mentions some cases in which gastric disturbances, super- vening during convalescence, are said to have induced, in the same way as unusual intellectual or muscular effort, a serious collapse and sudden death. Gangrene. The fundamental process of diphtheria is different from gan- grene. Agreeing with Bretonneau and the French school, I have defended this doctrine against the modern German school. But I have also shown that Bretonneau went too far in excluding gangrene entirely. An extreme degree of in- GENERAL DISCRIPTION OF DIPHTHERIA. 1 53 flammation and the septic nature of diphtheria appear to me to explain sufficiently the formation of these eschars. Diphthe- ria, like other diseases which frequently affect nutrition, as ty- phoid fever, measles, scarlatina, variola and cholera, act as predisposing causes; the local inflammations find a soil fully prepared. If the reaction be in the least violent the vitality of the tissues is destroyed and sphacelus is produced. In the majority of cases the eschar is observed at the point where the inflammation has acted with the greatest intensity ; thus the tonsils, the uvula and the pharynx are the sites of election. When an external cause is added to the above the determina- tion of gangrene receives thereby an additional impulse. Such is the influence of compression exercised by the canula upon the wound of tracheotomy and upon the mucous membrane of the trachea. It follows also cutaneous diphtheria ; in this re- lation the vesicular or pustular eruptions, such as herpes and impetigo, constitute a very manifest predisposition. The lungs themselves may be attacked ; broncho-pneumonia is then the exciting cause. In some cases gangrene manifests itself in several places at once, or successively. The general alteration of nutrition appears to me to explain sufficiently this diffusion. Is it necessary to invoke capillary emboli ? The state of science does not allow of a categorical answer. Briefly, gangrene finds in diphtheria the way prepared ; every cause which diminishes locally the vitality of the tissues : in- flammatory impetus, compression and eruptions, act as deter- mining causes. The points of the body where gangrene is seen most frequent are : the tonsils, the uvula, the pharynx, the soft palate, the lips, the trachea, the larynx, the lungs, the integument and the wound of the tracheotomy. As material lesions, those of the lungs excepted, it has no great impor- tance, for it rarely produces any great destruction, but it is of no less serious prognosis when it is spontaneous, because it is the index of a profound intoxication, a grave alteration of nu- trition. Thus it is not encountered only in the most severe forms. Gangrene of the wound following tracheotomy, and ulcerations of the trachea, present a diminished importance, because pressure must add greatly to the general cause. 154 diphtheria, croup and tracheotomy. Disturbances of Circulation. HcEmorrliage. — This is observed in diphtheria as in the ma- jority of infectious diseases ; there it is common. It occurs from the mucous membranes indiscriminately and from the skin. The alteration of the blood and of the walls of the ves- sels furnish a satisfactory explanation of it. Therefore, it oc- curs not only when the way to it is opened by a solution of continuity of the tissues, viz., the wound in tracheotomy, fall- ing off of the false membranes, separation of the eschars, but also in cases in which the internal and external teguments ap- pear healthy at the point where it occurs. Thus, epistaxis ap- peared in many cases during the prodomes ; for example, when as yet no false membrane was found in the nose. The most frequent, without doubt, is epistaxis. Then follow those occurring in the throat at the point whence arise the false membranes. In this locality it sometimes constitutes only oozing, so slight as not to be perceived from without, but which infiltrates the false membranes and colors them brown. While admitting those which occur at the time of the opera- tion, the wound is also the site of frequent haemorrhages. I have, in a former wcrk, indicated that one may observe them until the eleventh day. We should also note, in the order of frequence, those which arise from the surface of the gumg, lips, or from the nose and throat, at the same time. There are, finally, those which have their seat in the skin or sub-cutane- ous connective tissue ; they present themselves in the form of purpura, or ordinarily of ecchymoses of limited extent. Green- how cites a fatal case of hsematemesis in the course of diph- theria in a boy sX. 15. Lespine reports a similar case. While often occurring but once, haemorrhage may recur several times either on the same day or on several successive days, or at lono-er intervals. It may be repeated five or six times. It may also occasion an almost continuous oozing. In quantity it is often moderate, sometimes very moderate each time. But it does happen that the sanguinolent exhalation assumes un- pleasant proportions, and that we are obliged to resort to plugging the nasal fossae or to the application of perchloride GENERAL DISCRIPTION OF DIPHTHERIA. 1 55 of iron to the throat. I know of only one case of alarming haemorrhage, and I shall speak of it later. The beginning of the disease, that is the period embraced between the initial symptoms and the fifth or sixth days, is the date of most fre- quency for haemorrhages. Then they are observed from the seventh to the fourteenth day, the latest date that I have not- ed. This predilection of haemorrhages for the early days of the disease is not astonishing when one reflects that they are always the index of very serious cases of short duration. They are, really, in diphtheria, formidable symptoms from the con- dition of profound intoxication which they represent. They are the necessary accompaniments of infectious and malignant cases. Epistaxis, that particularly which arises during the pro- dromes, or just at the onset, before the appearance of false membranes, is that form, the influence of which is the most deleterious. Those which appear only at the time of the sep- aration of the false membranes from the seventh to the four- teenth day, have a less serious significance. In 25 cases of early epistaxis, death occurred in 20; in ii cases of later epis- taxis it occurred in 8. Haemorrhage trom the mouth and from the throat, or simply constant oozing from these parts, are of quite unfavorable prognosis; 14 deaths in 15 cases. A boy aet. 4 1-2 years, admitted to the hospital on the twelfth day of a diphtheritic angina, with coryza, presented a contin- ual sanguinolent oozing from the throat, nose and lips ; on the sixteenth day the haemorrhage assumed, suddenly, such a de- gree that the patient succumbed in a few minutes. It is the same with sanguineous exudations, scarcely visible, which in- filtrate the false membranes ; death occurred in every case. Haemorrhage from the wound presented a serious significance, although a little less. In 7 cases arising in the first few days, 5 died ; in 7 cases observed later, 5 died. Sub-cutaneous haemorrhages, as well as purpura, are of no better prognosis. Haemorrhage is therefore an extremely grave prognostic in diphtheria, not from its abundance, which is nearly always moderate, but because it is a sure index of malignancy. It is so much the more formidable as it approaches to a period nearer to the beginning. 156 DIPHTHERIA, CROUP AND TRACHEOTOMY. CEdema. — Independently of that which pertains to albumi- nuria, we sometimes encounter in the course of diphtheria, oedema localized or generalized, which coincides with normal urine. The former have been seen from the fifth to the ninth day of diphtheritic angina following scarlatina ; it is probable that it had its starting point in this eruptive fever. The other, which alone should engage us, is free from this origin. At one time it is limited to the face or upper extremities, at another it is general and should be called anasarca. Its appearance is late ; it occurs from the eighteenth to the twentieth day from the invasion; it is of short duration, and terminates nearly always in recovery, at least when other complications do not supervene. What is its cause ? We might refer to cold, but this has not been noted. Must we recognize in its pathogenesis a paralysis of the vaso-motors ? This mechan- ism, indicated by several authors, has been placed beyond doubt by Ranvier. The action of diphtheria upon the nervous system is so evident, so common, that one might admit with- out much difficulty the extension of this action to the system of the great sympathetic. Endocarditis. — From the examination and the discussion of facts which have been presented to prove the anatomical ex- istence of endocarditis in diphtheria, I must conclude that this lesion is much less common than announced by John Bridger, Bouchut and L. Lagrave. Let us see what the ex- amination of the patient teaches us. I take the signs of endo- carditis to be such as L. Lagrave gives them. They are : I. Force and fulness joined with irregularity and rapidity of the cardiac contractions. 2. Increased area in which the im- pulse of the heart is perceptible. 3. Bruit de souffle usually sys- tolic, and localized towards the apex of the heart. This lat- ter, says the author, is the most valuable of these signs, and we may add, the only one which is certain. Now, what diffi- culties has one not experienced in examining the heart when it is agitated by croup? The oppression, the anguish, and the restlessness of the patient fully explain the disturbance of the heart's action. The laryngotracheal wheezing, its reverbera- GENERAL DISCRIPTION OF DIPHTHERIA. 1 57 tion in the chest, strongly obscure the bmit de souffle. If the ex- amination be made after tracheotomy one finds the same obsta- cles in the metallic and strididous sound which the air produces in passing through the canula, and in the gurgling produced in the interior of this instrument when it is obstructed with the products of expectoration, without counting the rales of vari- ous kinds and the bronchial souffle which are the expression of the very frequent pulmonary complications in croup. Thus it is explained, that in the majority of cases L. Lagrave failed to note the souffle, and that in others he found doubtful mur- murs and very slight prolonging of the first sound, but none of the frank, rough murmurs which render endocarditis unques- tionable. In 47 cases, in which the autopsy presented lesions which L. Lagrave referred to endocarditis, the murmur had been observed only 6 times, and often with equivocal char- acteristics. There was nothing surprising in this result when the real anatomical value of these lesions is understood. Yet, one might take exceptions to the significance of the cardiac murmur (souffle) recognized under these circumstances; and one should be ce certain that it did not exist anterior to the diphtheria. Angina without croup and cutaneous diphtheria are more favorable to the perception of the cardiac symptoms ; the restlessness of the patient is less, the oppression is gener- ally null, and pulmonary complications are uncommon. How- ever, in 5 cases of diphtheritic angina, cited by the same au- thor, the murmur was observed in but 2 cases. We see how rare are the cases which, in this series of observations, so ably made and presented as arguments in support of the propo- sition, may be regarded as convincing. John Bridger, who reported lOi cases of endocarditis, observed the systolic mur- mur (souffle) in only 4 cases. How does he demonstrate the existence of endocarditis in the others ? My personal investi- gations are absolutely negative. Observations of diphtheria to the number of 149, taken in these later years, since the ap- pearance of the works of Bouchut and L. Lagrave, have not furnished a single case of endocarditis. I should fear to ex- press myself in such a positive manner if I should trust to the 158 DIPHTHERIA, CROUP AND TRACHEOTOMV. single testimony of my senses, but a large number of these patients were auscultated also by Barthez and by d'Espine and Gombault, his assistants ; there was never any difference as to the result of the examination. The conclusion of this chapter, therefore, is that diphtheritic endocarditis, while be- ing admissible by analogy, is extremely rare, as pathological anatomy and clinical observation alike demonstrate. Grave Disturbances of the Exdo-cardial Circulation. Thrombosis. Sudden Death. — Closely connected with the disturbances of the general circulation, viz., haemorrhages and oedema, one has noted in the course of diphtheria, particularly during convalescence, the occurrence of very serious symp- toms, nearly always fatal, and which appear to have their seat in the cavities of the heart. Richardson, Beau, Gerlier, Meigs, Duchenne of Boulogne, L. Lagrave and Beverly Robinson have insisted upon their frequency. These phenomena follow either a rapid or a slow course. In the first, when the false membranes have disappeared, and convalescence appears established, the patient is suddenly seized with praecordial dis- tress, and he complains of terrible oppression in the same re- gion and at the same time with extreme dyspnoea. The coun- tenance is changed, the eyes are expressive of deep anxiety, and a general pallor covers the body. Cyanosis has never been noticed ; in contrast to many other cases, in which death occurs from the heart, there is no tendency to asphyxia, but to syncope. The extremities first become cold, then the whole body. Cutaneous sensibility is preserved. The patient is restless; under the control of a veritable jactitation, he is con- stantly moving about ; it is with difficulty he can be kept on his bed, and the hands are constantly thrown from under the covers. He appears to struggle in spite of his weakness. The adult has the impression of approaching death, and bids farewell to his friends. Respiration is frequent, but ausculta- tion proclaims no abnormal sound; sometimes the respiratory murmur assumes more of the puerile tone. The pulse is small, irregular, unequal; it soon becomes thready; its fre- GENERAL DISCRIPTION OF DIPHTHERIA. 1 59 quency is moderate ; it rarely exceeds 80 to 100 pulsations per minute ; more frequently it slackens and falls to 50 or 40 pul- sations; in one case it beat not more than 26. The sounds of the heart present the same irregularities ; they are feeble, muffled and deep. This weakness increases progressively and the patient expires quietly at the close of a period varying from one to several hours, if he is not suddenly carried off by syncope. Examination of the heart gives no information. Ordinarily the blowing sound is not heard. The praecordial dullness remains normal. When the course of these symptoms is slow, the general aspect is the same ; the duration only dif- fers. In the beginning the strength is still preserved and the patient moves easily in his bed ; exhaustion comes on only to- wards the close. Pallor, general coldness and jactitation are also decided. The cardiac murmurs are confused, disturbed, and appear paroxysmal ; slight blowings have been noticed in some very rare cases. Respiration is often interrupted with long and moaning sighs, quite like those in tubercular menin- gitis. The intellect preserves its integrity. Death occurs at the end of two, three, or even seven days, as in a case cited by Meigs, in consequence of progressive debility, or suddenly in syncope. These symptoms are rare. They seldom appear at the beginning of the disease, but from the tenth to the twenty- first day, during established convalescence, when all local or general symptoms have disappeared. In one case, however, they made their appearance on the sixth day. Authors, wit- nesses of these facts, have explained them by the formation of clots in the heart, or cardiac thrombosis. This theory is open to important objections. I have shown that the coagula found under these circumstances have none of the character- istics assigned to clots formed during life, by authors who have treated the subject with ability. Besides, these same concre- tions are met with in a large number of subjects dead of dis- eases very different, and in which cardiac symptoms have been absent. Adding, then, that they are nearly always accompa- nied, in subjects dead of diphtheria, by serious pulmonary lesions, one cannot, however, demonstrate a probable patho- l6o DIPHTHERIA, CROUP AND TRACHEOTOMY. genetic relation between these products and tlie cardiac symp- toms of diphtheria. How then shall we explain these phe- nomena, so remarkable ? We cannot deny that they have their point of departure in the heart. The praecordial distress, the varieties of the pulse, the tendency to syncope, the cardiac palpitation, indicate this in a positive manner. The obstacle which presents itself to the contractions of the heart, not being found in the cavity of the organ, it must be sought then in its walls. Myocarditis and the degeneration which follows it have greatly prepossessed several authors, who attribute to it great importance in the formation of clots, in consequence of the feebleness of the contractions which resulted from it. This influence is very acceptable in theory ; however, it is proper to observe that myocarditis is rare, and that it is ordinarily local- ized and incapable of exercising any considerable influence upon the contractions of the heart. By a singular coincidence in the cases in which it has been found on autopsy, the clots were absent or without vital characteristics ; and no cardiac symptoms had been noticed before death. If myocarditis is a factor in the mechanism of enfeeblement and arrest of the heart, it must, therefore, elucidate all the cases. The only explanation which can be offered is, by exclusion, diplitheritic paralysis. Thus, as I shall show in treating of this important perturbation of the nervous system, a great number of authors have described, supporting themselves by authentic observations, the cardiac disturbances which accompany it. These symptoms are identical with those which are given as arising from cardiac thombosis; moreover, they appear from the tenth to the twenty-first day, at the period when diphthe- ritic paralysis prevails. The action of paralysis in the patho- genesis of cardiac symptoms attributed to thrombosis, appears, therefore, very plausible. These conditions, so favorable and so frequent, especially so far as the second is concerned, viz., myocarditis and paralysis of the cardiac fibres, render the for- mation of clots at a date just before death not so common as one might think. This rarity is anatomically demonstrated. In the same cases in which we might admit that coagulation GENERAL DISCRIPTION OF DIPHTHERIA. l6l is formed during life we must recognize that it has been purely passive. Convulsions. Eclamptic paroxysms are very rare symptoms in diphtheria. They generally appear to have no special relation to diphthe- ria, particularly when they supervene at the beginning of the disease. Convulsions are anything but rare in children, par- ticularly at the initial period of acute diseases, whatever they may be. Physicians who are acquainted with infantile pa- thology understand this peculiarity. They appear, therefore, sometimes at the beginning of either benign or malignant diphtheria, as in all other diseases ; they have no influence upon the prognosis. Others manifest themselves after trache- otomy ; I shall speak of them at the same time as of the se- quences of this operation. Diphtheritic Paralysis. The paralytic phenomena which appear during the course of diphtheria or during convalescence therefrom have been recognized or suspected from the remotest antiquity. Hippo- crates in Book VI. of Epidemics, Coelius Aurelianus, Marcus Aurelius Severinus (1641), and Bellini at about the same pe- riod, gave vague hints of it. They are found clearly pointed out in the writings of Nicolas Lepois (1580), of Ghisi (1747), of Miguel Heredia (1690), of Chomel (1749), of Marteau de Grandvilliers (1767), of Samuel Bard (1784), of Jurine (1809) of Albers of Bremen (1809), of Bretonneau and of Rilliet. The question was not thoroughly investigated until after the disser- tation of M. Maingault. The impulse given at that time gave rise to numerous works of which the principal ones were those of Roger, See, Trousseau, Gubler, Colin, Charcot and Vul- pian, Lallement, Billard, Perate, Tavignot, Foucher, Hermann Weber, Ormerod, Brenner, Tille, Ravn, David Easton, Kraft Ebing, Oertel, Rosenthal, Greenhow, Wade, Paterson, Roger and Peter, Lorain and Lepine, Bailly, Mansord and Duchenne. Paralytic troubles appear most commonly during convales- cence, and from eight to fifteen days after recovery, that 1 62 DIPHTHERIA, CROUP AND TRACHEOTOMY. limit perhaps extending to thirty days. They may show themselves sooner, in which case they are manifest during the local development of diphtheria, from the fifth to the eleventh day from its onset, and sometimes even from the second or third day. If they appear at a late period, when they do appear their manifestations in the several systems develop without inter- ruption. If, on the contrary, they come early, it is not rare to see them ceasing after a short time to recur at a period more or less remote and under another form. Their onset may be free from general symptoms, yet it is quite often announced by fever or by the appearance or re- currence of albuminuria. When, during convalescence from diphtheria, the thermic curve is observed to suddenly rise again, paralysis is one of the imminent complications. Every apparatus is subject to diphtheritic paralysis. Noth- ing is more capricious, more unforeseen, than its extension, or than the variations in its distribution. Though often limited to a single organ, it may involve one or several of them. Finally, in other cases it extends to the whole organism. Its place of election and the site to which it is usually lim- ited is the velum palati to which should be added the upper portion of the larynx. The latter region is often the only one affected, and that almost always before the velum palati ; the patient coughs at the instant of deglutition because of con- tact of food with the mucous membrane of the laiynx. When tracheotomy has been performed particles of food pass through the wound or the canula. After a few days the cough takes on a dull stifled sound. Paralysis of the velum palati is marked at first by a nasal intonation — speech is slow, articulation of sounds is difficult, and more or less loud snoring is heard during sleep. At the same time deglutition becomes much embarrassed. Drinks or liquid foods are expelled through the nose. Solid substances only can pass, and that when they form a bolus of some size. GENERAL DISCRIPTION OF DIPHTHERIA. 163 When the pharynx is affected at the same time, swallowing of food becomes far more difficult ; it engages at times in the air-passages at the risk of causing the grave accident of suffo- cation. Solid food may also be rejected. To the danger of suffocation is added that of inanition. The rejection of food soon inspires a real horror of taking nourish- ment. If the mouth of the patient is opened it is seen that the velum palati does not retain its usual position ; it is mo- tionless and pendant ; its insensibility is evident, and tickling the mucous membrane with a feather, or even pricking it with a sharp instrument does not provoke a single reflex movement. At the same time, with the velum palati, the tongue, the lips and the cheeks may be enfeebled. The patient is then unable to inflate the cheeks, to whistle, to blow out a candle, to gargle, or to suck. The face is motionless, the lips allow the saliva to dribble out, and the tongue is moved with diffi- culty. Sometimes it hangs out of the mouth and is the seat of vibratory movements. From that condition arise troubles in phonation which I shall review further on. Paralysis may be limited to the fauces, but often extends to other apparatus, and may become general. As it affects sensibility and the organs of sensation as well as motion, I shall describe separately the difficulties which it brings to these diverse functions. Movement may be enfeebled in all or a portion of the mem- bers. In the first case the lower limbs are first attacked, while* in the second they alone are usually affected. The patient feels a tingling and a sense of weight in the legs ; walking is difficult; ascent or descent of stairs is painful. Standing up- right necessitates great effort and becomes impossible ; htretched upon his couch, the patient at length no longer has power to lift his limbs. Rarely does the paralysis remain localized in the lower limbs ; on the contrary it tends to involve the upper extrem- ities also. The arms are moved with difficulty ; grasping ob- jects a little heavy becomes impossible, and tremors affect the limbs. The muscular force, measured by the dynamometer. 164 DIPHTHERIA, CROUP AND TRACHEOTOMY. descends from the normal, which is from 50 to 55 kilo- grammes, to 20 kilogrammes ; and it even falls to 10. Soon the patient becomes absolutely unable to use his arms, and must be fed by an attendant. He can neither sit nor turn himself in his bed. That is not all. The muscles of the neck are affected in their turn as well as those of the face ; the head, unsupported, falls upon the chest, and rolls over at the least impulse. That attitude, joined to the immobility of the face, stamps the patient with an expression of hebetude which is most striking. The muscles of the trunk, the intercostals and the diaphragm are also attacked. The thorax remains immovable ; the ab- domen is depressed or remains relaxed during inspiration in- stead of dilating. The expiratory muscles also sometimes be- come paretic. From this muscular debility there result imper- fect functional action of the lungs, insufficient haematosis and a passive congestion of tlie organs. The respiration is panting, the patient experiences a feeling as of a foreign body in the chest, bronchial mucus accumulates, cyanosis appears in the extremities and on the mucous surfaces, and asphyxia becomes imminent. Post-mortem examination shows that to this con- dition there corresponds a congestion of the lung which may extend as far as splenization. I have also recognized in these cases pulmonary infarctions, and sub-pleural, sub-pericardial and sub-arachnoid ecchymoses. We can conceive the gravity which the slightest lesion may assume when it develops in a lung so little able to resist. The heart itself does not escape paralysis. Perate, Main- gault, Bissel, Hermann Weber, Billard, Duchenne, and Bailly have described the cardiac troubles which attract attention in patients attacked with diphtheritic paralysis, viz., praecordial distress, small, slow and irregular pulse, becoming at times thready and imperceptible. Billard, who was able to observe in his own person this whole series of symptoms, has given us his sensations : "At the moment when sensation began to return to the limbs, cardiac palpitation v/ith intermittence and a sense of suffocation, made GENERAL DSJKIPTION OF DIPHTHERIA. 165 me fear cardiac paralysis and a complete arrest of the circula- tion." Though usually very serious, these complications may be cured, as the case of Billard and others have proved. Un- fortunately death is the usual result. It is brought on by the progress of the cardiac debility which may extend over a pe- riod of perhaps two days, or it may seize the patient suddenly and carry him off in syncope. Even in those cases where it comes on slowly death never results from asphyxia, but al- ways from syncope. I have described this condition in detail in the chapter on cardiac thrombosis. All these phenomena, in which we recognize the symptoms of cardiac paresis, show that the heart may be attacked with paralysis as well as the pharjMix, the intestines, or the eyes. In the larger number of cases the debility affects the heart after other organs, or at the same time with them. It is, in some sense, the final limit of the extension of the paralysis. In certain instances observed by Perate and Bissell, to which must be added others by Beau and Gerlier, the heart alone was paralyzed. If this fact seem at first surprising we should re- member that paralysis of single organs is not rare in diphthe- ria. Do we not often see the palate alone affected? If this fact, by virtue of its frequency, does not seem conclusive enough, we can adduce others cited by Loyaute and Roger, in which paralysis has attacked exclusively regions usually ex- empt, such as the eye, the rectum and the trunk. Paresis limited to the heart has, moreover, some analogies. There is no serious reason to urge against what is believed to be the cause of the cardiac complications of diphtheria especially as those disorders are observed during convales- cence, a period peculiarly subject to diphtheritic paralysis. It is rational to attribute them to the influence of a patholoo-ical fact admitted on all hands, rather than to cardiac thrombosis the fact of which is questionable, and which is at least very rare in this connection. The rectum and the sphincter ani are quite frequently at- tacked. We then observe constipation, to which succeeds in- continence of fecal matters. Debility of the abdominal mus- cles is another frequent cause of constipation. l66 DIPHTHERIA, CROUP AND TRACHEOTOMY, When the paralysis affects the bladder there are dysuria and tenesmus. The cavity of the viscus becomes considerably di- lated, and micturition comes on only from over-distention. When it affects the sphincter there is, on the contrary, incon- tinence. The genital functions often experience the consequences of diphtheria. Complications of these organs are as frequent as those I have just enumerated are rare, and are the result of generalized paralyses. They are observed even in light paral- yses, and in those that are limited to the fauces. The diffi- culty consists in impotence and in complete loss of virile power. Is anything analogous experienced by women ? If so the fact has not been noted. The paralysis is usually symmetrical. Very rarely does it assume a hemiplegic form. I have met, for my part, one case of right hemiplegia. Even under these circumstances it is ex- ceptional that the hemiplegia is absolute, that is to say, that the side which seems well is not weakened to a certain degree. Some cases of facial hemiplegia have been noted. The changes in motility which are met with in diphtheria do not, according to all authors, belong to true paralysis. Hermann Weber observes, moreover, an incoordination ex- pressed by choreic movements. According to Brenner, the affections of motility are of three kinds: I. True ataxia, caused probably by a lesion of a centre of coordination of movement. 2. Ataxic paralysis character- ized by paresis of certain groups of muscles of the extremities and by complete paralysis of other groups. 3. True paralysis which may attack equally all the muscles of the extremities and which may be complete or incomplete. The inequality of the paralysis in the different groups of muscles can, in fact, give rise to choreic movements. The action of electricity on this form of paralysis has been carefully studied. It has been established that the faradic contractility is lessened while the galvanic contractility is notably increased. The affections of motility are usually steadfast. Yet, they GENERAL DISCRIPTION OF DIPHTHERIA. I67 may be subject to curious variations. The paralytic symptons alternate with one another. They appear in healthy members on one day — to disappear the next. Remissions and exacer- bations succeed each other without known cause, and give rise to a perpetual come-and-go. This instability has attracted a l.Mge number of authors (Gubler, Trousseau, Billard, David Easton, Weber, etc.). In its return motility follows the same order as in its de- parture. It reappears first in the lower limbs and afterwards in the upper extremities, just as after a cerebral lesion. Sensation passes through the same vicissitudes. It is either obtunded or abolished. We can verify and measure its im- pairment by means of Weber's compasses. Anaesthesia is at times accompanied by analgesia. It may occupy the entire cutaneous surface, but is most commonly distributed like hys- terical paralysis in isolated tracts. It precedes the paresis, and likewise begins at the lower limbs. Sometimes the upper extremities are alone affected. According to Hermann Weber, it should not extend above the elbows or the knees. This localization is quite often ob- served, but it will not do to make it a general law, as it admits of numerous exceptions. Its onset is announced by numbness and tingling, proceed- ing from the toes up along the limbs, and a certain sensation of coldness in the feet. When it attacks the lower limbs the patient experiences symptoms of plantar anaesthesia. He does not feel the ground. It seems to him to sink under his feet. He cannot preserve his balance except by keeping his eyes open. Walking in the dark is impossible. When it attacks the hands small ob- iects cannot be perceived. The tactile sensibility of the tongue, the lips and the cheeks is diminished. Exceptionally the skin is hyperaesthetic. There is found also, at times, a certain tenderness on pressure along the spine. The organs of special sense are not spared. The eyes often become weak. Dr . Loyaute observed in one case complete, though transient, blindness. The visual l68 DIPHTHERIA, CROUP AND TRACHEOTOMY. troubles are oftenest limited to amblyopia. Presbyopia is fre- quent, while myopia, on the contrary, is extremely rare. Trousseau, however, speaks of a patient in whom myopia fol- lowed presbyobia. The pupils are dilated and immovable. When one eye only is affected there is diplopia and inequality of the pupils. No lesion of the media of the eye or of the retina has been proven. It is probable, and it is the opinion of opthalmolo- gists like FoUin, Graefe, Bonders and Tavignot, that the weakness of sight should be attributed to a defect of accom- modation, to paralysis of the muscles of accommodation, and perhaps to a certain degree of insensibility of the retina as well. We note, however, that Bouchut speaks of lesions of the retina which he recognized with the ophthalmoscope. In a recent thesis Perchant took the same ground. In certain cases of amblyopia, not in all, lesions analogous to those of toxic amaurosis will be met. They consist of a neuritis or a neuro-retinitis more or less intense, like that which is observed in amaurosis from tobacco, from alcohol, etc. The muscles of the eyeball and of the lids are not always exempt. Internal or external strabismus, of one or both eyes, in the latter case almost always convergent, and drooping of the upper eyelid are the result of paralysis of these muscles. The senses of hearings of taste, of smell are much more rarely affected. Impairment of the power of speech is sometimes quite com- plete. The speech may be slow, labored, or confused. Some have trouble in pronouncing the labials, others cannot articu- late a single consonant. Some pronounce certain words with difficulty. They read quite fluently, but when they come to those words they stop, stammer, and sometimes cannot over- come the obstacle. Others proceed after more or less hesita- tion. Certain patients show a stammering which gives their condition a kind of resemblance to progressive general paral- ysis. There may be complete aphonia, as Billard experi- enced. The paralysis of the muscles of the tongue, of the pharynx, GENERAL DISCRIPTION OF DIPHTHERIA. 169 and of the velum palati explains the impairment of the power of speech. The innervation of the tongue would seem to be compromised, and we might be tempted to refer these symp- toms to a lesion of the medulla. But that lesion has never been found. I shall have to fall back upon the interpretation which is wont to be given to these facts. The intelligence remains intact. If it sometimes seems al- tered it is never wholly abolished. It never reaches that de- gree of weakness which the dull aspect of the patient would seem to indicate, when he is seen with his head falling upon his chest, his tongue lolling, and the saliva drooling from his lips. He understands and answers to the point. General symptoms are rare. They are wholly absent in the simpler forms, except at the onset, which is announced at times by a little fever, or by the increase of albuminuria, if that exist. But when paralysis becomes general, we are often confronted by grave symptoms, such as excessive prostration, or continual tossing, vomiting, convulsions, coma and diar- rhoea, all the signs, in short, of ataxy and asthenia, or of a pro- found cachexia. The tenniiiation is usually in recovery. Death, however, supervenes under many circumstances. Inanition is one of the most frequent causes of a fatal re- sult. The difficulty of introducing food, the fear of suffoca- tion, the profound disgust inspired by the rejection of sub- stances through the nose, speedily threaten the patient with death by starvation unless the oesophageal tube is early em- ployed. Yet this means does not always insure the result hoped for, and the patient often succumbs to the progress of cachexia. When paralysis is generalized, when it affects the muscles of the trunk, causing to a greater or less degree an incom- plete functional activity of the lungs, it may be followed by death from asphyxia. Intercurrent diseases, such as simple attacks of bronchitis, may carry off the patient in a like manner. Sudden death is one of the accidents to be feared. It is produced in several ways: I/O DIPHTHERIA, CROUP AND TRACHEOTOMY. 1, By paralysis of the larynx, when a bolus of food, badly guided by the pharynx and not stopped by the larynx, both being paralyzed, enters the air-passages; it then causes suffo- catioK. The cases cited by Gillette, by Tardieu and by Peter have shown that this is an actual cause of death. Paralysis of the larynx, moreover, has produced death by another method. Symptoms such as aphonia, muffled cough and sighing respiration denote profound disorder affecting the play of the parts that form the larynx. Debility of the in- spiratory muscles of the larynx can obtain, as well as of the inspiratory muscles of the thorax or ol the neck. If it remain partial, respiration can go on only imperfectly, and the dis- turbance of haematosis slowly increases ; but when it becomes complete, suffocation is the immediate result. Gubler has shown the possibility of laryngeal paralysis. Aubrun, Perrin and Plouviez cite two cases of sudden death which they refer to that cause. Two cases of sudden death are found in the the- sis of Garnier, which he attributes to the formation of heart clot. They occurred in children whose fauces were paralyzed, who suddenly developed aphonia, became cyanotic, and died in a few minutes. As death at the heart gives rise in similar cases to syncope, and not to asphyxia, to pallor, and not to cyanosis, it is very probable that paralysis of the larynx was the real cause of death, as the aphonia further proves. 2. By faralysis of the heart. I have shown the influence of diphtheritic paralysis upon the heart. I have described the terrible accidents that result therefrom, and have proved that the cardiac disorders, attributed to thrombosis, may be re- ferred to this cause; among others, to-wit, sudden death. It is in the midst of convalescence that these accidents appear. The patient falls quickly into syncope while he is playing, or making some exertion, or a simple movement, and dies in a moment. In other cases he is suddenly seized with praecor- dial distress and with dyspnoea. The pulse becomes small, and shows a manifest retardation and irregularity till death comes on at a time varying from a few minutes to a few hours, in consequence of syncope or by a gradual failure of the GENERAL DISCRIPTION OF DIPHTHERIA. I7I pulse. With a patient whose pulse had been examined before the onset of grave complications irregularities were noted for several days before. In some very rare cases diphtheritic paralysis may ^,roduce gangrene of the skin. One patient with generalized paralysis presented gangrenous spots upon his wrists and lower limbs. The ^^?/r.y<f of diphtheritic paralysis is quite uniform. Its lo- calizations are linked together in an order which is usually followed. But if the chain is regularly formed, the number of links varies. In a given case the paralysis may develop all its manifestations, or only present a number of them, which it is impossible to determine in advance. Beginning usually in the fauces and the larynx, it is oftenest arrested in those parts. From thence, according to certain authors, it will pass at once to the eyes. In several cases I have seen affairs progress otherwise. The eyes were attacked after the extremities. It next reaches the lower limbs, then the upper extremities, the trunk and the neck. It invades, finally, the rectum, the blad- der, and, last of all, the organs of special sense. Anaesthesia almost always precedes the muscular debility. Recovery begins at the lower limbs and reaches success- ively the fauces, the upper extremities, the trunk, the viscera and the eye. The organs first paralyzed are almost always the first to recover their functions. However regular the course of diphtheritic paralysis may_ be, it offers numerous exceptions. Not a sign exists that en- ables us to see that any given organ will be paralyzed. From the fact that the legs are affected we cannot conclude that the arms will be, and from the fact that the muscles of the trunk are paretic we cannot infer the relaxation of the sphincters or troubles of vision. Moreover, the localizations of the paral- ysis present, at times, a remarkable instability, rapid alterna- tions, remissions and exacerbations that disconcert all prog- nostication. The interval that separates paralysis of the velum palati from that of other regions may be very short, or even be wholly wanting. The paralysis may be general at the onset. 1/2 DIPHTHERIA, CROUP AND TRACIlEOl OMY or it may affect the limbs and every apparatus while avoiding the velum palati and the pharynx, even where there has been pharyngitis. A small number of organs may be attacked singly. Cer- tain cases have been seen where the legs and the forearms were alone affected. In others it was the lips, the sacro-lum- bar muscles and the lower limbs. In one patient total blind- ness was the only symptom of paralysis. In some other cases the paralysis was confined to the muscles of the trunk and to the diaphragm or to the hands, feet and to the sphincter ani. Roger cites an instance of paralysis located in the sphincter ani. There are also cases in which it affects the limbs before at- tacking the pharynx and the tongue. I have seen it begin in the upper extremities, reach the velum palati and the pharynx and then attack the lower limbs. Finally it has been observed, in the absence of pharyngitis, in diphtheria of the skin, for example, that peculiarity not pre- venting the velum palati being attacked. I have seen it in a child with diphtheria of the skin confined to the region about the umbilicus, and in another who had simply diphtheria of the auricle. The duration of diphtheritic paralysis cannot be precisely fixed. Sometimes it is very brief, A\]ien it is limited to the larynx or the fauces, and lasts only from seven to nine days. But even under these conditions it often lasts longer and does not terminate before fifteen or eighteen days. When it becomes general, or when it affects the upper ex- tremities, the eyes, the face or the viscera it is not rare to see it last for a period of from three to four months. Exception- ally it persists from that to six or eight months. Duclos de Foretz, however, cited by Maingault, reports a case of paral- ysis of twenty months standing. Morriseau records the in- stance of a little girl who was attacked with diphtheritic an- gina set. 8 years, and still retained, nine years later, a slight nasal intonation. One of the patients of Roger presented persistent aphonia. Finally, Prosper Faucher has published a notice of a case of chronic diphtheritic paralysis. GENERAL DISCRIPTJON OF DIPHTHERIA. I73 What is the rc\dit\w q frequency of this paralysis? Every au- thor who has tried to solve this question has accounted for the difficulties which it presents. Many causes, in fact, prevent the ascertaining of paralytic complications. Many patients die quickly, without giving the paralysis time to disappear; others when scarcely entered upon convalescence are with- draw^n from observation before the onset of the paralysis. It is certain, then, that statistics give to the latter less frequency .han is really the case. They should not, therefore, be con- sulted, except with a view of approximate estimate. Roger, in 210 cases of diphtheria, noted thirty-six cases of paralysis. From a table compiled by Mansord it appears that it was noted by Lemaire, of Pont-Audemer, twelve times in eighteen cases ; by Hermann Weber, sixteen times in 190 cases; by Bouillon Lagrange, four times in fifty; by Moynier, eight times in twenty-nine ; by Barascut, three times in nine- teen; by Sellerier, three times in 160, and Monckton, of Maid- stone, nine times in 300 cases. In comparing these statistics we can see what an enormous discrepancy is manifest among them. Thus, while according to Lemaire the proportion is 66 per cent, that is to say, that the majority of the patients have exhibited some diphtheritic paralysis, it descends, according to Monckton, to 1.15 per cent. It seems unlikely that in this latter statement some cases of paralysis did not go unrecognized. In 1,382 cases of diphtheria I have met paralysis 155 times, which gives a pro- portion of II per cent, or one in nine, consequently a little less than that of Roger, which is one in six. There are enough materials to allow the conclusion, in a general way, that paralysis frequently accompanies or follows diphtheria. SequelcE. — Diphtheritic paralysis does not leave serious con- sequences behind it. Little by little the organs resume their motility and their sensation, whether general or special. It is only under exceptional circumstances that its influence has been strong enough to alter the structure of the organs it affected. Kraft Ebing cites a case in which a certain number of muscles remained atrophied for a long time. 1/4 DIPHTHERIA, CROUP AND TRACHEOTOMY. Larue, of Laval, records his observation of a little patient aet. 4 years, who was attacked subsequent to diphtheritic pharyngitis, with paraplegia, without paralysis of the velum palati or of any other organ. The extensor muscles of the leg and of the thigh atrophied. The flexors preserved their contractility, and brought the leg into complete flexion upon the thigh and the latter into extreme flexion upon the pelvis, so that the knees approximated the shoulders. There was at the same time considerable distance between the knees. It was necessary to employ forced extension and special appa- ratus to restore the limb to its normal position. This treat- ment resulted in cure. Prognosis. — Diphtheritic paralysis of itself, when limited to the fauces or to a small number of organs, presents but little gravity. Recovery is the rule, outside of very rare exceptions, which should be charged to suffocation by the entrance of food into the air-passages and to inanition. On the contrary, when it is general, prognosis becomes more grave. Then, indeed, it affects the muscles of respira- tion and the heart. Death is brought on by asphyxia or by syncope, by the natural progress of paralysis, or as a result of a pulmonary complication, often very slight. I have, nevertheless, seen a patient suffering from paralysis of the muscles of the thorax recover in spite of an intercur- rent pleurisy. In the absence of any complication death re- sults in severe cases from defective alimentation, from a pro- found cachexia, or from convulsions. Etiology. — Every form, every localization of diphtheria, the most simple as well as the most grave, the most extensive as well as the most limited ; whether it attacks the fauces or an- other part of the body ; whether albuminuria have been present or absent, may be followed by paralysis. That point settled, if we consider, on the other hand, the frequency of paralysis after diphtheria, we have a right to ask if that complication is indeed a manifestation of diphtheria, and if it has special features that distinguish it from paralysis following other acute diseases? These questions can be reduced to one: Is there a diphtheritic paralysis f GENERAL DISCRIPTION OF DIPHTHERIA. I75 The afifirmative has been upheld by Trousseau, by Main- gault and by See. According to these authors the paralysis is due to the poisoning of the system by the diphtheritic virus, to the disturbance experienced by the nervous system, a dis- turbance like that produced by poisoning from lead, bisul- phide of carbon, carbonic oxide, and from certain general dis- eases, such as typhoid fever, typhus fever, cholera, small-pox, and other eruptive fevers. Like these paralyses, that of diph- theria has some symptoms and a course peculiar to itself, which make it a distinct species. Gubler has undertaken to disprove this theory. Gathering a certain number of observations in which paralyses had been noted as following simple pharyngitis, pneumonia, pleurisy, typhoid fever, etc., some of which paralyses showed a more or less marked resemblance to that of diphtheria, he concludes therefrom that there is not a special diphtheritic paralysis, and that the disturbances of motility and of sensibility which fol- low diphtheria should be classed with those that follow acute diseases in general, and that they arise from debility of the or- ganism, or, to use Gubler's expression, asthenia, resulting from the intensity of the fever, from prolonged low diet, from loss of blood, from albuminuria, and from all other causes of or- ganic decline. Moreover, according to the same author, the importance of diphtheria has been over-estimated to the neg- lect of simple pharyngitis, by attributing to the former paral- ysis resulting from herpetic pharyngitis. The learned professor has rendered service to science by drawing attention to a class of paralyses but little studied. Paralysis of the velum palati, resulting from simple pharyn- gitis, seems well established, but it is less common than one would think, a priori. In fact, the herpetic pharyngitis, which Gubler classes among the forms of simple pharyngitis, is but too often, as I shall show later, a form of diphtheria. Moreover, we must further discriminate between cases of pharyngitis without exudation. Without wishing to give too much importance to the slightly paradoxical expression: Diphtheria without diphtheria {diphtherie sans diphtherie), it is 1/6 DIPHTHERIA, CROUP AND TRACHEOTOMY. incontestable that in times of epidemic we meet, side by side, and in the same surroundings, with severe and well marked cases, other very benign cases which, as they were engen- dered by the former, or transmit by contagion (a severe form of the disease), evidently come from the same source. In these cases the local symptoms are light, almost impercepti- ble, and are reduced to a simple redness; the false membrane is slight or absent ; the disease is defaced [friiste), to use Trousseau's expression, and behaves as scarlatina, typhoid fe- ver, yellow fever, etc., often do. But just as in those forms of scarlatina that appear so light we may all at once see compli- cations like albuminuria and anasarca become prominent, revealing the true character of the disease ; so diphtheria, though scarcely discernible in the fauces, may make itself known by secondary symptoms, such as albuminuria and paralysis. Paralysis following herpetic pharyngitis and pharyngitis without false membrane should not, therefore, be taken as ir- refutable proof of the existence of paralysis unconnected with diphtheria. It is very probable that many of these cases are in fact due to diphtheria. * This does not mean that simple pharyngitis, resulting from a cold, in the absence of any epidemic, without any source of contagion, may not bring in its train a paralysis of the velum palati and of the pharynx. The fact has been confirmed by credible observers. It should be admitted. But still it is the exception while paralysis following diphtheria is frequently observed. The importance of this discovery would be insignificant if we had only to point out paralysis of the fauces as following simple pharyngitis. The violence of the inflammation, its propagation in the submucous muscular layers would explain it, as Zenker, Hayem and others have shown, but in very rare cases these nervous troubles have been seen to extend, to at- tack several apparatus, and to take on a certaia resemblance to diphtheritic paralysis. Some other morbid states, as typhoid fever, small-pox, erysipelas, pleurisy, etc., have, exceptionally, GENERAL DISCRIPTION OF DIPHTHERIA. 177 it is true, given rise to analogous observations. The circum- stances under which these paralyses are presented justify the asthenic origin to which Gubler refers them. They are al- most always met after very severe and very protracted illness, during which the patient has been subjected to a restricted diet and to a reducing treatment. Those of diphtheria are developed, on the contrary, in entirely different connections. Far from choosing severe and protracted cases, it often fixes upon benign cases, in which the fever has been slight and brief, and following which the patients do not seem at all cachectic. Moreover, by reason of the character of the diph- theria, undoubtedly obscure at times, we may ask if its inter- vention has not been mistaken in many instances. Even admitting that, besides diphtheria, certain acute dis- eases may leave behind them acute paralytic troubles that con- form quite closely to the type of post-diphtheritic paralysis, we must agree that compared with the former, the latter pre- sent a crushing numerical superiority. From this frequency, from this very peculiar stamp which paralysis following diphtheria always preserves, from this great difference in the conditions that preside at the onset of these paralyses according as they belong to diphtheria or to other acute diseases, we can conclude that diphtheritic infection has an action on the nervous system which is probably special, which, in any event, is infinitely greater than that of any other acute disease, and that the paralytic complications which it de- termines deserve to be grouped under the name of diphtheritic paralysis. Pathogenesis. — Many theories have been proposed to explain the mode of the production of diphtheritic paralysis. Let us first examine what has been said in explanation of the paral- ysis of the palate. The first thought of observers has been to connect it with inflammation of the mucous membrane ; that propagation of the process to the muscular layers, and to the subjacent nerve termini, abolished the functions of these organs. The works of Zenker, Hayem, Liouville, Charcot and Vulpian, and Lorain and Lepine have, to a certain degree, 178 DIPHTHERIA, CROUP AND TRACHEOTOMY. given sanction to this hypothesis. These authors have proved the alteration of the nerve termini in certain cases of paralysis of the palate. But, while according a certain role to the in- flammation, we must be careful not to make it too important ; this reserve would be needless did paralysis always follow diph- theritic pharyngitis having a violent inflammatory course. But such is not at all the case. Not only is this kind of pharyn- gitis not always followed by paralysis, but the latter is ob- served after pharyngitis of very slight intensity. Moreover, it has been noted in cases wh^re pharyngitis did not exist, where the diphtheria occupied no locality but the skin. Besides, it the inflammatory element had any real importance, paralysis should often follow simple pharyngitis, in which the inflamma- tory condition is often very intense, much more so than in diphtheritic pharyngitis. But how rarely is paralysis produced under these circumstances compared with that which follows diphtheria. We must admit, then, that diphtheria has a spe- cial power to engender paralysis. How is this power exercised ? As far as concerns the paresis of the palate after pharyngitis, the interpretation is easily presented. The lesions of the ends of the palatine nerves described by Charcot and Vulpian, found also by Lorain and Lepine and several German authors, give the key to these phenomena. I have described these les- ions in the pathological anatomy and I will return to them later. The paralysis of the velum palati seems to be pro- duced by a peripheral alteration of the palatine nerves, an al- teration which results from the action of diphtheritic virus upon the nervous system. The generalization of the paralysis is more difficult to ex- plain. The theories, moreover, are more numerous. Gubler divides these paralytic difficulties into two classes, holding that some are due to the propagation ot lesions that exist in the pharynx along other nerves; and that the others are of asthenic character. The first class are those of sight, of taste, of hear- ing, paralysis of the tongue, the lips, the face, the muscles of the neck, respiratory and cardiac disorders. The proximity of the superior cervical ganglion permits the visual troubles to GENERAL DISCRIPTION" OF DIPHTHERIA. 1 79 be attributed to the great sympathetic. The anastomoses of the great sympathetic with the facial and the trigeminal, Meckel's ganglion, the origin of the palatine nerves, would ex- plain the weakening of taste and hearing, and the paralysis of the lips and face. Moreover, we find beside the pharynx, the trunks of the glosso-pharyngeals, of the pneumogastric and of the great sympathetic, the roots of the cervical plexus, the pharyngeal plexus into which enter branches from the pneumo- gastric, the glosso-pharyngeal and the great sympathetic. The propagation of the pharyngeal inflammation to these very important organs would explain the paralysis of the neck, the insensibility of the tongue, the cardiac and pulmonary troub- les. Nothing could be more ingenious than this physiological mechanism. It would be all very well if the pharyngitis or the pharyngeal paralysis were a condition necessary to the paralysis of other organs. But we know that the latter may exist without having been preceded by either pharyngitis or paralysis of the palate ; still more, paralysis of the palate sometimes follows a diphtheria which has not touched the fauces. And further, we should still ask why these re- flexions along neighboring nerves are so rare in simple inflammatory pharyngitis even when very intense, and why they should be so common in diphtheria even after such forms as are locally the least marked, while we have seen them absent after the most violent pharyngeal manifestations. We must then admit, here also, that diphtheria has a special action on these paralyses. Does the doctrine of asthenia explain the mechanism of the remote paralyses any better? I think not. Often the pharyngitis which preceded has been very mild, there has been little fever, the thermic curve has shown but an insignificant rise, the patient is well nourished, he has been under a tonic regimen, and nothing about him points to asthenia, that is to say, a general exhaustion due to denutrition of the tissues. Hermann Weber makes the same remark. He shows that English physicians employ largely in the treatment of diph- theria, wine, tonics and alimentation, which does not prevent l8o niPHTHERIA, CROUP AND TRACHEOTOMY. their having their full quota of secondary paralyses even after evidently mild cases. I do not pretend that asthenia is of no effect in any case. Its action is too evident in many cases of diphtheria for one to think of denying it, but it should be considered solely as a secondary cause. Would a lesion of the nerve centres, of the medulla ob- longata in particular, explain it better? The medulla, presid- ing as it does, over deglutition, facial expression, mastication, speech, cardiac and respiratory movements, has been scrupu- lously examined as to its condition. It has never been found altered more than other portions of the nerve centres. More- over, it would be hard to reconcile the existence of a lesion of the cerebrum or medulla with the changeability of symp- toms which often characterizes diphtheritic paralysis. Several authors, among others Brown-Sequard, See and Colin, have sought to class these paralytic phenomena in the category of reflex paralyses. In support of this hypothesis, Colin lays hold of a fact al- ready cited by Blache, relating to a child that pricked itself in the soft palate with a crochet needle. A local paralysis supervened, followed by general paralysis, resembling diph- theritic paralysis. Reflex action is evident in this case, but what correspondence can be found between this and a diph- theritic pharyngitis and its subsequent paralysis ? None, what- ever. If paralysis should supervene during the course of an inflammation of the fauces I would have no hesitation in re- garding it as reflex. But at what period do we see the paral- ysis of diphtheria appearing? During convalescence, from eight to fifteen, and even thirty days after recovery. How, in such a case, can a relation be established between the pharyn- gitis and the paralysis? Furthermore, the reflex theory is untenable, except in case of pharyngitis. Colin, indeed, con- siders the paralysis of the palate as a necessary intermediate between the pharyngitis and the generalization of the amyo- sthenia. But that " necessary intermediate " is wanting in a certain number of cases of pharyngitis followed by general paralysis. GENERAL DISCRIPTION OF DIPHTHERIA. l8l Hermann Weber has given out an ingenious variation of the reflex theory. Likening that which goes on in diphtheria to what is observed in traumatic tetanus, he reminds us that in the latter disease functional troubles can be produced in the nerve centres, consequent upon peripheral lesions, even after recovery from those lesions. It would be possible for diph- theria to show a like peculiarity, " Diphtheria and traumatic tetanus have this in common : i. Between the peripheral le- sion or modification and the onset of the central disturbance there elapses a variable period of time. 2. As wounds do not result in tetanus except in rare cases, so the difficulties in question follow only certain cases of diphtheria ; and finally, 3. Just as the smallest wounds may produce tetanus, so the mildest cases of diphtheria may cause subsequent nervous difficulties." This explanation, which the author gives, moreover, with all caution, explains no better than the former ones, those cases of paralysis unpreceded by pharyngitis. Neither should albuminuria be assigned as the cause. Trousseau has taken pains to show that the difficulties of sight following diphtheria were not dependent upon albuminuria. Diphtheritic paralysis is not met with in patients only that have, or have had albuminuria. Further, there is nothing in common, as the ophthalmoscope has shown, between the diphtheritic and albuminuric defects of vision. The preceding critical examination leads to the conc'usion that diphtheritic paralysis should be attributed neither to the excess of inflammation in the diseased part nor to its re- flection along the nerves of neighboring regions ; and that it is accounted for neither by asthenia, nor by a central lesion, nor by reflex action. If it be not referable to any of these causes, nothing further remains but to regard it as a peripheral paralysis. This view- can be supported by several proofs. They are : 1. The course of the paralysis which always begins at the periphery. 2. The results of examination by electricity. The muscular 1 82 DIPHTHERIA, CROUP AND TRACHEOTOMY. contractility is notably increased under the influence of gal- vanism, while it is abolished or considerably diminished when it is examined with the induced current. But this is one of the most valuable signs — we might say the most certain — for recognizing the peripheral origin of a paralysis. Kraft Ebing, Rosenthal, Erb, Duchenne, Legros and Onimus, have suffi- ciently insisted on this point. 3. The lesions of the periphery of the nervous system. While, indeed, observers have found no appreciable lesions in the centres, they have met in the nerve endings alterations which I have described. We will recall them in a few words. In the observation published by Charcot and Vulpian the palatine nerves were altered, certain nerve tubules being with- out myeline, and granular bodies were seen beneath the neuri- lemma. A small number of nerve filaments were wholly de- generated, and the rest partially. The latter were composed of two kinds of filaments ; the medullary substance was healthy in some, in others granular and presenting besides minute fatty granulations disseminated either among the tubes or within the common neurilemma. Lorain and Lepine observed a like case. Biihl has described a nucleolar infiltration which he found not only in the false membrane and in the subjacent mucous membrane, but also in the healthy mucous membranes, and in the roots and sheaths of the nerves; whence the paralysis. Oertel(see Path. Anat., p. 126) has many times met capillary haemorrhages in the sheaths of the nerve roots and in the peripheral nerves. H. Liouville, cited by Bailly, (see Path. Anat., p. 127) found the phrenic nerves affected. Lyden also reports a case (see Path. Anat., p. 126). We may then consider the existence of these lesions of the peripheric nerves as an assured fact, The preceding examples establish it in due form. Although few in number they are none the less of great value. Their rarity is easily explained. For a long time investigations have been guided solely in the direction of the nerve centres. It is only after repeated fail- GENERAL DISCRIPTION OF DIPHTHERIA. I83 ures in this line that they have been directed to the peripheral nerves. We can deduce from the existence of these lesions, together with the absence of central changes, that diphtheritic paral- ysis is produced by the action of the diphtheritic poison upon the nerve endings. Like curare, its toxic principle would seem to have an affinity for that part of the nervous system. From its action there would seem to result a neuritis of the peripheral endings, oftenest affecting the fauces and the larynx exclusively or at the first, but capable of beginning in any other region and of invading successively, and sometimes al- most simultaneously, very extensive surfaces, commencing al- ways in the peripheral expansions. This neuritis may fail to appear, like the pulmonary complications, the albuminuria or the hsemorrhages, as diphtheria does not always present itself with the complete array of its symptoms. CHANGES IN THE URINE. Beside the albuminuria whose frequency would merit a sep- arate place, there should figure certain variations in the quan- tity of the urine, as well as in the proportions of its constitu- ent elements. The urine is often lemon colored and transparent, but we also find it darker, the color of broth, and leaving on cooling an abundant deposit of urates. The oscillations that occur in its quantity and in its compo- sition in certain cases, have been studied by Callandreau Du- fresse. I give a resume of his researches. The quantity of the urine diminishes in proportion to the in- tensity of the fever; when the latter diminishes, the quantity of the urine again increases. During convalescence the ex- cretion is abundant, but when the case is about to end fatall}'-, it is considerably reduced. The density is increased during the early days ; it is repre- sented by 1016, 1018, 1022. It augments during the suffoca- tive period of croup, when it is 1028. Following an operation it diminishes for a short period, stops at from 1009 to 1012; but soon rises to 1017, 1025 or higher. 184 DIPHTHERIA, CROUP AND TRACHEOTOMY. In case of recovery it remains between 1026 and 1028, then falls to the normal. During the first days of convalescence it undergoes a slight increase, 1015 to 1020. In case of death it continues to rise, reaching 1034 or 1038, but generally oscillates about 1033. The curve of density has, therefore, a course parallel with that of temperature, and in the latter part of the disease it rises and falls at the same time. Urea. — The quantity of this substance has been determined only in cases of croup and after operation. Many changes may present themselves. If the diuresis mentioned above comes on after the opera- tion, the urea increases at the same time to 15 or 18 grams, quite a considerable amount compared with the averag^e for that age, which is about 10 grams. Then comes a relative diminution, 14 to 16 grams, during the duration of this fever. If the end is to be fatal the diminution continues and the urea falls to 4, to 3, to I gram. It diminishes while the den- sity augments. In some other cases the urea behaves otherwise. There is no increase after the operation; it remains at from 9 to 12 grams, then increases during the subsequent days up to 12 and 15 grams. If the patient recover it diminishes with the temperature, save a slight increase during the first days of convalescence. If the issue is to be fatal the urea, after a slight increase, di- minishes, as in the preceding case, while the quantity of the urine is diminishing and its density rising. Chlorme. — Callandreau Dufresse measured also the quantity of chlorine excreted in the urine. A simple calculation, based upon equivalents, enables us to obtain the sum total of the chlorides. When there is a slight polyuria after the operation, there is augmentation of the chlorine ; 3, 4 and 5 grams are found. If the termination is to be favorable, there is a slight eleva- tion likewise during convalescence, then a return to the nor- mal. Is not this augmentation, coincident with convales- cence, explained by the change in diet? GENERAL DISCRIPTION OF DIPHTHERIA. 185 If death be near, the chlorine diminishes like the urea. It may fall to 0.30 grams although the child is eating and drink- ing a good deal. These results should not be accepted with- out reserve, as the mode of alimentation may exert a power- ful influence on the amount of chlorine excreted. Sugar. — The analyses made by Fouris to determine the presence of sugar have given only negative results SECONDARY DIPHTHERIA. All that has been so far said of diphtheria presupposes that the disease has attacked a person in health. At the begin- ning of the chapter on diphtheria in general I observed that this disease, when secondary, takes on no new features. It is distinguished from primary diphtheria only by its persistence in assuming infectious or malignant forms and by its well marked tendency toward localization in those organs which are pre-eminently the seat of the primary disease. It will be seen on consulting the etiology that diphtheria is encountered during the course of or following numerous dis- eases. Some of them seem to have a special fecundity in giv- ing rise to diphtheria. These, likewise, are specific diseases : measles, scarlatina, whooping cough. Others predispose to diphtheria only by the deterioration they inflict upon the economy and by the long sojourn they necessitate in sur- roundings where the patient is exposed to contagion. All cachexias and all protracted diseases are of this class. Diphtheria following specific diseases attacks the same lo- calities as they. That which follows measles almost always attacks the air- passages. In ninety-three cases twenty were of the larynx alone, and nineteen of the larynx and fauces together. In these nineteen cases the pharyngitis appeared a goodly num ber of times, after croup, evidently the croup extending up- wards. In the same ninety-three cases four others were of the fauces, the larynx and the nasal fossae, seven were of the lar- ynx and bronchi, three of the fauces, the larynx and the bron- chi. Thirty-four others affected the larynx in company with l86 DIPHTHERIA, CROUP AND TRACHEOTOMY. other organs, such as the nasal fossae, the tongue, the gums, the eyelids, the genitals. In one case only was the diphtheria limited to the nasal fossae. In summing up these different types we see that in eighty-eight cases out of the ninety-three the air-passages were the site of the false membrane. This local disposition is in close relation to that which measles prefers, whose affinity for the same regions is well known. In those that remain, the fauces alone, the skin, the lips, the tongue, and the eyelids, have been the site of the exudate. It is proper also to notice that in all these cases the local manifestations were more or less numerous; measles, of all diseases, being the one that gives rise to generalization of diphtheria. Following scarlatina the aspect is entirely different, just as this exanthem voluntarily respects mucous membranes with the exception of the fauces, the diphtheria which follows scar- latina chiefly threatens the fauces, and if, in certain cases, we encounter it in other places, in the nasal fossae and in the larynx we may be almost sure that the fauces have been its starting point. It is in exceptional cases that the fauces are, or seem to be intact. In thirty-nine cases of scarlatinous diphtheria the fauces remained well only three times ; they were attacked alone fifteen times; together with the larynx, four times; with the nasal fossae, eight times; with the larynx and nasal fossae together, four times ; with the larynx and the bronchi, once ; with the nasal fossae and the lips, once ; with the lips and the skin, once. In two cares the diphtheria was general ; in two others the larynx was alone affected, and in one other membranous coryza was the sole local manifestation of the diphtheria. Whooping cough, whose action is normally felt particularly in the respiratory mucous membrane, gives rise to a diphtheria which, like that of measles, bears principally upon the same regions. In eighteen cases of diphtheria following whooping cough, the respiratory tract was the seat of the false mem- brane fourteen times. Of that number the larynx alone was attacked five times; together with the fauces, five times; with the skin, once ; with the fauces and the lips, once. In one GENERAL DISCRIPTION OF DIPHTHERIA. 1 8/ case the bronchi were invaded at the same time with the nasal fossae and the mouth, and lastly, in another, the nasal fossae were affected at the same time with the fauces. I find but four cases in which the air-passages escaped ; the parts cov- ered by the diphtheria being the fauces alone in two cases ; the fauces and the Hps in one case, and the skin and the lips in the last. As to diphtheria which supervenes as a last phenomenon in protracted diseases, chronic or cachectic, it shows a well- marked tendency toward generalization. It almost always at- tacks simultaneously the larynx, the bronchi, the nasal fossae and the pharynx ; often the skin, the lips, the tongue and the conjunctiva, together or separately. Prognosis. — What I have just shown on the subject of the localization of secondary diphtheria, and above all, of its ten- dency toward generalization, will serve to show the gravity of the prognosis. In 247 cases the issue was fatal in 196; recov- ery was obtained in forty-three ; the result was doubtful in eight cases, which gives about one recovery in five cases. But the principal interest consists in finding out the influ- ence of each particular disease upon the mortality. Measles gave, in 100 cases, eighty-three deaths, fifteen re- coveries and two doubtful cases, i. e., one recovery in about seven cases. Scarlatina gave, in forty-three cases, twenty-two deaths, sev- enteen recoveries and four doubtful cases; i. e., one recovery in two and a half cases. Whooping cough gave, in twenty cases, twelve deaths, six recoveries, and two doubtful cases, i. e., one recovery in three cases. Typhoid fever gave, in eight cases, eight deaths. Tuberculosis gave, in nineteen cases, nineteen deaths. Four cases of diphtheria, coming on in patients sick with pneumonia, all ended in death, as also four others which came on after pleurisy. Two cases following small-pox, two after urticaria, one after cholera, and one after purulent ophthalmia, were all fatal. The l88 DIPHTHERIA, CROUP AND TRACHEOTOMY. various cachexias, such as scrofula, rachitis, chronic diarrhoea, in thirty-five cases gave thirty-two deaths and three recover- ies, i. e., one recovery in about twelve cases. In the scale of gravity there come then in the first rank cases of diphtheria engrafted upon tuberculosis and upon ty- phoid fever; all ended in death. Those following pleurisy, pneumonia, small-pox, urticaria, have given the same result, but they are too few in number to warrant rigorous conclusions. Then come diphtherias devel- oped in cachectic patients. In the third rank comes measles; in the fourth, scarlatina, and in the fifth, whooping cough. The course of secondary diphtheria is usually rapid. Its duration is most commonly short, especially when the disease ends in death; in the contrary event the disease lasts much longer. One or two days often suffice to bring death. Ty- phoid fever and tuberculosis are distinguished by the rapidity which they impress upon the course of diphtheria. In eight cases of diphtheria following typhoid fever two cases ended in one day, three in two days, the three others did not last beyond the fifth day. In eighteen cases following tuberculosis three died in one day and six in two days. The maximum of deaths in diphtherias following cachexias occurs the second day. In those that belong to measles, as is shown, upon the second and third days equally. Scarlatina does not exercise a manifest influence upon the course of diphtheria. The most common duration is ten days. Three cases only ended in two days. From the numbers which precede we may conclude that secondary diphtheria has a very great tendency to become general, that its prognosis is very grave, and that it is very rapidly fatal. Some reservations may be made in favor of the diphtheria of scarlatina and that of whooping cough. ARTICLE SECOND— ON THE LOCALIZATIONS OF DIPHTHERIA. All mucous membranes, especially those that are in contact with the external air, and even the skin, serve as a substratum for the false membrane. From the junction of the symptoms of the diphtheritic infection with the functional troubles which arise from the presence of the false membrane, there arise as many different symptomatic groups as there are localizations. We shall have to study successively the following morbid con- ditions: Diphtheritic pharyngitis, croup, pseudo-membranous bron- chitis, diphtheritic coryza, oculo-palpebral diphtheria, diphthe- ritic otitis, buccal diphtheria, diphtheria of the anus and of the genitals, and cutaneous diphtheria. § I. Diphtheritic Pharyngitis. (Angina.) This is the idctis Syriacmn or Egypticmn of the ancients, the ajtgina maligna or angina gangrenosa of the authors of the middle ages and of later times. The three forms of diphtheria which I have recognized will guide me in the description of diphtheritic pharyngitis. I shall consider successively the three principal types in which it usually appears, viz., benign pharyngitis, infections pharyn- gitis and malignant pharyngitis. It would be rash to pretend that all cases of diphtheritic pharyngitis are ranged exactly within these three groups; degrees must be established within these forms as intermediate cases may be found. It is just so in all clinical classifications ; they should not claim an abso- lute exactness, but they should aim, while giving as close an approximation as possible, at clearness of exposition, and they attain this end by making salient and well-defined groups. Too much multiplication of divisions brings confusion. 189) IQO DIPHTHERIA, CROUP AND TRACHEOTOMY. Almost all autliors have acknowledged the division into pri- mary and secondary pharyngitis. But just as I have shown for diphtheria in general, secondary pharyngitis usually as- sumes the infectious form. This grouping has thus only an etiological value. I do not deem it worth while to regard it in the description of the symptoms. Benign Diphtheritic Pliaryngitis. — The onset is sometimes announced by a slightly marked febrile movement preceded by slight rigors. The temperature does not exceed 38° or 38.5° (ioo.6°-iOi.3° F.), the pulse remains at about 120 in children, but below that number in adults. To this movement there are added anorexia, and quite intense headache, accom- panied by fatigue, and pain in the back. Upon the same day or the next the patient complains, if he be old enough to ex- press himself, of a pain in the fauces which may be very in- tense, but is often moderate. It is perceived, at the begin- ning, only during deglutition, then it augments, manifesting itself by a feeling of heat, of warmth, of dryness, or of a for- eign body in the fauces, or further, by pain seated at the an- gle of the jaw. If the patient be very young he shows the sense of pain only by refusing to swallow, and sometimes even the dysphagia may be also lacking. Examination of the fauces shows from the first a more or less lively redness of the pharynx. The two tonsils, more often one only, are swollen, and the swelling extends to the corresponding pillars. Soon there appears upon the diseased part an opal white spot, thin, transparent, well circumscribed, and resembling coagulated mucus. Such is the false mem- brane at its entrance upon the scene. It thickens without de- lay and becomes opaque and of a white color, which at once gives it a resemblance to cooked white of &%g, but it becomes yellowish afterward. It is sharply circumscribed, thicker in the centre than at the edges, and its white color contrasts sharply with the red ground of the mucous membrane. But slightly adherent at the beginning, it can be lifted off, holding fragments of epithelium attached to its under side, but later the connection becomes more intimate ; it resists trac- LOCALIZATION OF IMrHTHERIA. ^ I9I tion, and cannot be torn off without the mucous membrar.e bleeding. Usually single, and of the size of a lentil, it gradually in- creases in size. Its habitual extension is quite limited, reach- ing but little beyond the tonsil upon which it originated. Yet it may spread beyond it and send the projections along the neighboring pillars, along the free edge of the velum palati, and along the side of the uvula. These extensions thin out in proportion as they depart from their point of origin, and when they have reached the uvula form only a raised edge, some- times scarcely perceptible. Finally the opposite tonsil may be attacked in its turn, rarely at the same time as the first. Such is the aspect of the exudate in the greater number of cases, corresponding with the majority of the known de- scriptions. But this aspect is far from being immutable. In place of being single and forming a large patch spread out upon the tonsil, the false membrane appears under the form of white or yellow points the size of millet seed, with sharply bounded contour and flat surface, from three to six in number, and sep- arated by the reddened mucous membrane. These spots may remain discrete, but oftener they spread and unite, either all together, so as to form a single patch, or in groups. These points have no resemblance to the white, rounded, salient, caseous concretions which form in the lacunae of the tonsils in the absence of any morbid condition, accompanied neither by redness of the mucous membrane nor by pain, nor by any sympton of pharyngitis. This form of diphtheritic pharyngitis is very important to recognize. We are often brought to consider this, under the name of herpetic pharyngitis, as a separate species. The gen- eral symptoms and all the accidents of diphtheria which ac- company it in certain cases give a sharp contradiction to that view. This exception to the habitual behavior of the false mem- brane is not the only one. Diphtheria is Proteus like in its be- ginning : it is impossible to assign it a pathognomonic local form. 192 DIPHTHERIA, CROUP AND TRACHEOTOMY. It is the sum total of the complex morbid phenomena and not the outward aspect of the product, which specifies it. We can lay it down as a principle that : diphtheria begins with the most varied local phenonieyia, a?id that the form and the disposition of the false membranes do not snfjice to enable its to prejudge either the nature or the prognosis of the disease. This aphorism is one of the most important in the doctrine of diphtheria, and I shall have occasion to emphasize it more than once. Whatever be its form and its disposition the false membrane has little tendency to spread. It may indeed gain a little ter- ritory, and even seize upon other portions of the fauces or of the mouth, but it has little disposition to become general or to appear upon other organs. It does not extend into the nasal fossae, but it may descend into the larynx and constitute croup. This is one of the reasons why it is indispensable to know the local variations of diphtheria at the beginning. In default of being posted upon this point one runs the risk of seeing a pa- tient attacked with croup, concerning whom he has made the diagnosis of herpetic pharyngitis or ordinary diphtheritic pharyngitis. The mucous membrane is red and swollen. It projects a little over the false membrane, which appears as in a setting. Under the exudate it is red, but neither ulcerated nor gan- grenous. The submaxillary ganglia are slightly swollen, they form lit- tle hard kernels, slightly painful, which roll under the finger. The surrounding cellular tissue does not participate in the swelling. Albuminuria is not very rare. The course of this pharyngitis is neither long nor severe. After a few days, from three to eight, the false membranes be- come detatched at the borders, which lift up ; they retract, as- sume a darker hue and fall off all in one piece or in fragments, or disappear, by attrition. The fauces become clean and the mucous membrane soon recovers its normal color. At the same time the functional troubles cease, the dysphagia is al- layed at the end of three or four days ; the fever, which had LOCALIZATION OF DIPHTHERIA. I93 never been intense, vanishes ; the headache and backache dis- appear, the tongue clears off, the appetite returns and the ade- nitis undergoes resolution. Recovery is attained after a short convalescence. The entire duration does not exceed eight or ten days. I have seen the false membrane fall off on the fifth day and re- covery become complete on the sixth. But if, in spite of the benign character of the disease, the false membrane descends into the larynx, which usually hap- pens at the end of three, four or five days, at the same time when it begins to loosen in the fauces, the disease is found to be modified, and follows the phases of the laryngeal affec- tion. Diphtheritic paralysis may be the consequence of this phar- yngitis. Infectious Diphtheritic Pharyngitis. — The beginning is much the same as in the benign form. A little more intensity, and especially of duration, in the general symptoms, make the dif- ference between the two conditions. The initial chill, without being violent, is more constant and oftener repeated ; besides, vomiting, diarrhoea, and even convulsions, may be added to the train of symptoms. The fever is more intense, the pulse exceeds 120, the tem- perature remains in the neighborhood of 38. °5 (101° F.), while it may reach 39° (i02.°2 F.). The fauces are more painful, they are dry and burning, and the dysphagia is very marked. Examination of the back part of the mouth reveals a lively redness and a general swelling, more marked at first, however, upon one side. The false membrane appears as before in from twelve to thirty-six hours at the farthest, from the first onset. But there the analogy between the two forms ceases. In certain cases the beginning is insidious. It is that of ca- tarrhal pharyngitis, remaining such for one, two or three days, when the diphtheria throws off the mask by the appearance of the false membrane. 194 DIPHTHERIA, CROUP AND TRACHEOTOMY. One tonsil only is at first attacked, but the other without de- lay becomes covered with the exudate, as well as the pillars, the uvula, the pharynx, the velum palati ; and it is not rare to see patches appearing along the internal surface of the cheeks, along the tongue, the commissure and the internal aspect of the lips. This remarkable power to become general is the truly characteristic feature of this form of pharyngitis, for not only does the false membrane extend rapidly over contiguous regions, but it springs up in the most distant parts. Still other important modifications in the behavior of the exudate mark this form. It is thick, salient, and formed of stratified layers which augment each day and of which the oldest are the most firm and the most resistant. I have shown in the pathological anatomy what degree of thickness and of resistance it may acquire. The surface is no longer smooth but roughened. The contours, instead of being rounded are irregular and fissured. Its color, at first white, changes rapidly, passing to yellow, gray, and then to dark gray. The mucous membrane becomes purple and bleeding. Un- der the influence of the oozing of blood and of contact with food the false membrane assumes a brown or blackish tint which gives it a gangrenous appearance, rendered still more striking by a repulsive fetor. It is not astonishing that it was long thought to be an eschar and that this form of pharyngitis received the name of angina gangrenosa. Yet such is not the case, at least in a majority of instances. As Bretonneau has shown, the mucous membrane is either healthy, or barely ex- coriated underneath the concretion. There is quite an impos- ing number of cases in which the violence of the inflammatory process brought on a veritable necrosis. Gangrenous or not, the fauces present a characteristic appearance. The back part appears to be brought nearer the opening of the mouth, the pillars, considerably swollen, approximate and conceal the pharynx ; the tonsils, voluminous and globular, are enormous, the uvula distended, elongated and deformed, hangs in front of the pillars; it may also be engaged between them or deviate to one side or the other, and it is covered with a pseudo-mem- LOCALIZATION OF DIPHTHEKIA. I95 branous cap which resembles, according to a picturesque and exact comparison, the finger of a glove. From the mouth there exudes an abundant sanious secre- tion, exhaling the same odor. Deglutition is difficult, for the pain often renders it incomplete, and foods are in part rejected. Liquids alone can be ingested. The swollen nasal mucous membrane, in its turn often cov- ered with false membrane, does not permit the passage of air. The patient breathes through his mouth, v/hich he keeps open. Respiration is completely performed ; the air penetrates fully into the chest, but in its passage it sets in vibration the velum palati and the back portions of the fauces, which have become relaxed. There results a snoring stertorous noise. The voice is nasal. The submaxillary ganglia rapidly enlarge to a considerable degree, the inflammation extends to the surrounding connect- ive tissue, whence follows an oedema which makes the skin tense and shining, and a quite characteristic pyriform aspect of the head is produced by the swelling of the neck. I shall, at the end of this chapter, return to the adenitis, a full de- scription of which would occasion too long a digression. The tongue is foul and slimy. The patient refuses food, even those kinds of which he is most fond, as much from en- tire absence of appetite as from fear of pain. Constipation is frequent. The fever continues without increasing. Sleep is often interrupted by the necessity of expectoration. Yet the strength is pretty well preserved, and the countenance presents only a certain degree of pallor. The patient sits up in bed, his mouth half open, wiping his lips whence saliva freely exudes, mixed with the faucal secretion. Examination of the urine discloses, according to the case, a certain quantitity of albumen. ' At this time other pseudo-membranous manifestations affect different points in the economy. The most frequent of all is that which attacks the nasal mucous membrane. A discharge, mucous at first, then serous and sero-sanguinolent, escapes, from one of the nostrils, the skin grows red, and, opening the 196 DJI'IITHERIA, CROUP AND TRACHEOTOMY. nostril, a lalse membrane appears, situated close to the en- trance. In other cases the exudate is not seen; it forms about the posterior opening or in the cavity of the nasal fossae, the discharge alone revealing its presence. Then comes the extension toward the larynx announced by roughness of the cough and of the voice. Wounds, excoria- tions, ulcers, cutaneous folds where the skin is so delicate in children, the Eustachian tube and the middle ear, the oesopha- gus, the anus, and sometimes the intestine, and finally the genital organs may be invaded, all together or separately. Having come to this point in the disease, i. e., at the end of from five to seven days, the patient may recover. Then the fever goes down, the false membranes cease to re- form, not only in the fauces but in the nose, upon the skin and upon the mucous surfaces. They become detached at their bor- ders, and are eliminated as in the preceding form, either entire or in fragments, or by molecular disintegration. Their exfoli- ation begins from the second to the tenth day and ends from the fifth to the fifteenth, sometimes later ; not being complete in one case till the twenty-fifth day. The swelling of the fauces subsides, the odor grows less and disappears and the nose ceases discharging. The hoarse cough ceases, the aden- itis undergoes resolution, the swelling subsides, and the head by degrees resumes its form. Sleep improves and appetite re- turns. Alimentation, however, still remains difficult, because the sensitiveness of the mucous membrane persists till the newly-formed epithelium has attained its normal consistence. When the issue is to be fatal many paths may lead thereto. The most common is the propagation of the false membrane into the larynx, resulting in croup and death by suffocation. But the pharyngitis also causes death by the intensity alone of the infection. The false membranes, instead of diminishing, remain stationary or augment, either by reproduction in situ or by occupation of other surfaces, the tongue, the cheeks, the lips, the nose, the skin, etc. The fetor increases, the sanious secretion, which forms about the false membranes, becomes more abundant. Rejected in part, but in part absorbed by the LOCALIZATION OF DIPHTHERIA. I97 digestive tract or by surfaces denuded of epithelium, it be comes a new source of infection to the patient, not of diphthe- ritic poisoning, as Bretonneau, supported also by Bouchut, has claimed — this poisoning is, once for all, rather of putrid in- fection. The diseased parts may then become the seat of true gangrene. The tissues assume a dark green tint. Eschars are formed which, if they have time to loosen, leave behind them considerable loss of substance, destroy the uvula, re- move large portions of the tonsils, and may even, as I have observed in one case, perforate the velum palati in one or more points. [I treated the case of a girl with diphtheria, in 1857, about five years old — Hoffman — who suffered a perforation of the veil of the palate. The hole was elliptical in shape ; and it has never closed, but does not seem to cause any inconven- ience. She had a second attack about two years ago (after about twenty-five years) which seems rather to have enlarged the hole. My friend, Dr. S. W. Ranney, of Hope, Ohio, did me the kindness to report the second attack.] An almost ir- resistible tendency toward ulceration is shown at other points, the skin, the lips, etc., wherever false membranes exist. The nose becomes the seat of a sero-sanguinolent discharge of a repulsive odor. False membranes project from its orifice, and extend down upon the upper lip. Epistaxis, often severe and repeated, occurs, and other haemorrhages arise from the mouth, the stomach, the anus and the bladder. The buccal mucous membrane is purple and bleeding and the false mem- branes are colored brown. The submaxillary swelling in creases, and at times reaches suppuration. The dysphagia also increases and renders alimentation impossible. The fe- ver persists, rising to 39° and 40° C. (102-104'^ F.), The face grows pale, becoming lead-colored. The mucous membranes assume a bluish tint without there being asphyxia. The ex- pression of countenance is sad, downcast or indifferent. The features are drawn. The eyes are expressionless and encir- cled a with dark ring. Intelligence, however, remains perfect. Sleep is nil ; strength diminishes and diarrhoea sometimes su- pervenes. Albuminuria persists or ceases. Finally the pa- tient dies in a state of marasmus. 198 DIPHTHERIA, CROUl' AND TRACHEOTOMY. The duration of this pharyngitis is long. Aside from the cases where death comes on about the fifth day, it occurs oftencst about the tenth or twelfth ; I have observed cases in which death has been delayed till the sixteenth, the twenty- first, and even the twenty-seventh day. Even when recovery takes place it may last for twenty-five or thirty days exclusive of the paralysis which may follow it. It is to this form that those cases belong which Barthez and Isambert cite and which lasted several months and which prompted in Barthez the thought of admitting a chronic form. The adenitis deserves a separate mention. It usually affects a large number of ganglia. Swollen, painful and rolling under the finger they early form a voluminous mammillated mass. But the cellular envelop is attacked in its turn, it thickens and soon conceals the inequalities of the glands. Painful to the touch and giving a sensation of puffiness on pressure, the skin retains the imprint of the fingers. It is tense and smooth, but retains its usual color. The region then becomes enlarged and uniform, the swelling effaces the angle of the jaw and often extends beyond it to reach the lower part of the face or the superhyoid region. When both sides are involved the lower part of the face be- comes considerably increased in its transverse diameter; the head thus deformed assuming a pyriform appearance. If the patient recover, resolution may occur, the swelling subsiding from without inward. The skin becomes less tense, the subjacent tissues relax and grow thinner, the nodosities of the ganglia begin to be felt. Soon the mass becomes dispersed, broken upas it were, the glands reappear from the matrix that enclosed them, and resolution goes on little by little until the return to the normal condition. But, in place of diminishing, the submaxillary swelling may increase. If it be on both sides it passes beneath the jaw, invades the anterior portion of the neck and gives rise to symptoms of compression of the trachea. Suppuration is speedy. The softening is perceived first at one point, then at others and reaches the entire mass. A well-di- rected but difficult treatment usually results in cure. LOCALIZATION OF DIPHTHERIA. I99 It is to be noted that the violence of the adenitis does not always coincide with the severe stage of the pharyngitis. It may appear in an unexpected manner when the pharyngitis is almost well, and when the false membrane has altogether dis- appeared, even in cases in which the adenitis was moderate during the height of the pharyngitis. We then see the fever relighted at the very time when convalescence seemed to be beginning, and the adenitis return with violence. Suppuration of the glands brings with it all the symptoms incident to ab- scesses of the neck, viz.: burrowing of pus beneath the fascia, compression of important organs, etc. In one case the pus had burrowed behind the pharynx and had formed in that region an enormous abscess which opened spontaneously. A continuous bloody discharge oozed from the mouth and from the nose, when, about the sixth day, a furious haemorrhage bursting from the nose and mouth, carried the pa- tient off in a moment. The autopsy showed that this haemor- rhage had its origin in the retro-pharyngeal center. Malignant DipJitheritic Pharyngitis — This form is the ex- pression of diphtheritic poisoning carried to its highest degree. The infection holds the first place, while the pharyngitis is relegated to the second. I shall, then, have to recur in great measure to what I have said of the malignant form of diph- theria. This species includes two varieties, a fulminating form and an insidious form. Fulminating [Explosive) Form. — All the morbid symptoms which pertain to the severe form of infectious pharygitis re- appear here, but with frightful rapidity. After a rigor, slight, but repeated, after some epistaxis which often marks the onset, general symptoms develop, and then the pharyngitis appears, taking on a gangrenous or pseudo-membranous character al- most from the first onset. The nose is prematurely invaded. The adenitis comes on early. The surrounding cellular tissue swells considerably, but without the oedematous doughy feel, it retains, on the contrary, a flabby consistence. If the false membranes take on a gangrenous appearance 200 DIPHTHERIA, CROUP AND TRACHKOTOMY, and odor; if the mucous membrane is purple and bleeding, we need not think that the exudate has always a very great ten- dency toward propagation. Admitting that it may show itself at the same time in the nasal fossae, and that it may rapidly in- vade the larynx, it is often hmited, and it may occupy but one side of the fauces, and that only partially, and be reduced to insignificant proportions. The appetite is nil ; there is extreme weakness ; the patient is as though dazed. In many cases I have noted an invincible somnolence, sometimes even coma. The fever of the first day rapidly gives place to collapse. The pulse grows slower, fall- ing to 60, 40, and even less. It becomes small, thready, and imperceptible. Hsemorrhages arise from various points, or are limited to a continual oozing from the mouth. The ex- tremities grow cold ; the temperature falls below 36° (97° F.), and the patient succumbs. A mild delirium sometimes termi- nates the scene, but somnolence and coma are the more usual signs. The urine contains albumen, but not in every case. Two, or at most three days, sometimes suffice for the evolu- tion of this pathological drama. The insidious form presents special characters which I have sufficiently developed in describing the insidious form of diphtheria in general. I could not go over them without repe- tition. It will be enough for me to still insist on the deceptive mildness which marks its beginning upon the slight extent of the false membrane, which sometimes presents the arrange- ment in points attributed to herpetic pharjmgitis. One sign, however, will put the physician on his guard, and will enable him to avoid error ; it is the swelling of the neck, that enor- mous, flabby swelling in which the cellular tissue participates more than the glands, a swelling out of all proportion to the local condition, and which Trousseau said, savors of its pesti- lence [sent sa peste). Death, the unavoidable termination, comes on in from six to ten days. Albuminuria is a frequent but not a necessary concomitant of this condition. It may be worth while to note a variation which sometimes LOCALIZATION OF DIPHTHERIA. 20I marks the beginning. The patient complains of a violent pain in the fauces which nothing in sight accounts for. Then there appears a slight swelling about the angles of the jaw quickly- followed by the sudden and simultaneous explosion of the false membrane, the enormous submaxillary swelling, and general symptoms. Section 2 — Croup. Designated by ancient authors under different names sug- gested by the principal symptom of the disease, laryngeal diphtheria was called: "Morbus strangulatorius" (Sgambati, Carnevale, Cortesio, Marcus A. Severinus, etc.), garotillo (Perez Casales), "angina laryngea exudatoria" (Hufeland), ''morbus truculentus infantum" (Van Bergen), "diphtheric tracheale" (Bretonneau), and laryngite pseudo-membraneuse "pseudo- membranous laryngits" a name adopted by several modem authors. But in our day it still retains the popular denomina- tion of croup, applied to it by Home. Like angina, croup may take on one or another of the three forms of diphtheria. But the local condition has much more importance than in angina ; the false membrane which obstructs the larynx asphyxiates the patient, however slight the diphtheritic poisoning may be. It appears, therefore, difficult to admit a benign form of croup, a morbid condition which, left to itself, is too often fatal. There comes, however, a time when the benignity returns and claims its rights. Let an effort of nature expel the false membrane, or tracheotomy interpose and terminate the asphyxia, then the disease follows a very simple course, and recovery is soon at- tained. One may, therefore, accept without paradox, a benign form of croup. All authors admit a primary, and a secondary form. I be- lieve this division no more justified for croup than for angina ; secondary croup assumes the infectious form, and sometimes the malignant, and follows a course, under these circumstances, as if it were primary. Certain differences in its course, dis- tinguish croup of adults from that of children. The beginning sometimes presents certain general signs 202 DIPHTHERIA, CROUP AND Tl< ACll liOTOMY. which we have found in all the manifestations of diphtheria, viz., slight chill, moderate fever or more commonly none, some- times, however, quite intense; vomiting, convulsions, general discomfort, headache and lassitude. The laryngeal symptoms appear afterwards. But it is only in exceptional cases that this course of events occurs ; in the great majority croup is preceded by diphtheritic angina or a coryza of the same nature. Bre- tonneau and Guersant gave it as an absolute rule. Numerous observers, viz., Trousseau, Rilliet and Barthez, Blondeau, J. Bergeron and Hache, have proved that diphtheria may com- mence in the larynx, and that croup may exist primarily — d'emblce. Some of them have admitted that the larynx was oc- casionally invaded after the bronchi. Rilliet :ind Hache have seen the larynx attacked first in a large number of cases. Ril- liet adds : "In half of the cases the false membrane developed in the pharynx subsequently to the laryngeal symptoms." Vauthier has seen angina fail in half of the cases. Bergeron has proved that it was absent in about one-third. J. Simon accepts this opinion, and estimates with Guersant that primary croup is observed in one twentieth of the cases. My conclusions conform to those of the above observers. Croup may exist primarily, that is to say, the false membrane may be deposited in the first place upon the larynx ; but one is correct in making the assertion only in the cases in which the disease has been followed from the beginning and when it has been possible to examine the throat and the nares every day. It is necessary, indeed, to bear in mind the circumstances under which the false membrane has rapidly extended from the throat to the larynx, and those under which the angina — not having been intense, has not attracted attention, so that at the moment when the laryngeal symptoms arise, the gut- tural false membrane has disappeared. Certain autopsies have indicated to me another cause of error sufficiently curious, of which it is important to take an account. In subjects dead of croup without apparent angina, in spite of attentively examin- ing the throat, I have found false membranes seated on the posterior face of the tonsils and extending thence towards the LOCALIZATION OF DIPHTHERIA. 2O3 larynx. The anterior face of the tonsils was sound, as well as the pillars. One sees, therefore, the restriction which, for fear of error, is placed upon the observer. It reduces the number of cases of primary croup. However, there are cases in which the false membrane com- mences evidently in the larynx or in the bronchi. A hoarse cough, dyspnoea, paroxysms of suffocation and even expulsion of false membranes coming from the larynx or from the trachea or bronchi ; such are the symptoms of the disease ; and, ex- amined regularly from the beginning, the throat has at all times been clear. This course is still more significant, when, after the expulsion of false membranes, an exudate appears upon the tonsils, as Rilliet has frequently observed. That is really the CROUP ASCENDENS. The estimate that I have made of the relative frequency of primary or ascending croup is still larger than that of Simon. Croup commenced primarily in one-eighth of the cases. In 1172 cases of croup the starting point was 142 times in the larynx. I refrain, however, from giving to these figures a pos- itive value; it is made largely from observations made at hos- pitals, and is quite open to the objections that I have raised. Considerable variations depend also upon epidemics. Bre- tonneau considered coryza as always preceding croup and even angina. This fact, which attracted the attention of the dis- tinguished physician of Tours in the epidemics which passed under his observation, has not been verified since, at least in a general and constant manner. The nose is often attacked at the same time as the throat, in the infectious form ; and some- times before, but most frequently the throat is the stage on which it makes its debut. When angina precedes croup, one sees evolved the pathologi cal whole which has been described above. Special symptoms announce the entrance of the false membrane into the larynx. When croup presents itself primarily, these symptoms an- nounce its onset. Jn very rare cases in which croup shows itself subsequently 204 DIPHTHERIA, CROUP AND TRACHEOTOMY. to tracheal or bronchial diphtheria these same symptoms are preceded by thoracic symptoms, by phenomena furnished by auscultation. The only symptom, the semeiological value of which is certain, is the expulsion of false membranes ramified or in bands the form of which may prove their tracheal or bronchial origin. The larynx once invaded, the local affection takes supremacy, the respiratory affection occupies the first rank, the poisoning, at least when it is not very profound, remains in the second. The respiratory symptoms may be divided, as proposed by Barthez, into three periods. The first presents only laryngeal symptoms without as- phyxia; the second is characterized by paroxysms of suffoca- tion between which the respiration is free or moderately im- peded, but without symptoms of asphyxia ; the third is marked by the cessation of the suffocative attacks, and by the estab- lishment of a continued ("enduring") and progressive dyspnoea accompanied by increasing asphyxia. First Period. — The first local symptom of croup is a slight dry, fitful and frequent cough. It becomes rapidly rough, hol- low and suffocative, qualities which distinguish it from the ringing, metallic sound of that which belongs to stridulous lar^^ngitis. Trousseau compared it to the distant barking of a young dog. It becomes more hollow in proportion as the dis- ease increases. Frequent in the beginning, it becomes more and more rare at the same time that it becomes more suffo- cative. It ends by disappearing altogether when the disease has reached its maximum of intensity. The patient complaines sometimes a little of pain in the region of the larynx, pain which is felt especially during movements of the organ, and upon pressure. The voice is also modified ; at first hoarse, it becomes coarse and then diminishes, often to aphonia. These variations of sound are due to the presence of false membrane upon the lips of the glottis; the effect produced is similar to that from a small piece of softened parchment placed between the reeds of a clarionet or of a bassoon — (Trousseau). At the end of a very variable time, from some h©urs to LOCALIZATION OF DIPHTHERIA. 2O5 several days, the respiration, which was effected without diffi- culty, begins to feel a certain impediment, first during the night. Then there arises a laryngo-tracheal wheezing, much more marked during inspiration than during expiration. This preponderance results from the anatomical disposition of the parts. During inspiration the lips of the glottis and especially the aryteno-epiglottic ligaments which are the most frequent seat of the false membranes, are drawn into the lar>^ngeal cavity ;the increase in their volume brings them in contact one with the other and contracts the caliber of the organ in pro- portion to the degree of their tumefaction. During expiration, on the contrary, the column of air tends to separate them. The ear placed over the thoracic walls hears this sound in all parts of the chest to such a degree as in part to drown the respiratory murmur. These respiratory disturbances are al- ways more marked during sleep. Second Periods. — The dyspnoea progresses; the slight re- straint of the first is followed by symptoms much more serious, the most important character of which is the intermission of the dyspnoea ; they are the paroxysms of suffocation. Sud- denly the patient jumps up in bed, sits up or springs out, clasps his mother around the neck a victim of indescribable distress and appearing to implore assistance. He makes the most powerful efforts for breath ; the alse of the nose dilate, the mouth is opened wide, and the head and trunk thrown back. All the respiratory muscles, those of the chest as well as those of the neck, are brought into contraction ; the child aids their action by grasping the edge of his bed or any object to aid him that may be within his reach. The violent con- tractions of the diaphragm produces in the child a deep de- pression at the pit of the stomach (scrobiculus cordis) at each inspiration, this peculiarity is explained by the incomplete ossification of the sternum at this age. The xiphoid cartilage, unable to resist the powerful contractions of the diaphragm, is drawn backward and upward by this muscle. The mechan- ism of the epigastric depression appears to me to be due to this cause rather than to the production of the vacuum in the 206 DIPHTHERIA, CROUP AND TRACHEOTOMY. thorax which might draw the diaphragm upwards. If it were the latter, the immovable diaphragm would no longer repel the abdominal viscera during inspiration. Now, to the attentive observer there is no aspiration or traction of the viscera into the thorax, as in the case of paralysis of the diaphragm. These are, on the contrary, forcibly thrust down into the abdomen, and it is their decided protrusion which makes more percepti- ble the retraction of the xiphoid appendix. The dyspnoea becoming more intense the auxiliary muscles come into action ; the muscles of the neck contract energetic- ally, and there appears at the superior border of the sternum another depression which reveals more plainly the prominence of the thyroid body. The totality of these efforts is designated under the characteristic name of "tirage,'' sinking in of the soft parts, (retraction). When the abdominal muscles only are in action the phenomenon may take the name of abdominal retraction, {tirage abdofninal,) or substernal retraction : when the muscles of the neck come into line, it may take the name of cervical, or suprasternal depression. In his exasperation the patient grasps at his throat as if to tear away the obstacle that chokes him. Notwithstanding all these efforts the air enters only with difficulty, producing a stridulous wheezing analogous to the grating of a saw, the bruit serratic of Trousseau : the face be- comes cyanosed, the lips and the fingers under the nails be- come blue; the skin is hot, moist, and covered with profuse sweat ; the pulse is small, weak, and exhaustion is complete. In the course of five or six minutes, occasionally at the end of a quarter of an hour of this terrible agony, either spon- taneously or as the result of expulsion of a fragment of false membrane, the respiration becomes gradually easier, less noi- sy, the cyanosis disappears, the pulse recovers, quiet is re- stored, and the patient falls asleep. After this paroxysm the respiration returns almost to the point where it was before ; however, it is nearly always a little more restrained. At first coming at rare intervals, the paroxysms become more frequent. The first is often separated from the second LOCALIZATION OF DIPHTHERIA. 20/ by eight or ten hours, sometimes more sometimes less. The interval diminishes later to two or three hours, then to one hour; and finally there may occur several paroxysms in the course of one hour. In proportion as they become more fre- quent, their violence increases, and the patient may even die during a paroxysm. They may return spontaneously, or un- der the influence of the most various causes ; an effort, a fit of anger, fright, cough, the examination of the throat, and above all cauterization. As relevant, I believe it proper to insist upon the necessity of being careful in the examination of the throat in children sick with croup. This is one of the most frequent causes of paroxysms of suffocation, especially if the patient resists. Without always being followed by such grave consequences, this struggle is always followed by fatigue which is very prejudicial to the patient. This remark applies also to all the manipulations made about the throat, as well in croup as in angina. Third Period — When the disease follows its natural course, the calm which separates the fits of suffocation is replaced by dyspnoea. The paroxysms become more and more intense, and at shorter intervals. In the interval the distress persists. The dyspnoea continues. The sawing character of the inspiration becomes permanent and may be heard at a distance. The re- traction (tirage) is no longer interrupted, and manifests itself above as well as below the sternum. The respiration is accel- erated, ranging from 20 to 40 in the minute; in one case I have seen it '56. The patient endeavors to compensate for the in- sufficiency of the fullness by multiplying the number of in- spirations. If the respiration rises still higher we have to fear inflammatory complication on the part of the lungs. With the increase of restlessness, the distress becomes indescribable. On applying the ear to the chest the vesicular murmur is no longer heard ; it hears only the reverberation of the laryngeal sound, or the snoring, or rales of different kinds which indicc to the extension of false membrane to the bronchi. The face is purple and turgid ; the eyes are brilliant, restless and imploring. The patient is a prey of constant agitation, and cannot remain 208 DIPHTHERIA, CROUP AND TRACHEOTOMY. quiet. Surrounded by these conditions, death may occur dur- ing a paroxysm of suffocation. But in the ordinary course of the disease, whether the powers become exhausted, or the ob- stacle becomes insurmountable, the struggle ceases, the par- oxysms of suffocation disappear, the patient falls again upon his bed in a kind of stupor, and in a profound depression ; the face ceases to be cyanosed and swollen ; it becomes pale, al- though the lips as well as the skin under the nails remain purple ; the pulse becomes small, insensible ; the extremities become cold ; anaesthesia reaches a degree almost complete ; and the patient expires in collapse. This picture represents the aspect of the disease in cases in which its development is natural, in those in which the laryn- geal obstruction is the dominant morbid phenomenon, when there is no complication and when the diphtheritic infection is not too strongly pronounced. If these conditions be changed the scene changes also. When, for example, during an attack of coughing, or during an effort of vomiting, the laryngeal false membrane be- comes expelled a sudden relief of the symptoms is obtained, the asphyxia ceases, wheezing disappears, respiration becomes calm, and the patient falls asleep or returns to his play. But it is too often only a respite. The diphtheria is always there, master of the situation. The expelled false membrane is fol- lowed by another exudation which in the course of a longer or shorter time, varying from four to twenty-four hours, is in condition to present a new obstacle. The scene recommences, only more terrible, the patient being weakened by the pre- ceding attack. Three or four repetitions may follow, then comes death. Nevertheless, the termination may be more fortunate, the false membrane is finally detached without being reproduced, or after being removed once or twice. The ameliortion which results from it is followed by recovery. While this change in the course of the disease is quite unusual, it is less rare than Trousseau supposed. "There are, I repeat" says the illustrious professor, "exceptional cases, so rare that in the course of a long LOCALIZATION OF DIPHTHERIA. 2O9 medical practice in which it has been my province to see a large number of patients, adults as well as children, attacked with croup, I have met only six of them." In 2809 cases of croup I have known 204 to terminate by spontaneous recovery due to the expulsion of the false membranes. That is to say in the proportion (average) of one to thirteen. Thus far I have insisted upon the most prominent phenom- enon of croup viz., the dyspnoea. Around that gravitate other symptoms. The adenitis depends upon the form of the diphtheria. In the benign form it is slight or absent, in the malignant form it becomes voluminous. When the larynx is attacked primarily it is wanting. The fever is with difficulty appreciated in croup. As long as the disease is still in the beginning, the pulse, the respira- tion and the temperature allow an estimate of the intensity of the fever. At this time the febrile movement is ordinarily moderate ; the pulse remains in the neighborhood of 120 in the minute ; the temperature is about 38.5° (10172° F.). But when the respiration is embarrassed, a complete disturbance prevails over these functions. The anguish and the excitement of the patient cause rapidity of the pulse and make it irregu- lar. The respiration is altered in its rhythm ; it is at one time accelerated, at another retarded or interrupted. It is, there- fore, impossible to find, from this source, very exact notions concerning the fever. The temperature itself undergoes mod- ifications, it no longer expresses the variations of organic com- bustion under the influence of the diphtheritic poisoning, but the disturbances of calorification produced by asphyxia. It is not, therefore, to speak accurately, the febrile condition that can be determined, but only one of its elements — the tracing of the temperature. From the commencement of asphyxia, the temperature rises. I have never insisted on taking the temperature during a fit of suffocation, because of the extreme restlessness of the patient; one could not without cruelty, add an additional restraint to that which is so painfully imposed. Probably there is a rise in 2IO DIPHTHERIA, CROUP AND TRACHEOTOMY. the temperature corresponding to each paroxysm. In con- tinued dyspnoea the only condition favoring the examination, the themometer marks from 39° to 40° (102° to 104° F.). While, if by the expulsion of the false membrane, or from the effects of tracheotomy the air enters the chest freely, the tem- perature falls and returns to its point of departure; it rises again if the reproduction of false membranes or their extension to the trachea or bronchi, causes a return of the asphyxia. Nevertheless, the rise of the temperature is only transient. Continuation of the asphyxia causes a final decline of thermic range and death follows a coldness marked by 36° (97° F.) or less. Before reaching this fatal issue, the coldness may also be terminated by the expulsion of a false membrane or by tra- cheotomy. The entrance of air causes the thermometer to rise. These apparently contradictory results are clearly explained by Claude Bernard. In a dog in which the respiration has been obstructed by compressing and closing the nostrils, the temperature was seen to rise, and to become normal again when the compres- sion was removed. But if the asphyxia was maintained, the temperature finally sank. Brown-Sequard obtained similar re- sults upon birds. From these facts the latter observer con- cluded that asphyxia from deprivation of air caused a tempo rary elevation of animal temperature. The interpretation of the phenomenon would be the follow- ing; if the oxygen is no longer supplied from without, we must not conclude that it is entirely wanting ; the arterial and the venous blood still contains a large proportion. During asphyxia this oxygen is consumed and disappears entirely. At the beginning of the period of asphyxia the pulsations of the heart become less rapid, the course of the blood is slower, this fluid remains longer in contact with the intimate structure of the tissues. It is in these parts, and especially in the muscular system that oxygen completes its combustion. The excite- ment which marks the beginning of asphyxia and the convul- sive movements which sometimes accompany it, are important sources of heat which hasten the exhaustion of the reserve LOCALIZATION OF DIPHTHERIA. 211 oxygen. Hence the increase of calorification in the earl\- part of asphyxia. But when the supply is exhausted, all combus- tion becomes impossible and the temperature final!)- falls.- One can understand how, in asphyxia at the beginning, the return of air into the chest causes the temperature to fall by diminishing muscular action and the nervous phenomena. While in prolonged asphyxia the resumption of respira- tion causes the temperature to rise by supplying a new food to the organic combustion. It is in this manner that the rejec- tion of false membranes and tracheotomy are causes of a re- turn of the thermic tracing (temperature curve) towards the point of departure. After the expulsion of a false membrane the reproduction of the exudate brings new variations; after tracheotomy, the ex- tension of diphtheria to the bronchi, pulmonary complica- tions, adenitis and even the removal of the tube, act in the same way. The expectoration is the most certain source of valuable in- dications in respect of diagnosis, prognosis and treatment. At first it is mucous and colorless, but it ceases at the moment of clearly defined inflammation. Finally at a later period it con- sists of fragments of false membrane of various forms, sizes and composition. Those coming from the larynx are irregular plates, with ragged edges, without special form, sometimes they have nearly the form of a trumpet, when they come from the ventricles of the larynx, they sometimes retain the form of the vocal cords. At others, when expelled from the trachea they consist of long patches the surface of which represents portions of the surface of a cylinder; and often one extremity of the plate represents quite clearly the bifurcation of the trachea. The bronchi furnish their share also of the expectoration ; the false membranes which come from them are occasionally quite considerable ; they give an exact form of the part on whieh they are formed. See pathological anat. p. — The expectoration, while containing the false membranes contains also mucus, often sanguinolent, or even a sero-san- guinolent or sero purulent material, sometimes very abundant. 212 DIPHTHERIA, CROUP AND TRACHEOTOMY. Later, when the course is favorable, the material becomes simply mucous. The odor of the expectoration varies with the general con- dition; negative in the benign form, it becomes gangrenous in the infectious and malignant forms. When a thoracic inflam- mation develops itself, the expectoration ceases for the time, only to return at the time of resolution. When the expelled false membrane is thin and soft, it very much resembles mucus. To avoid all confusion, it is well to stir the expectorated material in a glass of water. Under these conditions the false membrane rolls out and resumes its form, color and opacity, while the mucus spreads out and remains transparent. Still other symptoms are met with in croup but they have nothing that connects them directly with this locali- zation; they are common to all the forms of diphtheria. They are : Anorexia, which is often absolute, and becomes one of the most serious of the perils which threaten the patient. The combination of inanition, infection, and asphyxia leaves no chance for recovery. Constipation, and occasionally diarrhoea which, independ- ently of cases in which it follows the use of emetics, may be encountered in the beginning, or in the course of the disease. In the forms in which infection prevails, the diarrhoea may be fetid as well as the other secretions. Vomiting, quite frequent at the outset, appears occasionally in the course of the disease, most frequently at the approach of a complication. Often also it is, as in the case of diarrhoea, the consequence of the treatment by emetics; occasionally this treatment produces a similar effect only after tracheotomy. Haemorrhages occur from various points, especially from the nose, mouth, cutaneous ulcerations, or from the wound of tracheotomy ; sometimes at the beginning, sometimes in the course of the disease. It is reckoned among the gravest symptoms. Albuminuria is so frequent in croup that some authors have considered it as dependent upon the asphyxia; it has been found that there is nothing in that view. LOCALIZATION OF DIPHTHERIA, 213 Finally, scarlatiniform or rubeoliform eruptions are met with under some circumstances. PATHOLOGICAL PHYSIOLOGY. The anatomical lesions generally comprise the symptoms observed in patients attacked with croup. Like all rules, this has exceptions. When we find, after death, wide fibrinous cyl- inders lining the respiratory mucous membrane, or simply thick concretions attached either to the lips of the glottis or to the margins of the aryteno-epiglottic ligaments, the dyspnoea and asphyxia find their explanation : the relation is established between the lesions and the symptoms. But when these parts are simply covered with a thin pseudo-membranous coating, when we find at the autopsy only trifling exudations or even none, and yet the respirator}' disturbance has been most vio- lent, then the connection is severed. The intermittent dyspnoea and the paroxysms of suffocation present also difficulties for explanation. Many times these paroxysms cease after the expulsion of a false membrane, but in numerous cases it is otherwise. Hence we find ourselves at one time dealing with an intermittent phenomenon which appears to depend upon a structural lesion — the false mem- brane ; at another with violent disturbances coincident with anatomical alterations quite insignificant in appearance. This want of correspondence has engaged the attention of all au- thors. Jurvie, Vieusseux, Albers of Bremen, Royer-Collard and Double have attributed it to a spasm of the glottis, the origin of which may be inflammation of the respiratory mu- cous membrane. In the view of these authors the false mem- brane plays a subordinate role in the embarrassment of the respiration, the spasm alone preventing the entrance of air into the chest. Bretonneau held an opposite opinion. The false membrane is the special agent in the suffocation. We may not, without error, regard the intermittence as a purely nervous or spasmodic phenomenon ; it is met with under many circumstances, viz., in cancer, in calculous affections, etc. This interpretation was fully admitted by Valleix, but only 214 DIPHTHERIA, CROUP AND TRACHEOTOMY. partly by Trousseau, and is no longer accepted. Barthez and Rilliet, Lallemand and Simon ascribe the principal part to the spasmodic element. Other authors, relying upon the lesions of nutrition found in the muscles of the larynx, by virtue of the law of Stokes, that is, upon the propagation of the inflammation to the muscles beneath the mucous membrane, have located the laryngeal dif- ficulties in the muscular paralysis resulting from this anatomical condition. The opinion of Bretonneau cannot be accepted in the present state of science. However real and however potent may be the obstructive action of the false membrane, there exist too many cases, in which an intense respirator^' dis- turbance coincides with a false membrane trifling in thickness and extent, for us not to seek another cause of dyspnoea. Let us consider first the paroxysm of suffocation ; it is near the beginning that it occurs, while it ceases or becomes more rare as the disease becomes more advanced, and as the exuda- tion increases in thickness. Besides, lar}'ngitis stridulosa pre- sents symptoms in every respect similar, viz., paroxysms of suffocation and of laryngo-tracheal wheezing without it being possible to attribute it to a false membrane or to a sufficient mechanical obstacle. Now a simple tumefaction of the mu- cous membrane would but seldom produce symptoms equally serious; oedema of the glottis alone might produce a suf- ficiently swelled condition of the parts. Whooping cough itself, during the paroxysm, gives rise to a similar wheezing. The presence of false membrane is not, therefore, indispensable in provoking an attack of suffocation. By what mechanism can the larynx contract to a degree sufficient to produce suffocation without the co-operation of exudation? The laryngeal muscles alone are endowed with that power. Do they act by paralysis or by spasmodic contraction ? Paral- ysis, based upon the alteration of the muscles, does not ap- pear to me satisfactory so far as the attacks of suffocation are concerned ; from that condition arises dyspnoea, not intermit- tent, but permanent, which, by the expulsion of false mem- LOCALIZATION OF DIPHTHERIA. 21 5 branes, would not be even changed. Periodicity is rarely found among the paralytic phenomena. Moreover, at the time when the paroxysms of suffocation appear there is nothing to prove that the muscular lesions are sufficiently advanced to de- stroy the function of these organs. Spasm, therefore, remains to be considered ; this is probably the most active agent in the laryngeal occlusion. As in stridu- lous laryngitis and in whooping cough, it is under the influ- ence of irritation of the mucous membrane. The laryngeal mucous membrane in the child is exquisitely sensitive; the slightest inflammation easily assumes the spasmodic form. Everv irritant, even inspired air, is to the inflamed membrane a causi of hyperaesthesia which, transmitted to the medulla by the superior laryngeal branch of the pneumogastric and re- tlccicd by the inferior or recurrent laryngeal to the muscles of the Larynx, excites the contraction of those muscles. Now, as these are all constrictors of the glottis except the posterior crico-arytenoid muscles, their contraction produces a degree of constriction of the glottis in proportion to the activity of the irritant. When this agent is inspired air, of which the action is continuous, the occlusion itself is continuous and moderate; it is announced by the laryngo-tracheal wheezing. But let this hyperaesthesia be suddenly increased by another im- pression, and the mucous membrane reacts violently. A sud- den and violent constriction of the glottis results therefrom, which, being added to the stenosis dependent upon the false membrane, closes the air-passage ; hence the suffocation. Causes trifling in appearance are sufficient, such as an emo- tion, fright, anger, a movement, or the displacement of the false membrane. When the reaction ceases the muscular con- traction relaxes, the attack terminates and the hyperaesthesia of the mucous membrane returns to its condition before the paroxysm. Fiequcntly it remains more marked, a condition which explains the greater intensity of the wheezing after the paroxysm of suffocation. In the adult, diminished irritability of the mucous mem- brane, the greater dimensions of the larynx and the existence . 2l6 DIPHTHERIA, CROUP AND TRACHEOTOMY. of the aryteno-glottic render the effect of the spasm less evi- dent ; besides, the attacks are more rare, and they announce the more direct interference of the false membrane. Such is in part the mechanism of a paroxysm of suffocation. I can scarcely believe that it is always so simple. There are too many causes of occlusion of the glottis present to suppose that they would not, by combining, produce phenomena more complex. To the reflex contraction, arising from inflamma- tion of the mucous membrane, is added that which results from the extension of the inflammator}' action to the muscular tissue itself. Under these conditions the muscles react as does, for example, the anal sphincter in dysentery, in such a manner as to cause a kind of glottic tenesmus which acts in the same way as the reflex spasmodic action. This hypothesis once ad- mitted, the suffocative attacks may therefore be the product of three factors of which the importance varies according to the case: i. False membrane. 2. Reflex contraction of the laryn- geal muscles from irritation of the mucous membrane. 3. Te- nesmus glottidis caused by the extension of mucous inflamma- tion to the muscular tissue itself. At a later period the paroxysms disappear, and the dyspnoea becomes continuous. Rarely does the false membrane become so thick and so extended as to entirely intercept the access of air. It is then that muscular paralysis intervenes. The laryn- geal muscles no longer contract, first, because the mucous membrane, having lost its sensibility, no longer reacts, and then, because they are altered and become fatty, as a number of autopsies have proved ; their contractile elements, which remain healthy, are in too small a number. The larynx is found then in a condition analogous to that which follows sec- tion of the superior and inferior laryngeal nerves, viz., sup- pression of sensibility and abolition of motion, hence asphyxia. COURSE. I have confined myself to signalizing the variations of the onset. Bretonneau represented croup as always being pre- ceded by coryza or diphtheritic angina, but it may suddenly appear primarily, and even be followed by angina. When LOCALIZATION OF DIPHTAERIA. 21/ it appears primarily and when it follows angina, coryza, or bronchitis, it begins by characteristic alterations of the cough, the voice and the respiration, which constitute the first period. The time occupied by the beginning of the angina appears to vary with the epidemics. In those which Breton- neau observed this period continued from two to seven days ; in that epidemic which passed under the observation of Fer- rand it lasted but a single day. In 232 cases of croup in which the disease has been followed from its beginning, I have seen the larynx attack : At the same time as the throat, - - - 1 1 times Some hours after, ___--. 6 times DAYS AFTER. TIMES. DAYS AFIER, TIMES. I - - - 29 8 - - - 13 2--- 33 9--- 2 3 - - - 46 10 - - - 5 4 - - - 33 II - - . I 5--- 26 12--- I 6 - - - 17 15 - - _ 2 . 7 - - - 6 27--- I Total. _____ 232 These figures result, in large part, from information furnished by the parents of the children. They can only be received with reserve. Among the patients who come to hospitals many are attacked with diphtheritic angina unnoticed ; the attention of parents is attracted only when the laryngeal symptoms ap- pear; it is often difficult to fix the date of the extension of the false membrane from the pharynx to the larynx. In making allowance for these unavoidable errors, we should, however, recognize the important grouping of the most numerous cases about the first seven days. Croup, when once established, runs a variable course, i. It runs through the three periods and ends in asphyxia, when it is abandoned to itself; 2. A violent attack of suffocation closes the scene ; 3. the expulsion of a false membrane gives tempo- rary relief or cures the patient; 4. tracheotomy intervenes and permits the diphtheria to follow its course by relieving the ele- ment of asphyxia; 5. numerous complications, viz: eruptive 2l8 DIPHTHERIA, CROUP AND TRACHEOTOMY. fevers, thoracic or other lesions impeding the course of the croup when the operation has been performed, and when not. Under these different circumstances the form of the diphtheria frequently changes, as also does the physiognomy of the dis- ease. The infectious form, in which are classed many of the cases of secondary croup, is characterized by the rapidity of the in- vasion, by the extension of the false membranes to the bron- chial tubes, or by the gravity of the symptoms of infection. Should the larynx be attacked primarily or after the throat, the development may be very rapid. Instead of some days, a few hours may suffice to overstep the space which separates these two regions ; sometimes they are attacked at the same time. The process develops itself with a kind of precipitation. One day, a day and a half or two days are sufficient to reach the development; and a severe attack of suffocation, sometimes re- peated, is the first symptom, immediately followed by continued dyspnoea. It is for this variety that the name fiilnii?ia)it form of croup (croup foudroyant) is reserved. In other cases it is the second period which fails; the continued dyspnoea is estab- lished without paroxysms of suffocation. This is principally observed when the false membrane descends into the bronchi. We do not then observe the violent struggles of the patient against asphyxia. There are no longer the restlessness, the turgescence of the face and the cyanosis, but there are prostra- tion, drowsiness, pallor and failure of the powers. Ramified false membranes are often expelled. If the croup depends on malignant diphtlieria,the spread of the false membrane is rapid — the blow is sudden, the paroxysms of suffocation most frequently fail, and as- phyxia is progressive. The following is a striking example of precipitation in the course: In a patient attacked with measles, on the morning of the fifth day of the eruption, inflammation of the sub-maxillary glands, larj'ngo-tracheal wheezing^ and obscurity of the vesicular murmur were observed; the throat presented only a little redness. In the evening there was the same laryngeal cough and with it expul- sion of a tubulated false membrane coming from the trachea, three centimeters (more than an inch) in length. The next day false membranes were on the tonsils, there Was increase of the dyspnoea of the continued type, and death followed in the night. The post-mortem examination revealed false membranes as far as the small bronchioles. All this occurred in two days. LOCALIZATION OF DIPHTHERIA, 219 But frequently the asphyxia is no longer, as in the preced- ing forms, the prominent phenomenon; infection holds the first rank. The patient having to contend at once against defective haematosis and the profound toxic effects, and haemorrhages, diarrhoea, adenitis, etc., soon sinks. Age also makes its impress upon the symptomatic totality. The condition which I have described belongs to the croup of children. That of adults takes a somewhat different course. The character of the cough and voice are the same, the aphonia occurs quite rapidly. But the dyspnoea comes on more slowly, the lar>'ngo-tracheal wheezing often fails, as well as the par- oxysms of soffocation ; the dyspnoea assumes the continued form and the the asphyxia becomes gradually established ; when paroxysms do exist they are of great violence, and the patient may expire during one of them. Aside from some of these peculiarities the disease follows the same course as in the child. The course of croup is continued and progressive ; the ac- cessions of suffocation, which impress upon it a kind of shock or paroxysm more or less violent, are followed by increase of the dyspnoea. Each paroxysm is nearly always more power- ful than the preceeding ; the respiratory restraint which sep- arates it from the future paroxysm is more intense than that which separated it from the previous one. These are the de- grees by which the disease rises progressively to asphyxia. Remissions, generally due to expulsion of false membranes, sometimes slacken the course of the disease, and even make it change front altogether, but they are rare and nearly always followed by an aggravation which gives to the progressive course a fresh impulse. Jaccoiid describes an intermittent form of croup characterized by complete remissions which ap- pear in the morning and may be prolonged until evening. Then the dyspnoea and paroxysms return. These alternations may be repeated for several days and thus give to the disease an appearance of intermittence. Often in the morning we ob- serve a certain remission of the symptoms ; but I have never, for my part, met with a true intermittence. 220 DIPHTHERIA, CROUP AND TRACHEOTOMY. In some very rare cases we may observe a cessation in the progress of the disease. A palient, set l8 months, attacked with croup, presented three remissions, on the third, the ninth and the twelfth day ; the first lasted one day, the second two days and the third five days; the last relapse took placeon the seventeenth day. During these periods of quiet the respiration became almost completely free, there remained but a slight roughness of ihe voice and cough. A fact still more remarkable was that the first relapse was marked by paroxysms of suffocation, which did not characterize the other relapses, at least up to the seventeenth day at which time the child was taken from the hospital by his parents. In another, aet 2 years, attacked also with croup, passed also to the second period, with paryoxsms of suffocation, a remission mani- fested itself the fourth day and continued four days, during which the res- piration was free and noiseless. The relapse which followed gave rise to attacks ot suffocation, but it ended in recovery at the end of eight days, and by paralysis of the soft palate and the larynx. In both cases there was diphtheritic angina. TERMINATION. Left to itself the natural tendency of croup is to asphyxia and death. Recovery is rare. In 2,809 cases of croup 204, that is one in about thirteen, were able to recover without re quiring surgical aid, 275 died in which tracheotomy could not be performed. Of the remainder, 2,312 had to seek relief from asphyxia by the tracheal incision. Recovery may be reached in cases in which, the diphtheria being benign, the false mem- brane thin, narrow, and the spasm moderate, the laryngeal ob- stacle is capable of producing respiratory disturbances of the first and even of the second period, but is not sufficient to com- pletely intercept the passage of air or to produce asphyxia. Croup ceases in the first or in the second period. The false membrane separates as in benign diphtheria, and recovery takes place. If the process is more active the symptoms are more grave, and the tendency to asphyxia is more marked. A chance of re- covery still remains, viz : the expulsion of the obstructing false membrane by the effort of coughing or vomiting. While too often transient, the benefit obtained by removing the obstruction from the larynx may become final from the first time, or only after several alternations of alleviation and return of these symp- toms. Asphyxia is the principal cause of death. Occlusion of the LOCALIZATION OF DIPHTHERIA. 221 larynx by false membrane or by spasmodic contraction, fol- lowed by paralysis of the muscles of the larynx, is generally the mechanism by which it is accomplished. Other causes may hasten the effects of it or add fatal consequences to these obstacles, which, so far as the structure is concerned, might be incapable of causing death. The propagation of false mem- branes to the trachea and to the bronchi is the most common and the most rapid method. The small quantity of air which passes the larynx finds no longer sufficient surface for the necessary exchange between the blood and the external air. The defective oxygenation, and, as a consequence, death, are inevitable, should bronchitis be somewhat extensive. All the thoracic complications, such as bronchitis, broncho-pneumonia, pneumonia, pleuritis, etc., act in the same way. Extensive poi- soning of the system is added to the respiratory impediment in producing death. The mechanical obstruction is surpassed by the poisoning which conduces to the dreaded result in the midst of ataxo-adynamic phenomena most pronounced. I have seen one case of this kind terminate fatally in less than twenty-four hours. Inanition, a consequence so frequent of the repugnance for food, which characterizes the grave forms of diphtheria, has no less influence upon the termination. Sudden death is not very rare. During the progressive pe- riod it is nearly always due to laryngeal asphyxia ; the patient sinks during a paroxysm of suffocation. In one case death by asphyxia was produced in a few moments without showing the usual appearance of paroxysms of suffocation. The au- topsy revealed the lower part of the trachea filled by a plug of false membranes formed by a patch detached from the su- perior part and rolled upon itself Convulsions are some- times the final phenomena. Sudden death by syncope, much more rare, is observed especially during convalescence, at a time when paralysis prevails. DURATION. All the causes which modify the course of croup and influ- ence its termination produce their effects upon its duration. Beyond all others, tracheotomy produces considerable changes 222 DIl'HTHERIA, CROUP AND JKACllKOTOMV. in the course of the disease or upon its issue, by suppressing the asphyxia, postponing death, or bringing about recovery. The time occupied in reaching one or the other of these is- sues, when croup is subjected to tracheotomy, would not give the real duration of the disease. When the operation is per- formed, and the laryngeal obstacle obliterated, croup, with its special symptoms, no longer exists, it is reduced to a diphthe- ria more or less extended, more or less complicated. It is of croup without the operation that we must make the necessary inquiries. Operated croup may, however, furnish very useful information. The operation is practiced, in the large majority of cases, at least in those which have come un- der my observation, in the third period, at the time of as- phyxia; and it is not preventive, but palliative, furnishing a supply of air to the unfortunate patient who is strangling. Excepting the cases operated on in extremis, it precedes, by a few hours, the moment when the patient would succumb if de- prived of its aid. In these cases the period comprised be- tween the beginning and the time of tracheotomy may, there- fore, be considered as representing quite approximately the duration of croup terminated by asphyxia. By consulting the following table one will see that in the cases of croup which died abandoned to themselves, as in those which were arrested for the time by tracheotomy, the most numerous are found in the first three days. As to the operated cases the transition is abrupt ; from the third to the fourth day the figures fall from 150 to ninety; on the following day the descent is still more considerable ; we find only forty-four cases. It is, there- fore, evident that the greatest number of patients succumb to asphyxia before the fifth day. In the column which contains the cases of death from croup, left to themselves, the decrease is progressive including the fourth day; then the mortality rises suddenly the fifth day, to fall again the sixth. The cases of this class appear, there- fore, to continue longer than those which reach tracheotomy. There is a reason for this difference. We operate by prefer- ence on those patients in whom the asphyxia by laryngeal ob- LOCALIZATION OF DIPHTHERIA. 223 struction is the dominant feature, those in whom the poison- ing seems sHght. These are arrested at the end of the third or fourth day at farthest. We avoid, as far as possible, op- erating on those in whom the obstruction is not Hmited to the larynx, in whom the diphtheria is general, and who show signs of profound poisoning. If in these cases the course may be rapid, as the figures show for the first three days, it is oth- erwise when death depends much less upon asphyxia than upon the general symptoms. In this category are found the patients who die on the fifth day and the following days: DURATION, Croup not operatec on- Croup operated on. r N From the beginning to Recovered. Died. the operation. Number of the day. Cases. Cases. Cases. I - 10 92 2 - 18 152 3 I 13 150 4 2 10 90 5 3 15 44 6 2 5 32 7 4 3 9 8 4 5 17 9 I 2 3 10 9 5 3 II 6 3 I 12 4 I — 13 2 — — 14 I — — 15 3 — — 16 I — — 17 3 — — 18 2 — • — 19 3 — — 20 I — — 21 I — — 22 3 — — 23 I — — 26 2 — — 27 I — — 32 I — — 60 I — — 224 DIPHTHERIA, CROUP AND TRACHEOTOMY. If the preceding figures give exact results in respect of croup terminating in death or in tracheotomy, it is not equally true for the cases which recover spontaneously. In fact it is diffi- cult to fix the time when croup ceases. The symptoms of this disease being the peculiar characteristics of the cough and voice as well as of the respiratory impediment, one may consider the disease as terminated only when all these disturb- ances have disappeared. Now, alterations of the voice and of the cough often persist for a long time. On the contrary, by limiting croup to the single presence of respiratory restraint would be to expose ones self to commit serious mistakes. Dyspnoea may cease before the false membranes have entirely disappeared, and we have no rational means of ascertaining this disappearance as to the exact moment. Careful examina- tion with the laryngoscope could alone supply the exact indi- cations. Another element of information more exact is fur- nished by the expulsion of the false membranes. If after the expulsion of one or several fragments of pseudo-membranous debris, the respiratory impediment ceases in a definite man- ner, we may presume that the last expulsion leaves the respi- ratory mucous membrane entirely clean, and fix that date as the termination of the croup. Now, the expulsion of false membranes seldom extends beyond the first week ; it may cease from the next day after the operation, but it may reach the twenty-second and even the thirty-second day, as I have myself witnessed. These latter cases are exceptional; they are only explicable by successive exudations of false mem- branes. It is necessary to consider also, the concretions which are expelled at the end of the first ten or twelve days. In re- ality, while in the tracheotomized cases which recover rapidly, the false membranes cease to appear at the end of ten days, in croup not operated the maxinum of recoveries is made in the first eleven days. Moreover, we have observed that the false membranes of the throat which are held more tenaciously than those of tthe respiratory passages, separate from the fifth to the fifteenth day. It is useful also to know the duration of tracheotomized LOCALIZATION OF DIPHTHERIA. 225 croup. This is no longer the duration of croup in which only the evolution of false membrane and its effects are considered, but that of croup in its complex condition in which it appears most frequently. Under these conditions croup has a dura- tion, in the fatal cases, of from one to fifty-two days ; the greatest mortality manifested itself between the second a^^d eighth days. In those in which the issue was favorable the duration was from eight to 126 days, without showing any great preference for any one period in particular. The most numerous recoveries definitely were on the fifteenth, twentieth and the thirtieth daj's, Th^e elements which enable one to determine the length of the periods of croup are more rare. Not only one or two of them may be wanting, but the information furnished by tiie attendants is very indefinite. For the second and the third periods especially, the results fail of ^^recision. By rejecting the doubtful cases I have arrived at the conclusion that for the first period the duration oscillates most frequently between one and four days; and that it seldom exceeds one day for the second, and rarely extends beyond a few hours for the third. Duration. Days. I 2 3 4 5 6 7 8 9 10 SECOND ATTACKS (rECIDIVES.). Croup may attack the same subject at several different times. Guersant, Gombault, Warmont and Millard have had to operate PERIODS OF CROUP. Number of Cases. A First period. Second period. Cases. Cases. Third period. 7 Few hours. 45 60 I] « « 32 16 7 6 it (C I (( I « I <i I (( 226 DIPHTHERIA, CROUP AND TRACHEOTOMY. on some patients for croup, who had been tracheotomized quite a long time previously, for the same cause. I have met some cases of a second attack of croup, but the second has not, as the first, required tracheotomy ; it has always been benign; in three cases it returned ; to wit, in one of them after one year, in the others nineteen days after the recovery of the first. Croup not operated has furnished a larger number of return cases. The return has not always followed croup, but also an- gina only. In ten return cases, five attacked the larynx, the others were limited to the tonsils. They appeared from the fourth to the twentieth day. They were all benign. Except in one case which depended upon an infectious diphtheria there was no occasion to operate. COMPLICATIONS. All the complications which depend upon diphtheritic poi- soning appear also in croup. They have reference to the blood, the nervous system, the digestive apparatus, the lymphatics, etc. I have already described them, and it will be sufficient here to mention them. Others, although making a part of the train of diphtheria, and remaining liable to figure -in all the lo- calizations of this disease, assume, however, more intimate re- lations with croup, of which they are the true complications. I now speak of the lesions of the respiratory apparatus. A third group is composed €>f diseases entirely foreign to diphtheria, such as the eruptive fevers, typhoid fever, etc., which, in the hospitals especially,are found so frequently in the course of croup. Of course I shall not consider as complica- tions the other localizations of diphtheria, viz., angina, coryza and pseudo membranous bronchitis which may co-exist with it. I. — Complications Affecting the Respiratory Apparatus. These implicate the larynx, the trachea, the lungs and the pleura. LARYNX. The lesions which reach the larynx are ; I. Ulcerations similar to those which affect the trachea; their description will be the same with those of the ulcerations LOCALIZATION OF DIPHTHERIA. 22/ of that organ. It may be proper to say here that they are pri- mary, or are due to the extension of those from the trachea. Sometimes they are deep and produce necrosis of the car- tilages. 2. Muscular lesions caused by the propagation of inflamma- tion from the mucous membrane to the muscles. These altera- tions are not incurable, but they cause a persistence of the res- piratory and phonetic disturbances for a long time after the separation of the false membranes, and compel the patient to retain the canula. I shall consider them with the causes which retard the removal of the canula. 3. OEdema of the glottis, polyps of the larynx of which the study will also be treated in the same chapter. TRACHEA. They are of two kinds, traumatic and ulcerous. 1. Traumatic . These are the ruptures which are produced under the influence of paroxysms of suffocation. Latour has cited a remarkable case of it. Traumatic emphysema is the consequence of this solution ef continuity. 2. Ulcerous. These are the more frequent. They are known under the name of ulcerations of the trachea. In a previous work I made a monograph of these ulcerations. I will give them a resume, modified slightly in consequence of later ob- servations, in the part which will treat of the sequences of tracheotomy. There will be found the place of these lesions which are, in the great majority of cases, the result of pressure of the canula. LUNGS AND PLEURA. The pulmonary complications are : Simple bronchitis, bron- cho-pneumonia, pulmonary congestion, pneumonia, pleuritis, emphysema, apoplexy, gangrene and oedema. In the chap- ter on the pathological anatomy I have described the lesions which correspond to these complications, have noted their fre- quence, and established their pathogeny. I have proved that several of these morbid states should be considered, less as complications developing themselves under an exterior in 228 DIPHTHERIA, CROUP AND TRACHEOTOMY. flucnce, than as diphtheritic manifestations arrested in develop- ment, or as congestions or visceral inflammations which arise in diphtheria as in typhoid fever and in general diseases. In this light it is better to regard the bronchitis and broncho pneumonia. Others, such as pneumonia, pleurisy, gangrene and oedema, give evidence of propagation to the pulmonar\ parenchyma ;ind to the pleura, of this inflammatory condition, limited at first to the mucous membrane of the bronchi. Tht emphysema proceeds from the respiratory restraint ; the ap- oplexy is, at the same time, connected with the asphyxia and the infection. I have also demonstrated by figures that these complication.- were not under the special influence of tracheotomy ; that in the cases in which autopsies were made the lesions had been ascertained at a period sufficiently near to the beginning to justly admit of their frequently being attributed rather to the development of the morbid process than to the operation. To these evidences we might add others. Croup, not operated on, diphtheritic angina alone, and even isolated diphtheritic coryza, are accompanied with these same pathological conditions. On the other hand, comparative pathology proves, as Duhomme has observed, that the pulmonary phlegmasiae are very rare in those who have undergone tracheotomy for any other disease except croup. The period at which the complication is diag- nosticated during life, confirms, as I shall prove later, this view of the subject. I shall develop these arguments more fully when I shall treat of the sequences of tracheotomy. Let us recognize, however, that, if this operation is not the special cause of these phlegmasiae, it has, however, its part in their production. The proof of it is in the diminution of these com- plications since the use of the cravat has prevented the cold and dry air from reaching the bronchial mucous membrane. Before this practice nearly all the patients succumbed to bron- cho-pneumonia. This was the cause of numerous failures, which at the beginning nearly compromised an operation which, since, has restored to life so many patients. It is curious to observe the increasing progress of success coincident with LOCALIZATION OF DIPHTHERIA. 229 the more skilful application of the after-treatment, especially now that the field of contra-indications is being, little by little, considerably restricted, we operate on a multitude of patients that would have been abandoned a few years since. I shall still have to set forth the symptoms of these complications wherein they have relation to croup, and to show their influ- ence upon the course of the disease. Before proceeding farther it will be proper to say a few words respecting auscultation in subjects attacked with cro7ip, zvliether operated or not. We encounter in this study difficul- ties of which we must be informed. It is only necessary to place the ear over the chest of one of these patients to learn how difficult it is to recognize the estab- lished stethoscopic signs. Before the operation the difficulty arises from incomplete entrance of air into the chest; the signs which might reveal a pulmonary lesion are lost in the general silence or are masked by the laryngo-tracheal wheez- ing which resounds in the chest to such a degree as to drown all other sounds. By its intensity and by the character which it assumes on auscultation, this phenomenon may give rise to certain errors. Slightly intense, it has a certain re- semblance to the respiratory murmur. This analogy, it is true, is imperfect but an ear unaccustomed to this kind of auscultation may be deceived; I have seen persons experi- enced in ordinary auscultation commit this error. Such a mistake may be fatal to a patient by authorizing irreparable delay of an urgent operation. A careful auscultation always enables one to distinguish the two sounds. When the air enters the chest one hears the murmur which characterizes the opening of the vesicles ; when it does not enter, or enters but little, one is assured that the sound heard does not arise under the ear, but is only the re-echo of the wheezing produced in the larynx. When the wheezing is very intense, it has the character of the bronchial souffle, also an error to be avoided ; this is perhaps the most difficult. The comparison of the two sides and percussion will assist in recognizing the nature of the sounds. In cases in which the reverberation is feeble, one 230 DIPHTHERIA, CROUP AND TRACHEOTOMY. may perceive the murmur (rales) if they exist. We see how little confidence can be placed on the stethoscopic phe- nomena. The only symptoms which cause suspicion of the development of a thoracic complication, are the frequency of the pulse and respiration and the elevation of temperature. If the difficulty is great in distinguishing the sounds which oc- cur within the bronchial tubes, what will not that be which at- tends the examination of the sounds of the heart! Percussion may render some service only in the cases in which it reveals a very evident and quite localized difference in the sonority. Differences less marked are often causes of error, and are remarkable for their great instability. After the operation air penetrates the chest, but auscultation en- counters other obstacles no less potent, to-wit, the sounds which come from the canula. Whether these sounds be whistling, or gurgling, or rattling, etc., they extinguish, none the less, if somewhat intense, those which are produced in the lungs and in the heart. The principal is a whistling with a metallic ring, which one may easily take for the bronchial souffle. When the canular sounds are moderate the stetho- scopic signs are heard more easily. The details are well to know in order to fi.x the diagnosis ; it presents many diffi- culties ; the rational signs indicate it, but the physical signs often fail. Since the canula can be removed for a few mo- ments without inconvenience, it is necessary to withdraw it while one auscultates the chest. This is the only means ot judging whether the respiration is clear and full, and of recog- nizing abnormal sounds. Connnoii Characteristics. The Beginning. — Croup, under ordinary conditions, gives rise to moderate fever. The pulse varies between 96 and 120 in the child, and be- tween 72 and 80 in the adult. Respiration, while slightly accelerated, remains in the neighborhood of 36 to 48 in the minute; and finally, the temperature does not exceed 38° or 38.5° (100° to 101'/,°)- As soon as a thoracic phlegmasia arises, the fever lights up, the pulse rises to 120 or to 160, the respiration to 50 or 60, and the temperature to 39.5° (103°) or LOCALIZATON OF DIPHTHERIA. 23 1 1040*^ ("04°) or higher. If this onset is near the beginning of the disease, the transition is imperceptible, and the patient appears with this symptomatic development which of itself, in the absence of every sign furnished by auscultation, is a certain index of a lesion of this nature. Should it be later, then, to a condition almost apyretic succeeds a febrile state, and oppression accompanied sometimes by vomiting and con- vulsions. These common characters being indicated, I coifie to each complication in particular. Let us observe, before going farther, that these morbid conditions, being often asso- ciated, as anatomical examination has proved, the symptoms peculiar to each are rarely distinct; they are very commonly confounded, the more feeble masked by the more prominent. I. Simple Bronchitis. — Nothing distinguishes it from ordi- nary bronchitis ; during the asphyxial period of croup its symptoms are veiled by the laryngo-tracheal wheezing; the small quantity of air which enters the chest communicates to the chest-walls and to the bronchial liquids only vibrations insufficient for the production of physical phenomena. After tracheotomy, one may, by taking proper precautions, perceive the signs furnished by auscultation. When it is limited to the large tubes and is superficial, fever and oppression are moder- ate, expectoration soon becomes decidedly mucous, and the prognosis appears favorable. If more intense, it gives rise to a quite abundant muco-purulent expectoration, which is often expelled at the moment when the trachea is opened. Its ex- tension to the bronchioles presents a more severe character, the fever and the oppression increase, the expectoration is diminished which gives rise to the expression, the ca/nila is dry. The prognosis becomes more doubtful not only because of the addition to the croup of a condition which of itself is not devoid of gravity, but because this bronchial phlogosis is often only the first stage of broncho-pneumonia or of pseudo- membranous bronchitis, both so much to be dreaded. Simple bronchitis should not be confounded with another thoracic af- fection. One should not take for rales which characterize it, certain coarse and dry sounds analogous to the pleural frictions* 232 DIPHTHERIA, CROUP AND TRACHEOTOMY. indications sufficiently common of bronchial diphtheria at the begfinninp;. When it coincides with other thoracic lesions, which often happens, it remains decidedly in obscurity. 2. Broncho-Pneumonia. — According to results furnished by anatomical examination we see that the characteristic lesions of broncho-pneumonia are found in the earlier stages of the dis- ease, that is from the third to the sixth day. Investigations nicSde during life confirm in every respect these results. The diagnosis has been fixed at the following dates: [Of 129 cases 98 occurred within the first nine days]. The greatest number of cases, therefore, is also found at the com- mencement of the disease, from the second to the seventh day, with this peculiarity, that the second day is, with the fifth and the sixth, the one which corresponds to the highest figures. I have also made a counter evidence in respect of the in- fluence of tracheotomy in the production of broncho-pneumo- nia. The post-mortem results have proven that taken in its re- lation to tracheotomy, broncho-pneumonia was established ana- tomically, especially in the first two days which followed this operation. The examination during life led to the same con- clusions. Period when the diagnosis Number of Period when 1 he diagnosis Number of was made. cases. was made. cases. Evening of the operation. 4 9th day - 3 1st day - 19 loth " - I 2d " - 44 nth " - I 3d " - 1 1 1 2th " - I 4th " - 4 13th " - 2 5th " - 6 14th " - 2 6th " - 3 15th " - 2 7th " - 2 18th " - 2 8th " - 2 25th " - I Tetal, - - - - - no The first two days have manifestly the highest numbers. The data furnished by the examination of the patient ac- cord, therefore, with those from pathological anatomy. Trache- LOCALIZATION OF DIPHTHERIA. 233 otomy is certainly not the only cause of broncho-pneumonia. This pulmonary inflammation developes itself at the begin- ning of the disease, when the process is in al' its power, then it rapidly diminishes in frequence at the end of a few days. The symptoms of broncho-pneumonia are often obscured dur- ing the period of asphyxia of croup. It is only after the op- eration that it is practicable to fix the diagonosis; to the fever, and oppression are added the signs furnished by auscultation and percussion, viz., sub-crepitant rales, bronchial souffle, and dullness. In the absence of others one of the most reliable symp- toms is the acceleration of respiration. Millard has established correctly, that one may suspect a pulmonary inflammation every time when the respiration exceeds 50 inspirations in the minute. htiology. — Though it is not doubtful that broncho-pneumo- nia is one of the accessories of the diphtheritic impulsion, yet one may not deny the action of cold in its production. The want of proper care in tracheotomies powerfully favors it. In cases especially, which arise at a period remote from the be- ginning, when the first effort is declining, it is difficult not to assign an important place to this influence. The inspiration of an atmosphere too cool through the canula or by the wound, contact of the cutaneous surface with air insufficiently warmed, are its principal modes. Anaemia, and the general shock which follows croup, render patients very sensible to external in- fluences. Prognosis. — The gravity of broncho-pneumonia in case of croup is excessive, and so much the more as it is often accom- panied with other grave lesions, viz., pseudo-membranous bronchitis, pneumonia, pulmonary apoplexy, gangrene, etc. This it is which carries off the largest number of tracheoto- mized cases ; in 199 cases of broncho-pneumonia only eight were able to reach recovery. It is dreaded at all periods of the dis- ease. At the beginning its gravity is not always revealed very plainly in the midst of the symptomatic confusion, sometimes so complex, which characterizes this period, but it appears in plain view when, supervening in a patient nearly well, it sud- 234 DIPHTHERIA, CROUP AND TRACHEOTOMY. denly destroys an edifice erected at a cost of persistent labor and incessant solicitude. Of the eight cases of recovery of which I have spoken, three corresponded to the third day of the disease, two to the fourth, one to the fifth, one to the thir- teenth and one to the fourteenth. Thus, of the numerous cases developed from the fifth to the forty-first day, we find only two recoveries. 3, Pulmonary Congestion. — Rarely found alone, it must be nearly always reckoned with other more serious lesions ; often precedes them. When the croup is simple, it (the former) is the result of asphyxia ; the cyanosis is one of the signs which reveal it. Auscultation tells nothing because of the difficulty of respiration. It disappears after tracheotomy. When it co- incides with other grave pulmonary lesions it is consigned to a second rank and disappears in the whole. Finally, in certain cases of profound infectious diphtheria, it exists alone as in typhoid fever and other diseases of like nature. It is recog- nized by its ordinary signs, viz., subcrepitant rales more or less extended, with corresponding dulness. The gravity of the situation depends then upon the general condition. Pulmo- nary congestion can claim only the position of an epiphenome- non. It is, after all, a secondary element which complicates several morbid conditions, whether it preceds, accompanies or follows them. It contributes to each its contingent of aggra- vation ; but it has no morbid personality. 4. Pneumonia. — The symptoms of pneumonia appear also in the early days of croup. From the second to the fifth day the cases were most numerous. In a list of twenty cases, eight cases of croup are included not operated on. It is proper to remark that pneumonia ap- peared once in one case of diphtheria limited to the throat. In regard to its relation to tracheotomy, pneumonia furnishes analogous results : LOCALIZATION OF DIPHTHERIA. 235 Date of the Diagnosis. 1st day before tracheotomy, 1st day of tracheotomy, 2d << << 3d « It 4th « <4 5th « « 7th It H 8th It H loth u << 71st <( <( Total, No. OF Cases. 2 2 2 I I I I 2 15 The intensity of the symptoms of pneumonia enables it to be more easily distinguished than other complications. Thus diagnosis coiild be formulated twice before tracheotomy and in several other cases, notwithstanding the coexistence of other serious pathological conditions, such as pseudo-membranous bronchitis and broncho-pneumonia. Therefore, there exist no difficulties in this respect. Pneumonia runs its course with' more or less rapidity, depending upon whether it ends in reso- lution, passes to suppuration, or causes death, while remaining in the second degree. The prognosis is grave ; in forty-eight cases seven only recovered. This mortality is explained by the other bronchial lesions which exist at the same time, and of which it announces the propagation to the pulmonary parenchyma. The facility of transition to the third degree proves the intensi-. ty often assumed by the pulmonory inflammation, since in thir- ty-two pneumonias shown at the autopsies, nine of them were in the stage of grey hepatization. Of the seven recoveries, four belonged to croup not operated on ; they had begun re- spectively on the second, third, fifth and tenth day of the dis- ease. The three which belonged to operated croup were dis- covered on the preceeding evening, the thirtieth and seventy- first days of the operation respectively. This last is so late that it might be considered as independent of croup, and as purely accidental. Thus, in eight cases of pneumonia supervening in 236 DIPHTHERIA, CROUP AND TRACHEOTOMV. cases of croup not operated on, four terminated favorably. In forty occuring in tracheotomized cases, only three recovered. These results correspond with the difference in gravity which croup presents in these two series, and, at the same time, with the simplicity of pneumonias in the first as opposed to their complexity in the second. 5. Pleiirisy. — This is not, properly speaking, a direct conse- quence of croup, but an extension of the pulmonary inflamma- tion to the pleura. Ten cases of pleurisy in twenty-nine could be recognized during life. It is more difficult to establish ex- actly the date of their appearance; the commencement passes often unnoticed, either by other complications existing pre- viously and obscuring it, or by its slight intensity and its mild- ness attracting attention only after a considerable time. The cases indicate a certain grouping of pleurisy around the first days of the disease, but several of them are disseminated without apparent order. Besides, it is natural that the trans- mission of the pulmonary lesions to the pleura, and, therefore, the beginning of the pleurisy, should occur at variable periods. The diagnosis is often rendered obscure by the coincidence of other pulmonary lesions. However, the classic characteristics of pleurisy, which I need not recall, permit an exact estimation in the majority of cases. Prognosis. — Of twenty-nine cases of pleurisy, the recovery was effected in nine. Of these nine cases, eight continued during the active part of the trache- otomized croup. This reversing of the ordinary proportion, which usually gives the greater number of deaths on the side of the cases of tracheotomy, shows once more the absence of direct dependence between croup and pleurisy. The pleural phlegmasia is especially connected with other pulmonary in- flammations of which it is only an extension. 6. Pulmonary EmpJiyscrna. — However frequent emphysema may be, it is very difficult, and, so to speak, impossible to as- certain its presence during life. The symptoms of asphyxia and those of the other pulmonary complications always pre- vent its recognition. Besides, it is never sufficiently intense, except in cases of traumatic origin, to cause suspicion of its LOCALIZATION OF DIPHTHERIA. 23/ presence. Traumatic emphysema is no longer a complication of croup, but an accident of the operation of tracheotomy. 7. Pulmonary Apoplexy. — Respecting this, I should also limit myself to what I have said of the anatomical lesions, and of the pathogeny. Whether it be the result of asphyxia or of the infection, it is accompanied by other lesions, the symp- toms of which mask those belonging to it. In a case of diph- theritic paralysis, extending to the respiratory muscles, which terminated by asphyxia, the pulmonary apoplexy ascertained at the autopsy furnished no s)'mptoms during life except slow dyspnoea and rales of bronchitis. It is infrequent; I have only met with it eighteen times. 8. Pulmonary Gangrene — I shall say the same of gangrene ; its history has more connection with the anatomy than with the symptomatology. Its coincidence with broncho pneu- monia has always rendered its beginning obscure. The morti- fication of the tonsils, of the uvula, and of the walls of the wound in the neck, may point in the direction of the diagno- sis. But how frequent are these cases of gangrene compared with those of the lungs. The peculiar odor is significant only when the wound and the throat are healthy. The only symp- tom which appears to have any value is the profound prostra- tion into which those patients sink a few days before death, who show at the autopsy the lesions of pulmonary necrosis. If this depression appears in a patient already attacked with gangrene of the wound or of the throat, and suffering at the same time oppression, there will be occasion for doubting the existence of pulmonary gangrene. 9. Pulmonary CEdema. — This form of dropsy, probably the result of the impeded circulation of the lungs, does not ordi- narily reveal itself by any external sign. However, the case observed by Traube presented some interesting peculiarities. A woman, in the ninth month of pregnancy, came, com- pletely cyanosed and breathing with difficulty, to the clinic of the professor. False membranes lined the throat, and exam- ination with the laryngoscope showed that they extended to the larynx. The respiration was stertorous, and could be 238 DIPHTHERIA, CROUP AND TRACHEOTOMY. heard at a considerable distance. Tracheotomy was per- formed. An unimportant amelioration was the immediate re- sult. Then, at the end of a few minutes, the patient expelled through the canula, without the efforts of coughing, a perfect flood of serosity. Respiration was more free, and the stertor diminished. But in the evening the patient was delivered of a dead child, and expired a few moments afterwards. At the autopsy the larynx and bronchi were found lined with false membranes, and a pneumonia of the right side, but only traces of pulmonary oedema. Should we in this case regard the oedema of the lungs as existing previously to the tracheot- my, or as an infiltration following the congestion of these organs? I should be so much the more inclined to admit this latter hypothesis as the autopsy showed only traces of the liquid in the lungs. An oedema, produced under the influence of pregnancy, would not be, from all aj^pearances, evacuated so suddenly and so completely II. Complications Foreign to the Disease and to the L0C4L Condition. Measles. — This exanthema sometimes disturbs the course or the convalescence of croup, especially in hospital. Its fre- quence is inconsiderable ; I have encountered it in but nine cases, of which one was in a croup case not operated on. It appeared in the others from the seventh to the thirtieth day of the operation. Date of the Number of Date of the Number ot appearance. cases. appearance. cases. 7th day of operation. - i 21st day of operation. - i nth " «' " - 2 25th " " " - I i8th " « «* .2 30th " «' '. _ I Total, -..-.- 8 To these eight cases I will add the croup case not operated on, in which the measles appeared the thirtieth day from the beginning. Twice it followed a case of scarlatina, which itself had appeared after the operation. The beginning is al- LOCALIZATIQN OF Dli'HTHERIA. 239 ways announced by fever and by a remarkable arrest of the proces of cicatrization of the wound ; it may even occur that the wound, entirely cicatrized, will reopen. The bronchial symptoms never failed ; broncho-pneumonia of measles car- ried off the largest part of the patients. Death was the ter- mination in two-thirds of the cases. The child without opera- tion succumbed also under this same influence. One should anticipate such a result when he sees the measles, a disease which exposes so seriously the bronchial tubes, follow croup, which spares them no less. The prognosis is, therefore, veiy grave, which is so much the more to be regretted because the measles levy this tribute upon patients who have passed through dangers of tracheotomized croup, so terrible, of which the recovery was almost certain. Prophylaxis. — Isolation of patients attacked with croup, especially those operated on, should prevent, as far as it is possible, this occurrence. The operated patients who die in this way are victims of the morbid promiscuousness which ex- ists in the wards of the hospital. Scarlatina. — This eruption, while it should not be con- founded with the scarlatiniform eruption, which appears in the course of diphtheria, is more rare than measles, which is in ac- cordance with the inferiority in number in which scarlatina is found proportionately to measles as to general frequence, I have collected seven cases of it. It appears at a time nearer the beginning, on the third or fourth day of the operation ; in one case it was postponed to the thirty-second day. Date of its Number of Date of its Number of appearance. cases. appeajance. cases. 3d day of operation. - 3 32d day of operation. - i 4th " " " - 2 Total, - - . . . - 6 The patient not operated on was taken on the ninth day from the commencement. The invasion is announced like that of measles, when it comes on sufficiently slowly, by the same disturbances on the part of the wound. The prognosis is, be- sides, favorable, recovery having occurred in all the cases. 240 DIPHTHERIA, CROUP AND TRACHEOTOMY. One I of these patients sank under measles which he contracted three weeks after the scarlatina. Erysipelas. — This complication being peculiar to trache- otomized croup, I shall speak of it in detail with the sequences of the operation. Whooping Cough. — This is fortunately very rare ; I have ob- served it in only four cases; this spasmodic catarrh attacks croup cases not operated on as well as those on which the operation of tracheotomy has been performed. Two cases be- longed to the first and two to the second class. In the first two it appeared on the third and on the fourth days respect- ively from the beginning. In the other two it commenced on the day before the operation in one case, and five days after the operation in the other. In these children the tW'O diseases ran a parallel course in its development. The whooping cough seemed to exercise in the diphtheria its fatal influence upon the bronchial tubes. The four patients died of broncho-pneu- monia. Far from entailing, as usual, a certain degree of suf- focation, the paroxysms did not render the attacks of dyspnoea more numerous ; several of them were not followed by any at all. In one patient only certain paroxysms were followed by violent fits of suffocation. The paroxysms occasioned, in the tracheotomized cases, quite a curious modification ; the char- acteristic wheezing was wanting. The prognosis has not ap- peared equally fatal to all observers ; several cases of recovery have been reported. SEQUELS. When the false membrane separates, the inflammation de- clines, the croup is considered as cured under ordinary circum- stances. It is quite otherwise in those in which the respiration remains difficult and the voice hollow. These prolonged difficulties appertain to anatomical lesions which I have already described. The persistence of the tumefaction of the laryngeal mucous membrane or even its cedematous infiltration, and the degeneration of the laryngeal muscles are so many causes of oppression and roughness of voice, which continue a long time LOCALIZATION OF DIPHTHERIA. 24I after recovery. The cedema of the glottis is with difficulty- distinguished, its production is quite rapid, and in all the known cases it has only been recognized at the autopsy. The con- tinuation of the alterations of the voice, during a time which varies from some months to a year, is due to the tumefaction of the mucous membrane or to muscular alteration. The laryngoscope, by exhibiting the state of the mucous membrane and the action of the muscles, permits an elucidation of the question. Other accidents, such as strictures and polypi of the trachea, sometimes follow croup, but especially croup tracheotomized. I shall examine them in connection with the sequences of tracheotomy. Section III. — Diphtheritic Coryza. One of the first symptoms of this affection is obstruction ac- companied by a certain redness of the nasal orifices. Very soon, if not at the same time, there escapes a nasal discharge, serous, mucous, colorless, thin, yellowish and quite often san- guinolent; it exhales a peculiar odor which may be quite fetid, but which is not that of gangrene nor of ozena. At a period a little further advanced fragments of false membranes are ex- pelled in the efforts to blow the nose. At first small in quan- tity, the discharge forms but a slight oozing; it consists entirely of a few drops of clear serosity which can be made to escape by compressing the nose. It soon increases in quantity and bathes the upper lip, which it reddens and causes to swell. The patient, finds himself obHged to be constantly using his handkerchief. This discharge is known by the name oijetage. It is observed first on one side only: sometimes it occupies both, either pri- marily or successively. If then one partially opens the nostrils, he sees them lined internally with false membranes, white, thin, and resistant at first, but yellowish and brown later. Exam- ination with the nasal speculum will show approximately to what point the nasal fossae have been invaded. Frequently the false membrane projects from the nose, and it is seen to ex- tend upon the inferior extremity of the septum ; it may reach still farther and spread upon the upper lip. The alae of the 242 DIPHTHERIA, CROUP AND TRACHEOTOMY. nose are swelled ; the redness, limited at first to their borders, extends and reaches the nose itself the skin of which becomes tense shining and erysipelatous. It is not uncommon for this redness to extend on the face beyond the nose. Impermea- bility to air results from this nasal engorgement. Respiration is loud and snoring; its two periods are of equal length. The voice has a nasal tone. The patient breathes with the mouth open ; the teeth and lips becoming quickly dry, assume a shiny appearance and become covered in places with thick, dark, and hardened coatings. These respiratory symptoms may exist without any false membrane being visible, notwith- standing the use of the speculum. In these cases the poste- rior orifices of the nasal fossae must be examined by introduc- ing the rhinoscope behind the soft palate ; we will then ob- serve false membranes coating the superior portion of the pharynx and penetrating into the nasal fossae. This examina- tion is possible only in cases in which the tumefaction and the sensibility of the throat are moderate. To the morbid phe- nomena just enumerated must be added epistaxis which is one of the usual and sometimes grave symptoms of diphtheri- tic coryza. Often slight and limited to a simple oozing which darkens the discharges, it quite frequently reaches the amount of a real haemorrhage. It is rare that diphtheria remains limi- ted to the nasal fossae. At one time it extends into the nasal duct and excites free lachrymation, then it passes through the puncta lachrymalia and expands upon the conjunctiva. At another it reaches the pharynx and travels up the Eustachian tube to the middle ear. But the parts for which it has the greatest affinity are the throat and larynx. Bretonneau has generalized this fact by demonstrating that angina and croup were always preceded by diphtheritic coryza. According to him, the nasal fossae were the nidus whence the diphtheria spreads. He then proceeds to affirm that this disease propa- gates itself from the higher parts to those more dependent. The history of diphtheritic angina and of croup more than proves that this rule has many exceptions. Diphtheritic coryza is very frequently followed by angina and croup, but it is not rarely LOCALIZATION OF DIPHTHERIA. 243 consecutive to angina, or is developed at the same time with it, which former case is the most frequent. Aside from all propagation by contiguity, we find other diphtheritic manifes- tations at distant points of the economy. Thus, diphtheritic coryza frequently coincides with the formation of false mem- branes upon the skin, upon the genital organs, the anus, or upon the lips and tongue, and sometimes in the bronchial tubes without the medium of the larynx and trachea. The general symptoms which accompany diphtheritic corzya are those of infectious or malignant diphtheria. This localization has been justly considered as one of the most serious, one which best characterizes diphtheritic infection (Barthez and Trousseau), Excepting the rare cases in which the false membrane does not extend beyond the nose, or in which other manifestations do not arise in various regions, diphtheritic coryza is always a very grave prognostic. When death is not the result of infection or of propagation to the air-passages, epistaxis is one of its fre- quent causes. The coincidence of coryza with other diphtheri- tic manifestations makes its duration difficult to prove. How- ever, Barthez and Rilliet mention two cases in which it ended in three days. On the other hand, Isambert has spoken of a patient who expelled false membranes for several months when blowing his nose. Excepting this case, diphtheritic coryza is acute, and does not appear to be accompanied with ulceration of the mucous membrane ; it attacks neither the cartilages nor the bones of the nose. It is observed at all ages, but it is more frequent in children Section iv. — Pseudo -Membranous Bronchitis. The aspect of bronchial diphtheria varies according as it coincides or not with croup, as it is observed before or after tracheotomy. One might suppose at first sight, that, consider- ing it, independent of croup, or indeed in croup tracheoto- mized, the air penetrating the chest, it would present itself with its peculiar characteristics. There is nothing more frequent, because of other lesions which run concurrently with it. In the description of symptoms I shall establish two categories. 244 DIPHTHERIA, CROUP AND TRACHEOTOMY. In the /■;-j>7 will be found bronchial diphtheria accompanying croup as it is before the operation. In the second I shall place bronchial diphtheria without the intervention of croup and that which is observed in croup after the operation. The ab- sence of the laryngeal obstruction on the one hand, its removal by the operation on the other, allow the two latter forms of pseudo-membranous bronchitis to be placed side by side. When bronchial diphtheria exists in a patient attacked with croup and not operated upon, it signalizes itself, aside from the local and general symptoms of croup and of diphtheria by a notable acceleration of the respiration: the number of inspir- ations is from 50 to 60 per minute. Dyspnoea is considerable, but it loses the intermittent and spasmodic character peculiar to croup, and it assumes the continued type; asphyxia is pro- duced slowly. The face instead of being cyanosed, and turgescent, is pale; the lips only and the skin under the nails are bluish ; the eyes are dull, and the patient dejected. The retraction (tirage) is moderate. This form of dyspnoea fur- nishes the most certain sign of bronchial invasion with false membranes. Other symptoms are of great value; they are furnished by auscultation and expectoration. Auscultation rarely furnishes definite signs; the respiratory restraint pro- duced by the laryngeal obstacle prevents the manifestation of morbid sounds under the ear. It may furnish, however, under certain circumstances, valuable information. When the exu- dation commences and reaches only the large bronchi, one hears, towards the root of the lungs, coarse creaking with a dry tone, a rubbing sound which has a certain analogy with pleuritic friction. Later, when the false membranes com- mence to separate, creaking or croaking may be replaced, ac- cording to ancient authors, by a tremulous or flapping sound. I doubt whether this sign still inspires any great confidence. Fnally if the false membrane extends to a large bronchial di- vision, the respiratory murmur is notably enfeebled on the af- fected side. In the absence of difference in percussion, the inequality of vesicular expansion in the two lungs, is one of the best signs of pseudo-membranous bronchitis, at least at the LOCALIZATION OF DIPHTHERIA. 245 beginning. Later the rubbing sound completes the picture. Tliese symptoms are inconstant, the insufficient access of air into the chest often prevents them from being perceived ; the co-existence of another pulmonary lesion masks them in many cases. The expectoration constitutes the best, and, so to speak, the only unobjectionable sign. That is the only lesion itself which comes under the eye of the observer during life. I will not repeat the description of the false membrane which may be expectorated; it will be found under pathological an- atomy. At the time when expelled the false membranes are curled up, flattened, and sometimes quite resembhng thickened mucus, when they are recent. They resume their form, ar- rangement, and characteristic color if they are shaken in a glass of water. When bronchial diphtheria is not accompanied by croup or if it follows on operated croup, the signs furnished by auscultation appear in all their clearness, especially during the first hours following tracheotomy. But it is necessary to this that the pseudo-membranous bronchitis should not be compli- cated. Now, we have seen how frequently it exists with such lesions as broncho-pneumonia, pleurisy and pulmonary apo- plexy. The cases are rare in which the vascular murmurs and the subcrepitant rales do not mask the symptom, which the bronchial false membranes produce. Moreover, these symp- toms are uncertain; one is reliable, that is the expulsion of pseudo membranous fragments forming hollow or solid cyl- inders, and bands or threads. When it is somewhat general- ized it rapidly leads to asphyxia. It may occur, however, that the expulsion of large false membranes will again permit the air to come in contact with the bronchial mucous membrane, and afford decided relief. But a new exudation is often pro- duced ; asphyxia resumes its course and the patient succumbs. Of all the pulmonary lesions this most certainly leads to as- phyxia; it is with this that we most frequently encounter sub- pleural ecchymoses and even true infarctus. When localized, it is of less importance; it is not rare to see patients recover who have expectorated false membranes of considerable size. The termination, most common of pseudo-membranous bronchitis. 246 DIPHTHERIA, CROUP AND TRACHEOTOMY. when it is extensive, is, therefore, death. The course, when it extends over a large surface, is rapid. Asphyxia is its speedy consequence. The description which I have given of the period at which it is met with in autopsy, shows that it has been anatomically verified between the second and the fifth day of the diphtheria. Now as it is rarely one of the diphtheritic manifestations at the beginning, we may conclude that its de- velopment is rapidly effected. In cases of recovery, it some- times persists a very long time : I saw one case expectorate false membranes till the twenty-second day. I would not af- firm that in this case the concretion belonged to the bronchi; at a somewhat distant period the fragments lost their characte- ristic form. Others expelled tubular false membranes the same day of or on the day after the operation. Between these ex- tremes lies the medium. It is in the first ten days that the false membranes are most commonly expelled. When, after this relief, the respiration remains finally calm, and auscultation furnishes the signs of integrity of the bronchial tubes ; recov- ery may be considered as attained. In the large majority of cases bronchial diphtheria is a continuation of croup ; the propagation is effected by contiguity from the larynx into the bronchi. This connection may fail. Still more rarely pseudo- membranous bronchitis exists alone. I have never seen such a case, and I should be tempted to believe that those which have been cited were really accompanied by croup or by some other unrecognized diphtheritic manifestation. In fact, I have always found with it one of these localizations, viz., coryza, conjunctivitis, labial or lingual diphtheria, or diphtheria of the skin, the genital organs, or, finally, angina. In these cases it is accompanied by symptoms of maliginant diphtheria ; pros- tration, cachexia, haemorrhages, gangrene, adenitis, etc. The details respecting the treatment show that the diagnosis of bronchial diphtheria is possible by auscultation only when it exists alone. Otherwise, the expulsion of tubular or branch- ing false membranes is the only sign of value. The prognosis is always very serious when bronchitis is somewhat extended, particularly when it is complicated with LOCALIZATION OF DIPHTHERIA. 24/ broncho-pneumonia or pneumonia. The gravity resides as well in the imminence of asphyxia as in the profound toxaemia of which bronchial diphtheria is one of the expressions. Even when slightly extensive it is always dangerous ; and it is an ad- ditional element of asphyxia when there is croup ; it is in every case a sign of more advanced infection. Section V. — Oculo-Palpebral Diphtheria. {^Diphtheritic Conjunctivitis^ The study of this form of diphtheria has engaged a certain number of authors. To the names of Bouisson, Laboulbene, Magne and Gibert, whom I have already cited, must be added those of Chassaignac, Hutchinson. Warlomont, Wecker, Peter and Trousseau, E. H. Martin, Raynaud and Duplay. Still rejected by a few authors, by MarjoHn and Lefort especially, diphtheritic conjunctivitis is accepted by the large majority of observers as one of the many local manifestations of diphtheria. The appearance of this form of diphtheria is something quite sudden, the false membrane forming rapidly, the lids swelling considerably and exuding an abundant discharge. But in the ordinary course matters transpire differently. The onset is slow, the disease has the appearance of a slight ocular affection. Coryza opens the course; followed soon by redness of the con- junctiva, swelling of the lids, and with discharge. The flow is at first sero-mucous, then purulent, but it very soon changes in character, and, when the false membrane appears, it ceases and the eye becomes dry. It reappears when the false membrane separates. The variations in the quantity of discharge forms one of the most important characteristics of ocular diphtheria. This liquid is acrid, irritates the skin, and marks its way by a red and painful streak. The lids are red, swelled, tense, shiny, and difficult to be opened for examination. Instead of being soft and oedematous as in purulent ophthalmia, they are indu- rated, rigid, and appear to inclose the eye in a resistant hull. Pain on pressure is extreme. Sometimes it is quite violent spontaneously, but in many cases it seems to pass unnoticed. With the least touch, however, it becomes intolerable ; the use 248 DIPHTHERIA, CROUP AND TRACHEOTOMY of chloroform then becomes indispensable in order to make a complete examination of the conjunctiva. The heat is intense and often intolerable. By partially opening the eye, or better, by everting the lid we see the palpebral conjunctiva covered with a smooth, thin, false membrane, leaving the mucous mem- brane visible by the former's transparency, folding with the lid, quite adherent, and impossible to be separated. If we examine the eye at an earlier period, we find the mucous membrane smooth, yellowish, scattered over with spots of pseudo-mem- brane which soon unite to form a general uniform false mem- brane. The palprebral conjunctiva alone is attacked, at least pri- marily ; the ocular conjunctiva remains healthy or is infiltrated so as to form chemosis. But it may also be attacked and then become coated with a false membrane pierced in the middle with a circular opening representing the situation of the cor- nea. At this time the eye is almost completely dry from the compression exerted upon the vascular system and upon the conjunctival glands by the false membrane. However, in rais- ing the lid a serous liquid escapes, of a dull gray, formed ot tears, mucus, epithelial debris, coloring matter of the blood, and a few leucocytes. At the end of a period varying from a few hours to three or four days, the false m.embrane commences to separate at the edges, later it falls off, but often it is replaced by another ; several exudations may form successively. Finally, the exudate disappears either by becoming detached or reab- sorbed. With its detachment a notable relaxation of the con- junctival ischa^mia coincides. The ocular mucous membrane again becomes red, even gran- ular ; the dryness ceases, and the secretions reappear. The discharge becomes at first like it was in the onset, then it as- sumes a simple purulent appearance. It would be difficult at this period to distinguish conjunctival diphtheria from purulent ophthalmia. But it is at the very moment when the detach- ment of the false membrane gives hope of the happy termina- tion of the disease, that grave alterations of the cornea appear. The compression of the conjunctival vessels which has pro- LOCALIZATION OF DIPHTHERIA. 249 duced the chemosis and restricted the nutrition of the cornea, is followed with opacity and even real necrosis which limits it- self to ulceration or extends to perforation of this membrane. The lesion is the more profound in proportion as the compres- sion has been more prolonged and intense. Hernia of the iris, staphyloma, and even suppuration of the ball are among the too frequent terminations of this process. Whether the cornea has degenerated or remained sound suppuration gradually dimin- ishes, the granulations cicatrize, sometimes without leaving any traces ; at others, if the reparation is irregular, by produc- ing either entropion or ectropion. Both eyes are often at- tacked, but rarely with the same intensity ; one of them is al- ways much less affected. Local diphtheria of all kinds may coincide with it, to-wit, croup, angina and cutaneous diphtheria. The most frequent by far is coryza. Grave general syviptojns accompany diphtheritic conjunc- tivitis ; it is not often observed only in the course of diphtheria of the most infections form. It is not at all surprising that death should be the almost constant termination, not only by the profound alterations of the eye, for death often supervenes during the first few days, before perforation of the eye and suppurative ophthalmitis, but because of the gravity of the general condition. 'W^q duration z2,nx\o\. be determined as in other ocular diseases, because of the importance of the general symptoms which may carry off the patient during the evolution of the disease. In cases which I have observed, two patients escaped a fatal issue, and the duration of ophthalmia was fif- teen days ; in two others, who succumbed to the diphtheritic infection, when the eye was nearly well, it was from the twelfth to the seventeenth day. Duplay estimates it geneaally from the fifteenth to the twentieth day. Prognosis. — It follows from the preceding presentation of symptoms that diphtheritic conjunctivitis is of serious import- ance from every point of view, as far as concerns the local condition, and respecting the general state as well. In twenty patients which I have observed, nineteen succumbed to diph- theritic infection. These cases, not occuring in the same year, 250 DIPHTHERIA, CROUP AND TRACHEOTOMY. and not belonging to the same epidemic, preserve all their fatal characteristics. The conclusions of Gibert are the same. It is true that the patients seen by Gibert and by myself were nearly all attacked with secondary diphtheria, and nearly all consecutive to measles. Graefe rarely saw death follow this form of ophthalmia. Were all the cases reported by him, in- deed, under the influence of diphtheria ! This is at least open to doubt. They were probably cases of diphtheria in the German sense of the word. When death can be avoided the patient seldom escapes serious occular changes. The figures presented by Graefe prove this too plainly. Total loss of the eye, opacity of the cornea, and anterior synechia are frequent. Adults were attacked even more severely than children. The amount of fibrinous infiltration is the criterion of the prog- nosis : the deeper it is, the more the circulation is obstructed, the greater are the dangers of destruction (necrosis) of the cornea. The induration, and the resistance of the lids, will furnish the best information in this respect. The rapidity of its course possesses much value. If the alteration of the cornea commences before the beginning of the period of elim- ination of the false membrane, the eye is irrevocably lost. If, on the contrary, this alteration commences only after the seventh day, the prognosis is favorable. In conclusion, oculo- palpebral diphtheria is very serious, first, because it is the indi- cation of a strongly marked infectious state, and then, because it too frequently leaves in the diseased eye, the most serious disturbances. Etiology. — It is in the infectious and malignant forms of diphtheria that it is usually met with, and especially in the secondary forms, and particularly in those consecutive to measles. In fact, it should be observed that diphtheritic oph- thalmia rarely appears in primary diphtheria. It selects cases of secondary diphtheria, not only those which come after measles, but those which attack patients under treatment in hospital for various morbid conditi'^ns: pleurisy, paraplegia, tuberculosis, etc. Following measles, it begins from the third to the seventh day of the eruption. When secondary to other LOCALIZATION OF DIPHTHERIA. 2$ I diseases, it appears from the seventh to the thirteenth day from the entrance to the hospitals. Age has a manifest influence. It is observed between one and ten years. However, it is met with in the adult, but rarely. It is often preceded by diph- theritic coryza, particularly when it is associated with primary diphtheria. Its propagation, appears to be effected by the medium of the nasal duct. Section vi. — Diphtheritic Otitis. Diphtheria attacks the superficial as well as the deep struct- ures of the ear. The sulcus behind the ear is one of the places of election. But diphtheria which prevails on this ^ace being rather a variety of cutaneous diphtheria, I refer it to the chapter which will treat of this localization. Diphthe- ritic otitis may be external or median ; the descriptions of ex- ternal otitis, and of otitis media are too well known to be re- peated here. I shall only have to point out peculiarities which they present when they are dependent upon diphtheria. These two forms of otitis, particularly the median should be consid- ered in their etiological relations with diphtheria, the symptoms being almost the same as in the simple cases. Otitis Externa. — This arises by extension of the diphtheritic lesions, originating on the auricle or on the facial integument which surrounds the tragus. Thence, the exudate penetrates into the external meatus where it gives rise to itching, pain, tingling, dulness of hearing, and a sanious, sanguinolent dis- charge which exhales a diphtheritic odor. Ordinarily, this form of otitis here limits itself; it may inflame the membrana tympani ; but I know of no case in which it has perforated thrs membrane. At the end of eight or ten days the false membrane separates, sometimes finally and sometimes to be replaced by one or several other exudations, and recovery takes place, unless the gravity of the general condition leads the disease to a fatal issue. It may take a reverse course. In place of being due to the extension of diphtheria from the sur- roundings of the ear, it depends under certain circumstances, upon the extension of otitis media. 252 DIPHTHERIA, CROUF AND TRACHEOTOMY. Otitis Media. — This is much the more frequent. It was no- ticed by Wreden and by Duplay. It is consecutive to diph- theria of the nasal fossae and of the pharynx, which, by in- sinuating itself into the Eustachian tribe, ends by penetrating the tympanum. The first period, that of invasion of the tube and of the middle ear, may often pass unnoticed, particularly in young children ; pain in the region of the ear is complained of by those who are old enough, and it is aggravated by mas- tication, coughing, blowing the nose, and is confounded with that of angina. Attention is called to the ear in many cases, only when discharge supervenes. At the end of a few days the pain quite suddenly ceases, and one perceives upon the ear crusted spots of moderate extent which direct attention to the examination of the ear. At this time one recognizes the presence, in the external meatus, of a sero-purulent, slightly thick fluid, moderate in quantity, fetid, and often bloody. The examination with speculum shows that the membrane is perforated ; and one frequently discovers at the bottom of the external meatus a white, thin, false membrane which extends sometimes to the external opening of this canal. Examination of the hearing discloses complete deafness of the affected ear. Otitis, thus established, follows the course of the ordinary form. At the end of a variable period decline occurs, the false membrane becomes detached, discharge diminishes and ends, in certain cases, by gradually ceasing, while in others it per- sists. But when it ceases entirely, it is but temporarily; changes of weather, moisture and exposure to cold frequently cause it to return. Hearing returns in a certain measure, but it always remains imperfect if the otorrhoea has continued for a long time, and becomes lost every time the latter returns. Such is the inevitable ending of diphtheritic otitis when the false membrane extends into the tympanum. When it is lim- ited to the Eustachian tube its symptoms cannot be distin- guished, masked as they are by the symptoms of angina. The disease is seldom limited to one ear alone. But it seldom at- tacks both with the same degree of intensity. Double per- foration of the drum-membrane is relatively not very common. LOCALIZATION OF DIPHTHERIA. 253 It may coincide with a great number of diphtheritic manifesta- tions. The most common are angina and coryza. The gen- eral symptoms are those of diphtheria, sometimes augmented by certain cerebral symptoms peculiar to otitis, such as ver- tigo, vomiting, insomnia, delirium, and a febrile condition which suddenly raises the ordinary thermic curve of diph- theria. Prognosis. — From a local point of view the prognosis is seri- ous. Perforation of the membrane without any chances of [with the chances against] reparation, and loss, or at least ob- tundity of hearing, are the inevitable consequences, when the process has developed to a certain intensity. The influence upon life is not usually disastrous. The fatal issue, when it does happen, is due much more likely to diphtheritic infection or to other localizations of this disease, which exist at the same time, than to otitis. Etiology. — Diphtheria of the nasal fossae or of the pharynx is the almost essential condition of diphtheritic otitis. While compatible with primary diphtheria, it is most frequently ob- served in diphtheria secondary to general diseases and to the exanthemata such as measles, scarlatina, variola and typhoid, which are accompanied by active inflammation, on the part of the throat and nasal fossae. Of these diseases scarlatina is the one, the influence of which is most frequently observed. Section VII. — Diphtheria of the Digestive Tract. Next to angina, the most common of the localizations of diphtheria, not only on the digestive tract, but on all the or- gans of the economy, should be enumerated certain less fre- quent manifestations on other portions of the digestive mucous membrane. Nearly all being accessible to view, their symp- tomatic description differs but little from the anatomical de- scription. Diphtheria of the Mouth. — The mouth is often the seat of diphtheritic productions. One meets with them on the lips, on the internal surface of the cheek, and on the tongue. Since there has been accorded a separate existence to ulcero-mem- 254 DIPHTHERIA, CROUP AND TRACHEOTOMY. branous stomatitis, to that morbid condition which Bretonneau confounded with diphtheria under the name of fegarite {can- criini oris), the majority of authors have attributed to this pro- cess all the pseudo-membranous lesions of the mouth. Diph- theria of the mouth does not find its place in the works which treat of stomatitis. On the other hand, Trousseau, while ad- mitting the ideas of Bergeron, yet gave too large a part to diphtheria ; there is, therefore, reason for conceding to the truth its place between these two extreme opinions. Diph- theria of the mouth exists beyond question; the numerous cases in which it is found at the same time with diphtheritic angina proves it most fully. Hayem has published an extremely in- teresting observation showing, in addition to a diphtheritic an- gina, lesions of the same nature largely invading the mouth, the tongue and the lips. These cases are not the only ones ; buc- cal diphtheria is not always a simple propagation of angina, it is frequently independent of it. The false membranes develop by preference on the posterior surface of the lips, the free border, the commissures, and in the fold between the lips and gums. The lower lip is most frequently attacked. The internal surface of the cheeks, the palate, the alveolar margin of the gums, and the tongue, either on its edges, on the dorsal surface, near the point or on the sides of the frenum, are less frequently attacked. Wherever they may be the false mem- branes are yellowish-white, round, thin at the edges, thicker in the center, adherent in the beginning, later becoming detached at the edges, becoming loosened in one piece, or disappearing by disintegration. Their structure is that of the diphtheritic exudates. The mucous membrane nearly always remains sound. At the commissures these membranes assume the form of a border which follows the edge of the lip, or a patch which is projected upon the integument like prolonging the cavity ot the mouth. Upon the cheeks its form is the same as upon the lips. Upon the tongue they are in patches of the same kind, more extended when they are situated on its edges. In certain cases they form on the tip a cap like that which often surrounds the uvula. When the lesions are very extensive, the face is LOCALIZATION OF DIPHTHERIA. 255 swelled about the parts affected, the tissues are indurated, pain- ful on pressure, and often oedematous. The mouth is opened with difficulty, particularly when the commissures are attacked; the movements of the jaws tear the mucous membrane and make it bleed. When the tongue is implicated it becomes two or three times its normal size and protrudes from the mouth. Rarely the margins of the gums are attacked ; they do not al- ways escape ; they ulcerate and leave the teeth exposed. Sali- vation is profuse, streaked with blood and often contains frag- ments of pseudo-membrane. Real haemorrhage may occur from the buccal mucous membrane. The breath exhales a horribly fetid odor which extends quite a distance, but which differs entirely from that of gangrene. The sub-maxillary lym- phatic ganglions are often tumefied as well as the surrounding connective tissue. During the first few days the impossibility of opening the mouth, and the swelling of the tongue, prevent the examination of the throat. When relaxation occurs one may often observe the existence of false membranes on the ton- sils, the uvula, and the pillars. It is rarely that diphtheritic stomatitis presents a like intensity. In the most common form the lesions are limited to the lips ; and they affect the tongue only in distinct patches of limited extent. The tumefaction, like the false membrane, is then confined to the lips, more fre- quently to the inferior, but it may extend to both at once. In this case the lower lip is attacked first ; the swelling of the tongue is generally quite moderate. More rarely still patches develop upon the internal surface of the cheeks ; they coincide nearly always with others seated upon the lips. In one case, however, they occupied this position exclusively. After ten or twelve days, frequently more, the false membranes separate and fall off, leaving the mucous membrane healthy. An ex- ception must be made of those on the tongue which erode quite deeply the mucous membrane and recover by leaving a cica- trix, as Hayem has proved. The false membranes of the mouth have not the tendency to invasion of those of the skin and other mucous membranes. When they have attained dimen- sions approaching that of a dime in diameter, they remain sta- 256 DIPHTHERIA, CROUP AND TRACHEOTOMY. tionary. However, they sometimes extend from one lip to the other, and from the lips to the cheeks. From the standpoint of general symptoms it is important to distinguish buccal diph- theria according as it is due to the extension of diphtheritic angina to the mouth, or as it is isolated and secondary to a general disease. In the first case the stomatitis follows the fortune of angina. In the second it nearly always belongs to infectious or malignant diphtheria ; and it is accompanied by grave general symptoms and by pseudo-membranous produc- tions at different points of the economy, to-wit, on the skin, the eyelids, the anus, the genital organs, and in the nasal fossae. Croup and pseudo-membranous bronchitis are also observed at the same time as the buccal diphtheria without the connecting link of angina. Under these conditions death is nearly always the result of diphtheritic toxaemia. Thus, on the one hand, the false membranes that are met with in these two categories of cases are identical as pathological products ; on the other, they may in both cases accompany the symptoms of diphtheritic in- fection even when they have only a trifling importance as to the local conditions. One may, therefore, conclude that diph- theria, true to its character as a general disease, develops itself upon the buccal mucous membrane, as well as upon all others, and that it remains independent of ulcero-membranous stomati- tis from which the most decided differences separate it. While this localization of diphtheria is often a consequence of angina, the converse is rarely true. Trousseau speaks of a case in which angina and croup were occasioned by the propagation of buccal diphtheria; but these facts are exceptional. The dura- tion may be long. If one may believe Trousseau, it may even remain stationary for several months. It is evident that the il- lustrious observer was still under the influence of the ideas of Bretonneau, and confounded buccal diphtheria with ulcero- membranous stomatitis. I have never seen the total evolution exceed fourteen days ; in cases in which the end is favorable, it has terminated in six days. When the diphtheritic toxemia is intense death occurs in three or four days. Etiology. — What precedes gives us sufficient instruction on LOCALIZATION OF DIPHTHERIA. 257 the origin of diphtheritic stomatitis. It is primary or secondary. When primary it is most frequently one of the accessories of diphtheria or of croup. In some rare cases it is primary and isolated. When it constitutes a part of the totality of angina or of croup, one frequently observes it from the beginning, or at least from the time of the first examination ; when one sees it arise in a patient observed from its origin, it is between the third and the eighth day that it usually appears ; and in a patient attacked with croup without angina it supervenes the four- teenth day. When secondary it appears nearly always in the train of measles. In thirty-three cases of secondary buccal diph- theria, twenty-one were consecutive to measles, three to whoop- ing-cough, three to scarlatina, and one to typhoid fever, the others had supervened as ultimate phenomena of different cachexiae. After measles it begins from the second to the eighteenth day of the eruption. After scarlet fever it was ac- companied by angina ; after typhoid fever it was postponed three weeks. Cachectic patients suffered for a period vary- ing from six weeks to eight months, and they were at hospital from ten to twenty-five days. The prognosis varies with the cause. By itself, stomatitis has no gravity. That which depends upon ah angina does not aggravate the prognosis of the latter. That which is secondary or without angina follows the changes of generalized infectious diphtheria. The false membranes, met with at the autopsy, in the oesophagus and stomach seem not to have been revealed by the symptoms during life. The dysphag-ia and the digestive- disturbances which they may have produced, were sufficiently explained by the angina which accompanied them. The same is true respecting haematemesis pointed out by d'Espineand by Greenhow ; there is nothing to authorize us in placing them to the account of gastric diphtheria. The cases of intestinal diphtheria, pointed out by Roche, are accompanied by symp- toms of enteritis and discharge of false membranes per anion^ Cases of this kind are extremely rare ; one may always sup- pose the products discharged to be only swallowed false mem- branes coming from the throat. He must await othef and more 258 DIPHTHERIA, CROUP AND TRACHEOTOMY. conclusive facts before pronouncing a decided opinion on this question. Anal diphtheria, pointed out by d'Espine who re- garded it as coming from the throat by successive invasions, is very rarely seen. In no case have I seen evidence of pseudo- membranous propagation by contiguity from the throat to the anus, though both points were always attacked either at the same time or the one after the other. Croup, cutaneous diph- theria, and that of the genital organs, coincide frequently with that of the anus. The commencement occurs at the circum- ference of the anus in the radiating folds ; the false membranes, at first limited, sometimes multiply, enlarge, unite and extend to the mucous membrane of the anus which swells and be- comes raw and bleeding. Their extension is outward as well ; and reaches the perineum, the buttocks, and the vulva; but it never gives rise to very extensive lesions. If death does not interrupt its course anal diphtheria continues from six or eight days to a month. I have always seen it attended with other diphtheritic manifestations, on the part of the throat, the lar- ynx, or other organs. Sometimes, it depends upon secondary diphtheria, particularly on that which follows scarlatina. Not infrequently it is the extension of vulvar diphtheria. The prognosis is not grave when we consider it only as a local lesion. But, first of all, the general condition must be taken into account; in this aspect, the appearence of oral diph- theria always indicates a certain tendency of the disease to be- come generalized. The gravity depends entirely upon the de- gree of toxaemia. However, the mortality is not high ; in four cases a fatal termination occurred in only one ; still this was a case of operated croup. The patient reported ;by Dr. Espine succumbed to malignant diphtheria. Section VIII.— Diphtheria of the Genital Organs. Glans and prepuce. — Herard has published two observations of diphtheria of the glans in hemiplegics. Trousseau in his clinical medicine reports one case of diphtheria of the prepuce. I LOCALIZATION OF DIPHTHERIA. 259 I have also met one case. It is, therefore, one of the rarest forms of diphtheritic manifestations. The exudate develops upon the preputial mucous membrane or on that of the glans, sometimes upon both. When it occupies the glans it extends into the canal of the urethra. When it extends on the pre- puce, this becomes swelled, tense, infiltrated, and red, as well as a portion of the skin of the penis. The glans can not be exposed. A fetid, serous, liquid escapes from the opening of the prepuce. Micturition is painful; this difficulty extended to retention of urine in the case which I observed. The inguinal glands swell. At the end of a few days, when the tumefaction subsides, the glans may be liberated and the presence of false membranes verified ; they are white, thin, adherent, with irreg- ular margins, and without gangrene or alterations of the mu- cous membrane. Diphtheria of the throat, nose, larynx, lips, etc., co-exist with that of the penis. It appears that excoria- tions of the skin or of the mucous membranes serve as a point of departure to the diphtheritic exudate. In the case which I have cited, recovery was effected at the end of fourteen days. From a local point of view, the prognosis is not alarming ; aside from the retention of urine, serious symptoms are not ob- served ; neither ulceration, nor gangrene, at least in the case of which I speak. The general condition, however, should oc- casion reserve, for diphtheria of the penis constitutes a part of the forms of diphtheria which becomes generalized. Vulva, Vagina, and Uterus. — Trousseau, Isambert, Empis, and Behier, have reported diphtheria of these organs ; the vulva is, of those parts, the most frequently attacked. Violent pain announces the outbreak, afterwards on the internal surface of the labia majora, appear small pseudo-membranous points which extend, unite, and form veritable diphtheritic patches ; the labia swell, become oedematous, red and livid, and an abundant discharge appears on the surface. The inguinal glands become enlarged. The exudate may remain limited to this point. Often, however, it extends to the labia minora, the vagina, and even the uterus ; on the other hand, it extends on the skin towards the anus, the buttocks, and the inguinal region. 260 DiniTIlERIA, CROUP AND TRACHEOTOMY. Epidermic elevations filled with turbid scrosity arise near it. The false membranes become detached at the end of a period varying from a week to a month ; frequently they are repro- duced. Recovery takes place without cicatrix, unless from complications of an ulcerous, or gangrenous nature, which, how- ever, are not rare in vulvar diphtheria, particularly when it is secondary. The influence of gangrene is especially deleteri- ous , not only is it followed by loss of substance quite consid- erable, but it is indicative of profound toxaemia, a poisoning of the system, the consequence of which is death. Diphtheria of tbe vagina follows that of the vulva ; by separating the walls of the vagina one may discover the pseudo-membranous deposit. That of the uterus is seldom discovered except at the autposy ; it has been observed in women during confinement. The pla- cental attachment furnishes a favorable spot for the develop- ment of diphtheria. We may entertain suspicions, when, after a vulvo-vaginal diphtheria which supervened in a recently deliv- ered patient, the false membranes having disappeared from their first location, we see the general symptoms of infectious diph- theria persist or increase. Vulvar diphtheria nearly always co- incides with angina and croup. It may be isolated as a diph- theritic manifestation ; it may also be the initial phenomenon of blood-poisoning. In one of the cases cited by Trousseau it alone showed itself in a woman exposed to the contagion and who died: in another it was the primary symptom; angina fol- lowed in the course of a few days, and the result was also fatal. In one of my patients it was limited to the vulva and to two small diphtheritic patches on one of the inguinal furrows; one interesting peculiarity was that the urine contained albumin. The patient recovered. Etiology. — Anal diphtheria is either primary or secondary. In the former case it co-incides with angina, or also with pri- mary croup. Ulceration, herpetic, eczematous or other erup- tions, so frequent in this region, invite diphtheritic localization. This is also what happens when diphtheria commences at the vulva; similar accidents serve as the door of entrance, starting point. In women recently confined, the contusion, excoriation LOCALIZATION OF DIPHTHERIA. 26l of the genitals by the passage of the foetus or by obstetrical manipulations tend greatly to favor inoculation. When it is secondary, vulvar diphtheria belongs particularly to scarlatina and to measles ; it then assumes more readily the gangrenous form, and attains to the greatest gravity. In fact it is nearly always fatal. Under other circumstances the prognosis should be based upon the general condition, the lesion having of itself a moderate importance. Section IX. — Cutaneous Diphtheria. Though pointed out by Chomel in 1749; by Starr in 1750; and by Samuel Bard in 1771, it was Trousseau who gave prom- inence to its importance. It is now generally admitted, though certain authors, Billroth among them,still confound it with hospi- tal gangrene. Every point of the skin previously inflamed, or deprived of its epidermis may become its seat. This is why we observe it as a sequence of blisters, wounds, excoriations, fis- sures, after eruptions which ulcerate the skin as herpes, eczema, and impetigo. It readily develops in the folds of the skin, also where the latter is thin, and in fleshy subjects, where it is easily inflamed or excoriated : such are the folds about the scrotum, the anus, the umbilicus, and the ears. Such also are the ori- fice of the nose, the lips, the circumference of the anus, places where the skin becomes thin and upon which are frequently found eruptions. The scalp is one of the places of election because of the frequency with which impetigo prevails there ; the same is true also with the nipple, because of the chaps of which it is the seat. The parts affected become red, painful, bleeding, and form an ulceration often quite large, with irregu- lar margins cut perpendicularly, which sometimes appear on the healthy skin as lines, which Trousseau compares very justly to the men in backgammon. On the surface are deposited membranous concretions occupying its entire extent or form- ing islets separated by intervals of ulcerated skin ; they are thick, convex in the center, thinner at the borders, of a light yellow or rather grayish color, and quite adherent ; often they 262 DIPHTHERIA, CROUP AND TRACHEOTOMY. are formed of several stratified layers. It is easy to raise them at the edges by means of forceps. A sero-purulent, turbid, fetid, fluid transudes abundantly, and softens and putrefies the external layers. Around the ulcer the skin is inflamed, swelled, and erysipelatous. The elevation which it forms aids in mak- ing the part covered with the false membrane appear more excavated. The redness and the tension diminish by an in- sensible gradation. On the surface of this zone epidermic prominences are observed, often quite numerous, confluent, and so much the closer together as they approximate the ulcer. A number of these vesicles often unite to form phlyctaense. Their contents are turbid, milky and serous. When they are broken or when they become withered, the base is seen covered with false membrane which soon becomes united to the main one or to those in the vicinity. Other epidermic elevations follow the first and run the same course. In this way propagation is ef- fected. In certain cases gangrene participates ; the false mem- branes become brown, assume the characteristic odor, and, when they separate, debris is still found adhering to the cleansed surface. The power of cutaneous diphtheria to extend is often considerable ; and it may take on the serpiginous character. It is seen to embrace the back from the shoulders to the mid- dle of the loins. Trousseau remarked that it usually spread from above downward. It is not necessary, however, that the local condition always present a similar intensity ; the above description answers particularly to diphtheria following the ap- plication of a blister ; it agrees also with certain cases of diph- theria of the scalp, the scrotum, the groin, the thighs and the buttocks; but most frequently this condition is limited to ul- cerations of small or medium extent. The duration depends upon the extent of the false membranes, their tendency to spread, the cause which gives them origin and the region on which they develop. But when they are consecutive to blisters, and their tendency to propagation and to reproduction is very strong, they do not disappear till the end of several months. General symptoms exist, not only when cutaneous diphtheria coincides with angina or croup, but also when it prevails alone. LOCALIZATION OF DIPHTHERIA. 263 In these latter cases albuminuria has been observed several times, as well as diphtheritic paralysis, as is shown by the cases cited by Roger, Raciborsky, Paterson, Caspary, Philippeaux, and by Gamier. In these observations we see paralysis limited to the pharynx, or generalized, following diphtheria developed at the groove behind the ear, at the umbilicus, the groin, the surface of blisters, traumatic injuries, and cutaneous eruptions, without angina having existed. Thus, diphtheria may have the skin as its only seat. It is also very interesting to see that the external tegument may be the first point invaded, and that the throat and larynx may be attacked afterwards, at the time, or separately. Of this I have observed several cases. Trousseau cites a few cases of it in his Clinical Medicine. William Mort- lake reports the case of a child eight years old who, after hav- ing been attacked with diphtheria around the umbilicus, was seized, in spite of the decided amelioration of this local deter- mination, with angina and croup which carried it off Robert Bahrdt relates an analogous case in which angina and croup su- pervened two days after a diphtheria which had developed upon a wound ten days previously. The child was three years old. Etiology. — Diphtheria attacks every point of the skin in- flamed or deprived of its epidermis by ulceration or by trau- matism. A simple injury serves as a place of entrance (porte d'entree) to diphtheria into a system till then intact; such is the case of Paterson's, in which a man, while yet healthy, put his excoriated finger into the throat of his child affected with diphtheritic angina ; the finger was soon attacked with diph- theria, which remained limited to that point, but was followed by general paralysis. Trousseau speaks of a child attacked with cutaneous diphtheria arising on the spot of an excori- ation produced on the thigh by the rubbing of a wheelbarrow, who died of croup as a consequence. What is observed in syphilis and in other virulent diseases occurs in these cases : there is a true inoculation. It is generally admitted that the absence of the epidermis is indispensable to the development of cutaneous diphtheria. It may be so when the person is 264 DIPHTHERIA, CROUP AND TRACHEOTOMY. healthy and when the excoriation serves as the port of entry to the diphtheritic poison. When the patient is previously in- fected it often happens that the false membrane is developed under the epidermis ; the exudation is produced at the ex- pense of the corium Malpighi and gives rise to vesicles or phlyctenae, the base of which is lined with false membrane. In these cases a simple irritation of the skin is sufficient to call out the diphtheria. Thus it shows itself on places at- tacked with eczema, impetigo and parts affected with inter- trigo, about wounds, the punctures of leeches and blisters. I have seen, in a patient attacked with croup, a paronychia be- come the starting point of cutaneous diphtheria; in another, an old burn of several months and cicatrized reopened and became covered with false membranes; in a third, a wound of the hand, produced by a fragment of glass, had the same ex- perience. These examples might be multiplied. It must not be supposed, however, that under the circumstances the cuta- neous diphtheria was inevitable. When the poisoning is very slight it happens that the solutions of continuity and even the surfaces of blisters may escape diphtheria ; this I have been able several times to verify. When a blister is about to be at- tacked not more than a day or two passes before the false membranes appear. Excoriations already existing, surfaces covered with impetigo or eczema may be attacked at a more distant period. A burn, above spoken of, became pseudo- membranous only at the end of twenty-four days of croup. Cutaneous diphtheria often figures in secondary diphtheria; it is then attended more readily with gangrene. Prognosis. — Trousseau regards cutaneous diphtheria as much more serious than that of the pharynx. Literally taken, this conclusion would be wanting in accuracy. Indeed, by itself, this local manifestation of diphtheria frequently recovers. I have seen cases end in this way in which large surfaces had been invaded. Notwithstanding, death is not rare from ex- haustion which results from the very free suppuration. On the other hand, patients are seen to succumb in whom cutane- ous diphtheria occupied but a limited place in the morbid to- LOCALIZATION OF DIPHTHERIA. 265 tality; and, as in all the other manifestations of diphtheria, its gravity resides in the degree of infection which it represents. Left to itself, and without any other localization, it may be at- tended by alarming general symptoms and cause death ; the amount of poison introduced into the economy becomes rap- idly fatal before provoking the membranous exudation on other points ; and one finds himself in this case in the pres- ence of malignant diphtheria with unimportant local manifes- tations. Often again, when it is alone, it is the expression of a benign diphtheria and recovers. Associated with other local- izations it becomes the index of the generalization of diph- theria; and it is only one of the elements by which we can es- timate the intensity of the poisoning. When called forth by the excessive application of blisters it may recover, but it fre- quently renders the prognosis less favorable, either because of the suppuration which it occasions, or because of the stimulus it seems to give to the disease. I shall cite in this connection the history of a patient attacked with mild diphtheria of the nose, which simply attracted attention and was recovering with facility when some one had the unfortunate notion of ap- plying a blister to the nape of the neck with the pretext of hastening the cure. This issue was not long in covering itself with false membranes, and the patient died in a state of maras- mus, without any considerable extension or suppuration hav- ing taken place. The disease, which seemed dormant, was aroused under the influence of the cutaneous irritation. Course, Duration, Termination. In passing, I have already indicated, in each of its forms and localities, the course which diphtheria takes. This disease is always portrayed by one or several local expressions. How- ever slight they may be, should they be weakened to the point of not being pseudo-membranous, these local determinations sufficiently so modify the course of the principal disease that the reciprocal action of these two elements exhibits peculiar combinations. While preserving the impress of the general disease, each combination possesses peculiar properties which 266 DIPHTHERIA, CROUP AND TRACHEOTOMY. make it act differently from another in which a different local condition enters. Thus, in describing the course of these local manifestations, a course which is itself influenced by the form of the diphthe- ria, I have shown in that way the course of this disease. It is, therefore, necessary to refer to each of those chapters. There is another point to which I desire to return, that is the order in which these localizations follow. Brettonneau, and Trousseau after him, assigned to the propagation an order in some sense invariable. The pro- gression is regularly made from the superior towards the in- ferior parts, from the nasal fossae to the pharynx, from the pharynx to the larynx, then to the bronchi. Likewise, when the diphtheria attacks the skin, the extension is made also to- wards the dependent parts : from the ears towards the neck and back, and from the back towards the loins. The cele- brated physician of Tours regarded diphtheritic contagion as a kind of auto-inoculation produced by an acrid liquid which secreted by the diseased surfaces, would contaminate success- ively the more dependent parts. This order, which was evi- dent in the epidemics of Touraine observed by Bretonneau, has numerous exceptions. Some observers, such as Boudet,Vau- thier, Rilliet, Barthez, Isambert, Newcourt, Axenfeld, Empis, Millard, Crequy, Bouillon, Lagrange, Bergeron, Blondeau, Hache, etc., have reported such. As pertinent to the origin of croup, I have proved that an- gina and coryza do not always precede croup, but that in quite an important number of cases, in one-half, according to Rilliet, one-third according to Bergeron, and one in twenty according to J. Simon, and by my figures in one in eight cases, croup appears before the angina. We have also seen pseudo- membranous bronchitis precede croup. Other facts no less interesting have been revealed to me during the examination of the various local manifestations. I have showed that cutaneous diphtheria may, in spreading, ascend, in place of descending. I have pointed out the ex- tension of the false membrane from the nose to the eye by the LOCALIZATION OF DIPHTHERIA 26/ nasal duct, and from the pharynx to the ear by the Eustachian tube. Still more, I have indicated the coexistence of diphthe- ritic localizations having between them not a trace of conti- guity, viz., angina or croup with cutaneous diphtheria, or with that of the genital organs, and vice versa ; the diphtheria ot the lips, skin and genital organs accompanying, together or separately, angina or croup, and finally developing separately or combinedly, without pharangeal or laryngeal manifestations. The consequence of these exceptions is that the law im- posed by Bretonneau should be annulled so far as its being an absolute rule is concerned. In the cases in which it is the least affected, in the relation of angina with croup, it is sub- ject to numerous infractions. Facts such as Bretonneau ob- served suggested to him the famous theory according to which diphtheria, at first localized at its point of entrance into the economy, like syphilis when it is still only represented by the chancre, is expanded afterwards, from step to step, to the in- fecting of the whole organism. The different epidemics, and new facts observed since that time, have enabled us to recog- nize wherein this view, so specious, was arbitrary. The ap- pearance, often simultaneous and most frequently without in- tervention of diphtheritic productions upon points the most diverse of mucous and of cutaneous surfaces, has furnished a powerful argument for the theory which I shall at a later pe- riod establish, a theory which holds that diphtheria, like all infectious diseases, contaminates primarily (d'emblee) the en- tire economy, and that from this intoxication result the most varied pseudo-membranous localizations and visceral lesions of the most general character. Recedives — Second Attacks. One attack of diphtheria does not protect from a second. This disease may attack a second time — recedive. I find in my observations twenty-nine cases of second attacks of diph- theria, without counting those spoken of by Gambault, Mil- lard, Roger and Peter. The interval which separates the two attacks of diphtheria varies from a few days to several years. 268 DIPHTHERIA, CROUP AND TRACHEOTOMY. It was, counting from the recovery of the first : 2 days in 3 " 4 " 5 " 6 " 7 " I lO days in 2 II (< 3 15 <( 3 19 <( I 20 (( 3 I > ear I 12 a 2 I I 2 2 2 I 29 Total, -------- I have seen one patient in whom there was a double recedive. The second occurred some days after the recovery from the first recedive. The reproduction often affects the same place, but it does occur that the second attack affects a different lo- cation. When the first attack consisted in an angina the sec- ond was generally also an angina. In case of a previous croup angina alone may be reproduced, however, I have seen several cases of second attacks of croup. Those that I have seen did not lead again to the operation ; the angina alone, or croup not very serious, reappeared. It does not always hap- pen thus, as well-known observations of tracheotomy prac- ticed twice on the same subject for croup clearly prove. The second attacks occur without apparent cause; they are often determined by eruptive fevers, measles or scarlatina. Their gravity has nearly always been less than that of the first attack ; in twenty-nine cases of recedive, twenty-two termi- nated favorably. The double recedive gave a third recovery. It has appeared that in many of these cases the diphtheria, in being repeated, lost its gravity. Diagnosis. The presence, in parts open to inspection, of large false membranes exhibiting the characteristics of the diphtheritic exudate ; the development of extensive adenitis in their vicinity, and in the submaxillary region in particular ; together with the establishment of special general symptoms, warrant us in af- firming without hesitation that diphtheria exists. But certain LOCALIZATON OF DIPHTHERIA. 269 circumstances give rise to difficulties. The age of the patient is an important one. An adult and a good sized child will ex- press their feelings, and will call the physician's attention to the region where they feel pain. It is quite otherwise with a little child; an examination of every function and of every organ is indispensable in the absence of information furnished by the patient. A diphtheritic pharyngitis existing under these con- ditions, which is not a rare case, and deglutition being moder- ately painful and and adenitis being wanting, the disease runs a risk of being unrecognized. The precept laid down by Trousseau should then be observed strictly, that whenever a little child is sick for several days and the morbid condition re- mains ill-characterized, the physician should examine the fauces. He will then very often discover a diphtheritic phar- yngitis, whose existence not a single special symptom had giv- en him reason to suspect. I shall be still more radical. The fauces should be inspected in every child, at least where there are not found at once unmistakable symptoms of a definite dis- ease. Still it is prudent, in hospitals especially, and in an en- vironment where diphtheria holds sway, to often ascertain the condition of that region, not only at the beginning, but during the course of every disease. Allowing cases of secondary diph- theria to pass unnoticed, will thus be avoided. This sort of complication ought, in fact, to keep the attention aroused. Everything conduces to overlooking it. If it be a matter of exanthems, such as measles or scarlatina, which no- toriously favor the development of diphtheria, the observer should be on his guard, and error will be relatively uncommon. But if it be a question of typhoid fever, a disease which is often accompanied not only by difficulty of deglutition, by dryness of the fauces or by a sjDecial pharyngitis, but by stupor, and by coma deep enough to veil the manifestations of diphtheria ; when diseases like pleurisy, pneumonia or capillary bronchitis, in which oppressed breathing is one of the symptoms, are to be dealt with, or cachexias such as scrofula, chronic diarrhoea or tuberculosis which bring in their train the most varied func- tional troubles, such an omission is possible and is not rare. 2/0 DIPHTHERIA, CROUP AND TRACHEOTOMY. On the other hand, we may see the severest diphtheria give rise to barely a few general symptoms, allowing the patients to go and come, and preserve almost intact their habitual modus vivendi. The autopsy alone often reveals these secondary diphtherias. The feeble intensity of the group of symptoms is perhaps the most serious difficulty to be met with in the diagnosis of diphtheria. The slight importance of the lesions, and the absence of apparcjit infection have led to the separation from this disease, under the names of herpetic or diphtheroid pharyngitis, of morbid conditions W'hich were really only benign forms. Not that I would deny the existence of herpes of the fauces, for I shall develop later, the characteristics which distinguish it from diphtheritic pharyngitis. I only maintain that cases of diph- theria where the localization has been discrete and made up of isolated points, have been mistaken for herpetic pharyngitis. At its beginning diphtheria assumes, in fact, the most various local dispositions, from a pseudo-membranous patch carpeting the whole of the fauces, to isolated points like those of herpetic pharyngitis. How often have we seen these so-called cases of herpetic pharyngitis end in croup, or in a generalization of diphtheria. How many examples they have exhibited of cases originating by contagion from the most fully marked cases of diphtheritic pharyngitis or on the other hand transmitting, though they themselves are benign, the most serious manifes- tations of diphtheria. The facts reported by Guerard and by Peter are most conclusive upon this point. The coexistence of Jierpes labialis does not suffice to invest the pharyngitis with an herpetic character. Like Peter, I have seen the gravest diphtheria, coexisting with patches of herpes upon the lips, and I have met cases of so-called herpetic pharyngitis, accompanied by albuminuria and followed by pa- ralysis. The color and thickness of the false membrane do not give any more instructive information ; for those which are white, thin and semi-transparent, are as justly diphtheritic as those LOCALIZATION OF DIPHTHERIA. 2/1 which are thick, opaque, and dark gray or brown. An ener getic inflammatory reaction, and a lively redness of the mucous membrane, prove no less in favor of diphtheria than a torpid course without reaction. The objective characteristics are then not sufficient to set the question at rest. Never do they authorize the exclusion of the idea of diphtheria, but they often warrant its admis- sion. The general symptoms, information as to etiology, and above all, the later course of the disease are necessary to settle the diagnosis. We may then lay it down as a principle, that, in a certain number of cases the diagnosis of diphtheria cannot be made from the beginning, and that only the course of the disease will enable us to Judge imderstandingly: also, that from the beginning of an affection suspected to be pseudo-membranous, we should act as far as concerns the isolation of the patient, as though we were dealing with a veritable case of diphtheria. If the disease is benign, and of slight extent, the diagnosis is still more difficult; for the aggravation later on no longer fur- nishes the information which is above given. Then it is, that the albuminuria,the adenitis and in default of these the etiolog- ical circumstances are of valuable aid. Light pseudo-mem- branous manifestations appearing in an environment where diphtheria is raging, should be accredited to that disease. I will develop that question more fully when I treat of the natme of diphtheria. Such are the difficulties which complicate the diagnosis of diphtheria. We shall find them again in most of the localiza- tions of this disease, augmented by the confusion which might arise between those localizations and different lesions occupy- ing the same regions. We must needs, then, establish the to- pographical diagnosis of diphtheria and distinguish its local manifestations from the morbid conditions which, when they attack the fauces, the air-passages and other organs, might be mistaken for the former. I shall reproduce in discussing the diagnosis, the order which I adopted in detailing the symp- toms. 2/2 DIPHTHERIA, CKOUP AND TRACHEOTOMY. Since diphtheria, aside from entirely exceptional cases, is a disease with a course essentially acute. I shall only have to discriminate its localizations from the acute affections of the same regions. Pharyngeal Diphtheria. It is particularly with regard to diphtheritic pharyngitis that the diagnosis is likely to be difficult. The pharyngitis which presents itself with large, thick, dark gray, pseudo-mem- branous patches, with single or double sub-maxillary swelling, with coryza and the characteristic odor, leaves no ground for doubt : the diagnosis is self-evident. Those forms of attenu- ate pharyngitis, those in which the product is like the exudate, those also which give rise to a real exudate, but not a diph- theritic one, should be scrupulously differentiated from diph- theria. Before entering upon the differential characteristics, I must again insist upon the difficulty of diagnosticating diph- theria at the beginning. The distinctive signs which I am about to detail are rarely clear enough at this period to war- rant the formation of a positive diagnosis. This pharyngitis has no peculiar mode of attack, but begins in several very dif- ferent ways as regards general symptoms as well as from the standpoint of local signs. The physician should also be im- bued with the precept that every pharyngitis, wlietlier acco7n- panied or not by an exudative product or the like, however discrete or benign it may appear, should be regarded with sus- picion, and held under observation for several days before a diagnosis can be legitimately made. The kinds of pharyngitis, the product of which resembles the exudate, are : follicular tonsillitis with exaggerated pro- duction of sebum., piiltaceons pharyngitis, pJiaryngitis'of scarla- tifia, gangrenous pharyngitis and ulcero-inenibranoiis pharyn- gitis. One kind only presents a true exudate, viz., herpetic pharyngitis. These inflammations of the fauces do not present points of semblance to diphtheritic pharyngitis except in its benign form, or at its beginning; gangrenous pharyngitis alone being likely to be confounded with severe diphtheritic pharyngitis. LOCALIZATION OF DIPHTHERIA. 2/3 Follicular Tonsillitis. — This form of pharyngitis is character- ized by an exaggerated production of the sebaceous material of the crypts of the tonsils. Usually insignificant as to gen- eral or functional symptoms, it shows only a slight redness of the mucous membrane. Masses of white material push out from the follicles, forming upon the surface of the gland white spots which show a certain resemblance to false membranes in process of formation. But on close examination these spots appear much more salient than false membranes. From the first they are thick and salient, while the false membrane is thin and pellucid at the beginning. Often the orifice of the follicle from which the concretion is projecting can be recog- nized. The latter is almost always single, and, when there are several, they are distant from one another, and show no ten- dency to unite. There is no submaxillary swelling. Finally, scraping the tonsil with a spatula, immediately detaches the suspected product and brings out a cheesy mass with a foetid odor which crushes under the finger, and is at once recognized as sebaceous material. Pultaceoiis Pharyngitis. — Though sometimes coincident with a simple catarrhal condition of the faucal mucous membrane, pultaceous pharyngitis is much oftener, according to Trous- seau's expression, cited by Peter, the pharyngitis of low gen- eral conditions, the pharyngitis of the feeble and the old, that of scarlatina and of typhoid fever. It is accompanied by a febrile movement, usually slight, and by a certain saburral condition. But that which constitutes its important point with regard to its diagnosis from diphtheritic pharyngitis, is the presence of false membranes of a very special character. These productions form large patches of a creamy white, which almost always occupy the tonsils, more rarely the pil- lars. They have no tendency to spread, and when once pro- duced they enlarge but little. They are thin, and permit the mucous membrane to be seen through them, if not every- where, at least at several points. They are soft, falling to pieces simply by rubbing with a brush or a sponge, and com- ing away in fragments without leaving a single visible altera- 2/4 DIPHTHERIA, CROUP AND TRACHEOTOMY. tion of the mucous membrane and without the slightest haem- orrhage being brought on by the operation. The special characteristic of these false membranes is their structure. As Peter has demonstrated, it is epithelial simply. In it the microscope has discovered only pavement cells, en- tire or altered, together with nuclei and nucleoli and rem- nants of cells and of broken up nuclei. Neither fibrils nor amorphous material nor anything, has been met with, which indicates the existence of fibrin in its different forms. Stripped of these products the mucous membrane remains red, smooth and covered with a recent and delicate epithelium. The results contributed by histology are of great impor- tance. However different, in fact, pultaceous pharyngitis may be from diphtheritic pharyngitis in its course, in the absence of adenitis and in the appearance of the false membranes, there is still ground for mistake. Diphtheria at its beginning too often furnishes false membranes which are similar in gen- eral appearance. But the excessive friability of the pultaceous product will always allow fragments of it to be detached, which, placed on the stage of the microscope, will at once clear up the diagnosis. Scarlatinous Pharyngitis. — In the same class with pultaceous pharyngitis it is well to place the pharyngitis of scarlatina, the product of which is the same, but which, by the fact of its origin, is accompanied by special symptoms. The frequency with which scarlatina is followed by true diphtheria renders the diagnosis between simple scarlatinous sore throat and diphtheritic sore throat one of great importance. The pharyn- gitis in question is not rare. It is an exaggeration of the in- flammation which scarlatina necessarily produces in the fauces. It is oftenest limited to an intense congestion of the mucous membrane, a congestion like that which appears upon the skin. But when the eruption is violent desquamation of the epithelium occurs, whence comes a production of pultaceous, white patches. The characteristics of scarlatinous pharyngitis have been clearly indicated by Trousseau, Barthez and Rilliet, and by LOCALIZATION OF DIPHTHERLV. 2/5 Peter. The rapidity of its appearance, the almost sudden in- tensity of the febrile movement, and the existence of an eruption upon the faucal mucous membrane like that upon the skin, only darker, permit the scarlatinous nature of the diph- theria to be established. But this is not enough in the case. We must distinguish between the two affections produced by scarlatina ; in other words, must find out whether the scarla- tinous pharyngitis is pultaceous or diphtheritic. The diag- nosis is so much the more difficult because scarlatina is very often accompanied by glandular swelling, and we are de- prived of one of the best means of differentiating diphtheria from other diseases. The pultaceous appearance of the patches, such as I have described in the preceding chapter, usually suffices to show that the pharyngitis is not of a diphtheritic nature. But since, in this case as in every other, the products of diphtheria may assume at first a pultaceous appearance, microscopic examina- tion will be necessary, otherwise the course of the disease only can clear up the diagnosis. The distinction which I make between the pharyngitis of scarlatina and that of diphtheria has not been always admitted. The diphtheria that follows scarlatina, even when generalized, was considered as a pharyn- gitis secondary to scarlatina, a pharyngitis the product of which might invade the whole economy, but which was inde- pendent of diphtheria. Peter, supporting his very clear judg- ment by the authority of Trousseau and that of Barthez, sepa- rates scarlatinous pharyngitis, properly so called, from diph- theritic pharyngitis secondary to scarlatina. I indorse without hesitation the opinion of these eminent physicians. Every- thing, in fact, separates these two forms of pharyngitis, which have in common only a white product situated in the fauces. But without reckoning that this product is absolutely different in the two cases, its structure being exclusively epithelial in the one case and fibrinous in the other, how dissimilar are the characteristics of these two processes ! Who has ever proved that this epithelial desquamation, following scarlatina, had the power of becoming general, of attacking the nasal fossae, the 2/6 DIPHTHERIA, CROUP AND TRACHEOTOMY. larynx and the bronchi? Is not this, on the contrary, the course so peculiar to diphtheria? Finding in scarlatina, as in measles and typhoid fever, a soil ready prepared, diphtheria there develops, but takes the site which the scarlatina itself offers, that is to say, its first mani- festation always appears in the fauces, the point where scarla- tina produces its most intense inflammation. Rarely does it go beyond that limit, but if it appear in other regions, it is usually after it has affected the fauces. Once developed in the pharynx, the diphtheria may migrate to any other part, and al- though, indeed, the celebrated proposition of Trousseau al- ways obtains, viz., that " Scarlatina has no love for the laryjix," it is none the less true that the organ may be attacked ; but in the great majority of cases it is by an extension of the process which began in the fauces. The presence of albuminuria also separates these two kinds of pharyngitis. Though, in fact, we can recognize in the two cases, the presence of albumen in the urine, it is found in each of them at quite different stages. In diphtheria it is quite frequent near the beginning; in scar- latina it is found much more rarely, and only during the per- iod of desquamation and at a time when the pharyngitis has, moreover, usually disappeared. Pharyngitis oj Typhoid Fever. — Like scarlatina, typhoid fever engenders erythematous or pultaceous sore throats. The lat- ter species, the one which alone interests us, has of itself but slight importance and for that very reason we must avoid con- founding it with diphtheritic pharyngitis secondary to typhoid fever. The latter has especially pre-occupied authors, and many cases of it are cited by Louis, Herard, Oulmont, and Chedevergne. In his interesting work on pharyngitis following typhoid fever, Chedevergne shows too great a tendency to con- found these two kinds of pharyngitis. Peter, on the contrary, distinguishes them with care. The pultaceous pharyngitis of typhoid fever is of the same nature as that of scarlet fever. It is formed like the latter, by a desquamation of the epithelium of the mucous membrane. The characteristics of the product are identical. LOCALIZATION OF DIPHTHERIA. 2// According to the happy expression of Peter, pultaceous pharyngitis is to the isthmus of the fauces what the whitish bor- der of the gums is to the mouth. The mucous membrane is red, dry, and as though varnished, submaxiUary engorgement is always absent. In short, this sore throat would be overlooked if the patient did not some- times complain of the fauces, and if care were not taken to fre- quently inspect this same region. The extreme friability of these products, which are always easily removed by a tongue depressor, and finally the microscopic examination permit them always to be recognized. Gangrenous Pharyngitis. — For a long time confounded with diphtheritic pharyngitis, gangrene of the fauces, was separated by Samuel Bard and afterwards by Bretonneau who, going to the opposite extreme, denied it absolutely. In rendering to each his due, the works of De la Berge, and Monneret, Becquerel, Rillietand Barthez, Gubler, Trousseau, Peter, and others, should be mentioned. Great difficulties often complicate the diagnosis. If gangren- ous pharyngitis is sometimes a primary affection, it is still more often secondary, and then it follows the same conditions as diphtheria does, i. e., measles, scarlatina, small pox and typhoid fever. What is more, it complicates diphtheria itself in certain cases. Yet, when the disease is observed from the beginning, we have the advantage of several important differential signs. Al- though often taking on a grayish or even a brown tint, the false membranes of diphtheria are usually white at first, and if they become brown later on, it results from what they absorb from the blood which oozes from beneath them, or at their cir- cumference. The eschar, on the contrary, though often pre- ceded by a yellowish spot, assumes from the very first the ap- pearance of gray, brown, blackish, or entirely black patches. It is cast off like the eschars, much more slowly than the false membrane, and leaves behind it losses of substance, often con- siderable, while in diphtheria the mucous membrane is almost always intact. 2/8 DIPHTHERIA, CROUP AND TRACHEOTOMY. The mucous membrane, red, swollen and tense in diphtheria, is livid, purple and uidematous in gangrene. The fetid odor, moreover, is different in the two cases. In the first it is a pe- culiar odor quite different from that of gangrene, it appears at an advanced stage of the disease, when the false membranes with their absorbed blood begin to putrefy, while in the sec- ond it is the characteristic odor of gangrene and is perceived from the first. Adenitis is less common in gangrenous pharyngitis than in diphtheria, but the difference is not sufficiently marked to be of value. The general symptoms being almost exactly the same in both, there is nothing to be hoped for on that side. Albumin- uria constitutes a valuable element in the diagnosis. Although it may not be found in diphtheria, its presence will suffice to exclude gangrenous pharyngitis. When gangrene complicates diphtheria, it is usually at a cer- tain interval after the beginning that the symptoms of sphacelus appear. To the false membranes there succeed eschars which install themselves on the sites of the former, either after their detachment or before. At the moment when the false mem- brane becomes detached, the subjacent mucous membrane, in- stead of looking healthy and with its normal aspect, appears covered with an eschar. The odor becomes gangrenous; and we have before us the transformation of the first process. This is a difficult point in diagnosis, and is possible only in frankly characterized cases, while in others doubt is unavoidable. Ulcero-tncnibraiwus Pharyngitis. — This form of pharyngitis, which is most often only a propagation of the lesions of ulcero- membranous stomatitis, finds its place with gangrenous pharyn- gitis, for it also belongs to the necrotic process. The mortified products, which are its principle characteristic, may pass for false membrane. The diagnosis is singularly facilitated by the almost constant co-existence of an ulcero-membranous stoma- titis, the characteristics of which differ completely from those of diphtheritic stomatitis, as I shall show further on. When the stomatitis is lacking it is necessary to be more cautious. LOCALIZATION OF DIPHTHERIA. ^79 General symptoms are almost wanting in ulcerative pharyn- gitis. There is no fever, no albuminuria and adenitis is absent or is very slight. The objective symptoms may be deceptive, especially at first. At this time the mortified surface presents, principally upon the uvula and upon the palate, a glossy ap- pearance which may cause it to be confounded with a false membrane. Upon the tonsils, on the contrary, in place of a single eschar, are found many pieces. But the surface soon ceases to be smooth. It becomes downy and grayish, its out- line, rounded and perpendicular, is surrounded by a reddened and swollen mucous membrane. Elimination occurs, not by a detachment of the borders, as in diphtheria but by a sort of abrasion. If some doubt should remain a microscopical examination of the products would demonstrate their gangrenous nature. They have, in fact, as principal constituent elements, epithelial cells and elastic fibers joined together in bundles. These fibers are derived from the chorion of the mucous membrane which is in part destroyed by the sphacelus. Mugnet (Aphtha). — Confusion will rarely occur except in cases where the thrush is very confluent, and covers the ton- sils and palate with a large and thick coating. But under these very circumstances the confluence is not the same every- where. Upon the lips and upon the gums the thrush will al- most always appear with its true characteristics, i. e., under the form of small disseminated white points, like clots of curdled milk, and separated by intervals of inflamed mucous mem- brane. Microscopic examination should, moreover, show the presence of o'idium albicans in this coating. Herpetic Pharyngitis. — A confusion, much to be regretted, exists in many minds, between herpetic pharyngitis and diph- theria. Imbued with the false idea that diphtheria is always announced by large, thick, gray pseudo-membranous patches and by a serious general appearance, imbued with that error so dangerous in its consequences, they have separated from diphtheria cases of discrete pseudo-membranous pharyn- gitis to class them as herpetic pharyngitis. Far be it from me 280 DIPHTHERIA, CROUP AND TRACHEOTOMY. to think of denying herpes of the fauces. The description of it which Gubler, with his well-known talent, has given, should be preserved, for it establishes an incontestable fact, the knowledge of which fulfills certain desiderata. But the danger is so much the more formidable, because a deceptive security may prevent its recognition. An almost irresistible current has driven a large number of physicians to always see herpetic pharyngitis, when the trouble was benign diphtheria. Clinical physicians of great merit, Roger and Peter, have fully recognized this abuse and have noted the ex- istence of benign diphtheria. Such is also the opinion of Barthez, and my own. I have sufficiently insisted on the different modes of begin- ning in diphtheritic pharyngitis for that clinical point to have become evident. Benign diphtheria appears in certain cases with the aspect of herpetic pharyngitis. How can these two morbid conditions, so similar in appearance, but so different in reality, be distinguished? If the disposal of the false membranes in small, round and discrete patches, be not sufficient, the presence of herpetic patches upon the lips, while indeed more convincing, has still but a restricted value. I have several times seen, and other observers have as well, the severest diphtheritic pharyngitis and the most infectious croup coinciding with Jierpes labialis. The only time when herpetic pharyngitis can be recognized is at the first, while the vesicles are still intact, or at least while intact vesicles are still found beside the minute ulcerations. When, on the contrary, they have all vanished and have been replaced by small round ulcerations, covered with a white, thin and adherent exudate, there is only a probability in favor of herpes. When the vesicles are coherent, and their union has formed a somewhat large concretion, the difficulty is still greater. The existence around the circumference of these patches of circular indentations which prove the union of small round patches, has indeed been claimed as a distinctive sign. But on the other hand, these indentations are quickly effaced, and the contour becomes uniform, while on the other LOCALIZATION OF DIPHTHERIA. 28 1 the diphtheritic false membrane may.be formed by the fact of the confluence of small patches. The ulceration of herpes and the false membrane of diphtheria have then such numerous points of resemblance that it becomes more difficult than ever to discriminate one from the other. If, then, the presence of an herpes labialis, the disposal of the products in rounded and discrete spots, their white aspect and their thinness may not exclude them from diphtheria, it is evident that the objective characteristics are not sufficient for a diagnosis except in those rare cases in which the vesicles can be found again. The absence of submaxillary adenitis and of albuminuria present a certain value, but these symptoms may be wanting even in fully confirmed cases of diphtheria. Only a probability can, therefore, be conceded in favor of herpes of the pharynx, and doubt persists in the greater num- ber of cases. The course of the disease cannot be foreseen. Under these circumstances, the coui'se to be followed should be the same as though diphtheria were unquestionable. The usual precautions should be taken and the patient isolated. If it be proved subsequently that the suspected pharyngitis was only a herpes, one will have come off with a few useless meas- ures, but if the opposite error has been committed, if, by mis- taking a diphtheritic pharyngitis for herpes, the physician has neglected isolation of the patient, he exposes himself to re- grets for his exaggerated faith in herpetic pharyngitis ; for be- nign diphtheria, though pseudo-herpetic in the patient, not content with transmitting itself to other members of the family, may determine in the latter one of its gravest forms, and cause terrible ravages. Examples of malignant diphtheria transmitted by subjects affected with benign diphtheria are common, and numerous cases of it have been cited. The most striking one is that of Gilletti,' of sad memory. Peter, who records this instance, in which he was one of the actors, reports that a household ser- vant in a certain family was attacked with an angina, pro- nounced by the physician to be common membranous sore 2C>2 DIPHTHERIA, CROUP AND TRACHEOTOMY. throat. No precautions were taken, but the patient was al- lowed in the midst of the family. Moreover, she rapidly re- covered. But after a few days the baby of the house was at- tacked with diphtheritic pharyngitis, soon followed by croup which resulted in death in spite of tracheotomy performed by Peter. Gillette, who was also called in consultation, and who remained a long time with the patient, contracted the disease and died of a generalized diphtheria. Two deaths were the re- sult of that error in diagnosis. Diphtheria Without Diphtheria. (Diphtherie sans Diph- therie), I have spoken before of those cases of pharyngitis without false membrane, which are, in times of epidemic observed in centers where numerous manifestations of diphtheria are en- countered. In families it is not rare to see these sore throats alternating with pseudo-membranous sore throats. They be- have like simple sore throat. They only have a greater ten- dency to produce sub-maxillary swelling. The diagnosis can never, in such cases, be positively made, as the most striking objective expression of diphtheria, viz., the false membrane, is wanting. Analogy is the principal argu- ment. There can be no objection to admitting that the false membrane may be lacking in diphtheria, like the eruption in measles or in scarlatina, especially when one of these cases of pharyngitis without false membrane is seen to be acquired from a case of pseudo-membranous pharyngitis, and to transmit, in its turn, another exudative pharyngitis. In this case, an un- questionable anatomical diagnosis should not be pretended. It is rather a matter of rational diagnosis imposed by the laws of general pathology, and by the study of the habits of the dis- ease. Laryngeal Diphti^eria. The symptoms of croup consist in alterations of the cough, of the voice, and of the respiration. Whenever these symp- toms are met with in patients already suffering from diphtheri tic pharyngitis, no doubt is possible ; their cause is evidently the propagation of the pharyngeal lesions into the larynx. But LOCALIZATION OF DIPHTHERIA. 283 at the time when the patient comes under observation, the pharyngitis may be wanting, either because it is already past, or because it has been altogether absent. Under these circum- stances, which are not rare as I have shown before, the task becomes more difficult. The only irrefutable symptom ot croup, is the expectoration of false membranes representing fragments of a cylinder, and appearing to be detached from the air-passages. This is the substantial diagnosis, it is the lesion itself. Since this very important sign is often wanting, croup may be confounded with different affections of the air-passages, which also occasion difficulties, of cough, of voice, and of res- piration. These affections are : Laryngitis stridulosa, severe ac7Ue laryngitis, cedema glottidis, foreign bodies^ polypi of the larynx and capillary bronchitis. Laryngitis Stridulosa or Spasmodic Laryngitis. — There is no disease with which the physician should make himself more ia- miliar. It is the terror of parents who confound it with croup, and I might say, the nightmare of the physician whose sleep it disturbs more than all other diseases put together. Nineteen times out of twenty, a physician who has anything to do with diseases of children, is suddenly awakened by some one crying and demanding his immediate assistance : "Hurry, doctor," he exclaims, "my baby has the croup." The commencement of the case should result in reassuring the physician almost completely, and in making him suspect false croup. He may, while on the way, encourage his guide a little. Examination of the patient confirms the anticipated diagnosis, and justifies the prognosis, in the immense majority of cases. In fact, one of the best characteristics of laryngitis stridulosa, the best one as I believe, and certainly the most striking, is its sudden onset during the night. The child has gone to bed perfectly well, or more accurately, with a slight cold. Between lo o'clock in the evening and 2 o'clock in the morning it wakes up, a prey to a hoarse paroxysmal cough which is at the same time loud and accompanied by oppressed breathing with retraction (of the lower end of the sturnum) and soon, by the attack of suffocation. Often the cough and the 284 DIPHTHERIA, CROUP AND TRACHEOTOMY. dyspnoea do not interrupt its sleep, which persists up to the point where the paroxysm of suffocation approaches. That feature announced by so great a fuss, makes more noise on, the whole, than it does harm, as we shall soon see, for it does not announce croup but laryngitis stridulosa. With the suddenness of the onset of false croup should be contrasted the mode of invasion of true croup, which is almost always preceded by a pharyngitis or by a pseudo-membranous coryza, and which, even in those cases where it comes on sud- denly, almost always begins with alterations of the cough and of the voice, the attack of suffocation coming on later. Some other differential symptoms will serve to elucidate the diagnosis. The cough is entirely different in the two cases. In croup it is infrequent, harsh at first, and finally muffled. In laryngitis stridulosa it is frequent and at the same time hoarse and loud, imitating more or less the crowing of a cock or the barking of a puppy. This cough is the true croupy cough which points, as we see, not to croup, but to false croup. It indicates that the vocal cords still vibrate, although in un- wonted sounds. That of croup is, on the contrary, stuffed up by the false membranes which, according to Trousseau's com- parison, act like a bit of wet parchment upon the reed of a clarionette. The course of the disease differs essentially in the two cases. Sudden as suffocation is in false croup, it is just as short in duration. Often the attack is single, the dysp- noea decreases, the retraction diminishes, the cough becomes moist, and order is restored. The patient falls asleep again, and w'akes up after a long refreshing sleep, retaining only a slightly hoarse cough from its nocturnal attack. When the attacks are repeated they gradually diminish. If the op- pression persist during the interval the laryngo-tracheal whist- ling disappears. The retraction alone remains, and that gradu- ally diminishes. How different is the course of croup. In place of an explosion, followed by a lull, we find ourselves in the presence of a series of symptoms, the intensity of which is constantly increasing, from the simple hoarse cough with neither paroxysms nor suffocation, indicative of simple laryn- LOCALIZATION OF DIPHTHERIA. 285 gitis, to the dyspnoea, which, by a gradual progression reaches asphyxia, by passing through attacks of suffocation and con- tinued dyspnoea. There is often no fever at all in false croup, at least when the latter does not begin in the course of a slight bronchitis, and, in any case, it diminishes rapidly after the first attack. The existence of a submaxillary swelling, or the presence of albumen in the urine, would be evidence in favor of croup. The gravest difficulties may arise. The intensity of the suffo- cation may be such as to compromise the life of the patient. This supposition is rarely realized, for laryngitis stridulosa is always benign. One case only, the one which Trousseau re- ported, is known to have ended fatally. The course of the symptoms and the character of the cough in very severe cases will almost always indicate the true nature of the disease. We should, nevertheless, keep watch of the patient, with a fear of actual suffocation, and hold ourselves in readiness for trache- otomy. In croup without pharyngitis, with an abrupt begin- ning and a fulminant course, the diagnosis has for its data the growing intensity of the symptoms and the ejection of false membranes. In case of doubt we should act as though it were a question of croup, and shape our course accordingly. Trousseau speaks of the possibility of laryngitis stridulosa in patients suffering with common or herpetic pharyngitis. Here the embarrassment is augmented by the uncertainty as to the nature of the pharyngitis. What I have said of the rarity of herpes of the fauces, and of the errors too frequently committed by confounding it with certain forms of diphtheria, is such as to prompt a very justifiable reserve as to the nature of a laryngitis which might develop under like circumstances. Yet, if it were fully shown that the pharyngitis was frankly herpetic, there would be good reasons in favor of simple laryn- gitis. However, it should not be forgotten that diphtheritic croup has been seen coincident with herpes of the lips and with that of the fauces. In spite of all these precautions, and a careful examination of the symptoms, the diagnosis may re- main undecided. The only probability in favor of croup is 286 DIPHTHERIA, CROUP AND TRACHEOTOMY. the increasing severity of the dyspnoea. Moreover, the doubt would not last long, for laryngitis stridulosa is decided within twenty-four hours, or two days at most. Severe Acute Laryngitis. — Rarely primary, this form of lar- yngitis is very often secondary being met especially during the course of measles, scarlatina, or small-pox, and in a num- ber of febrile affections like pneumonia, bronchitis, etc. A certainty of the primary origin of the laryngitis in question would, therefore, be very important in eliminating the idea of diphtheria ; in fact, measles, scarlatina and small-pox are found among the commonest causes of croup. The distinction is established by means of the following signs : When laryngitis is primary it begins with a violent febrile condition, and when it is secondary the fever reappears if it had subsided. In croup,on the contrary, the fever is rarely high. The cough is hoarse from the beginning, but is not muffled; it is frequent, in place of being infrequent, as in croup, and it is violent and tearing (rasping). Dyspnoea is intense from the beginning, it increases rapidly, and is continuous, almost never assuming an intermittent form. Retraction is uncommon. Pressure upon the larynx causes a sharp pain. Still oftener than laryngitis stridulosa, simple laryngitis may cause such suffocation that tracheotomy becomes necessary. Millard cites one such case, and I have met with several. A pseudo-mem- branous expectoration during or after the operation would be, in the absence of any other diphtheritic manifestation, the sole proof of croup. Although cases of simple laryngitis, submit- ted to tracheotomy, have often been taken for croup, the error was not prejudicial to the patient so long as the laryngeal symptoms reached asphyxia. The fever continues throughout the disease, and general symptoms, such as delirium and con- vulsions, sometimes accompany it. GLdema of the Glottis. — The repetition of the attacks of suf- focation, the dyspnoea and retraction (tirage) which persist in the interval, the character of the cough and of the voice, which are dull and muffled, and the difficulty in deglutition, give laryngeal dropsy a great resemblance to croup. The LOCALIZATION OF dRiTHERIA. -^7 course of the disease usually differs. As oedema is ordinarily secondary to chronic affection of the larynx, its course is slow, and, in place of reaching its limit in a few days, or even m a few hours, like croup, it often requires several weeks. When the oedema succeeds a sub-acute inflammation of the larynx, it comes on very rapidly, a few hours being sufficient, and the diagnosis becomes very difficult. A little boy, twenty- three months old, who had been coughing for four days, en- tered Saint Eugenia, No. 13, Saint Benjamin's ward, having had attacks of suffocation. An emetic and the action of the va- porarium brought some relief, but during the night a more vio- lent attack carried him off; before aid could be obtained for him. The autopsy revealed the existence of an oedema of the glottis. This very suddenne^ss, joined with the absence of pharyngitis should exclude diphtheritic laryngitis. Yet ful- minant croup sometimes progresses in the same manner. Moreover, the disease ending in suffocation in both cases, the treatment is the same, and the diagnosis is of little value from this standpoint. It is not so as to prognosis. When the as- phyxia is removed by tracheotomy, acute oedema rapidly re- covers, but too rarely does croup do so. The submaxillary swelling, indicated by many authors as an important differen- tial sign, should lose much of the value accorded to it. Aden- itis, in fact, when it is considerable, whatever be its nature, is itself a cause of oedema of the larynx, by reason of the pres- sure which it exercises upon the vessels of the neck. After scarlatina, notably, such cases are not rare. I have published a very interesting one. In another, a girl of twelve years, oedema of the glottis was determined by a glandular enlarge- ment of strumous origin, occupying the submaxillary glands on both sides and in such a way that the two tumors joined by passing in front of the neck. Tracheotomy was performed and a cure obtained. Thus the testimony of adenitis does not favor croup, more than it does oedematous laryngitis. The circumstances under which the disease is produced, should be carefully taken under consideration. The existence of a cervical tumor, or of a disease which readily brings on Sc 288 DIPHTHERIA, CTIOUP AND TRACHEOTOMY. laryngeal lesions, as do measles, small-pox, whooping cough, typhoid fever, and tuberculosis, should favor diagnosis of oedema of the glottis. The appearance of laryngeal symptoms in a subject already suffering from anasarca, would make one sus- pect also laryngeal dropsy. Yet in these very conditions error is still possible. I saw at Saint Eugenie a patient three years old who entered the hospital with anasarca, with attacks of suffocation and with albuminuria. There was no history, and he had no submaxillary swelling but what was attributable to the facial oedema. The diagnosis was, oedema of the glottis resulting from acute Bright' s disease with anasarca. Tracheo- tomy was formally indicated and was performed, but at the moment of opening the trachea, an effort at coughing forced from the wound a large piece of false membrane. During the following days other false membranes were expelled. Thus we had to deal with croup. Did the anasarca depend upon a pri- mary nephritis or did it depend upon the diphtheria, which is possible, but rare ? This was difficult to determine in the ab- sence of a history. In spite of that complex condition, the pa- tient recovered. And now, to conclude, I give a case in which diagnosis was impossible during life, and was furnished only by the autopsy. It relates to an oedema of the glottis in a patient suffering from diphtheritic pharyngitis and coryza. A girl of six years entered Saint Eugenie on account of a diphtheritic pharyngitis which was perfectly well marked and accompanied by coryza, considerable adenitis and swelling, and by albumin- uria. Two days after her entrance she showed laryngeal com- plications. An extension of the false membrane into the larynx, was naturally supposed. The general condition was so bad and blood poisoning so profound thattracheotomy was decided to be useless. Death occurred caused rather by the infection than by asphyxia. To our general surprise, no false membrane at all was found in the air-passages. The tonsils alone pre- sented some remnants of it. The borders of the epiglottis and the aryteno-epiglottidean ligaments were converted into thick mammelated, tremulous pads forming tubercles as large as peas, and permitting a turbid serous liquid to ooze out on press- ure after incision. LOCALIZATION OF DIPHTHERIA. 2^9 Direct exploration of the epiglottis by means of the finger, and Jaryngoscopic examination have been vaunted as the final means of decision. ■ These means have great value in theory ; but their application is necessarily subordinate to the tolerance of the fauces. Usually very difficult with children, they are impracticable with patients whose breathing is oppressed and who experience reflex movements followed by suffocation, at the least irritation of the fauces. Spasm of the Glottis. — The sudden onset of the attacks of suffocation, the perfect freedom of the respiration between times, and their frequent coincidence with contraction of the ex- tremities or with convulsions will leave no doubt at all as to diagnosis. We may add that spasm is met with especially in early infancy. Foreign Bodies in the Larynx. — Paroxysms of cough, and at- tacks of suffocation are the results of that accident, but beyond the fact that the history usually puts one on the right track, the cough and the voice are not at all of the same sound as in croup. Auscultation of the larynx, by revealing a flapping or valve-like noise, indicates the presence of a foreign body in that cavity. Besides there is often heard at a distance an in- terrupted scraping, a to and fro sound. The foreign body may come from the interior, in which case it consists usually of entozoa, of lumbricoids in particular, which pass out of the digestive passages and find their way into the larynx. Noted by Haller, these facts were more fully brought to light by Arronsohn, Tonnele, and by Barthez and RiUiet. The attention is not attracted at first, to an accident of this nature, yet some suspicions might be aroused if the attack of suffocation came on suddenly, and in the day time, in a subject perfectly well; if also we could learn that the child was subject to passing worms, and if we could be sure that no foreign body had come from the outside. Introduction of the finger into the back part of the fauces sometimes enables the body of the lum- bricoid to be felt. Retro-pharyngeal Abscess. — Its acute character, the difficulty of deglutition and the extreme dyspnoea, may cause retropha- 290 DIPHTHERIA, CROUP AND TRACHEOTOMY. ryngeal abscess to be confounded with croup. In the former case the dyspnoea is usually continuous, while the dysphagia is not in proportion to the condition of the fauces, upon which false membranes are not found, and constriction of the jaws is often very pronounced. The neck is rigid and motionless. The muscles of the neck may be contracted. Pressure upon the cervical vertebrae is often very painful. The neck is swollen, tumefied and oedematous. This tumefaction is very different from that which characterizes diphtheria, a tumefaction due at once to the adenitis and to a soft swelling of the cellular tissue. With abscess there is a general puffiness descending lower than in croup, and finally, in the former there is found to exist upon the posterior wall of the pharynx, a red, smooth, tense, and fluctuating tumor caused by the pushing forward of the pharyngeal mucous membrane. Capillary Bronchitis. — The excessive dyspnoea and the cy- anosis, which are met with in suffocative catarrh, when it at- tains its maximum intensity, may palm it off for croup. I have seen certain cases in which suffocation was so predomi- nant that the error was followed out clear to the end, and tracheotomy was performed. Yet, by not allowing the dysp- noea to have too great weight, it will be seen at once that in suffocative catarrh neither adenitis, pharyngitis, attacks of suf- focation nor laryngo-tracheal whisthng are observed. The cough and the voice preserve their usual tone, and auscultation shows the presence of numerous sibilant and subcrepitant rales, almost always generalized. Fever is intense. Respi- ration is considerably accelerated, and from 80 to 100 inspira- tions a minute may be counted. Now that we have learned to distinguish croup from other diseases, there remains still one question to be solved : Are there several kinds of croup? In other words, is such a thing known as non-diphtheritic croup? Just as benign diphtheritic pharyngitis has often been denied, and turned into a separate species, which has been confounded with herpes of the fauces, so the attempt has been made to class croup without apparent blood poisoning as a non-diphtheritic disease. Does not this LOCALIZATION OF DIPHTHERIA. 2gi distinction, which is evidently applicable only to cases which are primary croup, arise from a confusion between croup and severe laryngitis stridulosa ? We have above seen that there are some instances where the latter affection, though usually benign, may be serious enough to result in death. Here is a cause of error from which we should protect ourselves, and which may have led astray the partisans of this theory. On the other hand, it is said that the laryngeal mucous membrane, when highly inflamed, may become covered with a fibrinous exudate which is non-diphtheritic. This is a view entirely theoretical. If, in fact, we may, by means of chemical irri- tants, cause pellicles resembling false membrane to arise on the laryngeal mucous membrane, there is no proof that nature spontaneously produces like lesions in the absence of diphthe- ria. In making an extensive abstract of the German termin- ology which makes two different diseases of croup and diph- theria, I do not believe that many observers have met, at least in our country, these cases of non-diphtheritic, pseudo- membranous laryngitis. West has also given the support of his authority to this theory. The following passage will en- able us to judge of it: "There are, indeed, two diseases which have often been included under the com- mon name of croup, though the points of difference between them are at least as numerous and as important as are those in which they resemble each other. Oi these two diseases, the one is almost always idiopathic, the other is often secondary ; the one attacks persons in perfect health, is sthenic in its character, acute in its conise, and usually proves amenable to antiphlogistic treatment; the other attacks by pref- erence those who are out of health or who are surrounded by unfavorable hygienic conditions, and is remarkable for the asthenic character of the symptoms which at- tend It. The one selects its victims almost exclusively from among children, is in- capable of being diffused by contagion, is governed in its prevalence by the inlluence of season, temperature and climate, but rarely becomes, in the usual acceptation ot the term, an epidemic ; while the other attacks adults as well as children, is propa- gated by contagion, and though it occasionally occurs in sporadic form, is suscepti- ble of wide-spread epidemic prevalence. The one is developed out of catarrh, and the amount of disease of the respiratory organs is the exact measure of the danger which attends it; while the other afiects the organs of respiration, secondarily, its peril is often altogether out of proportion to the degree in which they are involvec, and death itself may take place although they are altogether unaffected. In this latter ailment, too, a long train of sequelae not unfrequently remains after the local symp- 292 DlPirrilKRlA, CROUP AND TKACiiEOi OMY, tonis have been dissipated ; the evidence of its affinity to the class of blood diseases rather than to that of simple inflammations. Cynanche trachealis, cynanche laiyngea, are the appellations of the former; Home and Cheyne, and Albers its historians. Angina maligna, the garotille, morbus strangulatorius, diphtherite or diphtheria, the synonyms of the latter , Severinus, Bard, Starr, Rumsey, Bretonneau, Trousseau and Jenner some of the writers who have most carefully described it." [I will here add a further paragraph from West which seems to be quite pertinent to the present discussion : "Different, however, as the two diseases are, there are yet between them points of similarity no less striking — Fades non una, nee diversa tamen — and the diagnostic difficulties which are thus almost inevitable, are slill further enhanced by the not in- frequent simultaneous prevalence of both affections." C. West, M.D., "Lectures on the Diseases of Infancy and Childhood." Fourth Am. Ed. from the 5th revised and enlarged English ed. 186S. p. 310. The following are the conclusions of the Committee of the Royal Medico- Chirurgical Society appointed to report on the subject of membranous croup and diphtheria, on which com- mittee Dr. West was at first appointed chairman : 1. Membranous inflammation confined to or chiefly affecting tlie larynx and trachea may arise from a variety of causes, as follows: a. From diphtheritic contagion. h. By means of foul water or of foul air or other agents, such as are commonly con- cerned in the generation or transmission of zymotic disease (though whether as mere carriers of contagions cannot be determined). c. As an accompaniment of measles, scarlatina, or typhoid, being associated with these diseases independently of any ascertainable exposure to the special diph- theritic infection. d. It is stated on apparently conclusive evidence, although the committee have not had an opportunity in any instance of exatnining the membrane in question, the membranous inflammation of the larynx and trachea may be produced by various accidental causes of irritation, the inhalation of hot water or steam, the contact of acids, the presence of a foreign body in the lar\'nx, and a cut throat. 2. There is evidence in cases which have fallen under the observation of members of the committee, and are mentioned in the tables appended, that membranous affec- tion of the larynx and trachea has shortly followed exposure to cold, but the know- ledge of the individual cases is not sufficient to exclude the possible intervention or co-existence of other causes. The majority of the cases of croupal symptoms defi- nitely traceable to cold appear to be of the nature of laryngeal catarrh. 3. Membranous inflammation, chiefly of the lai7nx and trachea, to which the term "membranous croup" would commonly be applied, may be imparted by an influence, epidemic or of other sort, which in other persons lias produced laryngeal diphtheria. 4. And conversely, a person suffering with the membranous affection of the air-pass- LOCALIZATION OF DIPHTHERIA. 293 ages such as would commonly be termed membranous croup, may communicate lo another a membranous condition limited to the pharynx and tonsils, which will com- monly be regarded as diphtheritic. It is thus seen that the membranous affection of the larynx may arise in connection with common inflammation or widi specific disorders of several kinds, the most com- mon of which in this relation is that which produces similar change elsewhere, and is recognized as diphtheria. In the larger numberof cases of membranous affection of the larynx the cause is obscure (i. e., in any given case it is difficult to predicate the particular cause in that case). Among those in which it is apparent, common irritation seldom presents itself as thtr source of the disease, accidental injury is but very infrequently productive of iL But few cases of undoubted origin from exposure to cold are on record. On the other hand, in a very large number of cases infective or zymotic influence is to be traced. The membrane, even when chiefly laryngeal, is more often than not associated with some extent of a similar change in the pharynx or tonsils; and whether we have regard to the construction of the membrane, or to the constitutional state, as evinced by the presence of albumen in the urine, it is not practicable to show an ab- solute line of demarcation (save what depends upon the position of the membrane) between the pharyngeal and laryngeal forms of the disease. The facts before the committee only warrant them in the view that when it ob- viously occurs from a zymotic cause or distinct infection and primarily affects the pharynx, constitutional depression is more marked, and albuminuria more often and more largely present, though in both conditions some albumen in the urine is more frequently present than absent. The most marked division indicated by the facts before the committee is that between membranous and non-membranous laryngitis. The committee suggest that the term croup be henceforth used wholly as a clinical definition implying laryngeal obstruction occurring with febrile symptoms in children. Thus croup may be membranous or not membranous, due to diphtheria or not so. The term diphtheria is the anatomical definition of a zymotic disease which may •r may not be attended with croup. The committee propose that the name membranous lar^'ngitis should be employed iD order to the avoidance of confusion whenever the knowledge of the case is such as to allow of its application. Chairman, W. HowsHiP Dickinson. C. Hilton Fagge. Samuel Gee. J. F. Payne. H. G. HowsE. R. H. Semple. H. S. Greenfield, Sec'y.] It is quite difficult to apprehend, from this passage, the ex- act thought of the EngHsh physician (West). Does he mean to speak of two forms of pseudo-membranous laryngitis of different nature? In the second of the two diseases he evi- dently has in view infectious croup. To what pathological 294 DIPHTHERIA, CROUP AND TRACHEOIOMY. type can the first be adapted? It is applicable at least to two morbid states, which the author seems to confound, viz., laryn- gitis stridulosa and primary croup without marked blood poisoning. In fact, the larger share of the characteristics which he gives to the first disease can be assigned to laryngitis stridulosa. The latter is developed, as is well known, under the form of catarrh, attacks children only, because of the re- stricted dimensions of their larynx, is neither epidemic nor contagious, and prevails almost exclusively during cold weather. If it refer to simple croup, without very evident blood poisoning, which is sometimes, as I have also shown, accom- panied by a certain inflammatory condition, it is easy to prove that the differences between the two diseases are much less evident still. Who has not seen a frankly infectious croup, beginning in subjects in perfect health and living in the best hygienic conditions.? Who has not observed, in times of epi- demic, the most locaHzed croup, and the least infectious in appearance, having been transmitted to a healthy individual, by another suffering from malignant diphtheria, and vice versa? If the first sometimes assumes the inflammatory type, the sec- ond may also do likewise at the beginning. Croup, the most simple to outward appearance, may be accompanied by al- buminuria and followed by paralysis. We add further, that in the sthenic form, of which the author speaks, the tendency to- ward generalization of the false membranes is much greater than in the infectious form, the opposite of what we observe in France. The confusion evidently comes from croup, local- ized in the larynx and appearing exempt from blood poison- ing. But as I shall show more in detail when I treat of the nature of diphtheria, this absence of blood poisoning is only apparent. Often these cases of croup which appear so simple are observed in surroundings where diphtheria exists; often they originate from cases evidently diphtheritic, and they often transmit severe forms of diphtheria. It is also not rare to see those which have the most benign aspect at the beginning afterwards assume characteristics of the most marked blood LOCALIZATION OF DIPHTHERIA. 295 poisoning. One of the arguments upon which the partisans of simple croup depend is the absence of pharyngitis. I have in- dicated how much that reason is worth. Much oftener than one would suppose, the pharyngitis is very slight, is unper- ceived, or has already disappeared when the patient, suffering from croup, presents himself for observation. I record, for the first time, a very important case of croup, in which pha- ryngitis appeared to be wanting, when the autopsy demon- strated that the false membranes had developed behind the tonsils and from thence had extended into the larynx. Ad- mitting the absence of pharyngitis, these localized non-in- fectious, simple croups, common sore throats, as certain au- thors would have them, should recover with the greatest ease, when tracheotomy has brought relief to the asphyxia. The results should be analogous to those of oedema of the glottis, but much shorter since it is a question of an acute disease. Unfortunately recovery is far from being the rule, even in those cases which are so simple in appearance. What is it, then, that prevents recovery, if it be not the very infection which was latent from the first? The conclusion which to me appears most justified is that croup, like every manifestation of diphtheria, appears under many forms, with or without ap- parent blood poisoning, with a sthenic or an asthenic charac- ter, but that it is difficult, if not impossible, to prove the ex- istence of a non-diphtheritic pseudo-membranous laryngitis. Diphtheritic Coryza. — This local determination of diphtheria cannot be confounded with any other disease. Although the existence of a pseudo-membranous coryza, aside from diph- theria, has been admitted, that notion is no better justified in this case than in that of croup. The important point is not to deny diphtheritic coryza. In a patient free from any other diphtheritic manifestation, the coryza, insignificant in itself, may enable the invasion of croup to be foreseen. When su- pervening in a subject suffering from diphtheritic pharyngitis it notably aggravates the prognosis. It should, therefore, al- ways be looked for. A serous, sero-purulent, or especially a sero-sanguinolent discharge, or an epistaxis, should make us 296 DIPHTHERIA, CROUP AND TRACHEOTOMY. suspect it. Often the oozing is insignificant, and pressure must be exercised upon one nostril or the other, to make it escape. To confirm the corpus delecti (the essential cause) we must not wait till the false membrane appears externally, or till pseudo- membranous fragments are thrown out, which may fail. It is necessary to examine the interior of the nasal fossae by par- tially opening the nostrils or by introducing a nasal speculum, which will enable one to recognize the condition of the ante- rior portion of that cavity. If this exploration gives no re- sult, the posterior orifice should be examined, which can be done by means of the rhinoscope. PseiLdo-Membranous Bronchitis. — An increase of the fever and oppressed breathing, and the frequency of respiration rising to 80 or 100 inspirations per minute, are the symptoms common to bronchial diphtheria, and to all its thoracic compli- cations. The establishment of the symptoms indicated will enable one to make a diagnosis, viz., dry, crackling sounds and ab- sence of vesicular murmur over a certain extent of the chest. These signs have only a relative value, for they may be masked by those of other pulmonary lesions. A diagnosis cannot be expected, except from a single sign, viz., from the expectora- tion of tubular and branched pseudo-membranous fragments. This is the pathognomonic and indubitable characteristic. Oculo-Palpebral Diphtheria. Purulent ophthalmia with fibrinous deposits is the only- lesion with which ocular diphtheria could be confounded. Some important characteristics differentiate these two morbid states. In the former case the discharge is abundant, puru- lent, and lasts during the whole of the disease, while in the second it is turbid and grayish, disappearing almost corn pletely during the exudative period, to reappear at the mo- ment of elimination. In the first the conjunctiva is red and granular, and the eyelids are tense and oedematous ; in the second the mucous membrane is smooth and yellowish, and th eyelids are hard, and form a sort of resisting cap. The exu- LOCALIZATION OF DIPHTHERIA. 29/ dates of the former are wholly different from the smooth and thin false membrane of the latter. The diagnosis presents certain difficulties only at the period of elimination, but the co- existence of other diphtheritic manifestations will render the diagnosis clear. Special authors have discussed the existence of pseudo- membranous conjunctivitis, developed apart from any specific action. The question has not been as yet definitely solved, but its solution can be foreseen by recalling what has been said of other manifestations of diphtheria. Diphtheritic Otitis. Always accompanied by the symptomatic array of pharyn- gitis, coryza, and often of croup, diphtheritic otitis media often is overlooked in very young patients, at least during its first period. The otorrhoea alone permits the diagnosis to be made. Yet, in older subjects, the recrudescence of the fever, the lan- cinating character of the pain, and its locality, which, very dif- ferent from that of pharyngitis, is felt in the temple, and about the temporo-maxillary articulation, and tinnitus aurium, ver- tigo, vomiting, and deafness will direct the line of research. Buccal Diphtheria. This local manifestation should be distinguished from aphthae, from gangrene of the mouth and from ulcero-membranous stomatitis. 1st AphtlicE. — Isolated aphthae will never be confounded with buccal diphtheria. The complete absence of general symp- toms, the presence, at the beginning, of a vesicle followed later by an ulceration with perpendicular borders, sharply defined, quite deep, or appearing so from the swelling of the surround- ing tissues, of rounded form, small size, forbid any confusion between these two morbid states, although the aphthae may also be covered with a fibrinous exudate. Only this exudate is thin and has no tendency to grow thicker nor to become pu- trid. When the aphthae are numerous and confluent, the diagnosis is more difficult, and it is certain that several authors have de- scribed, under this name, lesions which were nothing other 298 DIPHTHERIA, CROUP AND TRACHEOTOMY. than those of buccal diphtheria. Yet there is a notable differ- ence between these two conditions. While the confluent aphthae very often give rise to a febrile attack which may last from one to two days, there is no resemblance at all between this general condition, and that which pertains to diphtheria. The glandular swelling, while possible, is rare, and of slight in- tensity. The ulceration possesses, in gross, the characteristics of isolated aphthae. In place of the white, thick, and salient, false membrane of diphtheria, a true ulceration is seen, the general form of which is round, and whose edges are sharply perpen- dicular. 2nd. Gangrene of the Month. — The morbid product is not a false membrane, but a real eschar with a well pronounced gan- grenous odor. The surrounding mucous membrane is grayish. The cheek is swollen, oedematous, tense, shining, marbled, and of a purple red. At the centre of this engorgement, one point is found to be particularly indurated. Salivation is abundant. It is mingled with an infectious, sanguinolent, and finally sani- ous and putrescent liquid. Considerable destruction of tissue, of which the most remarkable is the complete perforation of the cheek, is often the end of this sphacelus. Buccal gangrene is ordinarily isolated, and is not compli- cated by any lesion of the fauces, larynx, or respiratory pas- sages. A grave adynamic condition frequently accompanies this lo- cal lesion. j^. Ulcero-membranons Stomatitis. — By reason of its site, which is so often the alveolar border of the gums, this disease has been confounded with buccal diphtheria. The analogy is, in fact, quite great, and it may be conceived that before the description given by Bergeron, ulcero-membranous stomatitis was taken for diphtheria. This is what appears from the works of Bretonneau and of Trousseau. Actually, the differences which separate these two conditions are perfectly well known. The history of ulcero-membranous stomatitis shows yet again to what grave errors one exposes himself by taking the lesion as the sole basis of the classification of diseases. This stoma- LOCALIZATION OF DIPHTHERIA. 299 titis is the type of the anatomical process which the Germans designate by the name of diphtheria. The inflammatory exu- dation forms not only upon the surface, but also in the sub- stance of the mucous membrane, which it infiltrates to a varia- ble depth, and which it destroys to the same extent. It is, consequently, eliminated, leaving a loss of substance. Thus, if we admit that which moreover is inexact, viz., the identity of the lesion in this stomatitis and diphtheria, we are led to con- found two affections, which, aside from a superficial resem- blance, are as dissimilar as possible in all their symptoms. In fact, ulcerative stomatitis, a disease of wretchedness and want, which develops in organisms deteriorated by bad hygiene or in convalescents, this ulcerative stomatitis, the reverse of buc- cal diphtheria.aimost always occupies the alveolar border of the gums, often has for its point of origin a carious tooth, extends in length and breadth along the gum, lays bare the teeth, reaches the lips and the inner surface of the cheeks, more rare- ly the palate or the tonsils, and produces oval shaped ulcera- tions. These ulcerations have an unhealthy appearance, being covered with a grayish detritus ; their borders are irregular, often detached. The tendency to spread is slightly marked. Only one side of the mouth is attacked in the larger number of cases. The odor is fetid, much more so than in diphtheria. The cheeks and the lips are often somewhat swollen. In case of great in- tensity there is now and then a little submaxillary adenitis, but this engorgement is never comparable to that of diphtheria. While it may reach the tonsils, and the velum palati, ulcero- membranous pharyngitis does not extend to the larynx, nor does it ever present analogous lesions in other parts of the body. While it often attacks subjects whose health is already af- fected, ulcerative stomatitis rarely aggravates their condition, for it is almost never accompanied by general symptoms. Left to itself it runs its course very slowly, but under the influence of appropriate medication it becomes rapidly modified. These characteristics differ sufficiently from those which buc- cal diphtheria presents, to render confusion impossible. f 300 diphtheria, croup and tracheotomy. Diphtheria of the Anus and of the Genitals. Herpes with ulceration, and gangrene are the only affections which could be taken for diphtheria on these organs. ist. Herpes. — The verge of the anus, the labia majora and minora, the glans penis, and the prepuce, are quite often the seat of herpes, which we must avoid confounding with diph- theria. If the vesicles are discrete, there can be no doubt, for they leave behind them a small, rounded, superficial ulceration with a yellowish floor, and the surrounding mucous membrane is slightly inflamed. When the vesicles are numerous and con- fluent, the diagnosis is more difficult. Instead of separate ul- cerations, there appears an ulceration sometimes quite exten- sive, the diagnosis of which requires an attentive examination. The greatest difficulties are met with in the female, on account of the arrangement which the numerous folds of mucous mem- brane about the labia majora and minora, give to the ulcer. These ulcerations have often an unhealthy look, giving rise to quite an abundant discharge, while their floor is covered with a yellowish detritus. After carefully washing the surface, we should see if we cannot find ulcerations in the neighborhood, either upon the mucous membrane, or the skin, which have come from isolated vesicles. Their discovery would be of very great importance, and would settle the diagnosis. On the other hand, in examining the ulcer we find that its floor is cov- ered with a yellowish exudate which is adherent, that its edges are sharply perpendicular and while in general they assume a rounded form, their circumference is made irregular by circu- lar dentations separated by reentering angles, and which repre- sent a part of the contour of the little vesicles around the edge, the other part being fused with the vesicles placed nearer the centre. In the female, care should be taken to separate the labia minora, as the ulceration sometimes extends along their internal surface and even into the vagina. To these local characteristics must be added the absence of general symptoms, and of any other diphtheritic manifesta- tions. LOCALIZATION OF DIPHTHERIA. 3OI 2nd. Gangrene. — Gangrene of the vulva should principally be kept in mind, as this is much the more common. That of the verge of the anus, while infinitely more rare, presents the most evident objective features. That of the vluva is, because of its situation, more difficult to examine. It is oftenest observed after eruptive fevers and typhoid fever or among women during confinement. Dr. Chavanne reported the history of an epi- demic of vulvo-vaginal diphtheria occurring among women dur- ing confinement, which epidemic was in reality only an epi- demic of gangrene. In many cases the gangrene appears un- der the form of a true eschar, and the diagnosis is evident, but sometimes, especially among women during confinement, the distinction is more difficult. The objective symptoms are not always sufficient, as diph- theria itself may be complicated with gangrene. Yet, the diphtheritic patch may in most cases be distinguished from the eschar, which oftenest assumes a gray or brown tint, exhales a distinctly gangrenous odor, and produces the most extensive destruction of tissue. Gangrene is limited to the vulva, while vulvar diphtheria coincides with other diphtheritic manifesta- tions ; and then, even when it begins at the vulva it may be followed by pharyngitis, as numerous examples prove. Al- buminuria and a secondary paralysis will decide in favor of diphtheria. This diagnosis, as we see, is determined more by the aid of the rational symptoms, than by that of the objective features. Diphtheria of the Skin. Hospital gangrene might be, in some cases, confounded with diphtheria of the skin, for this error has been to a certain de- gree sanctioned by the improper name oi dipJitheritis ofivounds given by Robert to hospital gangrene, and by the classification of Boussuge,who classes this affection among the diphtheroids. Billroth affirms the identity of hospital gangrene and diphtheria. All the French school, as well as several German authors, among whom I will cite Raser and Eiscnschitz, protest against this assimilation. In fact, if the surfaces attacked with hospital gangrene are at first covered with a grayish layer, the altera- 302 DIPHTHERIA, CROUP AND TRACHEOTOMY, tion instead of extending superficially as in diphtheria, gains in depth, converts the tissues into a putrescent mass which dis- charges an infectious ichor, often infiltrated with blood, and extends down to the bones which it denudes, strips them of their periosteum, and leaves them a prey to necrosis. It develops after amputations among those who are enfeebled by privation and who live in want. None of the signs of diphtheria are met with, neither reproductions in other organs, albuminuria, nor paralysis. Ulceration of the skin, especially that which is caused by vesicants, possesses at times a strong resemblance to diphtheria of the skin. In the former case, the floor of the ulcer is gray, and sanious; while the fibrinous exudation is absent or much less marked, than in diphtheria. Nevertheless, the diagnosis is sometimes very obscure when there is not found at the same time, some other manifestation of diphtheria. The presence or absence of an epidemic of diphtheria, will be of importance in the decision. Diphtheritic Paralysis. The subject of diphtheritic paralysis, has entered profoundly enough into medical science, so that paralyitic symptoms de- veloped on the part of the velum palati, of the pharynx, and the larynx, do not compel us to seek immediately for the exis- tence of a pharyngitis among their antecedents. It is not pro- bable that the error is still committed, of attributing the rough- ness of the voice, and the difficulty of deglutition, to syphilitic lesions or to hysteria. When the paralysis is generalized, er- ror is more easy, especially if the pharyngitis be lost sight of. In these cases, meanwhile, and in those where a history is lack- ing, we may even find ourselves -in the midst of diseases which afford a resemblance to diphtheritic paralysis. The absolute integrity of the intellectual faculties will forbid a belief in the existence of a progressive general paralysis, in subjects whose movements are uncertain, and whose speech is embarrassed. The melancholy, indolence, fixity of expression, apparent hebetude, amblyopia, strabismus, emaciation and slowing LOCALIZATION OF DIPHTHERIA. 3O3 of the pulse, will not be taken for symptoms of a tubercular meningitis at its beginning, or of cerebral tubercles. With these symptoms, in fact, will be found in cases of diphtheria, paraly- sis of the limbs or of the pharynx, which are not the result of the onset of these maladies, and which usually present an inter- mittent character. The ataxia which has been noted several times in the movements, will not be taken either as attributable to locomotor ataxia, when the different paralyses which follow diphtheria, are discovered. The order followed by the paraly- sis, in its successive invasion of organs, is one of the best ele- ments of the diagnosis. While that order is not constant, it is common enough to be taken into serious consideration. Al- most always, paralysis of the fauces forms the first phenomenon. It exists only for a certain time, and it is often at the time when movement returns to this part, that it diminishes or dis- appears in other parts of the body. When it affects the limbs, the lower ones are attacked first, and the upper extremities af- terward, and then the eyes and the respiratory organs. The hemiplegic form presents also certain difficulties, but we know that the hemiplegia is only apparent, and that the side which appears healthy is really also enfeebled. An important point to be remarked, is, that the paralysis fol- lows a protracted course, and becomes generalized only gradu- ally and after quite a long time. It never occurs all at once. These considerations have only a secondary value in all those cases in which faucal paralysis exists, which alone is enough to affirm the nature of the disease, or to call attention to its antecedents, while they are of especial value in those in which the history of the disease presents neither angina nor faucal paralysis. It may happen, finally, when certain of these facts remain doubtful, that the diagnosis may be confirmed in an unforeseen manner, by the faucal paralysis, which, in place of opening the scene, sometimes terminates it. Etiology — For a long time diphtheria appeared in the form of epidemics. We find in science the account of a great number of epidemics, some general and extensive, invading a city or 304 DIPHTHERIA, CROUP AND TRACHEOTOMY. an entire section of country, others circumscribed to a single ward, to a hospital, an educational institution, and sometimes even to an apartment (Vigla). Such are those which formed the basis of the celebrated works of Bretonneau, Trousseau and others. At first exceptional and limited to certain countries, they have become more frequent, and have extended to regions where they had remained unknown. Very few of the countries of Europe have escaped them. In certain large cities, notably in Paris, diphtheria has become endemic. Since 1856 it has prevailed in this capital continually, with frequent periods of intensification as appears from discussions which have taken place at the sessions of the learned societies, and from reports of the " commission for prevailing diseases." In England and in Germany it has followed the same progression. It is, there- fore, difficult to follow in many places, the course of the dis- ease and to study the conditions of its development. In fact, this information can be furnished only by the epidemics. By these we are enabled to investigate the climatic influences which preside over the development of diphtheria, and to seek its mode of transmission. While there are countries in which epidemics are more difficult to examine, there are others in which it has been possible to observe them recently with care. A comparison of the latter with those which served as a basis of the works of ancient authors, might possibly clear up this part of the history of diphtheria. The accounts published be- fore 1862 are too well known to require me to repeat the de- scription; I shall always be able to consult them in elucidating certain points. The following brief remarks refer to epidemics recently studied. In England Dr. Radcliffe, secretary of the Epidemiological Society of London gives in the following terms the history of diphtheria in that country : "At the be- ginning of the present century there had been only a few sporadic isolated cases of diphtheria. The first real epidemic dates in 1849; it prevailed from 1849 to 1850 in Pembroke- shire. The second arose in Cornwall in 1855. There were al- ways a few sporadic cases. During a portion of 1856 the epidemics became more numerous, and more frequent. In 1859 diphtheria became in England a veritable endemic." LOCALIZATION OF DIPHTHERIA. 3O5 In America, Dr. Wynne announced, in his report on the epi- demics of 1855 to 1861, a notable extension of the disease in the Western Hemisphere. He mentioned epidemics at Lima in 1855, and in 1858 ; in California in 1855 ; at Albany in 1858, and in New York City in 1859. The mortality averaged about 10 per cent. The epidemics extended by interruptions and ag- gravations without continuity. [An epidemic of diphtheria occurred in and about Leesville Ohio, in 1860-61. Dr. J. H. Stephenson sends me a very in- teresting report of it, and his experience with it. It was the first of the disease ever known in the county, and the first he had ever seen. The first case, that of a young lady, occurred in July. On the sixth day (third of attendance) "she coughed up a very heavy membrane of a dark color and a perfect cast of the trachea." The membrane reformed, and she died on the tenth day of the disease. No other case occurred till winter. Then the disease spread — whole families were pros- trated. The epidemic extended over a territory of about eight miles square. In a neighborhood five miles distant it v/as very fatal. In one family four died. In one family under his care, two brothers died in thirty-six hours. In some cases the mouth became gangrenous, and the teeth fell out before death. In a few cases there was a scarlatinal eruption. Some cases as- sumed the hsemorrhagic form — these all died. In one case ot pregnancy there was miscarriage of a dead foetus — dead, evi- dently, for some days. A light deposit was no guarantee against extension to the larynx; it occurred as frequently in these as in cases with thick, dense deposits. There were many other cases of sore throat not classed with the genuine disease. In his practice there were seven deaths. This description (given here very briefly) accords very closely with hundreds of local epidemics before and since in various parts of the country. Its cause and manner or agency of introduction, and in many cases its spread, were en- tirely unknown. Dr. A. G. Browing of Mt. Carmel, Ky., reports : Diphtheria had prevailed in that region since 1858, disappearing in the 306 DIPHTHERIA, CROUP AND TRACHEOTOMY. summer months. In the winter of 1865-6 Dr. B. and his brother treated thirty-seven cases with the loss of one. Dr. Bedford Brown, of Alexandria, Va., reports to the Vir- ginia State Medical Society, 1883, his experience since 1856. "The first case that had ever appeared in that section," a boy 10 years old, soon died. It soon spread all over the country. " Old Watson " makes no allusion to it whatever. "Wood," in 1852, devotes about two pages to a very imperfect description of the local features. Entire families were pros- trated with the disease, and many died. " Previous to the first case of genuine diphtheria (malignant ?) which I saw in the spring of 1856, for a period extending over about nine years, cases of true membranous laryngitis, or what is known as mem- branous croup came under my observation and professional care during every winter and spring. The appearance of this affection sporadically was expected to make annual visitations. They pursued the usual course of that disease, some ending in recovery after expulsion of the false membrane, but the great majority proving fatal solely and alone from mechanical ob- struction of the respiration by the membranous exudation. This was alone the cause of death." (Any cases of trache- otomy ?) The doctor seems to have failed to see the simi- larity in nature between the sporadic and the epidemic forms of this membranous disease — diphtheria. Local epidemics in Illinois, reported by Dr. B. F. Crummer, of Warren, Jo Daviess County, Illinois State Medical Society. Transactions, 1880 : i. A mother came to Warren from Iowa City, where diphtheria prevailed in fatal form, bringing her boy of seven years, hoping thereby to escape the disease. Af- ter five days the boy had diphtheria, pharyngeal in localization, and later faucal paralysis, as the doctor witnessed, but recov- ered within two weeks. This woman was visiting friends, who had children, she having received positive assurance from her physician that it was quite safe to do so, no means of disinfec- tion, however, having been used. In three unfortunate families (relatives) the disease developed, and proved fatal in eight cases; a number of the older children recovered, having LOCALIZATION OF DIPHTHERIA. 30/ had "diphtheritic sore throat." Ten other caseb with four deaths in other families, could be traced directly to the same original eight cases. 2. A minister removed to the vicinity of Warren from a Wisconsin village where scarlet fever and diphtheria were epi- demic. His large family soon all had fever and •' cankered sore throat," but all recovered. The people were advised by a certain pseudo-doctor of a new school that diphtheria should not be classed with contagious diseases. Visiting was unrestrained, and the disease spread to every family having young children. A lady whose children were just recovering, one of them hav- ing paralysis, kindly(!) volunteered to nurse an invalid friend, two miles distant. Result: death of two interesting children from diphtheria in the invalid's family. Total number of cases of this epidemic, twenty-six, with seven ! deaths. 3. In Rush Township, mostly confined to one school dis- trict, diphtheria was imported in January from Stephenson County, where the disease was rife, by two boys, aged respect- ively 14 and 16. They had been on a visit during the holidays. On their return they both had headache, sore throat, but were not confined to bed. Domestic remedies only were used, and they went to school most of the time ; their schoolmates, how- ever, complained of their stinking breath. Soon a six-year- old child of the same family was taken seriously ill, and a few hours before death a diagnosis was made, by a physician, of diphtheria. The disease spread rapidly, and in the course of six or seven weeks numbered filty-eight cases, with seventeen deaths, about 30 per cent. One family lost five young child- ren, and another four, several older ones in each instance re- covering. In this one county thirty-one precious lives were lost from a preventable disease. Twenty per cent of the fatal cases died of " diphtheritic croup." Further comment here is unnecessary, except to say: In two instances prompt isolation saved all the children so removed. During the year ending June, 1880, Illinois recorded 2,422 deaths from diphtheria. In fact, the medical journals are constantly reporting local epi- demics.~\ 308 DIPHTHERIA, CROUP AND TRACHEOTOMY. In France the real endemic condition makes the description of the epidemics difficult, at least in the large cities. There are statistics from the country where the manner of appearance and of propagation is easier to follow, the population being less dense. In 1863, an epidemic of diphtheria prevailed at Etupes in the district of Montbelaird. Teufferd gave an ac- count of it; and in 'j'j individuals, 17 died (about one-fifth). The cases were as numerous during the hot dry months as dur- ing the damp cold months. The forms observed were mem- branous angina alone, and angina with croup. The latter com- plication was always fatal. Another epidemic raged during the first half of 1862 in the parish of Ceyret (Puy-de-D6me). It was reported by Nivet. It spread chiefly among children, adolescents, and the poorer population. No case was seen in persons over twenty-five years of age. Simple angina and bronchitis prevailed during the epidemic in considerable propor- tion. Guillemant has given in his thesis the history of a very fatal epidemic which broke out at Louhans (Saone-et-Loire), in October, 1865, and continued till the close of 1865. In 2,500 cases there were 397 deaths. Of these there were 1,198 chil- dren, and 332 deaths, that is, about one-fourth. Females fur- nished 814 cases of whom 44 died, that is one in 18. There were 488 cases in men of which 21 resulted fatally, that is about one in 25. The epidemic developed in a sickly district of countr>', abounding in swamps, and turf-pits. Heavy fogs pre- vailed during two-thirds of the year. The inhabitants were found in a deplorable hygienic condition ; they were poor, and the lodgings and food were unhealthy. Disease of the potatoes and of the vineyards, rust of the grain, and mouldiness of the leaves of the trees coincided with the epidemic. A short time previously there had appeared among the horses and cows an epidemic characterized by a kind of inflammatory disease of the mouth and throat. In man mediate contagion seemed evi- dent. In another epidemic which scourged the community of Fabre"-es and of Saussan, in the southern part of France, from the latter part of September, 1865, to February, 1866, the hu- midity of the atmosphere appeared to Dr. Gingibre to act an LOCALIZATION OF DIPHTHERIA. 3O9 important part. In the same year an epidemic prevailed with severity in the district of Blaye. The first patient was a strange child which arrived with the disease, and the second, a young girl of the same family. In 1871, a destructive epidemic broke out at Thoury(Loir-et-Cher) and was studied by Picard ; of 2i at- tacked, 9 of which were children, 16 perished. Other epidem- ics of the same kind were signalized at Saint-Laurant de la Pree, in which children from three to five years old were at- tacked almost exclusively; at Vienna (Isere) there were 12 tracheotomies, performed in extremis, giving only two recover- ies. In 1872 several important epidemics were observed: in 20 cases of diphtheritic angina, reported by Pantaire at Rouelles, 12 ended fatally. Infection was very marked ; it destroyed many by asphyxia and furnished a positive contraindication to tracheotomy. The village is situated in a damp valley, deeply enclosed; the houses abutting towards the declivity of a. hill, received light and air only from one side. The difficulty of a circulation of air which results from these conditions explains to the observer the unusual gravity of the epidemic. Conta- gion was seen very plainly. The city of Nogent-le-Roi, a short distance from the preceding, was visited by an epidemic of which the account is given by Flammarian. From November 12, 1871, to September 20, 1872, 40 cases were observed. The climatic conditions were absolutely different from those of the surrounding country. The upper part of the city, swept by the wind, was alone attacked. An epidemic which prevailed se- verely in the villages of Lizolles and Echassiers gave opportunity for the very interesting observation of a case of paralysis of the veil of the palate and of the superior extremities which con- tinued six weeks in a woman who had an attack with only a simple tonsillitis without false membranes. It is difficult not to see in it a case of diphtheria without exudate. In the neigh- borhood of Arengosse (Landes) Malichecq showed the disease as making its first appearance twelve years previously, then becoming acclimated and assuming at varied intervals, a course clearly epidemic. At the same time diphtheria appeared for the first time in the neighboring villages ; importation seemed 310 DIPHTHERIA, CROUP AND TRACHEOTOMY. to have been the mode of propagation. Among the latter is found that of Sallespisse (Basses- Pyrenees) ; as nearly all the others, the epidemic which prevailed so severely in this place attacked children especially. Of 90 patients the children numbered "jj ; of 20 deaths they furnished 19. Dehee, ot Arras, has given the history of an epidemic which prevailed in the villages of Fampoux and Athies (Pas-de- Calais) ; of 1,555 inhabitants, 166 were attacked, and 47, all children, perished. The disease assumed two forms : infectious and generalized, or primary (d' emblee) laryngeal giving rise to asphyxia. The author considered the greatest intensity of the epidemic to co- incide with the period of hauling manure. I have cited the principal epidemics only; a great number of others have been cited, and yet a less number than have really existed. The re- ports upon epidemics published by the Academy of Medicine give us the following information on the course of diphtheria. The statistics are complete only from the year 1858. The num- ber of departments invaded were: In 1858, - - 31 In 1865, - - 26 In 1859, - - 40 In 1866, - - 23 In i860, - - 28 In 1867, - - 22 In 1861, - - 28 In 1868, - - 20 In 1862, - - 26 In 1869-70, - - 14 In 1865, - - 22 In 1871, - - 20 In 1864, - - 23 In 1872, - - 14 [An epidemic still later is reported by Sainton. He gives the history of an epidemic which, from November 20, 1874, to the close of 1875, prevailed in three communities. In the first (Bar-sur-Seine) in 422 children from i month to 1 1 years, there were 44 deaths. In the second (Celles-sur-Ource), there were 16 deaths in 154 children; in the third (Mussey- sur-Seine), 277 children were attacked, and 20 deaths. In summing up, he gives the following : 5,203 inhabitants, 628 pa- tients or cases, of which 80 died. The deaths were divided as follows: Boys, 38, viz., '/s; girls, n, viz., '/s; adults, 3, viz., '/ig. These figures are incorrect.] LOCALIZATION OF DIPHTHERIA. 31 1 In the opinion of the reporters these figures are below the facts: the years 1870-71 are, on account of the war, meagre in information. The figures from the departments attacked give only general results. We should know the number of patients. All of the reporters fail to give it. In Belgium, Dr. Henroz reports that at Bihain, a village of 250 inhabitants, 18 persons were attacked with membranous angina in a few days ; 4 of them died, 3 of these in the same family. Gangrene was frequent; haemorrhage from the nose and mouth was observed several times. Paralysis was constant either with or without ocular disturbances. The larynx was not attacked. Holland and Northern Getmany seem, accord- ing to published statistics, to have been the favorite seats of epidemics of diphtheria. In an abstract of the various epidemics of this nature which have prevailed in the Netherlands, Van Capelle established the fact that the influence of unhealthy dwellings, as well as the contagion in the schools, have been placed beyond question by all writers. Dillee, giving an account of the epidemic of Arnemuiden, declares that the contagion from individual to individual was evident. This epidemic appeared in March, 1864, in a house in which two suspected cases had been noted in October, 1 863. It afterwards extended to the neighboring houses, and attacked 168 persons of the 1,596 inhabitants; 29 died. Kohnemann reports that, in the island of Baltram on the northern coast of Germany, in a population of 149 inhabitants the mortality from diphtheria was 12.8 to the hundred. The western village alone was attacked, while the eastern village, situated at a distance of fifteen minutes' ride, remained entirely exempt. Wiedash infers from his observations during the epi- demic of the island of Nordeney that cold east winds and fogs had a very marked influence upon the development o' the epi- demic. He could predict with certainty the outbreak of new cases when this zveather prevailed. Becker gives an account of an epidemic which spread over a district of Hanover, attacked 153 of 487, and destroyed 29. The patients belonged to well- to-do families, to either sex indiscriminately, and to all ages. 312 DIPHTHERIA, CROUP, AND TRACHEOTOMY. Di]>htheria of the vulva presented itself twice, without angina. Albuminuria was nearly always present. Uhlenburg observed in the epidemic which occurred at Leer during the autumn of 1862, and which attacked more than a hundred persons, the in- fluence of fogs, which appeared to him to favor the develop- ment of the disease. Contagion appeared unmistakable. Mild cases sometimes gave rise to grave ones. Nevertheless, there were cases the etiology of which remained obscure. Bartels witnessed a large number of cases of diphtheria at Kiel and its vicinity. He makes no distinction between croup and diphtheria. The disease developed by preference in cer- tain localities. Contagion from individual to individual could not be demonstrated except in times of epidemics; but the symptoms and complications of sporadic croup were the same as those of epidemic croup. Only in latter years has diphtheria attacked adults also. The gangrenous form was often ob- served after scarlatina. Laryngeal diphtheria rarely appeared after this exanthema. Croup secondary to measles was gener- ally benign: tracheotomy was frequently followed by success. Croup consecutive to typhoid fever appeared only recently. Albuminuria appeared ordinarily from the beginning of the di- sease, and had no connection with the asphyxia. Paralyses were more rare. Denmark. Lange, in his official report on diphtheria in Denmark during the year 1865, showed that this disease as- sumed in a high degree the epidemic character, the primary affection as well as the secondary. The disease has constantly advanced in the different provinces since 1861. We find in 1861 - 550 cases. We find in 1864 - 5,987 cases, in 1862 - 1,220 cases. in 1865, 12,826 cases, in 1863 - 2,304 cases. The disease assumed the form of small local epidemics more or less intense, and without any very apparent cause. Their course was capricious and appeared not at all influenced by the seasons. It was toward the close of 1865 that it attained its maximum intensity. It exhibited itself under two forms LOCALIZATION OF DIPHTHERIA. 313 the inflammatory form, rich in false membranes, and causing death by extension to the larynx ; and the adynamic form, in which the false membrane is accessory. Consecutive paralyses were very frequent. According to the opinion of every med- ical reporter, the disease was eminently contagious ; but the contagion does not appear to them to have been indispensable in all cases. Diphtheria appeared to break out spontaneously in flat and marshy countries, while it usually spared the ele- vated and sandy plains. Three years later, Ditzel showed a report on an epidemic of diphtheria submitted to his observa- tion in the district of Frycensbiirg, during the year 1869. The honorable reporter notes a remarkable increase of cases of croup and diphtheria dunng later years. In 140 cases, 14 suc- cumbed, either from laryngeal extension, or to systemic poison- ing. There was no definite proof of contagion. The greatest number of cases was observed during the summer months. Both sexes were attacked in like proportions. The majority of the patients were between the ages of five and ten years. The fever was often sthenic at the beginning, but in the grave cases of angina it assumed the asthenic character. Convales- cence was always long and followed by paralysis, generally mod- erate. However, in 126 recoveries 20 were attacked with gen- eral paralysis. Albuminuria was without influence upon the course of the disease. The lymphatic ganglions were never tumefied. At Bucharest, Professor Felix gives the account of a serious epidemic which, in 1869-70, attacted 415 persons and destroyed 200 of them. One very curious thing was observed: the Jew- ish population, amounting to 1,400 souls, was almost com- pletely spared ficm the scourge. This immunity may be at- tributed, as it rccms to me, to the customs of the Jews in these couiitries. They live isolated in their quarter of the city, con- sequently under the most favorable conditions to avoid con- tagion. \Roiiinania. In 1879 Droumoff took for the subject of a thesis the account of an epidemic of diphtheritic angina which prevailed in Roumania in the district of Braila. Another epi- 314 DIPHTHERIA, CROUP AND TRACHEOTOMY. demic prevailed at Florence and vicinity from 1862 to 1872, re- ported by Drs. Morelli and Nesti in 1875. Luconi observed in 1875, 1876, at Veroli, a province of Frosinone {L'alj), an epidemic in which the great humidity of the summers of 1875- 1876 appeared greatly to augment the gravity of the disease. The author has noted a certain num- ber of cases of diphtheria without diphtheria (diphtheric sans diphtheric.) These statements give the following results : AGE. SEX, MALE. SEX, FEMALE. RECOVERIES. DEATHS. 2 to 10 years - - 124 115 194 45 10 to 16 years - - 37 44 7^ 9 16 to 30 years - - 19 22 33 8 30 to 40 years - - II 7 14 4 191 188 313 66 The same author witnessed an epidemic of like nature in 1873, which caused a mortality of one inhabitant in five. The Russian journals publish terrible details of the diph- theria now epidemic in Russia. It is reported that in certain communes and parishes all the children under 15 years old have died. The origin of the attack dates from 1872, when the disease first appeared in Bessarabia. Since then it has spread far and wide over the south of the Empire, whence it lately began to make rapid progress toward the east and northwest. In Pultawa, a province of considerably less than 2,000,000 inhabitants, there have been 45,543 cases, of which 18,765 were fatal, one in about two and a half.— Med. Rec. 1881.] Southern Germany. Leopold Graf gives a statistical state- ment of 24 cases of diphtheria, 7 of which terminated in death. Contagion was fully demonstrated in 9 cases. There was al- buminuria in one-half of the patients. In two cases autopsy revealed suppurative nephritis. Dr. Gaupp observed from 1865 to 1866 a limited epidemic at Schorndorf in Wiirtemberg. Of 66 patients there were 23 deaths. Tracheotomy was not performed because of the preponderance of adynamia. Contagion was clearly established. A. Mair, in his report on the epidemics of LOCALIZATION OF DIPHTHERIA. 315 Middle Franconia for the year 1868, states that contagion was recognized by all observers. Incubation lasted on an average from eight to ten days ; in certain cases it was from four to six weeks. (?) Relapses (recidives) were frequent. Complications on the part of different organs were quite common. Death usually occurred by asphyxia. Sxvitzerland. Croup, in Geneva, has had for a long time a special physiognomy which caused it to be regarded by all older au- thors as a local, inflammatory and spasmodic affection of the larynx. Vieusseux and Jurine, who described pseudo-mem- branous bronchitis and laryngitis have almost never observed membranous angina. While admitting an epidemic influence in the development of croup, they have denied contagion. Nevertheless, an epidemic of malignant diphtheria was ob- served by Baup of Nyon, in 1826. The author admitted fully that diphtheria is a general disease capable of being produced in different organs, viz., the ears, the anus, genital organs, and inferior extremities, localizations to which, following the ideas of that date, he gave the name of spontaneous gangrene. Ex- cept this account, authors are in accord as to the rarity ol membranous angina at Geneva, up to these latter years. Dr. Mark D'Espine, in his remarkable work on mortuaiy statistics, which embrace thirteen years of careful compilation of facts at Geneva from 1838 to 1847, and from 1853 to 1855, was able to note but twenty cases of membranous angina in 266 deaths from croup carefully analyzed. The disease attacked children principally, from I to 3 years old. The frequency of croup was particularly apparent during winter, next during autumn ; next following, spring and summer. The activity of the disease predominated in a marked degree upon the male sex. The in- fluence of social conditions appeared to be nil. Tracheotomy was performed during these thirteen years only eight times, and without success. According to a communication which Dr. D'Espine, Jr., kindly made to me, membranous angina has become for some years more frequent at Geneva ; and croup has also there assumed more frequently, the infectious char- acter. But exact information in this respect is wanting 3l6 DIPHTHHRIA, CROUP AND TRACHEOTOMY. [In 1876 the deaths from diphtheria for the whole of Switz- erland were 14 to 1,000 total deaths.] I shall close this review by giving the opinion of two writers who have compared notes of several epidemics occuring in dif- ferent countries : A. Hirsch, in his Manual of Medical Geography, arrives at the following conclusions : "A glance over the historical de- velopment and the geographical distribution of diphtheria jus- tifies the conclusion, that climatic circumstances exert no es- sential influence on the genesis of the disease. Seasons have no marked influence, since, of 109 epidemics of malignant angina 36 occurred in the spring, 20 in summer, 26 in autumn, and 27 in winter." Kieser is of the opinion that diphtheria is propagated at one time by contagion, at another by miasmatic influences. He classes the epidemics of these latter years as follows : FIRST CONTAGIOUS EPIDEMICS. Christiania, 1 861- 1864 - - - - Louhans, 1863- 1865 - - - - - Arnemuiden, March 1864 to July 1865 Kleverswerke (Holland) _ _ _ _ Rossum, July 1864 to August 1865 - - - ... Sweden, 1861-1862 - - - - - ... SECOND EPIDEMICS ALMOST EXCLUSIVELY MIASMATIC. CASES. DEATHS. Schleswig-Holstein, 1862-65 - - _ 10,759 1.63 1 Lisbon, 1859 i860 ------ 10,759 1,631 THIRD — EPIDEMICS EXCLUSIVELY MIASMATIC. CASES. DEATHS. District of Bordesholm (Holstein), 1859-65 - 247 Namdalen (Norway), 1859-61 _ _ _ . 247 23 Cases described by Luzinsky at Vienna, 1866, 247 23 This statement, as one sees, gives predominance to conta- gion. T.iis epidemiological review will furnish us the materials for solving the following questions : First — How do epidemics of diphtheria originate? Second — An epidemic, once created, how does it spread ? CASES. DEATHS 361 76 2,500 367 169 29 ARTICLE FIRST— ORIGIN OF EPIDEMICS. Epidemics of diseases manifestly infectious, such as cholera, yellow fever, and typhus fever, reveal nearly always as a starting point the importation of disease germs, either by one or more contaminated persons, or by objects which had been in a center of infection. Every one knows the history of these epidemics following the arrival in a port, till then perfectly healthy, of a ship having on board patients sick of yellow fever or cholera : we do not forget those which suddenly break out in places isolated from every center (foyer), the origin of which was due to the arrival of a contaminated individual or a trunk of clothes and linen which had belonged to the patient. The same investigations have been made respecting epidemics of diphtheria, and have often been crowned with success. Omitting the large cities in which the starting point is often difficult to find, country places and villages frequently present most valuable information. Bretonneau, Trousseau, and phy- sicians who have made observations in the country, have given numerous and striking examples of it. One of the most re- markable was furnished by Bonnet. A young girl of i6 years, was taken with diphtheritic angina in a village in which this disease prevailed. She went immediately to her parents, in a community about four m^les distant which had never been vis- ited by membranous angina, A few days later, this latter lo- cality was invaded by the epidemic ; the young girl who had brought it died, communicating the disease to her sister, who also died. The father, alarmed, went to a village about three miles distant to escape the scourge, but he died at the end of nine days, leaving angina to ravage the county to which he had come to seek a refuge. We cannot find a demonstration more striking of the power that diphtheria possesses of transmitting (V7) 3l8 DIPHTHERIA, CROUP AND TRACHEOTOMY. itself by importation. Without going so far, do we not fre- quently see a patient, affected with diphtheria, infecting the ward of a hospital or the entire establishment? We have not always, it is true, at hand data equally certain; we are very often compelled to remain in ignorance of the cause of an epi- demic. But do we not see other infectious diseases acting the same way? Typhoid fever, for example, a disease essentially epidemic and infectious, sometimes forms foci, which suddenly break out in certain regions without it being possible to trace back its origin. In large cities in which typhoid, measles, scarlatina, variola, etc., are in an endemic state, silence concerning the cause is not surprising. It is no longer a new epidemic which appears, but an aggravation of an epidemic already existing. In circumscribed localities, when the epi- demic appears for the first time, the explanation is more diffi- cult to furnish. Then it is the question maybe asked, whether diphtheria has not the power of developing spontaneously, whether an individual not exposed to miasma may not himself engender the disease. No fact gives foundation to this view. It is better to admit the ingenious theory of Trousseau on the latency oigerms (le sommeil des germs). "These miasmata, principles, germs, the name given them is of little importance," says the distinguished teacher, "may remain latent, dormant, for a greater or less length of time, buried in inorganic substances; then at a certain time under certain electrical or atmospheric conditions which we do not understand either, but of which no one denies the influence, they develop themselves, to attack those who are found susceptible to receive them." They may remain latent for months or years, in clothing, tapestry, etc. of apartments, awaiting conditions which favor their germination. Take for example variola. An individual is attacked with the disease. He had not been in communication with any small- pox patient. But has he not suffered the contact of contam- inated clothing? has he not stayed in a place occupied, per- haps at some previous time, by a variolous patient? Science is rich in facts which furnish argument in favor of this view. These facts are applicable in every respect to diphtheria, and LOCALIZATION OF DIPHTHERIA. 3I9 may refer to the origin of epidemics which appear to be spon- taneous. The origin of epidemics of diphtheria may, there- fore, very Hkely be explained, in the first place, by the importa- tion of morbific germs into a healthy country, whether the car- rier has been attacked with the well-marked disease, or whether he comes from another country with the poison germs remain- ing for a long time in a latent state in his clothing or in ar- ticles of contaminated furniture; in the second place, by bring- ing into new activity germs connected with a former epidemic which remained dormant for a longer or shorter period. This doctrine of importation accounts for a fact which, for some years, has struck every obsen^er, I mean to speak of the invasion of many countries by diphtheria in which it had never been known. Notably in France, diphtheria was confined during a long time to certain departments of the interior. At Paris diphtheria has been observed, for only quite a limited number of years, since the epidemics of 1842-43 described by Boudet and Becquerel. It disappeared again for a long inter- val ; it was seen no more, really, till 1855. It then returned in epidemics, and afterwards ended by establishing itself endemic- ally. The epidemic of 1855, which was the signal of the final invasion, was coincident with the important developments made in the means of communication in all Europe, and in France particularly. Paris became, in large measure, the place of attraction for the whole world. It is not surprising that epidemics, previously limited to certain points in France or other countries, should have been imported into the capital. Cholera furnishes us an example of the same kind. Its recent outbreaks have spread throughout all Europe with a rapidity unknown to those which preceded the extension of rapid com- munication. Compari.'^on of the epidemics of 1832 and 1849 with those of 1855 and 1866 leave no doubt in this respect. Everything proves that diphtheria has been affected by the same influences. In many places in France statements from physicians agree respecting the coincidence between the ar- rival of diphtlieria and the estalishment of railroads in their localities. Until then they had known this disease only by 320 DIPHTHERIA, CROUP AND TRACHEOTOMY. name. The diffusion of germs by the introduction of rapid transit, and by the active travel which results from it, appeared, therefore, to be the cause of the extension of diphtheria. Ad- mitting the morbific principle, the spores existing for a long time in a locality, and remaining torpid, what are the condi- tions which preside over their revivification ? The solution of this question would enable us to know under what circum- stances epidemics have their origin. We must recognize the fact that in this matter science is richer in theory than in ex- act data. According to the majority of authors climatic con- ditions have considerable importance. Since Home, all ob- servers have reiterated that croup had a great tendency to de- velop in low damp localities. Among the modern epidemics which I have cited, several appear to have been influenced by humidity ; such are those of Louhans, Nordeny and Leer. Among former ones we may mention that of La Chapelle Veronge, described by Dr. Ferrand as well as those of which Drs. Gendron and Orillard are the reporters. But in addition to these observers, several among the modern ones, like Ditzel, and others older, to the number of which must be added Bouillon Lagrange, have been placed under different circum- stances. *'I have observed this disease," says the latter, "under the most opposite condi- tions, on elevated planes, and in small, dark valleys, moist even in the midst of gen- eral dryness, in the heat as well as in the cold. During the entire continuance of the epidemic the dryness of the atmosphere was extraordinary, and for persistency, such as had not been seen for many years, the reverse of what had been observed in pre- vious epidemics of which humidity seemed to be the principal condition." Several authors have found the influence of season nil ; and diphtheria according to them, appeared at all seasons, viz., Tuefferd, Lange and Kohnemann. Hence, diphtheria may arise in all climates as the statements of Hirsch prove, and in every meteorological condition. Yet epidemics coincident with hot, dry seasons are exceptional, and they prove but one thing, that is, that atmospheric influence is but a factor not in- dispensable in the etiology of diphtheria. On the contrary, damp seasons and fogs seemed, in the majority of cases, to LOCALIZATION OF DIPHTHERIA. 321 favor remarkably the development of the epidemic. That of Louhans is very interesting in this respect ; the moisture had at- tained to its maximum in the country ; it rotted the crops, and mildewed the leaves on the trees. That in the island of Nor- deney is still more striking. Roger and Peter also admitted the influence of cold and moisture on the generation of diph- theria. The statistics of cases observed at the Hospital " Sainte Eugenie " for twenty years, in the service of Barthez, added to those of my private practice, furnish me the follow- ing results : Of 1,568 cases, the month of Brought forward, - 874 January furnishes - - 160 July furnishes - - - 119 February furnishes - - 157 August furnishes, - - 113 March furnishes - - - 153 September furnishes - 82 April furnishes - - - 144 October furnishes - - 124 May furnishes - - - 152 November furnishes - 122 June furnishes - - - 108 December furnishes - 234 Carried foward - 874 Total . - - - 1,568 The figures which this table presents to us assign the max- imum of frequency to that part of the year from January to May inclusive. From January there is an imperceptible de- crease to August, and it then suddenly falls in September to a decided minimum. The increase begins in October, and pro- gresses rapidly in December. The following comparative table, arranged from figures furnished by E. Besnier for the commission on prevalent diseases, presents the variations of croup in the hospitals of Paris during the period extending from 1868 to [1880, eleven years. I here insert a more com- prehensive table answering other purposes as well, from a more recent article by the same author] except the years 1870- 71 which furnish only incomplete statistics: 322 DIPHTHERIA, CROUP AND TRACHEOTOMY. < O HI U p ^ O o" O "S tt, CO > < <! W H Q CO jv; r/) W ^ E O H H O < J^ ^ p:^ < P > Q W ■n Pi - t^ <S\ VO o On rj- 00 00 8 vg r*i Ot • **yj^ ya r I^ O W-) vO vO t~» *n '"•'"" cr t^ c^ o C^ M I^ u-l CO TT s M ro lO I~» vO 00 t^ t^ VO VO vO t-^ 00 00 r^ ' •syfVP(j 00 00 Ti- O^ 00 ON lO O t^ O CO ^m N 1 <» fo ro N CO P) PJ ro ro T^ VO to N ! •* •S3SVQ % CO ^ 00 CO ? O VO ^ VO VO * VO tv ^ VO r <S^ ON M CO o ro ON VO N i>. 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ON VO r^ VO 'i- 10 »o VO ro 00 •fU33X3f£ vn rh „ n 00 VO ^ 10 OV PO „ t^ t^ 0^ Ov 'i- ^ 00 l^ vO VO 10 N ro ■* t^ M 00 M 1^ 10 i-« ro Tl- 00 t^ 00 t^ 00 r^ VO VO ■vj- t^ t^ l^ •S1{}V3(J VO VO vO VO ui 5 •* ^ N 00 ro 10 10 ON VO Ov VO •S3SVJ Ov VD VO „ "-) N vO ro 00 00 ■* 00 J^ 00 00 VO l-^ t^ Tj- 10 VO PI ro *■ »-* •)U33X3J t^ CO vO tJ- ti-> vO vO ^ re r^ r^ Ov fO fO 10 w-> ^ t~^ ON T vO 00 M M 00 00 r^ 00 •<J- r^ 00 r^ t>-. VO 00 r>. 10 !>. t^ i-~ t^ t^ 'SJ{tV3Q o> ro vO 10 N ov Ov ^ ^ 10 ro ro CO Tj- CI CO '^ N PI 't ro 10 VO 10 ON •S3SVJ vO vD vO 00 HN •H 10 r-. 00 00 '^ w^ 'il- u-i U-1 '^l- ir> Th VD an vO >o • ^ b V .0 u. u C!l 3 c OS 5 X! a. < 1) C 1 — . ■—1 3 < b OJ en .0 S > s u D 324 DIPHTHERIA, CROUP AND TRACHEOTOMY. The results vary slightly : the maximum is found in March, and the minimum in September, The difference observed in these two tables may pertain to the fact that the first contains diphtheria in all its forms from that of the pharynx to that of the skin, conjunctiva, etc., while the second is limited to croup. Influence of other Epidemics. — May an epidemic of another kind be the agent in causing the germ of diphtheria to spring up ? The frequent coexistence of epidemics of scarlatina and of measles with those of diphtheria has been noted. We know that these diseases frequently occasion secondary diphtheria. But there is nothing to prove at this date that they have the power to originate epidemics of diphtheria ; they may be con- sidered as agents which in times of epidemics, present to the morbific germ a prepared soil; this is the limit of their influ- ence. In connection with the epidemic of Louhans, Guillemont has brought to light an interesting fact. An epizootic preceded the epidemic ; it consisted of an inflammatory disease of the mouth and throat in cows and horses. ARTICLE SECOND— DEVELOPMENT OF EPIDEMICS. By virtue of previous causes, or by the action of others which remain unknown, one or more cases of diphtheria have broken out in a country exempt for a period of greater or less length. By what series of events do they constitute an epidemic ? In every disease which assumes the epidemic type we must con- sider two factors, the morbific germ and the organism with which it is found in contact. The conditions, therefore, which favor the development of an epidemic are, on the one hand those which maintain the vitality of the germ and preserve to it its germinating power, on the other, those which render the organism susceptible of being impregnated. There is another important point, the study of which should be undertaken be- fore that of the preceding, that is, the intimate mechanism by virtue of which diphtheria is transmitted from individual to indi- vidual. § I. THE MODE OF TRANMISSION OF DIPHTHERIA. Spontaneous development not being recognized, until evi- dence of the contrary as one of the attributes of this disease, contagion appears to be its most probable mode of trans- mission. I. CONTAGION IN DIPHTHERIA. In order to avoid all confusion it is important to state defi- nitely the meaning which I give to this term. It really appears to prejudge the question and to imply the necessity of contact between individuals. Now, transmission by contact alone be- ing sharply contested, many authors justly consider the word improper. By this standard it should be excluded from no- sology. Yet it is in such constant use that it may be preserved (325) 326 DIPHTHERIA, CROUP AND TRACHEOTOMY. on condition that an acceptable meaning be assigned to it. It may be understood, I think, in the sense of tra)ismissibility from individual to individual with or without a medium. While indicating the capability which this disease possesses of being transmitted from one person to another, this term reserves the mechanism by which the communication is effected. In this sense, contagion is admitted by most authors. Denied by Home, Michaelis, Vieusseaux, Jurine, and Albers of Bremen, it has been admitted by Wichmann, Bohmer, Field, Rosen, Guersant, Bretonneau, and Trousseau. The majority of physi- cians who have observed epidemics, or who have written, for some years past, on diphtheritic angina or croup, hold it as demonstrated. I fully adopt this view. The transmission of diphtheria may be accomplished by three modes: First, by direct contact ; second, by inoculation ; third, by the atmosphere (ambient air.) II. TRANSMISSION BY DIRECT CONTACT. Numerous facts have been invoked in favor of this mode of communica ion. Physicians in nearly every case, have fur- nished the proof at their own cost. Herpin of Tours, Gendron, Blache, Jr., Gillette, Valleix, Weber, and many others were poisoned by the morbid products expelled from the diphthe- ritic patient, into the mouth, onto the lips, and into the nose. These facts have furnished too large a number of reports to be repeated here in detail. Let me say in few words, that Herpin, while cauterizing the throat of a child attacked with diphthe- ritic angina, received into the left nostril a spurt of the morbid matter. Some hours afterwards there was closure of the left nostril, snuffling, dysphagia, and the next day membranous patches were spread over the tonsils and the uvula. On the latter the membrane reproduced itself three times. Diphthe- ritic paralysis terminated the attack; but he finally recovered. Valleix contracted diphtheria under similar circumstances. A patient afflicted with membranous angina, not serious, however, and who recovered, threw into his mouth a little saliva during an effort of coughing caused by examining the DEVELOPMENT OF EPIDEMICS. 32/ throat. The next day one of the tonsils was covered with false membranes; very soon the other, the uvula, and the nasal fossae were attacked. Considerable submaxillary engorgement arose, cerebral symptoms appeared, and death occurred in for- ty-eight hours without laryngeal symptoms. Blache Jr. con- tracted diphtheria under similar circumstances and died. Gendron of Chateau-du-Toire, during the operation of tra- cheotomy, at the moment of opening the trachea, received a shower of particles of false membrane, some of which fell on his lips. An attack of diphtheritic angina was the result of this accident. The martyrology of science contains yet many other victims. [Dr. Andres Arango y Lamar, Havana. St. Louis Med. and Surg. Jour. XLV(i883), p. 569. M. Reverdy, assistant to Dr. Bouchut at Paris. Med. Rec. N. Y. XVII. 302. (1880). Dr. Wilbur F. Sandford, Greenpoint, N. Y. XIX (1881). Dr. Samuel Rabbeth. London, Eng. N. Y. Med. Rec. XXVI p. 521, 550. (1884).] Prof. See has communicated to the Societe des Hopitaux a very curious incident. A woman was nursing a child (not her own) attacked with diphtheritic angina ; though the nipples remained sound, her own child which she continued to suckle, contracted a labial diphtheria and communicated it to its mother who had not abstained from kissing it. Presented as an example of inoculation, this case may be attributed, strictly speaking, to direct contact. We may apply direct contact in explanation also of the following incident: A child of two years of age is attacked with grave diphtheritic coryza ; it is deemed proper to apply a blister to the nape of the neck, and the blistered surface immediately becomes covered with false membranes. The child dies. Like many sick children this one demanded that the father or mother should carry it con- stantly in their arms. In this position the nose was frequently brought in contact with that of the person holding it. After its death both parents were attacked with diphtheritic coryza. Against these examples may be presented the negative result of experiments made by Peter. In one, this courageous phy- 328 DIPHTHERIA, CROUP AND TRACHEOTOMY. sician having received, during a tracheotomy, a semi-Hquid false membrane upon the left conjunctiva let it it remain under the lid, and experienced no unpleasant result from it. In another, he dipped a hair pencil into a soft false membrane ejected during an operation and painted his tonsils, the soft palate, and the pharynx with the pencil ; the result was nil, Duchamp obtained a similar result by repeating these two experiments. Fortunately, by chance these trials had no bad result, but they do not prove that direct contact will be without inconvenience ; their small number even prevents them from being conclusive. Repeated a large number of times they might produce results quite different; what they really demon- strate is that direct contact does not necessarily transmit diphtheria. That is a fact common with all contagious dis- eases, even in inoculable ones ; they are not propagated in every case by these methods. In these experiments two facts must always be considered, the seed and the soil. The soil may be unsuited to the germ, its receptivity nil ; the germ which sprang up in another soil, dies in this. But if the ob- jections formed from the experiment of Peter are not conclu- sive, there is still another which extends farther. It may be said, persons in whom we see false membranes develop under the pretended influence of direct contact, are living with the patients, or like physicians, visit them once or oftener daily, and are thus exposed to transmission by inhalation. That is a strong objection ; it may be true in a certain number of cases attributed to contact. Nevertheless, it is difficult not to invoke this cause in the cases in which the false membrane occurs at exactly the point brought in contact with the morbid product. To these arguments must be added that one coming from experiments on animals. The first series was made by Trendelenburg. Patches of pseudo-membrane from children affected with croup were introduced into the trachea of rab- bits and pigeons. In sixty-eight operations, eleven gave rise to evident diphtheritic manifestations; the lesions were the same as in man. The animals succmbed, usually, to asphyxial croup. The disease required twenty-four, forty-eight or sev- DEVELOPMENT OF EPIDEMICS. 329 enty-two hours to develop. Then taking the false membranes obtained from these animals, the author applied them to a second series of subjects: he again obtained several positive results. Control-experiments were made by placing in the larynx of other animals some irritant or putrid substances ; catarrh of the mucous membrane and abscesses were oc- casioned, but never true pseudo-membranes. Diphtheria of the pharynx, followed by descending croup, was never ob- tained. Oertel of Munich, with this purpose, undertook three series of experiments. In the first series he produced by means of chemical irritants, viz., ammonia, etc., an artificial croup identical in its lesions and symptoms with human croup, He never found at the au- topsy other organs inflamed ; the kidneys especially were per- fectly normal ^7.r« after prolonged asphyxia. Experiments of inoculation made with false membranes from these animals were always negative. In the second series, he introduced into the trachea, larynx and upon the tonsils of twelve rabbits, frag- ments of diphtheritic false membrane from man. Five died by suffocation and three by general toxaemia. At the autopsy besides the pseudo membranous inflammation of the larynx and trachea, he found capillary haemorrhages disseminated in many of the or- gans, and a decided hyperaemia of the kidneys. The application being made in the same manner to other animals, the false mem- branes obtained in the first of them were reproduced two or three times successively. In the third series, similar inocula- tion experiments tried with ordinary putrid substances gave rise to results absolutely different. Labadie Lagrave introduced into the larynx and trachea of two rabbits, false membranes re- cently expelled by children affected with croup, by performing upon these animals a preliminary tracheotomy followed by in- troducing into the trachea a soft rubber catheter of 5 centime- tres diameter used as a cannula. The false membrane previously diluted and mixed in a mortar was introduced by means of a curved forceps, directly into the cavity of the larynx, in the first animal and simply deposited in the trachea in the second. About twelve hours after the operation, both the rabbits hav- 330 DIPHTHERIA, CROUP AND TRACHEOTOMY. ing died from asphyxia, false membranes were found in a state of organization in the larynx of the first, and in the trachea of the second, occupying quite a large surface, and the mucous mem- brane about the three centremetres below it was red, thicken- ed, ulcerated, and contained a rich vascular network. Duchamp resumed the experiments under the same condi- tions. False membrane previously washed, then triturated, was introduced into the trachea and larynx of a tracheotomized rabbit with a hair pencil, care being taken not to bring it in contact with the margins of the wound. The animal died at the end of forty-eight hours, and the autopsy revealed the mu- cous membranes of the larynx and trachea covered with false membranes, which, examined under the microscope, showed exactly the characters of those of the child. The air passages were the seat of an intense inflammation; the lower lobes of the lungs were hepatized. A trial made with products found four days after death in the trachea of a child dead of croup, gave only negative results. Besides, these products had no longer the pseudo-membranoiis appearance ; they consisted of leucocytes, mobile and refract- ing granules, and elongated and ovoid spores. This series of experiments proves most fully the transmissibility of diphthe- ria by contact. Most authors find here also proof of inocula- bility, but the exact meaning of inoculability implying, it seems to me, the deposit of morbid products under the mucous mem- brane, or under the epidermis, by puncture or scarification, we should be satisfied here with proof of the first proposition. III. Transmis.sion by Inoculation. m this chapter must be comprised all cases in which the virus has been introduced into the sub-cutaneous connective tis- ue, or deposited on the surface with a solution of continuity of skin or mucous membrane. These facts should be classed in two categories. The first comprises those which have been obtained by experimentation ; the second, those which were produced accidentally. First. Cases From Experiment. — Since Bretonneau, persons DEVELOPMENT OF EPIDIMICS. 331 have been greatly inclined to believe in the possibility of inoc- ulation of diphtheria. " I have made, " says the physician of Tours, " some fruitless attempts to communicate diphtheria to animals. " Reynal has inoculated by puncture and by rubbing, chickens, with bloody debris of false membranes taken from chickens attacked with croup. The result has always been negative. These re- searches have reference to but one single species of animals, and nothing is said about the disease which produces false membranes in chickens being submitted to the same conditions of propagation as diphtheria. Rarley made four inoculations which produced no results. However, the animals were sac- rificed, one twenty-four hours, the other four days after the in- oculation. A longer delay would have been necessary in order to confirm the negative result of the experiment. Ilueter and Tommasi tried subcutaneous inoculation in five rabbits with false membrane from the trachea expelled by ex- pectoration,and with pharyngeal concretions detached by means of forceps. These fragments of false membrane were carried into the muscles of the back. The animals all died from twenty-four to forty hours after the inoculation, with symptoms "very different from putrid septicemia." The authors noticed a haemorrhagic infiltration of the wound and of the surrounding muscular tissue. Other animals inoculated with a bit of the muscles thus altered, succumbed at the end of thirty hours. The autopsy revealed the same lesions. There was nothing to indicate that diphtheria had been communicated as a conse- quence of these experiments. The principal argument of the authors is that they found in the blood of the animals after kill- ing them, small organisms which they designated as character- istic of diphtheria, organisms which were seen in the false mem- branes inoculated, and which did not exist in the blood previous to the experiment. It is demonstrated that these organisms are to be seen in many infectious diseases, in grave fevers, and that they have nothing peculiar to diphtheria. The authors have, therefore, produced symptoms of experimental septicaemia. There was nothing resembling diphtheria in the lesions which 332 DIPHTHERIA, CROUP AND TRACHEOTOMY. followed their inoculations. Eberth, of Zurich, engrafted (im- plantation) false membranes upon the cornea of animals. He saw develop, after twenty-four hours, a gray opacity, and an ulceration which showed no tendency to cicatrize, while a sim- ple traumatic lesion healed rapidly. These experiments again prove nothing on the inoculability of diphtheria. Ulcerations of an unhealthy kind, like all those which have their origin from septic products were obtained on the cornea. That these were diphtheritic lesions in the German sense of the word, I do not deny, but that they represent manifestations of the specific disease diphtheria would be difficult to sustain. Prof Felix, of Bucharest, tried to inoculate diphtheritic false membranes upon animals, and upon varicose ulcers in man. Although the trials were made nearly always with fresh products, the results were negative. Homolle, seeking to verify (control) the notions of Letzerich, cultivated by the method of this author, the spores found on the surface of diphtheritic false membranes. The products were inoculated into rabbits, as well as the spores collected immediately upon the false membranes. Septicaemic symptoms without special characteristics were the result. In the blood of these animals were found bright moving corpuscles attributed by some observers to diphtheria, but which are now recognized as belonging to septicaemia and to several infectious conditions. Other experiments were tried by the same author, and with the same result by inoculating rabbits with blood collected dur- tracheotomy from patients affected with croup. It was the same when pieces of false membrane were placed in contact with denuded epidermis. In one of the animals experimented on the injection of blood was combined with the application of frag- ments of false membranes to the conjunctiva previously cau- terized. Duchamp also undertook several experiments of the same kind and injected under the skin into the jugular vein of rabbits, and under the epidermis of a horse fragments of false membranes: the results were nil. Experiments Made on Man. — These are negative, but of little value because of their rarity. Trousseau first had the courage to inoculate himself with diphtheria products. He DEVELOPMENT OF EPIDEMICS. 333 dipped a lancet into a false membrane, which he had just re- moved from a diphtheritic patch, and made with it a puncture in the left arm, and then five or six in the tonsils and in the velum. He saw a vesicle quite similar to that of vaccine de- velop on the arm at the place of puncture; nothing appeared upon the mucous membrane. Peter made upon his lower lip three punctures with a lancet charged with semi-fluid matter recog- nized by the microscope as diphtheritic. One only of these punctures showed, for some hours after the inoculation, an ec- chymotic prominence. No disturbance in the health super- vened. Duchamp repeated the experiments of Peter with the same results. Like the trials made on animals, these having man for the subject were negative. Before pronouncing finally upon the experimental inoculability of diphtheria, more numerous cases would be necessary, especially in man. It would be interest- ing to know what would produce a false membrane when ap- plied to a blistered surface. Second. Accidental Inoculations. — Persons, especially phy- sicians, have been attacked with diphtheritic angina after being wounded with an instrument soiled with blood from patients attacked with croup. Similar results have followed the con- tact of wounds of the extremities, with pseudo-membranous products. These facts have received different interpretations. Several authors have questioned whether it is not necessary to regard them as examples of inoculation of diphtheria by blood or by false membranes ; while others have contended that these diphtheritic manifestations had no relation of causality with the punctures, and that they were solely the result of infection from a diphtheritic focus in which the persons lived. May any formal conclusions be deduced from these facts ? Let us examine first those in which the blood was the agent of inoculation, then we will pass in review those which refer to contact of diphtheritic products with wounds. A. Inoculation by the blood. — Bergeron communicated to the Societe des Hopitaux the history of two patients, both physicians, who found themselves in these conditions : 334 DIPHTHERIA, CROUP AND TRACHEOTOMY. The first, Dr. Loreau, punctured his finger with a bistoury which some one had just used in performing tracheotomy in a case of croup. An angioleucitis arose along the arm simulta- neously with a small abscess at the site of the puncture. Fif- teen days later, when his finger was not yet entirely well, he exposed himself to intense cold ; in the evening he experienced chills, and in the night pain in the throat. The next day a false membrane appeared on one of the tonsils and reached the other the next day. Recovery, however, took place, but was followed by general paralysis. The wife of our colleague took the disease from her husband ; she also recovered, but like him did not escape consecutive general paralysis. The paralysis in one of these cases continued four months. The second, Mr. Baudrey, a student of medicine, after suf- fering for two days with cold in the head, the result of a sud- den suppression of a free perspiration, was making z. post mor- tem, examination of a child dead of croup, and he slightly punctured his left thumb. Free washing with water, sucking it for some time, and pressure made the wound bleed freely. Nevertheless, in the evening, symptoms of an angioleucitis which extended to the entire left arm, manifested themselves. Five days after the chill, two days after the autopsy, a sore throat supervened, accompanied by sub-maxillary swelling. The next day the angina increased, and three days later diph- theritic false membranes, of limited extent, however, were dis- covered on the tonsils. The disease terminated in recovery. A surgeon of Elberfeld, Prof. O. Weber, while performing tracheotomy on a child affected with croup, wounded his thumb. A whitlow, an angioleucitis of the forearm and arm- an axillary adenitis, and later a diphtheritic angina with croupal cough were the result. Thomas Hillier speaks of a surgeon who, while performing tracheotomy on a child affected with croup, punctured his thumb. The next day he felt a sharp pain at the site of injury. The second day there appeared at the spot a pustule, beneath which an unhealthy ulcer formed. At the same time general symptoms appeared which compelled the physician to take DEVELOPMENT OF EPIDEMICS. 335 his bed. Soon after the existence of diphtheria of the throat was recognized which recovered. At the end of four weeks disturbances of motion in the limbs similar to ataxia occurred. The ulceration of the thumb required four weeks to cicatrize. These two latter cases, however incomplete they may be in respect of details and dates, belong to the same category as those of Bergeron's. They are all cases of phy- sicians attacked with diphtheria after being inoculated with blood from subjects suffering from the disease. Must a rela- tion of cause and effect be established between the two inci- dents, or a simple relation of coincidence ? So far as the first two cases are concerned, the eminent clinician who observed them, hesitates to express himself. While the second hy- pothesis appeared to him the most acceptable, the first did not seem inadmissable. In fact, one finds himself between two hypotheses. Strict argument does not permit of one being preferred to the other. Roger has taken strong grounds against that of inoculation. In fact, one may oppose numer- ous objections to this view of the case. The duration of incubation which in the first case was said to be fifteen days, appears to Roger too long, who admits that this period, with exceptions, requires not more than from two to seven days. One may, it is true, accord to this case the benefit of the exception ; but the second may dispense with this favor since the sore throat appeared two days after the puncture, and the false membranes five days after the same date. The absence of diphtheritic manifestations at the point where the virus is said to have penetrated, has also been offered against the notion of inoculation in these cases. Variola, vaccinia, and syphilis, producing, indeed, at the point of inoculation a a characteristic lesion, one might require as proof of the inocu- lation of diphtheria, the formation of a false membrane at the point injured. Bergeron responded that this was not a neces- sary condition, and cited the example of glanders, hydrophobia and certain cases of variola. Yet, it must be admitted that one case should receive great importance in satisfying that point. The surgeon cited by Thomas Hillier presented, as a 336 DIPHTHERIA, CROUP AND TRACHEOTOMY. matter of fact, at the injured place an ulceration of unhealthy character which required four weeks to cicatrize ; unfortunately the author did not say whether it was covered with diphtheria. But the chief objection is the following: The persons who are supposed to have contracted diphtheria by inoculation, lived in the locality (foyer) of an epidemic, and were found in fre- quent contact with patients affected with diphtheria; they were, therefore, placed under favorable conditions to be con- taminated at a distance, by the surrounding air and by inhala- tion. Moreover, if we admit that diphtheria might have the power of transmitting itself by the inoculation of the blood we would accord to this disease a power of inoculability still greater than to others, such as variola and syphilis which are so capable of inoculating. Variola, in fact, does not transmit itself by this means, as to syphilis, adhiic siib jiidice lis est. ["That the blood of a syphilitic person may prove the source of contagion, has been demonstrated by both experiment and clinical experience, as well as by observation of the fact that syphilis may be transmitted by vaccination when blood is mixed with the lymph obtained from a syphilitic child, while vaccine matter does not appear to be capable of conveying syphilitic infection, if care be taken to exclude the admixture of blood. It has been recently suggested that syphilis may be conveyed in vaccination by the admixture with vaccine lymph of epidermic scales, or of pus, as well as of blood." — Ashhitrst.'] One may still reply that many operators wound themselves in performing tracheotomy without experiencing any conse- quences. This argument has but little value and does not prove the non-inoculability of diphtheria but only the negative result, in certain cases of contact of the false membrane, not affirming the transmissibility of this disease by direct contact. It is, therefore, very difficult to decide upon the value of the cases just cited. In order that inoculations of this kind may be of value they must be produced in a medium exempt from diphtheria. The most that can be said is that it is impossible to prove beyond question the inoculability of diphtheria by means of the blood. IMoreover, by examining closely these DEVELOPMENT OF EPIDEMICS. 337 cases, we observe at least in three of them that the symptoms following the puncture are of two kinds : First, phenom- ena of septicaemia, characterized by angioleucitis, adenitis, and frequently by general symptoms ; then diphtheritic manifesta- tions. So that if the blood of diphtheritic subjects does not transmit diphtheria, it introduces into the organism septic products which may develop therein dangerous symptoms. As corroboratory evidence, I can add to the preceding cases the one of my friend. Dr. Pouquet, who, having slightly punc- tured his finger in performing a tracheotomy, was attacked with severe erysipelas and dangerous septicaemic symptoms which for a long time endangered his life. No diphtheritic manifestations were produced, If the appearance of diph- theria in the first patient was not the direct result of inocula- tion it is very possible that the profound disturbances pro- voked by the septic poisoning may have made the organism a suitable soil for the development of the morbid germs with which it was found in contact and favored, consequently, the appearance of diphtheria. B. Inoculation ivith False Membrane. — Diphtheria has been seen several times to supervene in persons having at the time wounds which had been placed in contact with diphtheritic products. It has been asked whether there had been inocu- lation in these cases. The only cases coming under my obser- vation were four. The //-J/ was reported by Guersant. A boy had sores on his feet ; walked barefoot on the floor where another having diphtheria had spit The first got eschars between his toes. The second was witnessed by Trousseau. It is more convincing. During the ep- idemic of Cologne a mother who was suckling her child affected with diphtheritic angina, had upon both breasts patches of false membrane. The third \% due to E. Bonnet of Poitiers: "A mother, 40 years of age, in the prime of life and of good constitution, received an injury on the left index finger a few days previously. The wound was in a fair way to recover. Her daughter, 14 years of age, was attacked with the disease (diphtheritic angina), and the mother wishing to cauterize the false membrane in the throat of this child was bitten precisely on the wound of the finger. The next day the wound became painful, assumed a pale aspect and 7i.faLe membrane developed there ; the day after the arm was swollen, distended, livid and purplish. A blister as a preventive (de precaution) which this woman had 338 DIPHTHERIA, CROUP AND TRACHEOTOMY. on her arm became gangrenous. The enormous tumefaction of the arm extended b» the chest, and, without having called in the aid of any intelligent persons, she died on the sixth day, the next day after the death of her daughter." Thu fourth is reported by Paterson of Aberdeen A farmer, 43 years of age, ia three weeks lost three children from croup. Without giving any attention to a re- cent wound which he had on the right index finger, one day he introduced this finger into the throat of the last of his children while attending to it The wound, until then perfectly simple and painless, inflamed, became painful and covered with a false membrane which persisted for eight days. The throat remained intact, but at the end of a month a paralysis supervened which implicated all four of the extremities while exempting the throat Complete recovery required four months. These cases, like he former ones, are open to criticism, the persons who furnished them were living, for a certain time, in an epidemic center. The germs of the disease, therefore, might have penetrated the organism by another channel. There is in this suppposition nothing unreasonable. Yet one may legitimately find for the diphtheritic intoxication another source. I abandon at once the first case, that of Guersant. The three others, on the other hand, present considerable im- portance. It has been objected to the one from Trousseau that the mother might have had fissures of the nipples and that those little sores could have become covered with diph- theria without it being necessary to appeal to their contact with the morbid matter. That is to answer by a hypothesis, to condemn a fact as hypothetical. On the contrary, the de- velopment of false membranes at the contaminated spot is of much importance, in favor of the entrance of the virus by this channel. In the last two, the wounds of the fingers, the one painless and the other nearly cicatrized, both became painful the next day after their introduction into the mouth of the pa- tients, and then became covered with false membranes. In one of the patients, a pre-existing blister became coated with diph- theritic concretions, after the ivound of the finger. The last es- caped, it is true, from the other local manifestations of diph- theria, but general paralysis confirmed the nature of the disease. The probabilities are all in favor of the view that the two wounds served as the channel of entrance to the morbific germs. If these latter followed this channel, everything tends to the belief that they were introduced at the moment when DEVELOPMENT OF EPIDEMICS. 339 the denuded integument was placed freely in contact with them in the mouth of the patients. One might object that they found access in one of the two cases by the blistered sur- face. But this blister became diseased after the wound of the finger. The objection, therefore, is valueless; con- sequently these two cases have all the characters of those in which the inoculation is beyond question, viz., the specific morbid product is produced at the place injured, and general impregnation of the economy is manifested afterwards. There is nothing wanting in the usual chain of morbid phenomena. We are then, it- seems to me, in a position to admit that there was true inoculation of diphtheritic products. I do not wish to state that the saliva of itself may be charged with morbid principles which it draws from the economy by secretion, as oc- curs in rabies. The saliva of a patient affected with cutaneous diphtheria of whom the throat remains sound, probably has no power of inoculation. In three of the above cases, the injuries of the nipples and of the fingers, if they were not in direct contact with the false membranes, were impregnated with the saliva which remained in long contact with the false mem- branes and served as a vehicle to the particles of false mem- branes as well as to the fluids oozing from the diseased surfaces. [The following are the conclusions of Drs. Curtis, and Satter- thwaite, of New York, drawn from their extensive and carefully conducted experiments on animals : "The results of our investigations may be summed up as follows : I. " Inoculation of diphtheritic membrane into the muscular tissue of the rabbit produces severe local lesions, and even constitutional disturbance and death. But these effects differ so in their pathology and clinical history from diphtheria in the human subject that there is no warrant for defining them as diphtheria, or for applying conclusions drawn from observation of this inoculation-disease in the rabbit to the case of diph- theria in man. II. " Effects exactly similar to the foregoing and of equal 340 DIPHTHERIA, CROUP AND TRACHEOTOMY. severity can, moreover, be produced by inoculation of a ma- terial not only non-diphtheritic, but non-infectious to the human subject under conditions where diphtheritic membrane is in- fectious, t. ^.,when brought into contact with the mucous mem- brane of the mouth and throat. The material referred to is the pulpy scraping of the upper surface of the human tongue. III. " Effects generally similar to the foregoing, though not of equal intensity, can furthermore be produced by inoculation of a putrescent matter which is not even of immediate animal origin, namely Cohn's fluid, allowed to spontaneously decom- pose. Cohn's fluid is simply an aqueous solution of ammonic tartrate, potassic and calcic phosphates and magnesic sul- phate. IV. " The foregoing inoculation effects are not due to sim- ple mechanical irritation, for inoculations of sand produce no effect whatever. V. "Thorough filtration of a proven virulent aqueous infusion of diphtheritic membrane or of putrid Cohn's fluid removes the infectious property of the same. Hence in such diphtheritic in- fusion the poisonous quality, probably inheres in some pai'tic- ulate thing, from which it is not separable by the action of cold water. VI. "Thorough trituration of proven virulent diphtheritic membrane and tongue-scrapings with a high percentage of sal- icylic acid fails not only to remove, but even markedly to mod- ify the intensity of the infectious quality of those substances. Hence, since sahcylic acid in even a minute percentage is capable of permanently suspending the vital activity of bac- teria, the inference is that the infectious qualities of diphthe- ritic membrane upon the system of the rabbit is not correlated to the vital activity of the bacteria present in such membrane. VII. " If, as is not improbable, the noxious principle in the diphtheritic membrane which produces in rabbits the effects described, be the same with or even analogous to the principle which produces diphtheria in man by direct infection, then the conclusion of VI. will apply to the infectious quality of such membrane in its relation to the reproduction of diphtheria in DEVELOPMENT OF EPIDEMICS. 34 ^ the human subject. If this be the case it follows as an impor- tant practical corollary that there is no theoretical gromid for assuming that preventing the bacteria of a diphtheritic patch from making their way through the underlying mucous mem- brane will, per se, prevent general diphtheritic infection of the system. VIII. "There is no relation between inoculable virulence of a diphtheritic membrane and the period, within three days, that has elapsed between the detachment of the membrane and the inoculation with the same, nor between inoculable virulence and gross amount of bacteria present on the mem- brane. IX. "There is a rough relation between inoculable virulence of a diphtheritic membrane and the severity of the original case of diphtheria, so far as this can be estimated by the ter- mination of the case in death or recovery. "But it must be distinctly understood that these nine propo- sitions are not put forth as proven, but merely as the results of our experiments and observations, so far as the latter go, stated in abstract form. Before the propositions can be con- sidered proved as truths, a large number of corroborative ex- periments will have to be made."] [Drs. Wood and Formad, of Philadelphia, close their interest ing report on the same subject with the following comments : " In looking over the last table it will be seen that in two of the ten experiments pseudo-membranous trachitis was caused by the introduction of organic matter into the trachea. In both of the cases in which false membrane was produced, the injected material was pus; and it will be noticed that only four such experiments were made, so that the proportion of suc- cessful results is very large ; much larger, indeed, than with true diphtheritic exudation in our experiments. " Trendelenburg found that not only ammonia, but also various other chemical irritants are capable of causing the formation of false membrane in the trachea ; many years since it was proven that tincture of cantharides will do the same thing. It would seem,therefore,that in the trachea,the formation 342 DIPHTHERIA, croup and tracheotomy. of a pseudo-membrane is not the result of any peculiar or specific process, but simply of an intense inflammation which may be produced by an irritant of sufficient power. This fact, certainly, is very suggestive in regard to the pathology of diphtheria, and whilst we are not prepared to commit ourselves to any theory, it does seem proper to call attention to cer- tain facts as indicating a very simple explanation of the pecu- liarities of the disease. "It is certain that as in the lower animals, so also in man, will chemical irritants produce a pseudo-membranous trachitis ; we are also well assured that there is no anatomical difference which can be detected with the microscope between the lesions of true croup and diphtheritic angina. A difference has been believed by some pathologists to exist between the two dis- eases, in that in croup the membrane separates easily, in diphtheria with great difficulty from the mucous membrane. This seems to arise from a misunderstanding. " The mucous membrane of the fauces and mouth has a squamous not easily detached epithelium, and consequently membrane connected with or springing from such surface is firmly adherent. The epithelium of the trachea is columnar, ciliated, and detaches with the utmost facility, even in normal conditions of the organ ; hence, membrane attached to it sepa- rates readily. The membrane of diphtheritic trachitis is always readily detached in the line of the epithelium. Our prepara- tions also show that the exudation of the croupous inflamma- tion excited artificially in the trachea is not merely superficial, but also extends below the basement membrane. Some of the best clinical authorities of the day teach that there is no essen- tial clinical difference between true croup and diphtheria, cases commencing apparently as local sthenic inflammation and end- ing as the typical adynamic systemic poisoning. Every prac- titioner must have seen cases of angina in which he was in doubt whether to call the affection diphtheria or not; the very frequent diagnosis of " diphtheritic sore throat " is a strong evidence of this. There have been cases in which diphtheritic matters absorbed by a wound have produced symptoms very DEVELOPMENT OF EPIDEMICS. 343 closely resembling those of ordinary septic blood poisoning from post-mortem wounds, etc. ; there have been cases of the formation of false membrane about wounds, etc., without any known exposure to a specific diphtheritic poisoning, indicating that the systemic tendency to this peculiar form of exudation is capable of being engendered by other than the specific poison of diphtheria; finally diphtheria seems sometimes to be pro- duced by exposure to cold. " A general view of these facts seems to indicate that the contagious material of diphtheria is really of the nature of a septic poison, which is also locally very irritant to the mucous membrane ; so that when brought in contact with the mucous membrane of the mouth and nose it produces an intense in- flammation without absorption by local action. Whilst ab- sorption is not necessary for the production of angina, it is very possible that the poison may act locally after absorption by be- ing carried in the blood to the mucous membrane. Further, under this theory, it is possible that the poison of diphtheria may cause an angina which shall remain a purely local disorder, no absorption occurring, or a simply local trachitis produced by exposure to cold, or some other non-specific cause may prc^- duce the septic material when absorption shall cause blood poisoning, the case ending as one of adynamic diphtheria. "Some such an explanation as those here offered seems to reconcile antagonistic opinions concerning the value of local treatment in diphtheria; because it is plain that the value ot such treatment must largely depend upon whether the angina has or has not been preceded by absorption. " There is one more important clinical feature of the disorder, which under other views of the disease seems inexplicable, but which with the present theory is easily explained. Diphtheria differs from the exanthemata by the fact that one attack in no way protects against the second. It will be seen that the theories here put forward remove the affection entirely from any relation with exanthemata; placing it rather with septic dis- eases, which, as is well known, may recur indefinitely. " We want, however, distinctly to state, that we do not con- 344 DIPHTHERIA, CROUP AND TRACHEOTOMY. sider these ideas to be more than suggestions, and it is useless to speculate except as a guide to further experimental research. It does seem to us that there are now two pathways clearly- open, which if carefully followed, must lead to important posi- tive or negative results. The first of these consists in the mak- ing of careful culture experiments to determine whether there is or not any difference between the bacteria of ammonia and diph- theritic false membranes; the second, the study of the induction of epidemics of pseudo-membranous angina and trachitis in the lower animals, and the relation to these of the rapid cases «f death produced in the lower animals by diphtheritic inoculation. " There is still another somewhat different view which seems also not repugnant to the known facts of the case. There may be bacteria, which, although they offer no points of difference detectable by our best microscopes, are really very diverse. Two spermatozoa or two ova in the higher animals, may seem to be exactly alike, and yet be potentially widely separated. Although, therefore, the bacteria of an ammonia false mem- brane seem identical with those of diphtheritic false membrane, they are not of necessity really so. Careful studies of the blood of patients \Vho die of diphtheria should be made, but at present it seems altogether improbable that bacteria have any direct function in diphtheria i. e., that they enter the system as bacteria and develop as such in the system, and cause the symptoms. It is, however, possible that they may act upon the exudations of the trachea as the yeast plant acts upon sucrar, and cause the production of a septic poison which differs from that of ordinary putrefaction, and bears such relations to the system as to, when absorbed, cause the systemic symptoms of diphtheria. Now, these bacteria may be always in the air, but not in sufficient quantities to cause trachitis, but enough when lodged in the membrane, to set up the peculiar fermen- tation ; whilst during an epidemic they may be sufficiently numerous to incite an inflammation in a previously healthy throat."] Conclusions. — Experiments of great interest appear opposed to the inoculability of diphtheria from man to animals by false DEVELOPMENT OF EIPDEMICS. 345 membranes in kind or by the spores which have been collected from their surface. These experiments being yet few, and be- ing found contradicted by those which prove the transmissi- bility of diphtheria by the contact of diphtheritic products with the mucous membranes, we may be permitted to appeal to other cases. The result obtained is very important and difficult to accomplish. It is, aside from certain ex- ceptions, more difficult to transmit a disease by simple contact than by occulation, the channels of absorption being more ac- cessible in the latter case. Many observers are reserved on the possibility of communicating by simple contact, syphilis and variola though so easily inoculable. The trials at inoculation from man to man are negative, but too few in number to be of authority, The cases of accidental inoculation with blood are not sufficiently decisive. This much is certain, that they have produced symptoms of septicaemia. The cases of accidental inoculation with false membranes or with liquids in contact with them, appear established upon incontestable facts. The con- clusion, therefore, will be with reserve, that diphtheria is inocu- lable, but rarely and with difficulty. This question, however, presents an interest of purely scientific curiosity ; its practical value appears nil. The utility of inoculation would exist only in the case in which one might hope to develop by this means as is done in variola, a benign form of diphtheria which would form a protection against more serious attacks in the future. But this hope can in no way be realized, since on the one hand, the benignity of inoculated diphtheria is not demon- strated, considering the small number of cases, and, on the other, diphtheria being a disease which returns, there would be no benefit in making the adventure. IV. Transmission by the Atmosphere. — If the transmissibility of diphtheria by direct contact and by ihcculation has been contested, all accord to this disease the faculty of propagating itself through the surrounding air. This is the mode, par ex- cellence, of transmission of epidemic and contagious diseases. It is that which corresponds to what was called propagation by infection, when we could not prove contact of the patient 346 DIPHTHERIA, CROUP AND TRACHEOTOMY. with a person affected with any form whatever of diphtheria. The researches of Chalvet, Rcveil and Eidvelt of Prague, have discovered in the air of hospital wards, in epidemic seasons, the existence of organic particles, emanating, in all probability, from the affected organisms. Whether we call them miasms or spores, these infinitely small particles, of which the air serves as a vehicle, have the property of attaching themselves to healthy individuals, and on them developing a disease similar to that which formed them. The respiratory mucous mem brane being of all the other absorbent surfaces, that which is in the most constant contact with the air, is the great channel by which these organisms enter the economy*. In this way transmis- sion by inhalation is effected. But the other mucous mem- branes in contact with the atmosphere ; the conjunctiva, the labial mucous membrane, that of the glans and prepuce, and of the anus, while presenting to diphtheria more limited access, are still under the required conditions to absorb the morbid particles. These give opportunity for the tratismission by ab- sorption from the surface of mucous membranes. Besides those normal modes, there is another purely accidental. The cuta- neous surfaces deprived of their epidermis possess also a very active absorbent power. The morbific germs may deposit themselves thereon, and insinuate themselves into the economy. This means of transmission differs from inoculation, in that the denuded surface is not, as in inoculation, placed in direct con- tact with the morbid product but by the medium of surrounding air. Diphtheria arises in these different ways. It is transmitted by inhalation of the surroimdijig air, by absorption ftom the sur- face of mucous membranes, and by absorption from the surface of wounds. Transmission by Inhalation. — The examples of this mode of propagation have been too often repeated to require a demon- stration of its reality. The extension of the disease to numer- ous individuals living in the same place, inhabiting the same house, apartment or room and sleeping in the same bed ; its I DEVELOPMENT OF EPIDEMICS. 347 propagation in the hospital ward from the bed of the importer to the neighboring bed, and then from the latter to the next and so on, as has been observed many times, all these cases are eloquent. In that way are infected parents and servants, friends who live with the patients, and the physicians who at- tend them, and among these persons the most frequently at- tacked are those who have been in most devoted attendance. It was in this way that Gillette contracted diphtheria of which he died. While suffering from influenza for several days, he brought from the country some miles distant from Paris, in a closed carriage a young patient affected with croup. Nine days afterwards his fhroat became covered with false mem- branes, and diphtheria rapidly extended to the entire respira- tory tract. There are, however, to this rule exceptions, the cause of which resides in the different aptitudes of the organ- isms to support the morbific germs. The agencies of conta- gion are carried away from places where patients are lying by the surrounding air, as well as by persons who have entered the infected medium. In this way the disease is spread with rapidity through the city, in the villages, barracks and every place where people are collected together. The cases which prove this mode of propagation are so numerous, so fully ad- mitted by all that I deem it unnecessary to reproduce them. Besides, I have already quoted a sufficiently large number of them. The extending power of diphtheria is considerable. It is often with great rapidity that it extends its ravages over an entire country. Some times it respects, without apparent cause, places comprised within the affected zone. The exten- sive contact of air with the respiratory mucous membrane, ex- plains why diphtheria has its place of election in the pharynx and nasal fossae. It is in these places that the germs penetrate first; they there find extensive surfaces on which to deposit themselves. Those which have not been arrested on their passage, penetrate into the larynx and bronchi ; here they may find a point favorable to their development ; croup is then pri- mary, which is notably the more rare form. Transmission by Absorption from the Surface of Mucous Mem- 348 DIPHTHERIA, CROUP AND TRACHEOTOMY. dranes.— Being in contact with the external air in a much more limited surface, the ocular, labial, preputial and anal mucous membranes rarely aid in the introduction of diphtheria. This function, however, is none the less a fact. We see, in epi- demics, not only persons having, as a single diphtheritic lesion, a pseudo-membranous conjunctivitis, a patch upon the surface or on the commissure of the lips, or indeed on the pre- puce or anus ; but it is not rare that these false membranes may be the first manifestations of diphtheria ; others appear afterwards in the throat, nose and respiratory passages, inde- pendently of propagation by contiguity. These same cases of diphtheria, developed on the external" mucous membranes, transmit to other patients diphtheria mild or grave, localized, in the same way or otherwise, or generalized. Transmission by Absorptioji Jrom the Surfaces of Woiinds. — When a portion of the cutaneous surface is denuded, diph- thertic germs may there implant themselves and become ab- sorbed. Blistered surfaces, impetiginous and eczematous ulcerations and varicose ulcers furnish favorable soil. The epi- demic of which Bonnet speaks furnishes interesting informa- tion. Serious symptoms produced at the outbreak had spread terror through the country ; the inhabitants had sought a sure preventive and had found nothing better than a blister on the arm. The application of it was adopted on a broad scale ; but cutaneous diphtheria was not retarded in its invasion. Every blister which Bonnet saw was covered with false mem- branes. Trousseau speaks also of the bad effects of preventive hYis\.tts {vesicatoifes de precatctiofi). In addition to these cases we see in an epidemic locality, the least ulcerations become the seat of diphtheria. Impetigo of the scalp, of the folds of the ear, and of the lips; eczema of the ear, scrotum, or of the cir- cumference of the anus, and simple excoriation of the folds of the thighs in fat children often open the door to the disease- Nothing is more common in the wards of the hospital. Diph- theria acquired in this way is very likely to spead. Once im- planted on a mucous surface, or on a wound, the germs are DEVELOPMENT OF EPIDEMICS. 349 absorbed, provided they meet favorable conditions, but, though they directly infect the economy and the false mem- branes may be a product of general poisoning, we see this membrane, as in the case of syphilis, very often spring up at the point through which the morbific matter has entered into the economy. This circumstance does not prevent the false membranes from appearing simultaneously or successively upon other points quite distant. Infection once effected, the vitiated blood alters, by its contact, the various organs and excites the formation of visceral lesions. The intimate mechan- ism of this process is not understood. § 2. Conditions Favoring the Vitality of the Germ. — Agencies which have awakened and revived the germ, support its vital- ity by prolonging their influence. These have been examined in the preceding articles. § 3. Conditions which Favor the Receptivity of the Organism. — We know that diphtheria transmits itself from individual to individual. Let us examine the conditions which put into action this transmissibility, in other words, those which render the organism susceptible of being impregnated by the diph- theritic germ. We will study the influences of the following causes : Damp cold, and sudden changes of temperature, bad hygiene, depressing influences, age, sex and temperament. Snddeii changes to damp cold temperature act upon the re- ceptivity of the individual as well as upon the general develop- ment of the epidemic. They are very active in the production of inflammations of the throat and air-passages. As in time of cholera, simple indigestion often becomes the determining cause of the attack, so a simple angina, a coryza, or a simple laryngitis may put the naso-pharyngeal mucous membrane in the necessary condition for the absorption of the diphtheritic germs. Defective hygienic condition : viz., destitution and occupying low, damp, ill-ventilated rooms are certainly determining causes. Nearly every reporter of epidemics testifies that the disease prevails to a greater extent among the poor. This in- fluence is not exclusive ; far from it, the wealthy class pays 350 DIPHTHERIA, CROUP AND TRACHEOTOMY. also, and even largely, its tribute, but it is none the less true that the great mass of patients affected with diphtheria, are seen at the hospital and belong to the portion of the poor pop- ulation. To these causes must be added all those of the same kind which diminish the resisting powers of the economy, viz. excesses, emotional impressions, fatigue, and in general, all depressing influences. Age is one of the most important conditions in the devel- opment of diphtheria. This disease is the heritage of child- hood. It is met with, indeed, from the earliest infancy, as Bretonneau has proved, to very advanced age, as Louis has shewed ; but all authors are in accord in assigning to it the maximum of frequency in the early years of life. Guersant fixes the age from two to seven years ; Trousseau at that from three to six ; Barthez and Rilliet adopt the figures of Guer- sant. In the epidemic of Ceyret all the inhabitants over 24 years of age escaped. In the epidemic of Louhans, in 2,500 cases, 1,198 were children. Bouiilon-Lagrange has pre- pared the following table respecting the age of patients in the epidemic which he has described : Under 2 years 14 cases. From 18 to 30 years - *s From 2 to 6 years - 18 cases. From 30 to 40 years - - 4 From 6 to 12 years 10 cases. From 40 to 50 years I From 12 to iS years - 9 cases. After 50 years - - ■ 2 This places the maximum between two and six years. In order to obtain the exact result it would be necessary to com- pare the figures furnished by several epidemics in which an account of all the cases had been taken. Unfortunately this has not been done. According to the summary of the Epi- demiological Society of London the disease is said to be espe- cially frequent during the first ten years of life, and particularly so from the fifth to the tenth year. The following table will give a result, as complete as may be, respecting the earlier ages. It contains all the cases of diphtheria observed in the service of Barthez at the Saint Eugenie during twenty years. They are proportioned as follows : DEVE -LOPMENT OF EPIDEMICS Under l year (ii mos,) 4 cases. Under 9 years Under i year - - - - 77 cases Under 10 years - Under 2 years ■ 314 cases Under 11 years Under 3 years - . - 319 cases Under 12 years - Under 4 years - 292 cases Under 13 years Under 5 years - - - 200 cases Under 14 years - Under 6 years - 103 cases Under 15 years Under 7 years - - _ 59 cases Under 16 years - Under 8 years 36 cases Under 17 years 351 24 cases - 23 cases 9 cases 12 cases 24 cases 12 cases 2 cases - I case I case Total 1,512 cases The real maximum corresponds to the ages from two to three years, but up to five years the figures still remain quite high. Therefore, it is from two to five years of age that diph- theria is most commonly observed ; it is emphatically a dis- ease of childhood. The cause of this preference is but little known. It has been attributed to the greater plasticity of the blood in the child ; nothing is farther from being demonstrated. It is nearer true to say that children have a special affinity for miasmatic and contagious diseases. They rarely escape mea- sles, scarlatina, small-pox, or whooping congh. They should be found in similar conditions in respect to diphtheria, a dis- ease of the same order. Moreover, their entire mucous mem- branes are particularly impressible, and it is with the greatest facility that they contract coryza and bronchitis. Perhaps this susceptibility of the mucous membranes to inflame predisposes also these membranes to absorb more readily the diphtheritic miasm. Sex. — Some statistics incline the balance to one side, while others turn it toward the opposite. Forgeot, Bataille, Bouillon Lagrange and Fourgeaud have observed epidemic diphtheria more frequently among girls. Jurine regarded croup as more frequent among boys. Boudet expresses the same opinion. Vauthier has seen diphtheria attack the two sexes equally. Barthez and Rilliet give the preponderance to the male sex, and they sustain this opinion by statistics of tracheotomy made by Trousseau and by Jansecowitch who give a large prepon- derance to boys. The recapitulation of 1,575 cases of diph- theria has given me 813 of them for the male sex and 762 for the female. These statistics made upon so large a scale in the 352 DIPHTHERIA, CROUP AND TRACH F.0'1 OM Y. service of Barthez, in which the same number of beds is as- signed to boys and to girls, should give, so far as statistics can, an idea of the question sufficiently exact. Though the figures for the boys are a little larger than those for the girls, the difference of 5 1 cases in their favor has but little signifi- cance, distributed as it is over so large a total. It appears, then, that diphtheria extends its ravages in the same proportion to each sex. Moreover, it would be useless to ask why it pre- dominates over one or over the other, or why it differs in this respect from the eruptive fevers. Teniperament. — Can we admit that diphtheria develops by preference in certain temperaments? Rilliet, who was much occupied with this question admitted that the lymphatic, tuberculous, eczematous, the cancerous temperaments and con- sanguinity constitute predispositions ; Bouillon Lagrange has seen in 73 patients, 57 lymphatics, of which 21 were scrofulous. Signalized by authors so reputable, these cases should be taken into account. I have a number of times met with diph- theria in lymphatic subjects, but also in many others who were affected with different diatheses or who were perfectly free in this respect. Diphtheria, like all infectious diseases, may seize upon any organism. Nevertheless, it must not be forgotten that secondary diphtheria is relatively frequent, and that this disease, while attacking untainted temperaments, affects also, and perhaps more frequently than any other dis- ease of the same class, debilitated constitutions. I have been surprised in my researches in secondary diphtheria, at the im- portant place which tuberculosis holds among diseases which are followed by diphtheria. It is not, therefore, impossible hat all conditions of organic deterioration render the soil suit- able for favoring diphtheritic germination. Scrofula may have a double predisposing action, first by depressing the economy, and then by the facility with which it causes inflammation of the mucous membranes. Likewise the eruptions with which it covers the skin often serve as starting-points to ulcerations which open the way to diphtheritic invasion. On the other hand, when the disease is seen to extend to DEVELOPMENT OF EPIDEMICS. 'i53 entire families, to certain members even who have been sepa- rated for a long time from the first attacked, may one not ask whether the generalization does not arise by virtue of the con- sanguinity of organization which unites the different individ- ualities of the same families, a conformity which would place them all, respecting diphtheria, in the same general condition of receptivity. Not every person exposed to diphtheritic in- fection is so unfortunate as to be affected. The immunity of some persons is owing to these individuals not presenting the personal, somatic, quality necessary to the development of the disease. § 4 — Conditions Unfavorable to the Germ. Dry climates, elevated localities, seasons regular and void of dampness, are generally unfavorable to the germ. Though the latter might preserve its vitality in spite of these condi- tions, it is none the less true that epidemics, developed without this influence, are, in fact, comparatively quite rare. The age of the germ is also an unfavorable condition. Although this organism may remain a long time inactive, in a kind of sleep, and resume afterwards all its energy, it is probable that the older it becomes the greater are the probabilities of its becom- ing altered and perishing. § 5.— Conditions Unfavorable to- the Receptivity. Of these adult age is the principal; in fact, diphtheria is rare after adolescence. Also good hygienic conditions in all that concerns the dwelling, alimentation and cleanliness. As in other contagious and infectious diseases, pregnancy seems to confer a certain immunity, which, however, ceases at the the time of delivery. On the contrary, females recently con- fined contract diphtheria with facility. Previous contamina- tion is not a sufficient preventive ; it is, in fact, fully demon- strated that diphtheria returns, though in restricted propor- tions. Secondary Diphtheria. Diphtheria most frequently attacks healthy individuals, but it intervenes in quite a large number of diseases, either 354 DIPHTHERIA, CROUP AND TRACHEOTOMV. during their course or following them. Many authors have been impressed with this coincidence. Measles have been sig- nalized as an antecedent of diphtheria by Barthez and Rilliet, West, Trousseau, Millard, etc.; scarlatina by Boudet, Andre and Peter; small-pox, by Boudet; varioloid, by Barthez and Rilliet; whooping-cough, by Finaz, Vauthier *and Andre; typhoid fever by Barthez and Rilliet, Andre, Oulmont, etc. In 1,456 cases of diphtheria, 247 were of secondary origin, which gives a proportion of i to 5.89. The diseases which were succeeded by diphtheria are in the following proportion : Measles, - 137 cases Pleurisy - 4 cases Scarlatina - - 95 " Tuberculosis - 29 " Whooping-cough - 20 " Various cachexiae (scrofula. Typhoid fever - 8 " chronic diarrhea, etc.) 34 cases Small-pox - - 2 " SyphiHs - - 3 " Urticaria - - 2 " Purulent ophthalmia I " Simple bronchitis - 4 " Cholera - - I " Pneumonia - - 4 " Doubtful cases - 3 " [An error in the original figures]. 347 cases. Measles, in this table, includes the largest number of cases ; scarlatina furnishes considerably less, which would seem to indicate that the former is more fruitful in diphtheria than the latter. This would be an error. Scarlatina furnishes relatively as many as measles ; it gives occasion to even a larger number. Its apparent inferiority depends upon the fact that it is much less frequent than measles. During twenty years, 1,453 measles cases and 605 of scarlatina entered the service of Bar- thez. Diphtheria consecutive to scarlatina, has, therefore, been noted 95 times in 605 cases, that is i in 6. Consecutive to measles there have been observed 137 in 1,453 cases, that is, I in 10. Consequently, scarlatina is, of all diseases, that which is most frequently followed by diphtheria. Tuberculo- sis and the various cachexias hold also an important place among the diseases which prepare the way for diphtheria. DEVELOPMENT OF EPIDEMICS. 35 5 These diseases may be divided into two groups respecting their action on diphtheria. The first, hke cachexiae, appear to prepare for it the soil, as they do for all specific diseases, by debilitating the economy and diminishing its power of resis- tance to miasmatic absorption. The others appear to have a quite special affinity for diphtheria. These are, like it, spe- cific diseases; measles, scarlatina, whooping cough, typhoid fever and tuberculosis. These diseases do not, strictly speak- ing, engender diphtheria ; they open a broad access for it. Their preparatory action is twofold; they act, first, like the preceding, by depressing the organism and by rendering it liable to contract any contagious disease, principally that which prevails at the time. But they also cause the economy to undergo an important local preparation. I have several times insisted upon the important role which in- flammation of various mucous membranes plays, in respect of the genesis of diphtheria. Now, all these diseases have a strong attraction on the part of the guttural and respiratory mucous membranes. It is, therefore, very plain that diph- theria may be strongly attracted to the organs so much dis- posed to receive it. In studying the symptoms of secondary diphtheria I have showed that it preserves the stamp of the primary disease; its local manifestations nearly always coincide with those of the disease which has prepared the way for it. That which follows measles and whooping-cough, prefers the respiratory apparatus ; that which succeeds scarlatina selects by preference the throat. Though less striking, these pecu- liarities are found in all the diseases which precede diphtheria. It is not only during their period of acme that these morbid conditions attract diphtheria ; they still preserve this power during convalescence. These things occur exactly the same ; the organs, still under the influence of crises which they have suffered during the first period, conduct themselves in the same manner in the presence of diphtheria. INCUBATION OF DIPHTHERIA. In order to estimate accurately the duration of diphtheritic incubation it is necessary to know the exact moment at which 356 DIPHTHERIA, CROUP AND TRACHEOTOMY. contact is effected. Inoculation or the deposit of morbific matter upon the mucous membrane alone offers precise data. Experimental inoculation failing, and accidental inoculation being contestable, there is, therefore, occasion for taking into consideration the results furnished by placing the mucous membranes in contact with diphtheritic products. These are presented under conditions of careful experimentation. In the experience of Trendelenburg, incubation has been from one to two or three days; in those of L. Lagrave of about twenty hours; in those of Duchamp it was from twenty-four to thirty-six hours, for the animal died at the end of two days, having the larynx and the trachea covered with false membranes, and the lungs hepatized. The small number of experiments, it is true, allows of a variation between twelve hours and three days, as the duration of diphtheritic incubation. It is well to observe that in the case of accidental inoculation cited by Dr. Bonnet, the incuba- tion was one day. This agreement proves once more the reality of inoculation under these circumstances. Before com- prehending these facts, one endeavored to attain the same end by seeking the time which intervened between the presumed contact and the period when the symptoms arose. For exam- ple, a person remains several hours in contact with a diphthe- ritic patient. At the end of a few days he is taken with diph- theritic angina. Everything tends to the belief that we know the duration of the incubation. Another example: a patient with this disease enters a ward free of diphtheria ; a few days pass, and cases of diphtheria break out among the patients pre- viously admitted for other diseases, or among the convalescents. In the first class of facts the problem Is very simple ; in the second it becomes more difficult, if several cases occur succes- sively, but near together. If we may flatter ourselves that we know the duration of the incubation in the first patient, it becomes very difficult to know at what moment the third was contaminated. Positive data fail absolutely. We resign our- selves to approximations, and are content with obtaining the maximum duration. Suppose that three cases of diohtheria DEVELOPMENT OF EPIDEMICS. 357 appear in a ward, four, five or six days after the entrance of an infected patient, one might say that, in the first case, incuba- tion lasted four days ; for the others one may affim that it does not exceed more than five or six days, but it is impossible to know whether it was shorter. We need not look for anything but the maximum of the incubation. But while these figures may be obtained when the facts occur isolatedly in a family, in a circumscribed place, or in a ward of a hospital still uninfected, we conceive that in times of epidemics the dispersion of morbific germs in the atmos- phere produces constantly cases of infection in which it may be impossible to apprehend the moment of contamination. If, in those conditions, a person healthy in appearance, enters, for any disease whatever, one of the hospital wards where diph- theritic patients are found, and at the end of a few days he should be himself attacked with diphtheria, there is nothing to prove that he may have acquired in the hospital the germ of the disease. Perhaps he may have received it from one of those limited, often undiscovered, infected centers of the large cities. Investigation should be limited necessarily to isolated cases, or to the beginning of the epidemic. Roger has con- cluded from the examination of seventeen cases, that the max- imum of the duration of incubation might be represented ap- proximately by a period of from two to seven days. Peter reached figures almost the same, by researches conducted in a similar manner. The approximate incubation may be, most frequently from two to eight days ; exceptionally it might be from twelve to fifteen. Dr. Mair, in the account which he gives of the epidemic which he observed in Middle Franconia, assigns to this peried an average duration of from eight to ten days. In some cases it may have been, he says, even from four to six weeks. This last limit shows the embarrassment in which the author found himself in the presence of cases de- veloped in patients who were in contact for a long time with infected centers of diphtheria. The results which I have ob- 358 DIPHTHERIA, CROUP AND TRACHEOTOMY. tained differ but little. In 98 cases incubation seems to have had the following duration : From I to 2 days 7 cases From 13 to 15 days 6 cases From 2 to 8 days 48 cases From 15 to 20 days 14 cases From 8 to 13 days 23 cases Total ----- -_q8 cases These results differ, evidently, from those of experiments, as we might presume would be the case in the absence of exact documents. The evidence was demonstrated in several cases ; we find, in fact, in all the tables, a certain number of cases in which incubation does not exceed two days. For others, and especially for those in which this period reaches fifteen or twenty days and more, there were very likely mistakes. It is, therefore necessary in awaiting more numerous observations, to accept the figures furnished by experiment and to recognize in diphtheritic incubation a probable duration of from one to three days, with the possibility of its extending somewhat be- yond these limits. THE NATURE OF DIPHTHERIA. In several chapters of this work I have given my explana- tion of the nature of diphtheria, and everywhere I have invoked the principle of specificity. The propositions, laid down here and there according to the necessities of the discussion, should be united into a body which represents the doctrinal sum total ot diphtheria. It is to Bretonneau that the honor belongs of having established the specific character of diphtheria, at the same time that he proved the ontological identity of the pseudo-membranous angina and croup. Popularized by the mighty dictum of Trousseau, this conception was completed by Barthez. By showing that infectious croup, and the disease designated by the name of simple croup, or common croup, were but different degrees of the same poison, viz., diphtheria, my eminent and cherished preceptor brought to bear a new argu- ment of great value in favor of the identity in nature of the different membranous affections. The discussions which took place at the same time in the Academy of Medicine and in the Societe des hopitaux, and in the works of Peter, Hervieux and others contributed to the further confirmation of that view. A general disease, specific, infectious, contagious, ca- pable of localizing itself upon the most various points, adopt- ing variable anatomical forms according to its region and pro- ducing numerous visceral lesions, such is the primary idea of the doctrine. Another point not less important, established by Breton- neau, is the exudative character of diphtheria of which he makes a specific phlegmasia, and which he distinguishes ab- solutely from gangrene, claiming that the mucous membrane is always healthy underneath the false membrane. That con- clusion was too absolute, as the observations published by (359) 360 DIPHTHERIA, CROUP AND TRACHKOTOMV. Becquerel, Barthez and Rilliet, and Empis and Isambert showed. Trousseau also had to modify the ideas of his pre- ceptor wherein they were extreme. Grounding himself upon the well known existence of gangrene in other specific dis- eases, as measles, scarlatina, small-pox, etc., he admits that gangrene of the pharynx may be an expression, rare indeed, but genuine, of the diphtheritic poison. I fully accept this view. Diphtheria is, to my mind, a dis- ease which is toiitis substaiiticB primarily general. All its forms, so diverse in appearance, are but different manifestions of a single cause which contaminates the whole economy. It should be placed in the nosological list beside those diseases whose manifestations are multiple in spite of the unity of the cause, such as measles, scarlatina, small-pox or syphilis. The major part of French physicians regard diphtheria in this light, nevertheless, disagreements exist upon certain points. Ac- cording to some physicians, the disease is local at first, and becomes general only by the absorption of prodncts which arise from the alteration of the false membranes. Others, hold- ing as null and void the works of Bretonneau and of his suc- cessors, put science back to the point where Home left it. In other words they make two different diseases of croup and angina gangrenosa. This is the German notion of diphtheria. Let us examine these two theories. First Theory. — The local origin of diphtheria has been supported in modern times by Bretonneau and by Trousseau, while Bouchut is still one of its few defenders. "There is, however," says Trousseau, "an essential difterence to be laid down between diphtheria and the diseases which we have just named, (small-pox, measles, syphilis); it is, that in the former, we must take the local affection into account more than in the latter. So, in small-pox, for example, we do not preoccupy ourselves with the pus'ules, at least, we do not preoccup yourselves with them except in view of the prognostic or diagnostic nieanin,;,'- we can draw from them. If we do not preoccupy ourselves with them from the standpoint oi treatment, it is no longer so in diph- theria. What lakes place here, may be, in fact, compared with what occurs in mal- ignant pustule, in which by directly attacking the local affection, we ward off the general disease of which that affection was a primary manifestation. So, also, in diphtheria, by interfering energetically to combat the first manifestation, we are sometimes able to arrest its progress and prevent its later manifestations." From this comes the supreme importance which Trousseau, like Bretonneau, ascribed to cauterization of the false mem- NATURE OF DIPHTHERIA. ^ 3^^ branes, and from this, according to Bouchut, arises the utility of amputating the tonsils covered with false membrane. The experience of these latter years will not allow the ac- ceptance of that view. In the chapter on Treatment, the re- markable unanimity of practitioners with regard to the uselessness of cauterization in diphtheria will be shown. It will also be seen that amputation of the tonsils has not re- sponded to the expectation of its author, for it has not pre- vented, in many cases, the extension of diphtheria, and in others, as I have witnessed, diphtheria has returned even upon the surface of the cut. On the other hand, the comparison which Trousseau laid down between diphtheria and malignant pustule, is no longer acceptable. In fact, while malignant pustule is a species of parasitic nidus the bacteria of which escape to penetrate little by httle into the blood, and in such a manner that when the lair is destroyed the infection ceases, the false membranes are, on the contrary, the proof of a general infection. They can be more justly compared to the indurated chancre which develops at the very point where the virus has penetrated the economy, but which is, in reality, the first of the secondary accidents. There is to-day no physician who pretends to arrest the course of syphilis by excising or cauterizing the chancre. This re- semblance between diphtheria and malignant pustule is still less acceptable as, according to all probability, the penetration of the diphtheritic poison into the economy takes place through the respiratory passages, viz., the nose, the pharynx, the larynx, etc.; and the cases where it is said to have been intro- duced through a solution of continuity, are very rare and are contested. If diphtheria were a local disease at first, beginning at the tonsils, and became general afterwards only by absorp- tion, what organs would be more exposed to the reception of the poison of the disease, than the digestive tract which is in habitual contact with the debris of the false membranes, swal- lowed together with the saliva and with food, if they are not constantly bathed in an ichorous fetid liquid which proceeds from the fauces. Notwithstanding these conditions so favora- 362 DIPHTHERIA, CROUP AND TRACHEOTOMY. ble to the development of false membranes, their presence in the oesophagus, the stomach and the intestine is exceptional. Another argument may be opposed to this theory, and that is the existence of cases in which angina and croup were consec- utive to diphtheria of the skin. In those cases pharyngo-lar- yngeal false membranes have been seen to develop secondarily. The mechanism indicated by the partisans of secondary poi- soning is inapplicable to tnese tacts. Is there not also an imposing number of patients with whom the generalization of the false membranes comes on with such rapidity that these products are seen to arise on all sides almost at the same time ? How could the economy have become infected by the first which appeared, which, moreover, had not had time to become decomposed? What does that very alteration prove, except the intensity of the blood poison- ing ? The most generalized forms are not those in which the false membranes become most decomposed ; it is rather the opposite which is observed. The tendency toward putrefac- tion, is met especially in the forms where profound poisoning coincides with a localized production of false membrane ; and it is often lacking in generalized diphtheria. But, it will be said, the symptoms of infection, absent at first, sometimes ap- pear only after a certain time, which proves that the poisoning is indeed secondary. To this I will reply that it is fully as common, if not more so, to find the diphtheritic poisoning ev- ident from the first, and that these are the cases which are most intense that begin thus ; that the false membrane is then but an unimportant element, and that we have seen patients succumb in a few hours, whose every apparent lesion was only an insignificant false membrane. These facts are a confirmation of a precept which I have en- deavored to make clear. It is impossible to establish a constant correspondence between the character of the false membrane and the degree of diphtheritic poisoning. There are often seen thin, discrete false membranes which could be easily taken, and which have been too often taken for herpes of the pharynx, accompanied by general symptoms of great gravity and re- NATURE OF DIPHTHERIA. 363 suiting at last in death. On the contrary, it is not rare to see large and extended false membranes, occupying the whole fauces, give rise to an almost imperceptible reaction and allow- ing of cure, provided always that they do not bring on death by a purely mechanical process, viz., by penetrating into the larynx. Now, can it be said that the false membranes do not undergo alteration, or that such alteration is without disadvan- tage ? Evidently not. They do undergo, in severe cases, a tfue putrefaction which to the first poisoning adds a second. These two are of very different nature. The pus, the altered blood and the fetid ichor which is discharged in great abund- ance, whether absorbed by the digestive mucous membrane or by the denuded surfaces, are a new element of infection, not of diphtheritic infection, however, but of infection by septic products ; in other words, of putrid infection, or of septicaemia. The conclusion from this discussion is that the false mem- branes are the effect and not the cause of the diphtheritic poisoning, and consequently their destruction is practically of secondary importance, so long as their alteration and their locality do not give rise to special indications. Second Theory. — This is the German anatomical theory which I have analyzed in detail in the chapter on Pathological Anatomy. Preoccupied first of all, with solving the question of specificity by means of pathological anatomy, Virchow's school distinguished two kinds of pseudo-membranous affec- tions. One is croup, a superficial exudation formed upon the surface of the mucous membranes or of the denuded skin, leav- ing the chorion of the mucous membrane intact, and seated upon the respiratory mucous membrane. The other is diph- theria, an interstitial infiltration formed in the substance of the chorion of the mucous membrane or skin, which results in the death of the tissues which it infiltrates. Its product is nothing else than a true eschar, and behaves in like manner. This process is seated in the pharynx. All diseases which presented a fibrinous exudation as a lesion, were classed in these two lists, and became either 364 DIPHTHERIA, CROUP AND TRACHEOTOMY. croupous or diphtheritic. Fibrinous pneumonia became croupous pneumonia, etc.; dysentry, hospital gangrene, ulcero-mem- branous stomatitis, etc., became diphtherias under the same head as pseudo -membranous pharyngitis. Conceived in these terms, and adapting to anatomical processes, names which had hitherto served to designate symp- tomatic groups, this classification of necessity brought in a most fantastic confusion. Ignoring the teachings of the clinic and under the pretext that early observers, such as Michaelis, Albers, Jurine and Vieusseux, had before their eyes simple croup which they regarded as non- contagious, and which is rarely accompanied by pharyngitis, an anatomical croup was discovered, an inflammatory disease limited exactly to the respiratory passages. Diphtheritic pharyngitis alone remained the general and contagious disease. But what was to be done with those cases in which the pharyngitis and the croup existed together? To this question Wagner answered that in the same patient there might exist, side by side, and probably by mere accident, a diphtheria of the pharynx and of the supra- glottidean portion of the larynx, a general, contagious disease, and a croup of the lower portion of the larynx, of the trachea and of the bronchi, a disease purely local and non contagious. Without speaking of the flagrant error, from a clinical point of view which this theory contains, its principal support does not rest upon a solid basis. I have endeavored to show that the results obtained by Virchow and his school were erroneous. I have been aided in that task by German observers themselves who have arrived at entirely different conclusions from their predecessors. One of the arguments which serves to bolster up the ana- tomical croup of the Germans, is the existence of a localized croup, which also appeared non-contagious, noted by the early authors. These cases should not be denied. We know this, and it is a point to which I have often called attention, that diphtheria sometimes presents light manifestions only, in which the local affection seems to prevail exclusively, and in which the con- NATURE OF DIPHTHERIA. 3^5 tagious power seems doubtful; but side by side with these cases, do we not see the gradation which insensibly rises from that attenuated form to the gravest forms characterized by in- vasion of the air-passages throughout their entire extent, by generalization of the false membranes and by gangrene of the mucous membrane ? Is it necessary, in order to show the foolishness of this class- ification, to notice the resemblance which it asserts between diphtheria, dysentery, hospital gangrene and ulcero-mem- branous stomatitis, diseases which are absolutely distinct there- from ? And for that matter, if there is a disease which anatomically is a diphtheria in the German sense that is ulcero- membranous stomatitis ; it is even much more diphtheritic than diphtheritic pharyngitis itself. Who would dream to-day of establishing a relationship between these two diseases ? Moreover, even in Germany they have begun to return to the ideas which the clinic teaches, for, in a discussion which took place at Berlin in 1872, in the Medical Society, although Dr. Waldenberg persisted in discriminating croup from diphtheria. Professor Traube declared that any clinical distinction between croup and diphtheria was impossible. To his mind diph- theria is a unit, but its products may be various , some being interstitial and ending in gangrene, while others are superficial and are like catarrh. This is, as we see, a complete return to the doctrine of Bretonneau. Like all the other physicians present at the discussion. Professor Traube had renounced cauterization because of its inefficiency. This communication is all the more valuable because Traube, one of the most illustrious physicians in Germany, has been the admirer and the successor of Schonlein, the principal de- fender, together with Virchow, of the local nature of croup. At Vienna there is the same divergence of opinion. Oppol- zer was still in 1868 proclaiming the difference between the nature of croup and diphtheria. Professor Skoda, on the contrary, declares distinction impos- sible at the bedside. He says that at Vienna, croup, whether primary or secondary, sporadic or epidemic, is almost always preceded by a membranous pharyngitis. 366 DIPHTHERIA, CROUP AND TRACHEOTOMY, The identity of croup and diphtheritic angina, for a time placed in doubt, is thus almost generally recognized, as the judicious observation of facts demands. To assimilate diph- theria completely to general diseases, one question still re- mains for solution, viz., can diphtheria, side by side with severe forms, assume benign, attenuated forms which nevertheless belong to its domain? That question seems to be solved as soon as stated. Every disease has its degrees. Barthez was one of the first to insist on this point. He proved the existence by the side of severe and well characterized cases, of milder ones, which could not always be referred to their real cause, unless the positive fact were kept in view which revealed their nature. Yet this truth has been contested, and only such cases have been willingly considered as belonging to diph- theria, as had formidable local lesions and an evident infection. It often happens that benign and discrete forms are set apart under the name of herpetic pharyngitis or common membra- nous sore throat. The differentiation has been given under the head of diagnosis. It must be considered that the process has by virtue of indi- vidual conditions been arrested in its evolution. The early authors naturally compared the disease to a seed deposited in a soil, which is the patient. If the soil be favorable, and the surrounding circumstances be propitious, germination takes place, a new entity is born and grows. But all soils do not favor the growth of the same germ. If the latter be deposited upon an unfavorable soil it dies or is incompletely developed. This is what happens in contagious diseases, and it explains why all subjects exposed to contagion do not take the disease with the same intensity, or even may escape it. This compar- ison is more applicable than ever in our day when the tenden- cy is to assign a very important role in the production of dis- ease to inferior organisms, such as spores, bacteria, etc. This arrest of development is not peculiar to diphtheria. Docs scarlatina cease to be scarlatina because the exanthema may have been light or fugacious, or because it may have been wanting? Do not the cases where the general symptoms are NATURE OF DIPHTHERIA. 367 insignificant, belong to scarlatina as well as those which are announced by a formidable ataxia? Are not discrete and con- fluent variola and modified variola or varioloid, varieties of the same disease ? How many degrees are there in typhoid fever, from the ful- minant ataxic form to the walking form? Do not measles, puerperal fever, and other specific diseases behave in like man- ner ? Is not cholera, even during epidemics, limited to a pro- fuse diarrhoea in a great number of subjects? Beside these arguments which analogy furnishes, in favor of the identity of the different manifestations of diphtheria, there are found others in the fact of the coexistence in times of epi- demic, of localizations the most varied as to site and intensity, and especially of their mutual transformation. Examples are not wanting of cases of benign pharyngitis coinciding in the same places and in the same families with cases of severe pharyngitis. We have also proof of the contagiousness of the most simple manifestations, and they do not confine themselves to transmitting the disease with inoffensive characteristics, but a benign diphtheria often communicates a severe diphtheria and vice versa. The facts sited by Vigla, by Guerard and by Peter, present benign diphtheria as communicating forms sometimes simple, and sometimes malignant, just as varioloid transmits discrete or confluent small-pox indifferently. On the other hand, malignant diphtheria appears there, susceptible of becoming in other subjects transformed into benign diphtheria. The communication of Vigla shows us a case of transmission which is likewise curious. A babe of twenty months suc- cumbed to a cutaneous diphtheria developed after vesication. Three days before it died the father of the child made a slight abrasion upon one of his great toes, and a false membrane de- veloped upon it rapidly and invaded a portion of the toe. At the same time the patient complained at two different times of pain in the fauces, together with general malaise ; but the most careful examination did not discover a single false membrane in the fauces. Recovery took place. At the same time, i. e., two days be- 368 DIPHTHERIA, CROUP AND TRACHEOTOMY. fore the death of the same child, the mother was attacked with a sHght diphtheritic pharyngitis which recovered in nine days. The very night before the day when the mother fell sick a lit- tle girl of 4 years — her other child — was taken with a vulvar diphtheria which recurred and made way for a croup without pharyngitis which rapidly carried off the patient. Thus in these four persons who composed this family, every one of whom was attacked, the diphtheria assumed a benign form with two of them, and a severe form with the other two. Guerard witnessed, in another family, just as interesting facts which developed themselves for six weeks. A child led the series and succumbed to croup. Two girls were taken two days afterwards with simple erythematous sore throat. Some days later the father had a pseudo-membranous phar- yngitis. Finally the two remaining children were attacked, after him, one with simple sore throat and the other with membranous sore throat. Thus — one croup, three erythematous sore throats and two membranous sore throats were obser\'ed successively in persons all of the same family. The observation cited by Peter shows analogous facts. In seven persons with the same surroundings, parents, friends and domestics, there were seen one little girl of two months suc- cumbing to a membranous sore throat, the mother attacked the night before the death of the child with a membranous sore throat and with diphtheria of the nipple. She recovered. The nurse who took care of the little girl was taken with a se- vere erythemato7is sore throat. Its father, grandfather, and mother had simple, medium, or benign sore throats. A neigh- boring woman who often came to visit the sick suffered from a simple laryngitis. The cook escaped entirely. I cited, when treating of the diagnosis, another observation which showed a sore throat, considered as herpetic, transmitting a fatal croup, which communicated to Gillette the generalized diphtheria to which he succumbed. Barthez has kindly reported to me an instance of the same kind which he witnessed as consulting physician. In a family consisting of father, mother, one child and a servant, the NATURE OF DIPHTHERIA. 3^9 child, aged two, was taken with a severe diphtheritic coryza. The family physician, under the belief that it would act favor- ably upon the coryza, applied a vesicant upon the back of the neck, which became covered with false membrane. The child died without any manifestations on the part of the fauces or of the larynx. The other parties had attended the little patient with the greatest devotion, carrying it incessantly, for it would not remain in bed, and were constantly exposed to contact of its face with theirs. The mother took a coryza of the same na- ture, of moderate intensity, and recovered without any other manifestation. The father also had a coryza of the same kind, but very light and characterized only by a false membrane oc- cupying the opening of the nostrils. In the servant there ap- peared an intense pharyngitis but without false membranes. Like instances have been produced by Beaupoil, Laboulbene, Bricheteau, and Morax. Such examples clearly prove the ex- istence of a benign diphtheria. Why not admit as diphtheri- tic, those light pseudo-membranous affections contracted in centers infected with diphtheria, and taken in contact with the •least doubtful and gravest diphtheritic manifestations? Four- geaud observed a great number of these reductions (mild examples) in the epidemic of which he gave an account. Should these sore throats, arising in the midst of the epi- demic focus, in company with pseudo-membranous sore throats of decreasing gravity, and taken by persons in permanent con- tact with the patients, be considered as incomplete manifesta- tions of diphtheria, or in other words, as cases of diphtheria ivithout diphtheria {diplitheries sans dipJitJierie)! I find no diffi- culty in entertaining this view. Not only have these sore throats followed pseudo-membranous sore throat, but they have pre- ceded them also. Moreover, in admitting this form of diph- theria we do not deviate from what we are doing with regard to other diseases. Diphtheria is, therefore, a specific and contagious general disease. It is one which is primarily infectious and suscepti- ble of exhibiting the most varied degrees of intensity. This gradation in intensity Professor Lasegue impliedly recognized 3/0 DIPirillEKIA, CROUP AND TRACHEOTOMY. in describing, under the name of dipJitheroide, a species of sore throat which he considered as a degenerated form of diphtheria. It is wholly different with the diphtheroide as Boussuge un- derstood it. Under this name this author created a pseudo- diphtheritic morbid entity, having a common feature with diphtheria, viz., the plastic product, but of absolutely different nature. He made it up of elements completely heterogeneous, viz, ulcero-membranous stomatitis, the disease described by Chavanne under the name of diphtheria of the genitals of par- turient women, an affection which is in reality only a gangrene, and he classed here also the asthenic phagedenic gangrene, observed in children by Caillault and Bouley, and even hospi- tal gangrene to which Robert had applied the improper name of dipJitliei'itis of %vounds. These morbid states have nothing in common with diphtheria; but they belong to the gangrenous process. From the showing that has just been made there results: 1st. that diphtheria is a general disease from the first; 2d, that it is one and specific, since it includes the different pseudo- membranous affections, whatever be their site and their intensi-^ ly ; and these affections transmit others of the same nature, but which often differ in site and in intensity. If we add that it is epidemic and contagious, we will have recognized in it all the features of general specific diseases. Like those diseases also, diphtheria is infectious. It impregnates the whole economy. It alters the blood profoundly, as the sepia color of that liquid, the leucocytosis and the haemophilia prove ; while the passage of that vitiated liquid through the capillary system explains the numerous visceral lesions. Its infectious nature is also proved by the gangrene, the adenitis, the albuminuria and the paralysis. Infection plays such an important role in diphtheria, and the patients are so profoundly saturated with it in certain cases, that they maybe- come the foci of.septicffimia at the same time as of diphtheria proper, and transmit the first to those to whom they do not communicate the second. The cases of Drs. Pouquet, Lareau, Baudry, Wagner, and those which were cited by Hiller, show NATURE OF DIPHTHERIA. 371 US physicians receiving by inoculation the blood of diphtheritic patients and presenting in consequence, erysipelas, and septi- csemic symptoms. The instance of Dr. Pouquet is still more complete and deserves to be cited in full. A child of two years was attacked with a diphtheritic sore throat and with croup which necessitated tracheotomy. It succumbed. Its grand- mother, who had not left it, contracted a severe diphtheritic sore throat which, however, recovered. Dr. Pouquet, who per- formed the tracheotomy, wounded his finger during the opera- tion. A frightful erysipelas supervened in the hand, and reached the arm. It was accompanied by the most formidable symp- toms of septicaemia, and placed our friend in danger for several days, and left upon his system a characteristic impress which slowly disappeared. The family physician, who devoted him- self entirely to the patient, with whom he passed long hours, contracted an erysipelas of the face, from which he had the good fortune to recover. This example shows what power the infectious quality of diphtheria may attain. We now know diphtheria in its nature, and in its totality. Let us inquire what process it adopts in its manifestations.. This general disease usually reveals itself by localizations upon the mucous membranes and upon the skin, determinations whose process is a specific inflammation giving rise to a special product, viz., the false membrane. At the time when Bretonneau wrote science was still under the rule of the doctrines of Broussais. Irritation explained everything, and there was no disease which was not an inflam- mation. While protesting against the exclusiveness of that school, and demonstrating that inflammation assumed different and specific features in its course as well as in its products, features which varied, not only with the structure of the tissues upon which it manifested its action, but also with the causes which it recognized, while bringing these profound modifica- tions into the prevailing doctrine, Bretonneau still remained sufficiently attached thereto, to make the disease which he de- scribed an inflammation and a specific inflafnmatiou, to which he gave the name of diphtheritis. 1^2 DIPHTHERIA, CROUP AND TRACHEOTOMY. A more extended knowledge of the disease showed that these inflammatory lesions were but the result of a general, specific and infectious disease, like the pyrexias, like the viru- lent affections which, impregnating the whole economy, man- ifest themselves on the exterior under the form of products of an inflammatory nature. Such are small-pox, syphilis, typhoid fever and the like. This principle having prevailed, the name was changed, and diphthoitis became diphtheria. The legiti- macy of this conclusion is self-evident, for it results from all that has been said in the different portions of this work. Recognizing diphtheria as a general, toxic disease, with what diseases should it be classed ? Is it, properly speaking, a virulent disease or one of those pyrexias which seems to re- sult from the absorption of a morbific germ by the respiratory passages? It should be placed, according to my notion, with typhoid fever, and especially with scarlatina and variola, with which it offers so many analogies. Like them, it appears as benign or malignant, discrete or confluent, and, as with them, the morbid poison is propagated by contagion. WHAT IS THE NATURE OF THE DIPHTHERITIC POISON ? The present state of science does not permit that question to be answered. The tendency which comes to us from Ger- many, and which consists in giving a large place in pathology to the parasitic element, could not fail to make diphtheria a zymotic disease. Letzerich, among others, has described a fungus, the zygo- desmus fitscns which he thinks the specific principle of diph- theria. I have shown in the article on PatJiolcglcal Anatomy that this parasite has no special relation to diphtheria, any more than the viicrococcns, another microphyte to which Oertel, Eberth, Nassiloff, etc., attributed the same properties. [In reference to the pathology of diphtheria, Loffler has re- cently been experimenting with reference to the specific path- ogenic micro-organisms which he claims stand in the relation of cause and effect to this disease. His experiments were divided into three classes : I. Histological examinations of the tissues of patients (ton- NATURE OF DIPHTHERIA. 373 sils, mucous membrane of the pharynx and larynx and inter- nal organs) who had died of diphtheria. 2. Cultivation of two species of bacteria which he had dis- covered during those examinations, namely, micrococci in chains and a bacillus. 3. Subcutaneous, muscular, corneal or tracheal inoculation of products of such culture from the fourth to the twenty-fifth generation upon several of the lower animals (mice, guinea-pigs, rabbits, pigeons.) Of the two species of micro-organism above referred to, the micrococcus seems to be identical with those observed and studied heretofore, but, his experiments led him to the fol- lowing conclusion, that "Since the chain micrococci excited in no animal an artificial disease even resembling diphtheria; and since they were only observed in a limited number of cases of human diphtheria, and then in association with bacilli ; and since they exactly resemble the micrococci of erysipelas and other infectious diseases, they are, therefore, only accidental complications of diphtheria. They may, however, sometimes excite a disease resembling it,'" The bacilli were then isolated and cultivated ; the result of the experiments with these new bacilli is stated by him as fol- lows : They were found in thirteen cases of diphtheria with fibrinous exudation ; they lay in the oldest part of the mem- brane and penetrated farther toward the tisues than the other bacteria ; products of the cultures of them, carried to the twenty-fifth generation, when inoculated under the skin of the guinea pigs and small birds, kill the animals, after the produc- tion of whitish or haemorrhagic exudation at the point of infec- tion and extensive subcutaneous oedema. The inner organs remain intact, as do those of the diphtheritic patients. Pseudo- membranes were generated by inoculation of the trachea of rabbits, chickens and pigeons or of the vagina of guinea pigs. There are then also evidences of several vascular lesions, man- ifested by haemorrhagic oedema, by haemorrhages into lym- phatic glands, and effusions into the pleural cavity. The bacilli, he says, have thus the same effects on the animal organ- ism as the diphtheritic virus. 374 DIPHTHERIA, CROUP AND TRACHEOTOMY. This bacillus is regarded as identical with that described by Klebs as the one pecular to diphtheria. It is about the length of the tubercle bacillus but double its breadth. Its modus operandi is supposed to be the development of a poison which causes the surrounding tissues to decay and produces paraly- sis of the blood-vessels, thereby causing congestions and exu- dations, and produces paralysis of nerve-centres and death. Alas, however, Loffler confesses that in certain well-marked cases of diphtheria the bacillus was absent. N. Y. Med. Rec- ord. 1885.] PROGNOSIS. This question has been treated in detail thronghout this work. Each form and each localization, as well as the compli- cations and the etiological data, have been appreciated from the point of view of the restrictions which they impose upon the prognosis. By referring to the corresponding chapters, the influence which these different circumstances exercise upon the "course of the disease, can be appreciated. There should be, therefore, no necessity for taking up the subject in detail again, but only of giving a general summary of it. Taken altogether, diphtheria is a severe disease. However benign it may appear, we are never sure that a sudden change may not arise and transform it into a fatal disease. The poison- ing may go on quietly and undermine the building, which un- expectedly falls to pieces, without showing a single positive symptom which could enable us to foresee the fatal termina- tion. On the other hand, cases which seemed desperate are seen to end in a return to health. Nevertheless, apparent gravity for the time being, in a case of diphtheria, always varies according to numerous circumstances. Certain of the causes which affect the prognosis remain impenetrable to our means of investigation. Why is one epidemic more fatal than an- other which has preceded it in the same region, and in appar- ently similar climatic conditions? We answer that question by the somewhat vague expressions of constitution medical or oi genius epidemicus, which only reproduce it in another form and thus show that the answer is yet to be found. Beside these questions which remain inappreciable, there are others whose domain can be recognized. Those which dom- inate all the others are the form of the disease and its localiza- tion. The infectious or the malignant form is always grave, what- (375) 3/6 DH'HTHEKIA, CROUP AND TRACHEOTOMY. ever be its localization, for the poisoning kills the patient^ though the false membranes may have only an insignificant development and do not obstruct the functions of a single or- gan essential to life. The outlook also becomes very dark when the patient presents wholly or in part the following symptoms, viz., profound alteration of the features, extreme pallor, pros- tration of strength, incessant agitation or somnolence, smallness and slowing of the pulse, a tendency to syncope, general or partial coldness of the body, complete anorexia, considerable swelling of the cervical ganglia with oedematous tumefaction of the cellular tissue, an ichorous and fetid discharge from the the nose and mouth, mortification of the tissues, brown color of the false membranes, etc. A limited extent of the false membranes, therefore, is not always an indication of benignity. Yet, apart from the cases in which the symptoms just cited are met with, a discrete false membrane oftener coincides with a diphtheria of little gravity. On the other hand generalization of the exudate is the most frequent index of a grave condition. It is the rule in such cases, while a limited false membrane is the exception. Its propagation to the nose, the conjunctiva, the Eustachian tube, the genitals, the skin, is an unpleasant sign, saying nothing of its extension to the larynx and to the bronchi which adds to the danger of infection, that of asphyxia. Localization of the disease is also of great importance in the matter of prognosis. However superficial the infection may be, the disease becomes fatal from the time when it compro- mises an important function. Such a diphtheria, when local- ized in the pharynx, on the conjunctiva, in the mouth, on the genitals, etc., would have promptly got well, but it kills the pa- tient by asphyxia when it produces an exudate on the surface of the larynx. Still, in this case, art is all powerful, and tra- cheotomy triumphs almost constantly, if some complication does not intervene. But if to the laryngeal diphtheria, that of the bronchi is added, the fatal influence of the localization again preponderates. We add, that the invasion of the bronchi is sufficient to exclude a case of diphtheria from the category PROGNOSIS. 377 of benign diphtheria, for such extension proceeds from in- fection. The form of the disease and its localization are, therefore, the two principal influences which govern diphtheria. The previous health is still another source of very inportant indications for prognosis. Secondary diphtheria is always grave, for it almost always assumes the infectious form and sometimes the malignant form. Among the diseases to which diphtheria succeeds, certain ones exercise a more pernicious influence than others ; and the abstracts which I have given in detail have enabled me to show that these diseases should be classed as regards gravity, in the following order: hi the Jit st rank, tuberculosis and typhoid fever. In the secojid rank, pneumonia, pleurisy, small-pox, urticaria and the various cachexias, snch as scrofula, chronic diarrhoea, syphilis, etc. /// the third rank, and always following the same order, mea- sles, scarlatina and whooping cough. Among the diseases which may precede diphtheria, we must include diphtheria itself. This disease in fact recurs. It seems that if diphtheria does not prevent a new invasion it renders it at least less severe. In 29 cases of recurring diph- theria 22 resulted in cure. The existence of a previous diph- theria, seems, therefore, favorable as to prognosis. Age. — The younger the patient the greater the peril ; while its maximum corresponds with the period comprised between birth and the age of tw^o or three years. This rule is verified in the vast majority of cases. The proposition should not be generalized to the point of pretending that diphtheria is less grave in proportion as the patient advances in years. It is more severe in the adult and in the old than in the youth. Eminently depressant in its nature, it requires of the patient a power of resistance and considerable vitality to enable him to recover. These considerations explain why it is so grave at the extremes of life as well as among subjects already run down by cachectic diseases. Sex. — Each sex has in its own turn had the advantage ac- 3/8 DIPHTHERIA, CROUP AND TRACHEOTOMY. cording to observers. In reality this circumstance has no more influence on the prognosis than upon the etiology. We meet with series more favorable to one or to the other, but just as I have shown in the chapter on etiology, it should be recognized that the two sexes are on an equality as regards diphtheria. Temperament, hygiene, social status. — The lymphatic or scrof- ulous temperament is, as many authors aver, of unpleasant augury in diphtheria. The lowered vitality of subjects so con- stituted explains that peculiarity. It also follows from the tables which I have prepared on the subject of secondary diphtheria, "that the mortality among the scrofulous is consid- erable. Bad hygienic conditions, those which are oftenest met with among the poorer classes, have also their influence. Want, crowded lodgings, absence of care and of nourishment, should be taken into serious consideration. Patients lodged in too close quarters are under the permanent influence of auto-infection. The necessity of a nutritious and diversified alimentation shows how much the chances of recovery are sub- jected to a bad regimen. Seasons. — The table of mortality from croup at St. Eugenie shows that the maximum of deaths coincides with the months of March, April and May, whence it insensibly diminishes to attain its minimum in June, September and October. These results correspond with those which pertain to etiology. The greatest gravity of the cases coincides with their greatest freauency, i. e., with the cold, wet and changeable seasons. In the tables prepared by E. Besnier, which figured in the reports of the Commission on prevailing diseases, and which comprise the period extending from 1868 to 1880, we see that the entries into the hospitals and the number of deaths declined to their minimum in June in September and October. Let us remember that these statements do not in- clude all the manifestations of diphtheria, but croup only. The following table is prepared from the documents. [See page 322] Complications. — The pulmonary inflammations which com- plicate diphtheria are reckoned among the most powerful PROGNOSIS. 379 causes of death. They carry off the immense majority of those cases which, by reason of the sHght intensity of the poisoning seemed progressing toward recovery. The most common, and at the same time the most formidable, is broncho-pneu- monia ; then come pneumonia and other affections which are much more rare. The eruptive fevers also find numerous vic- tims among the convalescents from diphtheria. Measles and scarlatina, which prevail endemically in the wards of the hos- pital, include most of them. Previous treatment. — Patients enfeebled by loss of blood, by mercurials or by alkalies, depressed by emetics, by repeated vomiting, by the terror which cauterization inspires and by the efforts which they make to escape it; and those who are attacked by diphtheria of the skin produced by vesicants ; all such pa- tients find themselves placed in conditions which aggravate the prognosis. Scquel(2. — The invasion of diphtheritic paralysis may be of evil augury. Although it more frequently recovers, it some- times causes death by its generalization and by its extension to respiratory muscles and even to the heart. Then the risk of asphyxia from the passage of food into the bronchi, and the possibility of inanition are among the accidents which should be borne in mind when giving a prognosis. Independent of the causes, general and particular, which make diphtheria a grave disease, the statistics of these latter years have established a marked aggravation in the disease both in the increase in number of patients and in the mortal- ity. The following table taken from the reports of the com- mission on prevailing diseases gives the statistics of croup alone since 1866 (see table, p. 322). The weekly bulletins of the causes of death according to re- ports to the civil government, give account of the ravages which diphtheria produced in the population of Paris, reckoned according to the census of 1872 at 1,851,792 inhabitants and 1876 at 1,988,806. [See also p. 383]. 380 DIPHTHERIA, CROUP AND TRACHEOTOMY. MORTALITY OF DIPHTHERIA FOR THE CITY OF PARIS. Years Population. Deaths from Diphtheria. Per cent, of deaths front diphtheria of the total deaths in the 1,000 Per cent, of the deaths from diph- theria of the 'uhole population in the 10,000. 1872 1,851,792 39,650 1,13s 28.80 6.17 1873 1,851,792 41,752 1,164 27.83 6.27 1874 1,851,792 40,759 1,008 24.70 531 1875 1,851,792 45,544 1,328 29-15 6.17 1876 1,988,806 48,579 1,572 32-35 7-94 1877 1,988,806 47,509 2,393 50.36 11.98 1878 1,988,806 47,851 1,989 41.68 10.00 1879 1,988,806 51,095 1,783 34-89 941 1880 1,988,806 56,628 2,033 35-90 I0.22 419,347 14,405 34-35 8.16 A considerable aggravation is seen to coincide with the year 1875. Far from diminishing, this tendency has only increased. The year 1876 proclaimed itself as particularly obnoxious in this respect. The advance is considerable. The proportion of deaths from diphtheria which was one in 5,763 inhabitants during the first three months of 1875, was one in 4,538 during the corres- ponding period in 1876. The numbers noted in the hospitals in Paris tell the same story for they show an increase in num- ber and in gravity, which has been perceived with regard to croup also during 1868 and 1880. (See p. 322). These results are corroborated by the statements of phy- sicians who observed diphtheria in the hospitals and in the city. The infectious and malignant character of the disease was PROGNOSIS. 381 more and more marked, and not only did the recovery of those who were operated on by tracheotomy become exceptional, but the fatality of diphtheria limited to the pharynx, assumed unwonted proportions. Bergeron reported that of ten patients in whom the circumference of the isthmus and the posterior wall of the pharynx were alone invaded, nine succumbed. 382 DIPHTHERIA, CROUP AND TRACHEOTOMY. Mo rta liiy Sta t is tics . MORTALITY STATISTICS ABROAD. For the Year 1884. s 5 < 1 s I <3 to •2 2285 "i 3188 985 914 •V. 1 4133 5 8 London, 4,019,361, 83,051 21,379 13,664 1732 1444 20.6 Liverpool, 573,202, 14,691 3,996 83 201 621 553 206 106 844 25.6 Glasgow, 517,941, 14,158 3,143 2,950 291 429 378 781 245 15 563 27.4 Birmingham, 421,258, 9,141 2,612 44 128 332 291 81 63 718 21.7 Dublin, 351,014, 10,090 2,151 1,596 121 360 23 135 "220 — 366 28.S Manchester, 338,296, 9,058 2,274 23 223 198 206 80 7 486 26.8 Leeds, 327,324, 8,032 2,104 67 487 219 165 145 I 536 24.6 Sheffield, 300,563, 6,871 1,941 17 475 21 128 91 34 530 22.8 Edinburgh, 246,703, 4,925 1,025 895 lOI 71 90 272 96 — 178 19.9 Bellast, 216,622, 5,073 913 1,119 36 161 9 89 83 — 234 234 Bristol, 215,457, 4,024 986 18 40 50 93 47 — 150 18.7 Bradford, 209,564, 4,286 1,123 8 ■hi 103 58 55 — 261 20.5 Hull, 181,225, 3,887 1,174 30 44 90 62 77 17 333 21.4 Newcastle, 151,325, 3,552 950 14 153 16 80 58 12 160 234 Havre, 105,867, 3>278 839 362 104 14 2 28 51 2 442 31.0 Rheims, 93,823, 2.808 917 277 lOI 7 yi 10 70 I 701 29.9 Nancy, 74,954, 1,864 342 166 17 8 10 3 62 I 148 22.2 Breslau, 290,000, 9,381 3,278 882 234 60 208 37 96 — 1043 31.8 Brussels, 171,293, 4,250 998 608 106 31 26 63 59 93 639 24.8 Cologne, 150,513, 4,061 1,549 341 28 6 10 106 24 13 481 26.2 Christiana, 122,000, 2,489 686 401 124 136 96 4 — 241 20.4 Frankfort, 145,100, 3,040 806 312 84 25 45 61 18 — 243 20.7 Hanover, 131,200, 2,738 832 214 71 30 25 n 36 — 225 20.8 PROGNOSIS. MORTALITY STATISTICS ABROAD— Continued. 383 For the Year 1884. 5^ s S is s <3 <-> 5i § Bremen, 119,561, 2,512 844 295 50 97 2 28 10 I 145 21.0 Dantzic, 116,162, 3.109 1,111 196 111 nz 2 35 36 2 330 27.4 Stuttgart, 109,937, 2,461 936 214 112 9 30 38 27 I 271 22.3 Strasbourg, 110,739, 2,907 1,194 564 58 6 74 31 24 — 572 26.2 Dusseldorf, 105,287, 2,741 1,266 222 n 19 19 50 33 — 375 25.6 Nuremburg. 105,176, 3,021 1,101 424 79 24 227 35 25 — 448 28.7 Chemnitz, 102,713, 3,414 1,692 107 19' 25 10 19 24 — 64 33-2 Magdeburg, 105,000, 2,822 1,022 215 103 37 46 55 38 — 270 25-9 Elberfeld, 101,000, 2,412 682 199 84 101 31 30 31 — 156 24-5 Barmen, 100,000, 2,260 627 170 108 37 68 22 29 — 232 22.6 Altona, 97,000, 2,590 836 248 74 47 20 48 34 — 303 26.7 Aix-la-Chapelle,89,i 16 2,549 1,056 271 19 — 15 82 25 — 361 28.6 Mayence, 64,120, 1,523 432 165 26 23 71 5 26 128 23.8 Amsterdam, 350,202, 10,298 667 465 237 128 66 5 76 28.3 Rotterdam, 166 001, 4,527 90 118 220 40 19 I 53 27-3 The Hague, 131,417, 3,354 — 100 18 73 23 16 — 60 25-5 Lyons, 376,613, 9,415 1,615 104 22 86 75 147 250 626 25.0 Berlin, 1,225,065, 33,205 12,984 1,897 2667 409 298 536 418 20 5696 27.1 Hamburg, 486,678, 12,753 4,319 1,201 465 127 117 188 130 — 1316 26.2 Dresden, 236,000, 6,199 1,190 444 462 88 57 140 50 1 441 26.3 Munich, 240,000, 7,469 2,982 710 184 69 123 ^33 40 4 1187 3I-I Leipzig, 164,636, 4,235 1,654 302 399 71 79 65 37 3 429 254 Koenigsburg, 154,000, 4,651 1,854 359 250 195 I 13 67 2 602 30.2 Burcharest, 200,000, 5,632 2,772 854 200 189 99 21 120 2 532 28.1 Paris, 2,239,928, 58,195 9,5" 5,342 2147 163 1548 450 Jf54 80 5938 26.0 In iiarrhre al disea ses in 1 'aris- -Che )Iera, 943- 384 DIPHTHERIA, CROUP AND TRACHEOTOMY. MORTALITY TABLE FOR 1880, ACCORDING TO U. S- CENSUS. States. 1 v! 1 •** s s i 1 t 1 United States, 8772 16416 38398 1 1202 22905 6556519155183670^107904 34094 Alabama, 403 25 ! 258 58. 783 1417 1729 1675 2722 665 Arizona, 3 3 10 II 15 18 19 33 16 Arkansas, 277 295 157 446 437 1341 955 1424 2852 688 California, 33 71 370 135 : 298 527 1802 1306 1514 567 Colorado, 70 46 249 34 78 146 210 182 556 92 Connnecticut, 46 "3 216 82 196 599 1389 I38I 1225 361 Dakota, 14 16 301 7 34 70 116 105 188 51 Delaware, 7 35 82 34 76 209 357 291 286 83 District of Columbia, 6 42 19 88 82 570 793 515 524 219 Florida, 16 5 27 50 lOI 216 263 358 346 180 Georgia, 526 31 594 654 993 1954 1718 1879 3066 1327 Idaho, 2 3 55 4 12 12 22 27 46 17 Illinois, 641 1369 2422 504 1653 4630 4655 5146 7400 2100 Indiana, 524 1319 1037 561 1458 2883 3943 3456 4964 1099 Iowa, 177 609 2326 144 723 i860 J925 I93I 2870 856 Kansas, 521 512 1098, 222 663 1801 1117 1306 2566 644 Kentucky, 273 378 394 551 816 1952 3733 2612 3415 958 Louisiana, 128 23 187 164 302 1227 1514 I76I 2103 867 Maine, 36 286' 1 895 56 193 433 1829 1136 1045 342 Maryland, 76 5S3| 623 291 475 1754 2381 2062 2040 744 Massachusetts, 84 80S 1610 290 620 2597 5207 3837 4385 I29*S Michigan, 25s 52S 2002 341 547 1463 2613 1902 2432 829 Minnesota, 93 20 1562 84 318' 1 857 848 760 990 452" PROGNOSIS. 385 MORTALITY TABLE FOR 188 ACCORDING TO U. S. CENSUS— Cont'd. States. Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, 1 "Si 1 1 =5 147 6 212 330 332 981 770 296 885 486 1452 4034 I 25 26 — 8 19 152 391 1041 41 210 522 — 18 17 II 17 46 37 138 344 15 117 314 52 567 510 99 280 X648 •54 119 10 178 50 60 661 1985 4097 748 1260 7207 425 "3 lOII 653 966 2063 263 1335 2103 502 1376 3715 16 47 188 28 103 159 400 2241 5483 470 1660 4666 I 540 230 28 84 317 302 18 551 459 585 1 280' 147 80 779 477 952 2033 326 90 235 600 1087 3403 24 25 749 17 55 121 49 65 296 41 118 269 421 268 568 419 679 2281 II 15 III 8 15 53 112 227 513 125 232 540 91 470 1934 133 395 1294 2 37 18 — 3 7 'S' ^ 1287 3604 18 416 61 866 2630 50 1285S 2130 5912 266 8073 691 1543 3767 1622 69 813 3025 100 969 1681 5 1436 4117 28 442 55 751 2941 72 10129 1792 5738 182 8199 575 1450 2368 2450 185 608 2569 61 742 1698 III 2678 6797 44 867 I 633 2549 295 12715 2599 5045 167 8072 5" 1949 3901 3898 457 699 3190 96 939 2028 •^ •^ 746 1636 15 240 27 241 822 131 3959 1027 1974 73 2434 158 987 1237 1308 71 141 1300 31 320 757 6 The mortality rate is 52.32 to the thousand of all deaths in which the cause ported, and in portions of the Lake S'ates it ran as high as 84.10 per thousand. IS re- 386 DIPHTHERIA, CROUP AND TRACHEOTOMY. MORTALITY FROM DIPHTHERIA AND CROUP IN THE UNITED STATES DURING 1883 AND 1884. 1883. 1884. City and Population. .« •S G Boston, Mass., 427,940, 445 163 608 345 142 487 San Francisco, Cal., 235,ock). 102 30 132 51 24 75 Providence, R. I., 120,000, 54 35 89 57 32, 90 Albany, N. Y., 99,495, 64 79 143 32 43 75 Buffalo, N. Y., 84 39 123 75 102 177 Minneapolis, Minn., 129,200. (?) 116 116 Brooklyn, N. Y., 665,602, 409 318 727 385 280 665 New York, N. Y., 1,397,895, 1009 644 1653 1090 748 1838 Pittsburg, Penn., 180,000, 170 II 181 321 4 325 Philadelphia, Penn., 927,995, 1006 500 1506 680 589 1269 Cincinnati, 0., 280,000, 78 62 140 71 81 152 Cleveland, O., 200,429, 247 lOI 348 139 57 196 Detroit, Mich., 140,00, 293 100 393 343 104 447 Indianapolis, Ind., 16 17 iZ 27 15 42 Chicago, 111., 630,000, 592 225 817 649 256 905 Bloomington, 111., 2 5 7 I 10 II St. Louis, Mo., 400,000, 425 116 541 553 134 687 Salt Lake City, Utah, 25,000 II 5 16 25 8 32, District of Columbia, 200,000, 85 24 "3 — — — NevF Orleans, La., 234,000, 67 20 87 94 61 155 Baltimore, Md., 408,520, 591 201 792 343 127 470 TREATMENT. The different forms of diphtheria, its local manifestations and its complications, by changing the aspect of the disease, modify the conditions to which the treatment should be adapted. Therapeutics not possessing any remedy which can justly claim to be a specific for diphtheria, the treatment should endeavor to fulfill the indications which appear in each case in particular. Now, these indications are numerous. There is a kind of non-complicated, benign diphtheria which recovers spontaneously with or without sequences ; another, implicating important organs, or dependent upon an infectious form, demands treatment the most assiduous and varied, and even requires the intervention of surgery. To arrest the production of false membranes, to destroy those that are produced, and to counteract the septicaemia and its depressing influences ; these are the general indications. Others are inferred from the local manifestations also of the disease ; they attempt to avert the functional disturbances re- sulting from the pseudo membranous exudation in the larynx, in the nasal fossse, in the bronchi, etc. A final series is de- rived from pulmonary,glandularand other complications, as well as from sequences, such as paralysis and anaemia. All medica- tions, of whatever kind, aim at meeting these indications. To exhibit them in an order which enables the reader to find them easily, I shall place each of them in relation with the indica- tion which is to be fulfilled, and the secondary ones will be grouped around the most important. They comprehend three principal classes : First Class. — Genet'al indications. I. To destroy the false membranes; II, To prevent their production; III, To treat the general conditions. Second Class, — Indications fiiftiished by the local manifest (387) 388 DIPHTHERIA, CROUP AND TRACHEOTOMY. tations. I. Angina; II. Croup; III. Coryza ; IV. Pseudo- membranous bronchitis; V. Blepharo-conjunctivitis ; VI. Diphtheritic otitis; VII. Stomatitis; VIII. Cutaneous diph- theria; IX. Diphtheria of the genital organs. Third Class. — hidications arising from complications and sequences. The first will be followed organ by organ, as I have done in giving the symptoms. The second comprehends diph- theritic paralyses. FIRST CLASS. General Indications. § I . To Destroy the False Membranes. For a long time all the efforts of therapentics were directed to this end. The promoters of this method were, we must acknowledge, consistent with the idea which they had formed of diphtheria. In their view, the false membrane was the starting point of the disease; the infection of the economy was the consequence of the alteration of the false membrane and of the absorption of the products of this alteration. Thus, we have seen Bretonneau, Trousseau and many others follow up the false membrane, caustic in hand, without stopping either for the pain or the struggles with the patients, without fearing the frequently terrible accidents which followed it as a consequence. They believed themselves bound to apply these means with " une sauvage energie," in the words of Trousseau. Now that it is fully demonstrated that the false membrane is the product and not the cause of the intoxica- tion, we understand that to suppress the false membrane is not to cure the disease. As fast as one causes the concretion to disappear, it is replaced by another so long as the tendency of the system to produce the false membrane persists. In follow- ing this course one undertakes a task perpetually returning, useless and even dangerous ! This principle, however, admits of exceptions. When the abundance and rapid thickening of the false membranes become a cause of embarrassment, when their rapid alteration makes them a source of infection, we TREATMENT. 389^ should seek to modify them. Their situation upon an essential organ, of which they compromise the action, for example, the larynx, is still a powerful motive for removing them. It is, therefore, especially in view of such cases, that it is well to be armed with local modifiers. This might be the place to notice the substances and the processes which have been made use of with this object, but to avoid repetition I prefer to reserve their examination for the time when I shall be occupied with the treatment of the local manifestations, and especially ot angina, against which and that of all the local determinations all the artillery of therapeutics has been brought to bear. § 2, To Prevent the Production of the False Membranes. Three orders of means have been brought into requisition to this end. The first are directed against the specific inflam- mation which produces the false membrane; they are the an- tiphlogistics. The second make the pretension of diminishing the supposed excess of the plasticity of the blood, which was claimed to be the cause of the fibrinous exudation ; these are the alteratives. The third, without affixing any theoretical ex- planation, claim to act as specifics. A. — Antiphlogistics. ist. Sanguineous Emissions. When all diseases were subjected to this treatment, diph- theria did not escape. It appeared that these means, alone or combined with local treatment, should be correct lor inflam- mation, supposed to be purely local, which produced the false membranes. Moreover, it follows from the reading of early observations, that the inflammatory element appeared to haye a sufficiently important part in diphtheria, which it has now lost in large measure, to the gain of the infectious element. In spite of these considerations, the confidence at first placed in these means should be withdrawn from them. Still more, they have been finally regarded as injurious. This result was antic- ipated. In a disease as an^miating and debilitating as diph- 390 UIFJIJ-HEKIA, CKOUP AND TKACIIICOTO.MY. theria, sanguineous emissions even limited, as those resulting from the application of leeches in the regions of the diseased parts, only increase this primordial disposition which is so un- favorable. The age of the patients, which is nearly always infancy, a period when spoliation is ill-supported, furnish an ad- ditional centra-indication. Another serious inconvenience de- serves to be noticed ; the bites of the leeches may become themselves the starting points of cutaneous diphtheria. There- fore, of no profit, of serious inconveniences, the general aban- donment of the system is sufficiently evident. 2. Revulsives. — One may offer to these the same objections. In fact they are either insignificant, like the rubefacients, or they are quite dangerous, being entirely without beneficial ef- fect, like the blisters. We know that these latter seldom fail to become covered with false membranes ; they aggravate the condition of the patient, and when placed on the front of the neck, in the vain hope of combatting croup, they constitute one of the most serious difficulties in the way of tracheotomy. [I have seen this more than once]. J. Emetics. — Employed especially in view of a mechanical action, they possess, however, a real antiphlogistic action which may be profitably combined with the first. But the lat- ter being much the more efficacious, I shall occupy myself with the details of emetics at the same time as with the means which act mechanically upon the false membrane. B. — Alteratives. The tendency of the economy to transude fibrin has favored the supposition of an excess of fibrin in the blood. Hence, the emplo}'ment of alterative remedies, contra-stimulants, and defibrinating means. This practice was ingenious and plausible, but it was defect- ive in foundation. Nothing is less proved than this excess of fibrin. The blood of the diphtheritic is poor in fibrin as well as in globules. The fact is shown by the tendency to haemor- rhages, by the feeble coagulability of the liquid blood, by the fluid appearance in which we found it in the cadaver, without TREATMENT. 39 1 speaking of the more advanced alterations such as sepia blood. Everything in diphtheria shows a tendency to what has been called the dissolution of the blood, the dyscrasia. It is, there- fore, not a case for the administration of medicines which ag- gravate this condition. This error having been generally rec- ognized, the alterative medication has received a blow from which it will with difficulty recover. The detailed exposition of this treatment will show still better its inconveniences. The therapeutic agents recommended with this view are the mercurials, the alkalies and the antimonials. I'sX Mercurials. — They have been employed internally in the form of calomel; externally in the form of mercurial inunctions. Calomel. — The important position in therapeutics given to this remedy by English and American physicians, should pre- serve for it a favorable place in the treatment of diphtheria. Besides, it has been given in every form, and in all doses, Thomas Bond, of Philadelphia, seems to have been the initia- tor of this treatment in America. Samuel Bard gave it in from 0.20 to 0.30(3 to 5 grs.)adayin combination with one-sixteenth as much opium to modify its purgative action. Rush increased the dose to 0.60 or 1.20 (10 to 18 grs.) a day. Physic went as far as 2 grammes (30 grains) in children less than a year old. The English physicians, among whom we should mention Dobson, Cheyne, and Hamilton, gave of it from 0.05 to o. 10 gr. (Y^ to 1V2 g^s.) every hour to children of one year, and 0.15 (2Y4 grs.) to those of two years, and so on, until the respiration was less embarrassed. Then diminishing, they left an interval between the doses of two, three or four hours, according to the indica- tions. Others administered broken doses according to the method of Law. The German physicians have dispensed this remedy with the same liberality. Autenrieth gave 0.07 (a grain) for each year of the child's age up to i.oo to 1.25(15 or 20 grains), always prescribing a vinegar enema in order to exert upon the intestine an energetic derivation. In France a much greater reserve has been shown. Bretonneau recom- mended to give every hour .20 (3 grains), and at the same time to apply mercurial inunctions every three hours. While 392 DIPHTHERIA, CROUP AND TRACHEOTOMY. liquefying the blood, they hoped that the calomel would modify the false membranes in passing, at the same time that by its specific action upon the mucous membrane of the throat and of the mouth it would facilitate the separation of the exudates, and obstruct their reproduction. If these hopes had been jus- tified this remedy could have been counted as a veritable anti- diphtheritic ; but they have ever remained in the condition of promises. Several authors who have used this mercurial salt report recoveries. But we know how difficult it is to appre- ciate exactly the action of a therapeutic agent, to estimate the influence that it has had upon the termination of a disease. It has given but little more success than other methods, and its use is founded upon an erroneous theory. Moreover, it is far from being innocent ; it often occasions serious symptoms which have been decidedly to the disadvantage of that which was really our object. All authors have reported excessive salivation, mercurial stomatitis with extensive ulcerations, loosening of the teeth, gangrene of the mouth, obstinate diar- rhoea, and free haemorrhages. Often it is the cause of a real cachexia of which the least danger is to prolong remarkably convalescence. These accidents have also attracted the atten- tion of Prof Barbosa, of Lisbon. Different means have been employed to avoid these incon- veniences. Miquel, of Amboise, had the ingenious idea of combining alum with the calomel. He gave alternately every two hours gm. o.oi (Ye gr.) of calomel, and gm. 0.15 (274 grs.) of alum in powder. The astringent action of the alum pre- vented the stomatitis, the diarrhoea and the haemorrhages. Aside from some disappointments which the author candidly states, this method has always been one of perfect harmless- ness, and it has removed in large part the dangers inherent to the mercurial preparations ; Barthez has verified the advan- tages of it in this respect ; even recognizing this point we may, notwithstanding, entertain doubts of the efficacy of this remedy. Mercurial Inunctions. — They act at once as a cutaneous local remedy and by absorption, and one may object that their TREATMIiNT. " 393 action is doubly injurious. The mercury absorbed gives rise to all the symptoms above cited ; its contact with the skin ex- cites mercurial eruptions which often ulcerate and become cov- ered with diphtheria. This mode of treatment should, there- fore, be proscribed absolutely, in spite of the opinions of Step- puhn, Behrens and of Bartels of Kiel. The latter recommends inunction with large doses, i.OO (15 grs.) an hour, and although his patients recovered, several attained this end only after a very long time, in spite of mercurial symptoms of all kinds. In conclusion, in spite of hypothetical advantages, the mer- curial treatment presents serious inconveniences which are real. The only form in which it may not be dangerous is that which Miquel has recommended. All others should be rejected. 2nd. Alkalies. — Based upon the same theoretical idea, the alkaline treatment was advocated in the beginning by Moure- mans. Of this class the bicarbonate of soda was the most employed. Mouremans prescribed the following : Aqux lactucae 120. (Siv.)Bicarbonate of soda 2.50 (grs.xxxvi). Syrup of mulberry or blackberry 30. (Si.) Dose, a table- spoonful every two hours. Baron in 1839 and then in 1856 recommended the eau de Vichy and bicarbonate of soda. He prescribed one or two bottles a day and from i. to 2. (15 to 30 grs.) of the salt. In 1853, Dr. Lemaire published some observations to demonstrate the good effects of the bicarbonate of soda in the treatment of diphtheria. But, as in these cases the salt of Vichy was not given alone, it is difficult to decide upon its efficacy. Dr. Laignez sustained the ideas of his teacher Baron. From read- ing the observations contained in the memoirs of these two authors, it is found that Baron had to deal with a mild form of diphtheria, or perhaps with simple herpetic angina, and that several of the patients of Laignez were attacked with benign scarlatinous angina. Marchal, of Calvi, also supported the alkaline method. He gave the bicarbonate of soda in the dose of i. (15 grs.) every hour, that is 12. (3 drachms) a day. But he did not furnish 394 DIPHTHERIA, CROUP AND TRACHEOTOMY. sufficient proof in favor of this method, and only reported a single observation; besides, it was a case of scarlatinous angina which he treated by bleeding at the same time as with the bicarbonate of soda. The medicine ought to be given from the commencement of the disease. Given too late or in insufficient doses, the alkalies are without effect. This treatment presents the same inconveniences as the mercurial, though in a less de- gree. If it does not produce symptoms on the part of the mouth, it does entail, in the end, a bad general condition, well known as the alkaline cachexia. Baron foresaw the ob- jection ; he preferred to reserve this means for sanguine sub- jects, and interdicted it in cases in which adynamia prevailed, or in which there was a disposition to haemorrhage. We may say, however, in defense of this medication, that the action of bicarbonate of soda is slow and that the evolution of diph- theria, however slow it may be, is rarely sufficiently so to wait till the alkaline medication has had time to produce its anti- plastic effect. In England they employ quite commonly the following remedy recommended by Volquarts : For children. Adults. Of I year. Of 6 yrs. Nitrate of soda. Bicarbonate of soda aa, i. 25(20grs.) 3.0 (45 grs. 8.-12. (23-3 3) Gum, 4. (i 3.) 8. (2 3.) 15- (4 3.) Distilled water, 90. (3 g.) 120. (4 §.) 800. (24 §.) Dose, a teaspoonful (for a child) or a tablespoonful for an adult every hour. In Germany Kiichenmeister prescribed the following: Carbonate of potash. Nitrate of potash aa, - - - - 3 (45 grs.) Syup 30- (I §•) Water 120. (4 §.) Dose, a tablespoonful every hour. Both these authors accompany the use of these draughts with an alkaline gargle of which I shall give the formula here- after. Dr. Kiihn administers carbonate of potash internally in doses of from i. — 4. (15 grs.) to 6.(1 72 5) according to the age; and habitually combines it with aqua calcis. I intentionally TREATMENT. 395 omit to speak here of chlorate of potash, the real action of which is purely local. The changes of the false membrane will be spoken of at the same time. The sub-carbonate of Ain- ino7iia, recommended by Rechou (1804) was also given. But this medicine, difficult to administer, has long since been abandoned. In conclusion, the alkalies have but a doubtful efficacy. From the admissions even of those who have most highly recommended them, we should fear their depressing and liquefacient action. 3d. — Taj'trate of Antimony. — Long since this salt was used in large doses in the treatment of diphtheria. From a passage taken from the memoirs of Jurine on croup, we learn that Bordeu had recourse to this treatment in the year 1744. Since that time this emetic has been prescribed by Laennec, Delens, Prus, Chantourelle, Mianowsky, Foster, Graves, Bazin, Fabre, Marotte, Gigon of Angouleme, Chapelle, Baizeau, Kor turn,Constantin, of Coutres, Bouchut, Beclere, Zorgo and Nonat. The emetic effect was not the one expected of this treatment, it was supposed to act directly upon the diphtheritic poison- ing. Gigon said: " With an emetic dose one combats but a single symptom, the ob- struction of the larynx, while the tartar emetic in a large dose, liquefying this par excellence, combats the morbid diathesis under the influence of which the albumin of the blood concretes and passes to the condition of a membrane. In this manner the medicine attacks the essence, the specificity even, of the diphtheria." Such was the theory which inspired the promoters of this method. Bouchut adopted the following formula : Syrup of gum acacia 100. (§iij.) Syrup of poppies, 15. (§ss.) Tartar emetic, 0.50-75 (grs. vij-xij.) M. Dose, half a tablespoonful every hour. Constantin gave the following formula: Syrup of gum acacia, 250. (§vijss). Syrup of morphine, 60. (5ij.) Tartar emetic, I. (grs. xv.) I\I. Dose, same as above. This physician did not fear to give to children from 3 to 4 years old as much as 9. (2 drachms and a quarter) in three or 3 6 DlPIITilERIA, CROUP AND TRACHEOTOMY. four days. To credit several of these observers, this emetic administered in this way, produced no inconveniences, espec- ially by taking the precaution, as recommended by Bouchut, of giving little drink to the patients, and making them take nourishment in the form of thick porridge. The same author says, "Tartar emetic is employed in this case as in acute pneumonia, and, saving in exceptions, it does not produce de- bility nor distressing prostration." It has not always been so with other physicians. Chappelle, of Angouleme, in 1852, after having extolled the effects of tartar emetic in large doses in the treatment of croup, sent in 1859 to the Academy of Medicine, a second memoir in which he declared that he had to abandon this treat- ment in consequence of the numerous reverses which had fol- lowed the successes of the beginning. The facts observed by Garnier in the service of Barthez and published in his thesis are not such as to encourage this method. Given in doses of 0.20 (3 grs.) this emetic produced vomit- ing, diarrhoea and prostration. Of six (6) patients, two (2) died suddenly after the disappearance of the laryngeal symptoms. In another the first spoonful of a draught of .60? (9 grs.) pro- voked such a diarrhoea that it was necessary to suspend its use. Fisher and Bricheteau reported that in six children observed by them, and who were submitted to this emetic draught, three took it during two days, and experienced in consequence ex- cessive vomitings and numerous stools ; asphyxia made no less progress, and tracheotomy had to be practiced. In two oth- ers, the first spoonful of the solution produced a diarrhoea so violent, with prostration and pallor of the face, that they were forced to abandon it. Finally, the last died suddenly after having taken this tartar emetic draught during twenty-four hours. It is quite interesting to note these three sudden deaths in twelve cases. While this termination may be well known in the history of diphtheria; it is presented with the facts which I have just cited with a frequency which is due, perhaps, only to a mere coincidence, but which is well calculated to inspire TREATMENT, 397 serious reflections. Barthez long since abandoned this treat- ment which he saw too often produce a cholera or diarrhoea, obstinate vomiting and alarming prostration. These symp- toms are so much the more to be dreaded in proportion as the children are younger. Tender age should be an absolute con- tra indication [true]. Moreover, in reading the observations offered in support of this mode of treatment, we see that, in the majority of the cases, it produced every day and several times a day abundant emesis. Also, the majority of the au- thors who have recommended it, insist upon the necessity of provoking vomiting. Their statistics show that the recoveries have been obtained from among the patients who have vom- ited. It is then not to the contra-stimulant action, but simply to the emetic effect that the recoveries may be at- tributed ; just as well give the medicine in emetic doses, it is more sure in effect, and less dangerous. In conclusion, the treatment by tartar emetic in large doses, involves precautions of the strictest character ; and, in spite of all the recoveries placed to its credit, recoveries which often have been due to the emetic action or perhaps to other means employed concurrently, as certain observations prove, in spite of these successes, we are bound to charge to its account not only failures, but grave symptoms ; namely, choleriform diar- rhoea, uncontrollable vomiting, prostration and perhaps sudden death. We should by all means avoid, in young children, these fatal effects which increase in inverse proportion with the age. Its employment, derived from a false theoretical concep- tion, should be rejected. It is not sufficient from one fortui- tous success that therapeutics be authorized to use dangerous and depressing means. [Hive syrup is the same thing]. C. — Specifics. /. Sulphuret of Potassium — liver of sulphur. Proposed for the first time by the author of one of the memoirs for the great prize in 1 808, this remedy was extolled as a certain specific, afterwards it fell into almost complete discredit. It is one of the remedies most frequently employed at Geneva, 39^ DIPHTHERIA, CROUP AND TRACHEOTOMY. and appears to have rendered good service to the physicians of that city. Maunoir prescribed it in doses of 0.60 — 0.90 (9 to 13 grs.) in twenty-four hours, in an emulsion. Senf advocated its use in children from i to 2 years, in doses from 0.05 — 0.07 (V* ^o I fe^-); to those older from o. 10 — 0.20 (i to 3 grs.) every two hours, dissolved in water and mixed with syrup. One can also give it in pills, incorporating it with the extract of liquor- ice. This dose appears too large to Rilliet, who preferred to administer only 0.05 — o.io (Yi to 172) every two hours so as to give from 0.50— i. 00 [y^j^ to 15 grs.) in the twenty-four hours, either in powder or in emulsion. It is given most frequently at Geneva in the form of a syrup composed, according to Chaussier, of the following formula: Mix 0.80 (12 grs.) of sulphuret of potassium with 30. (i oz.) of simple syrup. Give every two hours a tablespoonful of the mixture. Klaproth made also a syrup of it which differed in no essential manner from the former. Dr. Bienfait, of Rheims has again brought forward this remedy. A comparison which he made in the treatment of two series of patients has decided him in favor of the efficacy of the liver of sulphur. In the first, sixteen pa- tients were treated by emetics, cauterization, mercurials, etc., and one only recovered. In the second, he obtained three re- coveries in six cases by giving the sulphuret of potassium in doses of 0.15 (2Y2 grs.) in an emulsion of 120.00 (4 oz). Notwith- standing these recoveries, the liver of sulphur has appeared to many authors as a dangerous remedy. Its smell and taste are very disagreeable, and render it difficult to administer ; it whitens the inside of the mouth, and occasions a burning sen- sation at the pit of the stomach. Several physicians, Bour- geois and Chailly among others, have seen it frequently pro- duce vomiting as well as colic, and a choleriform diarrhoea. Barthez frequently gave it, but abandoned it because of the diarrhoea it produced, and because of its failures. It is neces- sary, therefore, to be very guarded in the use of this remedy, and one should avoid prescribing it for young children who are very liable to have diarrhoea. 2. Bromine. Ozanam first advocated the use of bromine TREATMENT. 399 and its compounds in the treatment of diphtheria. He at- tributed to the metalloid itself, a disaggregating property, and to the bromide of potassium a property at once liquefying and disaggregating. Bromine, accordingly, would be the specific of the pseudo-membranous affections, namely, angina, croup and aphthae [sic). This pretension of a remedy to a specific action in diseases as unlike as diphtheria and aphthae should be sufficient to shake the theory of the author. But to infer, from the solvent power which a medicinal agent possesses upon the morbid products, a specific action upon the disease which gives rise to these products, is to run into mere theory. At that rate diphtheria would count numerous specific remedies. Aqua calcis, lactic acid of which the solvent power is infinitely superior to that of bromine, would be antidotes much more powerful than it. According to the same author, the specific action of bromine should also follow from the fact that this substance when inhaled into the air-passages, determines the formation of false membranes in the throat. But we can say as much also of ammonia ; this gas has been employed by sev- eral observers to produce artificially false membranes in the pharynx and larynx. What resources should we not have then against diphtheria, if these views should enter into the domain of reality ! Unfortunately our means are much more limited; the specific of diphtheria is yet to be found. If bro- mine possesses an action on diphtheria, it is one of an entirely different nature. The labors of Gubler, Voisin, Martin, Damonetteand Pelvet, etc. have demonstrated that bromine and its compounds are eliminated by the salivary glands, by the buccal mucous membrane and that of the air-passages. We can then see in this metalloid a modifier of these mucous mem- branes ; moreover, the false membranes being in constant con- tact with a substance which exercises upon them a certain chemical action, may be profitably modified. The effects of the bromine may be analogous to those of the chlorate of potas- sium. Reduced to these terms the therapeutic action of bro- mine is, theoretically, acceptable. Are the facts cited by Ozanam convincing examples of this action ? I should hardly 400 DIPHTHERIA, CROUP AND TRACHEOTOMY. admit it. Indeed, bromine is eliminated especially by the urine, and it does not pass in a perceptible manner into the saliva, only when given in quite large doses. Now, Ozanam took for the basis of his formulae the brominated water or an aqueous solution of bromine, one to a thousand or one to five hundred ('/looo or Vsoo)- He formed a solution of it as follows : Brominated water, v-xx gtt. Distilled water, 150. (572 o). Simple syrup, 30. (i §). M. Take a tablespoonful from hour to hour. Under certain circumstances this physician added to this formula 0.05 (V* gr.) of bromide of potash. The infinitesimal quantity of bromine which enters into this preparation can have, in being eliminated, but an illusory action upon the false membranes. By raising the doses the conditions become such as to obtain, from this remedy, the effect which its physiolog- ical action promises. In several cases of diphtheritic angina with coryza and albuminuria, I have made use of the bromine medication internally and externally. The results have ap- peared satisfactory. The following is my manner of proced- ure : 1st. Irrigation in the nose and in the throat with the bromi- nated water, i to 500. 2. Give every hour a tablespoonful of the following solution: ]^ Aq. destillatae, 125. (4 5; Bromini pur., 6 gtt. Potassii bromidi, 2. 50 (7 grs). Syrup, 30 (i 5). M. This treatment has always been well borne. In this form the bromine remedy is of rational application, and may act upon the diphtheritic manifestations in the same way conceded to analogous medications, that is to say, not as a specific, but as a topical remedy. Dr. Schiitz, like Ozanam. has recom- mended the treatment by bromine. Dr. Clemens combines the bromide of potassium and the aqua chlorinii. He prescribes a solution of the bromide of potassium as follows: Potassii bromidi, 2. — 4. (Vi-I 5). Aq. destill. 80— IGQ. (272-3 5). TREATMENT. 40 I Syrup, simpl. 20.-30. (5-73.) M. Dose, a tablespoonful ever>' hour, with a teaspoonful of aq. chlorinii. [My friend Dr. A. K. Van Home, of Jerseyville, 111., has great confidence in the effects q{ bromine in ihe treatment of diphtheria. The following is the formula and method of administering: Bromide of potash (a saturated aqueous solution) 48. (1V2SO Bromine 32. (i g.) M. Dose, eight drops every one, two 01 three hours, ac- cording to the urgency of the case, given in cream. The above mixture should be kept in a ground-stoppered bottle, and carefully pro- tected from the light by colored glass or colored wrapping paper. Dr. Mollereau, of Paris, lately also recommends the use of bromine in watery solu- tion, I %. In severe cases of the laryngeal form, he gives three drops of the solution in a teaspoonful of water every fifteen minutes. In cases not so severe he gives the same amount less frequently. He says avoid milk and farinaceous articles duiing its use. Dr. W. H.Thompson, of New York, stil favors the bromine treatment]. 3d. Iodine. — Employed especially as a topical application and as an antiseptic, iodine has also been given internally, par- ticularly by Forget. Dr. Hamilton, of Edinburgh, speaks of two brothers attacked with diphtheria to which he gave the iodide of potash. The use of the remedy having been sus- pended, the disease became worse ; from the time of resuming the treatment it declined steadily to recovery. More numer- ous facts would be necessary in order to judge of the value of [Dr. Edward Adamson (Practitioner ; also Jour. Am. Med. Assoc. Oct. 3, 1885) speaks in the highest terms of the reliability of iodine (tincture). Only two cases died out of fifty-five, and in no case were there any troublesome sequelae. Dose, from 5 to 7 minims every hour or two hours, according to the cii cumstances. For children, give 2 or 3 minims every two hours in orange syrup or some other neutral syrup.] 4th. TJie Balsams. — Dr. Trideau, relying upon the proper ties possessed by copaiba and cubebs of being eliminated by the air-passages, believed he had found in these remedies specifics which would favor the detachment of the false membranes of the larynx. He claims to have employed this method with success in more than three hundred cases. The disease yielded at the end of three or four days ; it resisted, at the most, one week. These remedies are given in the form of a syrup. The following is the formula : 402 DIPHTHERIA, CROUP AND TRACHEOTOMY. Syrup of Copaiba. ^ Copaibae balsami ... - - go. (2V2 g.) Pulv. gum. acacise - - - - - 20. (5 3 ) Tinct. (essentise) menth. pip. - - - - 12 gtt. Tinct. opii ------ 2 gtt. Syrup. Simpl. 400. (12 §.) M. Syrup of Ctibebs, 1^ Pulv. cubebse - - - - - - 12. (3 3-) Syrup, simpl. 240. (7V2 §.) M. Give every other hour a tablespoonful of the syrup of copaiba alternating with the same dose of syrup of cubebs. This remedy had a great notoriety ; it is still employed by a number of physicians. It has, however, undergone some modifications. The cubebs are generally used alone ; the copaiba has, really, on the in- testinal mucous membrane, an irritant effect which it is nec- essary to avoid, the alimentation taking rank before all medi- cation. The pharmaceutical form, the most agreeable for the use of cubebs and that which I habitually employ, is the oleo- resinous extract which has the great advantage of containing in a small volume, the active principle of a large quantity of the powdered cubebs; if the patient is old enough, and if de- glutition is not too painful it is expedient to use this extract en- closed in soft capsules. Each capsule contains 0.50 (7'/. min- ims), a quantity which equals nearly 7.5 (2 5) of the powder. We give daily three or four or even six of these capsules, accord- ing to age. But when the patient is quite young, and when the difficulty of swallowing or any other cause prevents giving non-triturated substances, we must give the oleo-resin in the form of an emulsion of gum or otherwise. I use the following : Syrup acaciae (with some aromatic) 120. (4 §) Oleo-resinae cubebse, 0.50 — 2.0 (from 7 minims to ^^ 5) M. Dose, a tablespoonful every two hours, as far as possible at the time of eating. Cubeba is given also in the form of a sac- charated extract (saccharure) in the dose of 20. (5 5) a day. Bergeron gives it ordinarily in this form, except in the cases in which the capsules can be employed for cubebs. This mode of treatment has against it the very disagreeable taste of the TREATMENT. ^03 medicine. This is of little importance in adult persons, who can overcome certain repugnancies by appeal to their judg- ment, but it becomes a real objection in the case of young children. I have often seen the patients oppose, resist and finally absolutely refuse the medicine. That is a circumstance we should always suspect when we have to do with substances repugnant to the taste. It is to be feared that this has not been sufficiently considered in the multitude of observations in which the brilliant successes obtained by the balsams are ex- tolled. Is the curative effect of the system sufficiently proved for us to pass on ? And first, to consider diphtheria as a pure "specific catarrhal affection of the laryngeal and pharyngeal mucous membranes with adynamic tendencies," is perhaps to simplify the question too much. From this view, the treatment by the balsams be- comes rational ; but is it correct that diphtheria should be so understood ? We can answer very pointedly in the negative. The fibrinous exudate of diphtheria is no more catarrhal than that of pneumonia is fibrinous. The lesions made upon the mucous membranes of the pharynx, the larynx and the bron- chial tubes by the first, and those of the alveoli and pulmonary vesicles of the second are similar. The two diseases are not less absolutely distinct, although the Germans, too much influenced by the similarity of the lesions, have applied to this form of pneumonia the qualification croupal. Has any- one, even by making this confusion, attempted to treat pneu- monia by the balsams ? I think not. Diphtheria is no more amenable to this treatment than pneumonia. Theory is, there- fore, not favorable to the balsamic treatment. Is the practice in opposition to the theory? The excessive proportion' ot re- coveries attributed to this method seems calculated to create suspicion from the first. An action so constant, and an agree- ment so perfect between the physiological action of the reme- dy and its therapeutic effect are not things commonly met with. These observations, too briefly given by the honorable promoter of this treatment, are not calculated to dissipate these apprehensions. Did they concern true diphtheritic angina or 404 DIPHTIIKRIA, CROUP AND TRACHEOTOMY. fully confirmed croup? We may well doubt it, and so much the more as the successes appear to have been more brilliant in cases of primary croup, while they were negative (nothing) in cases of croup consecutive to membranous angina, that is, in the only case in which the diagnosis might be indisputable. This method has been tried on a large scale in the hospitals of Paris ; as in all the therapeutic systems it has given recov- eries, but upon these fortunate series, reported by Bergeron, Archambault, Moreau, Vaslin and Courcelle, have followed reverses no less numerous which have shaken greatly the early confidence of many physicians. The objections which this treatment suggests have been formulated with talent by Lavergne and Bastion. So far as I am concerned, I may add, although I have employed this treat- ment in a large number of cases, I have never observed from it any well established action. This is also the opinion of Bar- thez. Finally, the efficiency of the balsams is not sufficiently dem- onstrated to give us the right to impose these remedies to the diso-ust of patients. Besides, their use is not without incon- venience. They very frequently excite purgative effects which it is absolutely necessary to avoid. 5th. Expectorants. — With an idea similar to that of Trideau several authors have endeavored to modify the secretions of the affected mucous membranes. Only, in place of endeavor- ing to arrest them by the use of the balsams, they have de- voted themselves to the purpose of augmenting and maturing them by prescribing expectorants. Polygala Senega. — Introduced into the therapeutics of croup in 1 79 1, by Archer, this remedy was extolled as very powerful by John Archer, son of the former. This medicine was pre- pared in the form of a decoction of 15. (V'2 S) of the bruised root of senega in 250. (8 S) of well water, boiled down to 125. 4 oj). Dose, a tablespoonful every hour or every half hour, according to the severity of the disease. In some cases he prescribed the powdered senega in doses of from 0.20-0.25 (3-4 grs.) in a little water. Numerous recoveries were obtained by TREATMENT. 4O5 this remedy. But of all these virtues only one has been pre- served to senega, and that is its expectorant power which may be utilized in the bronchitis which accompanies diphtheria. This plant is then given in infusion, in the dose of 8. (2.5) in 100. (3 3) of water. In larger doses it frequently produces vomiting. The Kcnnes mineral (antimonii sulphuretum prsecipitatum) has been employed in the dose of .10 — .20 (I'y. — 3 grs.), espe- cially by Herpin, of Geneva. Its action is the same as that of senega. This remedy has, moreover, the inconvenience of often causing very distressing nausea, and provoking diar- rhoea, reasons which should positively contra-indicate it in the treatment of diphtheria, for reasons heretofore indicated. In the same list with these remedies we may place jaborandi, an agent recently introduced into therapeuties, and which has not been, so far as I knew, applied yet to the treatment of diphtheria. I have not tried it, but it seems that the decided secretory activity which it excites, not only in the salivary glands but in the respiratory mucous membrane, and real per- spiration of the trachea, might have a certain action upon the false membranes and facilitate their separation. In these cases we might administer it to children in the dose of I. (15 grs.) in decoction in a teacupful of water. [Recent statements of the treatment of diphtheria. Dr. N. Lunin, of St. Petersburg, has given the results in the treatment of 296 cases of diphtheria occurring in the Children's Hospital of the Princess of Oldenburg. Their constitution and condition are thus stated : 25 only were badly nourished, while 225 of the 296 were well devel- oped and well nourished. The tabulated results are as follows : 4^6 nirilTIlEKlA, CKOL'P AND TRACIIKOTOMV. Fibrinous /• orm. Phlcgmonous- -Septic Total. Form. •^ ' i •^ Method of Treat- •S ■:2 f^ <; 'a ment. « •^ ,^ ^ "i: -.** t3 8 ^ •^ ?i Ni ^ •2 N, C^ $ ^ 13 ^ ^ ^ ^ ^ Sublimate, . . 43 30.2 14 13 92.9 57 26 45-6 Iron .... 43 14 32.6 51 39 76.5 94 53 56.3 Chinolin . . . '9 6 31.6 9 9 1 00.0 28 15 53-0 Resoicin . . . lO 2 20.0 19 17 89-5 29 19 65-5 Bromine . . . 15 7 46.7 18 16 889 33 23 69.7 Turpentine . . 12 I 8.3 II 9 81.8 23 10 43.4 Total .... 142 43 30-3 122 103 84.4 264 146 55-3 Fifty-seven cases were treated with the corrosive subhmate. The throat was pencilled every two hours with a i per cent so- lution, and washed with a solution of i to 5,000. Wine and musk were also given. Ninety-four cases were treated with tincture chloride of iron of which from i to 8 cubic centimeters were given daily — not enough. The throat was gargled every two hours with a solu- tion of boracic acid, and stimulants were given. The chinoline was applied in 5 per cent solution with a pen- cil and a wash of i to 1,000 was also applied. Rosorcin, it will be seen, had little effect and bromine used in '/i to 72 per cent, solution was used as a local application every three hours, and in solution (.6 to i.oo per 300) was in- haled from every half hour to every two hours. Oil of turpentine was given in twenty-three cases internally, in gradually increasing doses up to ten drops hourly or 240 drops per day. The stomach was not disturbed thereby. A gargle of boracic acid was used ; wine and musk administered. This seems to have been the most efficient treatment for the fibrous, and iron for the phlegmonous-septic form. Med. Rec- ord. July 18, 1885.] treatment. 4^7 § 3. — General Treatment. The false membrane, although it is the most palpable symp- tom of diphtheria, is still but one part, sometimes the least im- portant of the morbid totality which the physician is to com- bat. Two principal conditions prevail : septicaemia and ady- namia. However variable may be these two elements of the disease, as to their intensity, they always exist in a manner more or less apparent. The general treatment of diphtheria, therefore, comprehends the antiseptic and the restorative treat- ment. The authors who consider diphtheria as a zymotic disease have also tried an antiparasitic treatment. But, as nothing is less demonstrated than this ontological view, and as, on the other hand, the parasite is in this theory only the agent of the septicaemia, the antiparasitic and the antiseptic treat- ment answer one and the same indication and should be united. Hence, I comprise them both under the name of antiseptic treatment. A. — Antiseptic Treatment. The entire catalogue of disinfectant remedies has been em- ployed against diphtheria. Among these therapeutic agents, one of the most vaunted was the perchloridc of iron. Recommended at first as a local application by Hatin, Gigot, of Levroux, and by Jodin, who regarded it as a parasiticide, this remedy became, under the influence of Aubrun, an antiseptic of energetic effect against diphtheria. In 1S67, Dr. Aubrun, Jr., gave this subject an im- portant place in his inaugural thesis. The following is the modits faciendi 3i6i0^i&6. by this author: The perchloride of iron is to be given dissolved in a little water. If the child re- jects it a little simple syrup may be added. Gummy solutions should be avoided ; they form with the ferric salt a thick magma which is difficult to swallow. The solution should be given in a glass or in a porcelain cup, and not in a spoon, the metal of which would decompose the ferric salt. The patient should abstain, while using this remedy, from drinks or food capable of altering it, such as wine, and in general, all sub- 408 DIPHTHERIA, CROUP AND TRACHEOTOMY. stances containing tannin. The dose is from 4! to 7. (i to 2 5) a day. It is given in divided doses of from 20 to 40 drops which is mixed in a glass of cold water. Every five or ten minutes, while awake, and even during sleep, we give a mouth- ful of this solution. Immediately after, the patient should drink a little cold milk without sugar, or soup. According to age, the patient can take during the day from three to five glasses of this solution which brings the quantity to about the amount above given. Authors recommend to continue the remedy with scrupulous regularity during several consecutive days, even during the first three nights. That would be, in fact, towards the end of the third day when the false membranes would become softened and detached. After recovery it is necessary to take the precaution to continue the perchloride still for some time in order to to avoid second attacks. As to alimentation it should, during the two or three earliest days, be composed exclusively of milk or soup (bouillon). Isnard, of Saint-Amand-les-Eaux, has reached the same conclusion. Courty, of Montpellier, has also obtained favorable results. He employs intenially and externally the following preparation : Tincture of chloride of iron, 30 to 50 drops in a glass of water. Dr. Colson declares that in America all the physicians reject cauterization and employ especially the perchloride of iron, chlorate of potash, and ice internally and externally. Heslop and Houghton prescribed the following solution : ^. Aqus 240. (772 S-) Tinct. ferri chloridi, 12. (3 3-) Acid, muriatici dil. 8. (2 5.) M. To betaken during twen- ty-four hours. Dr. Clarhas employed with success ferrated glycerine in a score of cases, half of which were grave. His formula was the following : Glycerine 60. (2§.) Tincture ferri chloridi gtt. 15, — 20. Dose, a teaspooful every half hour. Dr. Schobacher speaks highly of the use of perchloride of iron, as does also Prof. Steiner. TREATMENT. 4O9 Aside from the antiseptic action which does not appear to me demonstrated, we must recognize that the tonic and the coagulant properties of this remedy would have a favorable ef- fect in a disease which produces anaemia and dyscrasia. These properties very probably have had their part in the success re- ported by authors. But one is exposed to frequent disappoint- ments by expecting the action of this remedy to be otherwise, and in hoping to find often series of cases equally fortunate. After having enjoyed great favor the perchloride of iron has lost ground like all agents which have claimed to have a direct action upon diphtheria — of being its antidotes. In comparing the results obtained in a large number of patients, I have proved that the perchloride of iron w^as, in general, well borne, though it was not always so easily taken as Aubrun thought, but I have never been able to find in it a clearly proved action upon the disease. However that may be, this treatment has decided merits ; it answers one of the principal indications of diph- theria ; moreover, it is without disadvantages. In the same list with the perchloride of iron one may place gallic acid, extolled by Dr.Sebastin in 1866, in doses of from i.to 2.(15 — 30 grs.) a day. The Labarraque's solution (Liq. sodse chlorinatae) has been prescribed in doses from i. to 4. (7* to i 5) a day. The pcruiaiiganate of potash is also used, but this salt is quite difficult to manage, being decomposed by all organic substances. lodifie has been recommended in the form of tincture, either alone or combined with iodide of potassium. Dr. Lauton, in 1865, boasted of the juice of lemon mixed with the bruised bulb ol garlic. Those two substances had, as he thought, real anti. septic properties. Sulphur, employed locally before by Jodin as a parasiticide, has been given internally with the same object. It is adminis- tered in the form of washed flour of sulphur, of which 10. to 30 {2^ jiO to 15) are incorporated with honey. One may also mix a tablespoonful in a glass of water, and give of the mixture a tablespoonful every hour. In spite of the marvelous success referred to by the authors of this treatment, it is wise, I be- 4IO DIPHTHERIA, CROUP AND TRACHEOTOMY. lieve, to maintain a prudent reserve, for miracles are not to be revived. The sulphites, announced as antiseptics, have been recom- mended by Dr. Giacchi. The author uses the sulphite of mag- nesia in broken doses. He gives 6. (172 5) a day. Occasion- ally he prescribes at the same time the sulphite of sodium as an enema: Water, 500. (17 5); syrup of poppies, 50. (I'AS)- sulphite of sodium, 50. (1V2 o). Carbolic acid of which the disinfectant properties are so cel- ebrated, could not fail to be tried in diphtheria. It has been employed especially in the form of syrup. Its compounds have also been examined. Roger and Peter have given the carbolate of sodium; this remedy has appeared in some cases to have beneficial effects, but it has failed on many occasions. It is, in fact, as uncertain as the others. The sulpho-carbolate of quinia has been tried in the dose of .05 to .20 (7^ to 3 grs.) a day, and concurrently with the use locally of oxalic acid, by Drs. Prota Giurleo and Francesco, of Naples, at the solicita- tion of Dr. Noah Cinni, of Montefolcino. This practice is re- ported to have succeeded in all the cases! Salicylic acid has, for some time past, been highly recom- mended as being powerfully antiseptic, and is said to posses all the properties of carbolic acid without having its disadvan- tages. This compound, which is said to be at once febrifuge and tonic, is considered by Wagner as a powerful therapeutic agent. It is said to greatly abbreviate the duration of the dis- ease. Dr. Karl Fontheim is said to have obtained by this remedy remarkable success of which the details surely leave little to be desired. The disease continued, at the maximum, eight days, and three or four days at the minimum. The constitu- tional diphtheritic infection ceased, albuminuria disappeared, and paralysis was prevented. This compound, he claims, is also prophylactic ; in numerous families it limited diphtheria to the persons first attacked. The following is the formula : ]^ Acidi salicylici, 2. (72 5). Alcohol, q. s. Aquje, 200. {j^li §)• M. Teaspoonful three times a day. TREATMENT. 41 I It was used at the same time as a gargle and a local appli- cation. It is difficult not to entertain some doubt about the realization of such an attractive programme, and one is tempt- ed to ask if all this portrait is not too beautiful to be true. The method deserves a trial ; it is easy to manage and is less un- pleasant than carbolic acid. Hence, one may test the results obtained by the German authors, though he may end in a new deception. I should mention, in this place alcohol, which is one of the best antiseptics. I shall have to speak of it more in detail as applicable to the supporting treatment. Conchision. — The long array which has just been made of the above-mentioned means for the purpose of attacking diph- theria in its essence proves once more that the list of remedies used in any disease are in proportion inefficient as they are greater in number. The specific remedy for diphtheria is not yet discovered. We may doubt if it ever will be. Among therapeutic agents some are injurious and should be rejected, others being able to fulfill certain indications shall be used according to the cases. When there is a necessity to diminish the production of false membranes, remedies which are eliminated by the buccal or respiratory mucous membranes and by the salivary glands may be employed ; perhaps they may exert a moUifying influence on the vitality of the mucous membranes in such a way as to diminish the pseudo-membranous exudation. These substan- ces will be brought into requisition on condition that their use does not disgust the patient too much, nor interfere with ali- mentation, nor produce any injurious effect upon the digestive apparatus. When septicaemia prevails, that must be attacked. The means are no longer wanting. The best of ah is alcohol, which may be given in the form of various kinds of wine or of spirits and water, or grog. The other antiseptics are not always inoffensive when taken internally ; moreover, their action is far from being demonstrated. While a substance, applied di- rectly to the diseased tissue possesses antiseptic properties, there is no proof that it acts in the same manner when intro- 412 DIPHTHERIA, CROUP AND TRACHEOTOMY. duced into the digestive tract and taken up by absorption. When they have so repulsive a taste as carboHc acid, we may without inconvenience dispense with them. It would be bet- ter to resort to the perchloride of iron which at least possesses the advantage of acting as a ferruginous remedy. The favor which salicylic acid enjoys abroad may induce a trial of this product which does not appear to produce otherwise injurious effects. B. — Restorative Treatment. Alimentation. Food and tonics form the basis of this treat- ment. We cannot too strongly insist upon the necessity of nutrition in diphtheria. No medication can replace it. All the efforts of the physicians should tend to have nourishment taken regularly. When the appetite is preserved, and the dys- phagia is not intense, the difficulties are not so great ; but when deglutition is painful, when anorexia is complete, which is most frequently the case, it is necessary to contend with perseverance, «sing by turns, persuasion, promises and even threatenings. In the general direction of the treatment we should always have this important point in view. All med- icines susceptible of causing disgust, or of provoking nausea, or diarrhoea, should be, without hesitation, dispensed with. I say the same of cauterization and painful local applications, which increase the dysphagia and, consequently, the repug- nance for alimentation. Acting otherwise would be to lose the substance for the shadow, and to sacrifice, for means of which the efficacy is doubtful, the only one of which the effect is always beneficial, the only one indispensable. We cannot give positive rules respecting the details and the form of food. If the dysphagia is slight and the appetite suffi- cient, roasted or broiled meat and soup or porridge should make the basis of the diet. When the appetite is indifferent or gone, it should be stimulated, o. tempted by dainties the most agreea- ble to the patient : oysters, game, dainty dishes, cream, eggs and milk ; one may contrive variety. The nature of the food is not important provided it be taken. Avoid insisting on certain TREATMEiNT. 4I3 kinds of food which might appear more appropriate ; it may- result in an entire refusal on the part of the patient. A nour- ishment which appears but sHghtly restorative is still prefera- ble to complete abstinence. The patient who is left from the first to his own indifference about food, may be rescued later only with the greatest difficulty. If dysphagia is the principle obstacle we may^ have recourse to semi-solid food, to thick porridge to which is added juice of meat, vermitelli, cream, soft boiled eggs, the soft part of bread soaked in the juice of meat, or meat hashed or scraped quite fine. Alcoholics. — To food properly so-called it is necessary to add spirits in any form in as large quantity as possible. The preference of the patient should be still scrupulously followed, namely: Bordeaux wine, the alcoholic wines, dry or sweet; sherry, Malaga, champagne, beer and sweetened spirits (grog), may be used with success. The only precaution consists in diluting these drinks with a certain amount of water and giving them by small quantities. In this way we may introduce quite large quantities. Coffee is also an energetic stimulant very acceptable to children. Of all the antiseptics given in- ternally, alcohol is much the most certain. The more pro- nounced the infection is the more necessary it is to insist upon the alcoholic compounds. Bricheteau reports the history of a patient attacked with a spreading pharyngo-laryngeal diphtheria, which extended upon the blistered surface and was accompanied by profound adynamia. Bordeaux wine was ad- ministered, of which he took as much as a bottle and a half a day without experiencing the least symptom of intox- ication or headache. I am always careful to follow a similar course by taking in every case the precaution to test the sus- ceptibility of the patient in this respect. Tonics. — Quinine ought also to occupy a large place in the treatment of diphtheria. I prescribe it constantly in the form of soft extract, in quantity of 2. to 4. (^/., 5 to i 3) a day, in an infusion of coffee. It may be formulated thus : Infusion of coffee, 125. (43). Syrup of gum accaia, 40. (174 5). 414 DIPHTHERIA, CROUP AND TRACHEOTOMY. Soft extract of cinchona, 2. to 4. (72 to i 3). Dose, a table- spoonful every two hours. It may be also employed in the form of aqueous infusion, four teacupfuls during the day, sweetened or not. Trousseau gave I. to 2. (15 to 30 grs.) of the powder of yellow cinchona bark or 0.25 (4 grs.) of sulphate of quinine, in coftee. Cinchona bark with malaga wine and syrup is still much used ; they have the single inconvenience of requiring too large a vehicle for the same dose of the active principle. Iron finds also its indication in diphtheria, especially when the patient is convalescent, and it is necessary to attack anaemia when it has reached its maximum. The ferrated wine of cinchona well prepared, the syrup of citrate of iron and dialysed iron are the most acceptable pharmaceutical forms. Cold. — By virtue of their tonic action the practice of hydro- pathy should be counted among the general modifiers which have been used to combat diphtheria. In Germany, especially, this method has been brought into notice. Harder, Baumbach, Diitersberg and Bischof recom- mend cold affusions. The child is placed in a bath-tub, then some one pours upon the posterior part of the body two bucketfuls of water at a temperature of 12° or 13° (54° — 56° F.) Manner, physician to the children's hospital at Munich, uses, in preference, wrapping in a wet sheet and then covering with a blanket. The patient is left in this situation until full reac- tion occurs. The author surrounds the neck also with a cloth wet in ice water. This system was practised by Delacoux in a case of angina treated with caustics, and threatening the lar- ynx. He substituted the treatment thus commenced, by ap- plying to the neck a compress wet in cold water with Labar- raques' solution added, and renewed it every hour. A very perceptible amelioration soon followed, and the patient recov- ered. Dr. Klee reports, according to Dr. Alexandre, the case of a patient attacked with a grave diphtheria of the throat and nose, complicated with cerebral symptoms, convulsions, risus sardonicus and coldness of the extremities coincident with an TREATMENT. 415 elevation of the temperature of the body. Antispasmodic remedies produced no effect, and death was approaching. The child was sponged off twice with cold applications which calmed him immediately. German physicians seem quite sat- isfied with affusions and the wet wrapping. But the facts which they produce in its support are few and inconclusive. Besides, this method, that of Hanner in particular, is not with- out danger ; it requires to be applied with the greatest precau- tions. In fact, one cannot too much dread the thoracic com- plications of diphtheria. It is necessary, above all, to guard against producing any occasion for them, or opening the way to them. If I should judge by the application that I have seen made of the system, it would be necessary to abridge the suc- cess announced. However, the indication for this method may present itself. The ordinarily slight intensity of the fever in diphtheria rarely gives occasion for the application of cold as a diminisher of excessive caloric. On the contrary, the adynamia and the ataxic symptoms permit the rational use of the method, and from it we may obtain real neurosthenic ef- fects. In this case the cold ablution made rapidly and followed by wrapping in a blanket, will be a useful application. Cold has not only been applied to the surface, but ice and cold drinks have been used internally. All tends to the belief that in this way it acts still as a tonic. Dr. Violette reports that in a child, reduced by repeated vom- itings and at the same time by free and obstinate epistaxis, to an advanced degree of adynamia, this treatment, by the advise of Barthez, was replaced by tonics internally and insufflations of tannin. The debility having, however, continued, Violette added to this treatment pounded ice given night and day by teaspoonfuls every ten minutes. Twelve hours afterwards the improvement was considerable ; recovery was accom- plished. This method approximates that of Dr. Grandboulogne, who advocates the constant use of ice. Lacaze in a very severe and very fatal epidemic which prevailed in the island of Reunion (one of the Mascarene islands), was well pleased with the fol- 4l6 DIPHTHERIA, CROUP AND TRACHEOTOMY. lowing system : Iced drink of tamarinds, astringent gargles, and, from time to time, pieces of ice taken in the mouth. When, on account of tender age, the gargle could not be pre- scribed, he injected every half hour, into the throat and nose, simple ice water. This treatment seems to be commonly employed in the United States, according to the report of Dr. Colson ; it is also commended in England by Dr. West. In this local applica- tion the cold appears to act especially as a tonic. The anti- phlogistic action is, in Hict, of little importance, in diphtheria the inflammation being, generally, but slightly intense, and constituting but one of the secondary elements of the disease. When adynamia prevails, or h3emopt}'sis is manifest, the tonic action, local and general, of ice may be favorable. Conchision. — None of the means above cited have the power of preventing the production of false membranes. Therefore none of them exercise upon diphtheria a curative action prop- erly so-called. Hence, the specific of this disease remains still to be discovered. Will it ever be ? That is not probable. All tends to the belief that it no more exists than does one for typhus fever, or for measles, etc. To persist in the search of such means is to direct medicine in a false channel. A well- chosen treatment of diphtheria ought to be regulated not to the disease, but to the patient and to the indications which he furnishes. SECOND CLASS. Treatment of the Local Manifestations of Diphtheria. Independently of the general indications inherent to diph- theria itself, each local manifestation becomes, by reason of the organ attacked, the source of special indications. § I. — Diphtheritic Angina. {^Faucal Diphthend). This local manifestation, [localizatioii) the most common of all, is also, except cutaneous diphtheria, which is rare, the one which presents false membranes the most accessible to thera- peutic agents. Against this form are first directed the local TREATMENT. 4^7 means collected by art for diphtheria. For this reason I de- sire to present, in this place, the history of the local modifiers. Physicians of all periods have endeavored to destroy the false membranes, I have shown that quite frequently this practice has not the advantage which has been accorded to it ; but as it may be indicated in certain cases, I ought to pass in review the means that have been employed to that end. Local modi fiei's. — Several principal methods have been made use of ; their mode of action are as caustics, astringents, sol- vents, antiseptics and parasiticides. Of cauterization. — This system, as old as the disease, since it goes back to Aretaeus, was conceived in the idea that diph- theria was primarily a local disease, becoming general by the absorption of septic products formed on the surface of the false membrane, and gaining in extent by contiguity. To avoid infection and propagation the disease must therefore be destroyed on the spot, and at once, or at least, be essentially modified. From the red hot iron to the mildest class of caus- tics, a large number of caustics have been applied to the diph- theritic exudates. , A. — Caustics. Hydi'ochloric acid. — Boasted of by Van Swieten,and Marteau, of Grandvilliers, recommended by Bretonneau, Trousseau and Guersant, this caustic was used absolutely pure, fuming as Trousseau preferred it, or mixed with one-third or one-fourth of honey of roses, according to Guersant. According to Trous- seau this acid in a pure state did not produce cauterization deeper than that of nitrate of silver ; at any rate, it did not have the deep action of analogous substances, such as sulphuric acid and nitric acid.In admitting the correctness of this assertion, verified also by other authors, it is none the less true that the cauterization of the throat with hydrochloric acid is excessively painful and not exempt from danger. SulpJiuric acid and nittic acid are means more energetic, more painful, still more dangerous and produce deeper eschars. 4l8 DIPHTHERIA, CROUP AND TRACHEOTOMY. The actual cautery applied by some physicians has never had but a limited use. It is a violent, painful, and tear- fully dangerous means. Trousseau, such a great partisan of cauterizations, considered it as only applicable to cutaneous diphtheria. Caustic soda used by Roger and Peter in the ex- periments made with Reveil, performs a double action. While it is caustic, it exerts, at the same time, upon the false membranes a rapid solvent power. In this respect, it might be classed with solvents, and be employed profitably ; but its other effect would rather classify it with the caustics, admit- ting that there are solvents, the local action of which is harm- less. Catherctics — Mild caustics. — At the head of this list must be placed nitrate of silver of which the use, after having been uni- versal, is still by the force of habit continued by a large num- ber of physicians. The crayon is found in the pocket-case of every one, and its application is very easy. These are two conditions important to success which will keep it for a long time in favor. It is used in the solid state or in solution of one-fourth, one-third or of equal parts. The crayon is in more extensive use because it is convenient ; the solution is less liable to the inconvenience of producing upon the mucous membrane a white exudation resembling a false membrane. In applying the solution a camel's hair brush, a bit of charpie, or a little sponge rounded off and fastened to a sponge-holder or, what is better, to a flexible rod or a whalebone, is wet in it. It is necessary to squeeze out the excess of fluid before making the application to the throat, in order to avoid having the caustic run into the esophagus or into the larynx. The sulphate of copper in saturated solution was employed by Trousseau in preference to the nitrate of silver. It has not the disadvantage of the latter of indelibly staining the clothing. Perchloride of iron. — Before being given internally this rem- edy was extolled as a local application. Hatin, Gigot, of Levroux, and Sylva spoke highly of its advantages. It is also recommended by Prof. Steiner. It is said to have a mummifying action upon the false membranes, TREATMENT. 419 to-wit : those which are thin and sh'ghtly adherent become im- mediately detached ; the more resistant are separated only in patches like fragments of muscle macerated in water. This local application is reported to possess the farther advantage of con- stringing the subjacent tissues, and of preventing new membra- nous exudations. One should make twice during the first 24 hours, an application of the officinal solution of perchloride of iron by means of a hair pencil or a sponge. In spite of these advan- tages the perchloride of iron does not prevent the reproduction of talse membranes any more than other local applications. It has, moreover, the Inconvenience of being a painful application, more so than that of nitrate of silver. The facts observed by Moynier, Fischer and Bricheteau, Barthez and myself, furnish the proof of it. Besides, it has a very disagreeable taste which, added to the dysphagia which it produces, still increases the children's repugnance for food. Iodine. — Tincture of iodine has been used in the form of paint upon the false membranes by Perron, of Alexandria, and Zurkowski. According to the former physician this applica- tion is very painful. This must be taken into consideration, though Boinet denies the truthfulness of it and asserts that the tincture of iodine applied to the mucous membranes produces but moderate pain. Guersant advocated the use also of the acid sulphate of alumina in a solution of one to three or one to four of water. General Rules. — Every time that we make use of cauteriza- tion of the throat, it is necessary to have the patient's head firmly held by an assistant. It does not matter whether the patient lies down or sits up. The throat should be thoroughly illuminated. During daylight the face should be turned to- wards a window. If this cannot be done, or if the application should be needed in the evening, the light of a candle fur- nished with a reflector should be thrown into the throat; a simple silver spoon may answer as a reflector. But when there is less urgency it is preferable to operate by daylight, and to have the patient seated on the lap of an assistant sitting in Iront of a window. This is the best way to fully understand 420 DIPHTHERIA, CROUP AND TRACHEOTOMY. what one is doing. A second assistant holds the head con- veniently. A tongue depressor introduced to the base of the tongue enables one to strongly depress this organ and obliges the patient to hold the mouth wide open. The caustic is then applied quickly upon the diseased parts by means of a little brush or sponge ; the healthy parts should be spared as much as possible. When the operation is terminated it is well for the patient to rinse the mouth in order to dilute and remove the excess of the caustic which might spread about. If the patient is quite young, the mouth should be washed out. The liquid for the gargle or for the wash may be simply pure water or a liquid which neutralizes the free caustic remaining. In the case of cauterization with nitrate of silver, salt and water is proper; after caustic soda, vinegar and water is indicated. Cauterization is generally abandoned ; it has serious disad- vantages ; it is dangerous, and it is useless. It is dangerous. — However dextrous the operator, however tractable the patient may be, it is difficult to limit the action of the caustic to the false membranes ; a certain amount of it always extends upon the neighboring parts which it inflames. When thus irritated these become covered with diphtheria, or with eschars, as in cauterization with hydrochloric acid, or with a pultaceous coating, as after the use of nitrate of silver. These new products, possessing great analogy to the forming diphtheritic false membrane, are seen when the physician makes another examination ; he suspects the extension of the disease, and recommends more than ever cauterization. If he escapes this mistake, he is still more embarrassed ; in fact eschars and false membranes are confounded in one in which it is impossible to tell the progress of the disease. Eschars, often extensive and deep, and the attachments of diphtheria to points remaining healthy, are therefore consequences much more frequent than we suppose. Barthez has several times seen the production of vast eschars under the influence of this cause. Thence arose these aggravations of the disease, which did not escape the great practical sense of Trousseau, partisan of cauterization as was this illustrious' clinician. But what TREATMENT. 421 may not happen when the operator is httle experienced, and the patient resists, as is most usually the case ! A child that has been taken once by surprise, will not suffer himself to be taken off guard a second time, and will resist with all his might. It is understood that cauterization is then made at random and that the disadvantages before cited are inevitable and more serious. The patient is, in fact, not so well held, the tongue is imperfectly depressed, and the caustic is blindly splattered around on the tongue, on the palate, etc. Some ac- cidents still much more serious are produced. If one has not taken the precaution to strongly squeeze the sponge or the brush wet with the caustic, the contraction of the muscles of the isthmus compresses it and it spreads the fluid in the throat. It may be swallowed and spread in the esophagus as Cambre- lin has shown ; it may also pass into the larynx, where it causes cauterization, oedema of the glottis, etc. It also hap- pens that the patient sometimes closes suddenly his mouth before the instrument is withdrawn. Trousseau and Blache have witnessed this accident and its sad consequences, espec- ially when the cauterization is made with hydrochloric acid. The consequences are less serious when the cauterization is made with nitrate of silver. However, the crayon has been known to be crushed between the teeth and swallowed. I was recently called to a child who had suddenly closed the jaws while an application was being made to the throat with a brush dipped in a solution of nitrate of silver. The entire mouth had been burned and presented one large white surface. Fortunately the solution was not very strong. Several authors, Guyet among others, have cited cases of sudden death by spasm of the larynx, following as a consequence of painful cau- terization. The pain resulting from cauterization is added to the dys- phagia natural to angina and to the taste of caustic which is nearly always disagreeable, so as to make feeding impossible. The struggle that the patient makes in resisting at each cau- terization diminishes his strength. The preservation and aug- mentation of the strength are indications much more impor- 422 DIPHTHKRIA, CROUP AND TRACHEOTOMY. tant than the modification of the false membranes. All excitement, all struggling should be avoided ; quiet, the most perfect should be prescribed. All local medication that in- fringes this rule should, for that reason alone, be rejected, how- ever much extolled may be its effects ; the patient must not die of the remedy. // is useless.— Cdixxstxcs have no influence upon the general disease. If they remove the false membrane, most frequently detaching little pieces, they prevent in no way the reproduc- tion of the exudate. They arrest in no respect either its exten- sion or its propagation towards the larynx. Many cases of angina, on the contrary, from which this treatment has been withheld, remain limited to the throat. One will not, there- fore, be astonished, admitting such results, that cauterization is universally abandoned by enlightened physicians in France and abroad. In France, Cambrelin, Bricheteau and Barthez are opposed to this method. It is no longer practised in the hospitals. /;/ England, at the Harveian Society, Drs. Cleveland, Her- ville, Greenhow and Hillier have unanimously pronounced against cauterization, which they regard as more injurious than beneficial. Local astringents, and tonics given internally, ap- pear to them the best treatment. In America, Meigs and Pepper express the same sentiment. Dr. Colson informs us also that American physicians reject this method and employ especially the perchloride of iron, the chlorate of potassium, and ice internally and externally. In Germany cauterization is declining more and more. In a discussion which occurred in 1872, at a session of the Medical Society of Berlin, of which I have before spoken, Dr. Walden- burg opposed this means, and nearly all the physicians present had similar views. The opinion, therefore, upon the value of cauterization is at present fixed. Its abandonment is general and justified. B. — Removal of the Tonsils. Suggested by Bouchut, this practice should be classed with TREATMI.NT 423 cauterization. Its object is the same. It undertakes to des- troy the mischief on the spot, and to prevent infection of the economy. It was said to be an excellent preventive means of croup. The false membranes were said not to be reproduced upon the wound of the tonsils. Notwithstanding certain for- tunate cases reported by several physicians, this therapeutic method has had no other result than to give a denial to the theory which it should have sustained. Not only was the pro- pagation of the disease not arrested, but the wound of the ton- sils became covered with false membranes. Though this means did not succeed better, it may, however, when employed with a different object, render unquestionable service. When, by their enormous size, the tonsils obstruct respiration or degluti- tion, the patient finds a decided relief in their removal. Only a purely mechanical result, it is true, is produced thereby ; diphtheria itself is in no wise modified ; the wounds may even become covered with false membranes, but in such a case, this consideration becomes secondary, the principal indication has been met. C. — Astringents. These remedies claim to act upon the tissues by constring- ing them, giving them tone, and whilst shriveling the false membrane, hasten thus its separation. The principal ones are : Alum, tannin and borax. ^-J/7/;«.—Aretaeus prescribed it by insufflation, or incorporated it in honey. After having fallen into desuetude for ages it was restored by Trousseau who saw it used by an empiric, during an epidemic which he observed in Sologne. This remedy has the advantage of being easily applied, little painful, found every- where, and cheap. It is used as a gargle or as a mouth-wash in a dose of about 4. (i5). But its use is generally in the form of insufflations. This was the method of Areta;us ; in insuf- flating, it was carried to the bottom of the pharynx by means of a tube, or a hollow reed, or elder from which the pith has been removed. Trousseau used it the same way. At present the 424 DIPHTHERIA, CROUP AND TRACHEOTOMY. application is made much more simply with a gum pouch at- tached to a canula. The dose is not important ; it should be sufficient to cover freely the diseased surfaces with the pow- der. In the case of a child the physician takes his position as in cauterization, and places the insufflator in the throat, or the brush filled with the wash. The first method has the great advantage of not being painful and not provoking nausea. The insufflation should be made eight or ten times during the twen- ty-four hours ^or the first few days. Tannin. — This remedy is employed in the same dose and un- der the same form as alum. Aretaeus used gall-nuts as a mouth-wash and in insufflations. To render this medication still more powerful, one may, following the advice of Loiseau, of Montmartre, alternate, every quarter of an hour, the insuffla- tions of alum with those of tannin. This method is one which has given the best results, and has been employed by a large number of physicians. Barthez has often witnessed from it good local effects. Insufflations may be replaced by inhala- tions. For this purpose a solution strongly charged with tan- nin is placed in an atomizer. The operation is repeated five or six times a day. It has little practicability for children,who ill-submit to the applications which are a little too prolonged for them. Borax. — It is applied like the previous ones, either as a gar- gle, a wash, or by insufflations. The doses are the same as well as the effects. Sulphur. — Suggested by Jodin as being beneficial on the score of a parasiticide, sulphur has been prescribed by other observers who were less pre-occupied with theoretical ideas. Professor Barbosa, of Lisbon, author of remarkable memoirs on croup, has collected and published eighteen cases of child- ren and adults attacked with diphtheritic angina, and treated by the insufflation of unwashed flowers of sulphur (sulphur sub- limatum) made every three hours in the most serious cases, and every four hours in those of moderate gravity, and three times a day in the benign cases. From the next day the false membranes diminished in thickness, in extent and in consis- TREATMENT. 425 tence ; they assumed a creamy appearance and disappeared on the fourth day. We should, according to the advice of this author, cover all the false membranes with the sulphur, and a large part of the surrounding mucous membrane without fear- ing to use too much, this powder being perfectly innocent. The first application, and even those that follow, nearly always provoke contractions of the pharynx, cough, and sometimes vomitings which remove all the powder. It is necessary then to recommence the insufflation until tolerance is effected. When, for any reason, the insufflation cannot be practiced, sulphur should be applied either in the form of a mouth-wash, or even internally as an electuar}\ The insufflations should be directed towards all the accessible parts, in the throat, and in the nasal fossse and larynx if possible. In a quite recent com- munication with which Barbosa has kindly favored me, the learned professor insists very specially upon the really "admi- rable" effects of this medication. The distinguished ability that all recognize in him in such matters, imposes a duty of re- peating these interesting experiments. This remedy is also recommended in the same form by Dr. Ullersperger. Dr. Alban Liitz adds to the insufflation a gargle in which the flow- ers of sulphur is suspended in an emulsion : Flowers of sulphur, - - - 2.50 (40 grs.) Oil of sweet almonds, - - 180. (60). M. What is the modus operandi of sulphur administered by this method ? If we consider that the authors who employ it, rec- ommend the use of the unwashed flowers of sulphur, we may ask if the active principle is not the small quantity of sulphur- ous and sulphuric acids which the crude flowers of sulphur al- ways contains. Alcohol. — Much spoken of by the English, who use it either pure, painting it on, or diluted with equal parts of water as a gargle, this liquid has never had any well marked action. Oxalic acid. — Quite recently this article has been tried by 426 DIPHTIIKKIA, CROUr AND TRACHEOTOMY. Prota-Giurleo and Francesco, of Naples. It should be em- ployed bybrusliing on with a solution as follows: Oxalic acid - - - - I- (i5 grs.) Distilled water - - - - 20. (50.) M. or Oxalic acid _ - - - 15.(72.5.) Glycerine . . - - 100. (3.5.) M. At the same time the authors give internally the sulpho-car- bolate of quinine. They abstain from cauterization which they consider as dangerous. Kn resume, the astringent method, exempt from dangers, much more easy of application than the previous, constitutes really an undisputable advance. It has, however, still the in- convenience of irritating quite decidedly the throat, and of leaving a persistent disagreeable taste in the mouth, and thus presenting an obstacle to taking food. D, — Solvents. Impressed with the inherent defects of caustics and of astringents, several physicians have sought for medicinal agents which would exercise a solvent action upon the false membranes without attacking the neighboring tissues. The composition of the exudate being fibrinous, the problem con- sists in finding solvents for the fibrin which might not be irri- tant. Chemistry teaches that the acids, the alkalies and the mer- curials dissolve fibrin. It remains to choose from among these substances those which are harmless for the healthy tissues. Among the alkalies, the bicarbonate of sodium, ammonia, and lime-water have been tried. With the list of alkalies should be placed the neutral salts, which have a strong analogy to them; they are chlorate of potassium, chlorate of sodium and the iodate of potassium. From the acids we should reject the mineral acids of which we wish to avoid the caustic effect. The organic acids, such as the citric acid and lactic acid, have been studied in this respect. The mercurials have furnished calomel and red precipitate. To this list must be added a metalloid, bromine, which presents analogous effects. TREATMENT. 42/ In the chapter on pathological anatomy is found the list of substances which ha\- solvent properties. Those whose clinical value has been proved are the only ones which we may consider here. 1st. Alkalies. — Bicarbonate of Sodium. — At the same time that this medicine is given internally, it is prescribed as a local application either by insufflations or by gargles. The treat- ment of diphtheritic angina by gargles of eau d'Vichy is very extensive. "Is it efficacious? I do not deny its utility in cases in which the false membranes are thin ; but when they are thick and resistant, the salt of Vichy, because of its slight action upon these products, cannot have a very energetic ther- apeutic value. Avinioiiia. — Barbosa, of Lisbon, has proved the solvent properties of a mixture of equal parts of glycerine and aqua ammoniae. If there is still danger of its irritant action, the proportion of glycerine may be increased in this mixture. Aqua Calcis. — Brought forward by Kiichenmeister, the sol- vent power that this preparation exercised upon the diphthe- ritic false membranes was applied throughout Germany. Bier- mer, of Bern (1864) gave it great praise. In a previous work I have repeated the experiments of these authors and made numerous clinical trials. Since that period the treatment of diphtheria with lime-water has been established in practice. In France, England and Germany it has numerous partisans. Quite recently Prof Steiner extolled its beneficial effects. It may be used in several ways : as a gargle, by inhalations and by irrigations. Gargling is an excellent method when the pa- tient can so use it ; this must not be expected before the age of six or eight. Lime-water may be used pure, but in some cases it slightly excoriates the lips. It is better to add equal parts or half the weight of milk. The gargling should be made as frequently and as prolonged as possible. During the oper- ation the patient should avoid passing the expired air through the mouth ; carbonic acid rapidly changes the lime-water into inert carbonate of lime. Inhalations are made by placing the medicine in an atomizing apparatus. This procedure has one 428 DIPHTHERIA, CROUP AND TRACHEOTOMY. serious inconvenience. The condition of extreme division in which the lime-water is thrown infinitely increases its con- tact with atmospheric air, and greatly favors its reduction into carbonate of lime, the action of which is negative. Besides, it is not always easy to prevail on a child to hold his mouth open for the necessary length of time. Irrigation is a very good method; it is employed when the first two cannot be applied; it is preferable to the second. An irrigator being filled with lime-water diluted with milk, as for gargling, the patient, placed over a wash-basin, inclines the head forwards. The cannula introduced into the mouth, directs upon the diseased parts the entire contents of the instrument. It is well to re- peat the operation quite often, about every hour. Finally, if none of these three means is applicable it may be necessary to touch the false membranes with a brush dipped in saccharat-e of lime or syrup of livie. This preparation has the advantage of being stable. The saccharate is much more active than lime-water, with- out being at all caustic, since it contains a larger quantity of lime than lime-water, lO. (2Y2 5) of the saccharate containing 0.25 (5 grs.) of lime, while the same quantity of lime-water represents only O.oi ('/,; gr.) By its action of insulating bodies, the excess of sugar contained in the preparation explains this peculiarity. It increases and renders more durable the con- tact of the medicine with the morbid products. Treatment by lime-water gives good local results ; it is neither painful nor disao-reeable to the taste, and it does not interfere with the ap- petite. It may be classed with those which combine the con- ditions required of local treatment. 2d. Neutral Salts. Chlorate of Potassium. — This remedy is perhaps the one which has been most used in the treatment of diphtheritic angina. Robert Thomas, of Salisbury (18 18), first proposed it for an- gina maligna. Chaussier (1819) extolled it in croup. After having fallen for quite a long time into oblivion, it was pre- scribed by Hunt (1847) and by Babbington (1853) in gangrene of the mouth, by West, Henoch (1850), Herpin, of Geneva, TREATMENT. 429 Blache (1855) and Barthez in mercurial stomatitis, and in gan- grene of the mouth and pseudo-membranous stomatitis, and by Bergeron (1855) in ulcerous stomatitis. From ulcerous stoma- titis to diphtheritic angina there is but one step ; Blach crossed it and tried the salts of Berthollet in this disease. But this treatment was established upon a scientific basis only after the appearance of the memoir of Isambert (1856). This learned author showed that this substance was eliminated partly by the saliva ; that it increased the flow of saliva and resulted in a kind of elective action upon the mucous membranes of the throat ; the mucous membrane is changed and cleansed, and the false membranes separate. A general influence upon the economy has been ascribed also to the chlorate of potassium, by which there is an influence exerted against the reproduction of the false membranes. The salt of Berthollet is used as a local ap- plication, as a gargle, 8. to 10. (2-3.5) of the salt to 250. (83) of water; and internally, 4. (i5) in 125. (4S) of water, which is taken in spoonful doses every hour. After having been praised by many authors, among whom must be mentioned Andre,Thore, Petit, Millard, and Chavanne, and after having been prescribed as a specific in diphtheria, chlorate of potassium fell into almost complete discredit. It deserves better, and may render service, if one does not re- quire of it more than it can perform. Its action is, in fact, real, but feeble ; it is purely local. When a concentrated solution of chlorate of potash is placed in contact with the false mem- branes, it attacks them, but slowly. Now, being eliminated by the saliva, this compound is found in permanent contact with the exudates upon which it acts as the solution does, with this difference, that the latter is concentrated, while the saliva never contains the salt in strong proportion. This property of chlor- ate of potash of maintaining itself in permanent contact with the pseudo-membranous products was utilized, but in no case could one depend upon a rapid and energetic action. It may, therefore, give good results in angina with thin false mem- branes, but it remains without result when the exudate is thick and consistent. Its use should be supplemented by that of 43*^ DIPHTHERIA, CROUP AND TRACHEOTOMY. another agent more active, lime-water for example. In that case it does service, and so much the better as it is perfectly in- nocent, being deprived of the peculiar action of the alka- lies. [This remedy is regaining its lost ground in Europe, It is now used freely internally — even in saturated solution. The only precaution to be especially observed is not to give it on an empty stomach. — Seeligmfiller,Grunberg,HacJilcr, Hullmann, J. Santy. Am. Jour. Obs., May, 1885]. Chlorate of Sodium. — Possessed of a more energetic solvent power, as Barthez has shown, this remedy is employed like the chlorate of potash ; the solubility being greater permits of the administration of larger doses. lodate of Potassium. — Demarquay and Gustin proposed this salt in the place of chlorate of potash. It acts more promptly and in a less dose — from 0.25 to I. (4 — 15 grs.). A peculiar sensation of constriction of the throat is produced when 1.50 — 2. (20 — 30 grs.) are given. 3d. Acids. Lemon Juice. — This remedy has been in use for a long time. Guersant and Blache used it in mild cases. Re- villiout prescribed it in almost continuous applications, about every ten minutes. He used in the beginning as much as four lemons an honr, of which the juice was partly conveyed to the back part of the mouth. When improvement appeared he di- minished gradually the dose, so as to use not more than three, two or even one lemon in an hour. To complete the cure, from one hundred and eighty to two hundred lemons were sometimes used. Although, from the admission of the author, this remedy was quite painful, and it was said to have an un- doubted solvent action, yet it acts in the same manner as the caustics, and is open, therefore, to the same objections. Dr. Chatard, of Bordeaux, praises this remedy also, which, however, he changes slightly by prescribing the gargle only every half hour, and uses only seventy-seven lemons. Dr. Soule, of Bordeaux, in 1836, in this way obtained good effects from the local action of lemon juice. These effects may be obtained without danger, by using this product ia weaker TREATMENT. 43 I doses ; besides, it is in this way we generally proceed with the lemon treatment. Touch every half hour the affected part with a brush dipped in the lemon juice. Quite a number of practitioners unite this treatment with the alkaline. This lat- ter method consists in alternating the gargle of eau d' Vichy with the applications of the lemon juice. By whatever method this treatment is applied the results reached are not very con- clusive, which is not surprising considering the slow and quite feeble solubility of the false membranes in citric acid. Other solvents exist which deserve preference. Lactic Acid. — Suggested Bricheteau and Adrian it acts rap- idly upon the false membranes. This is, next to lime water, the most powerful re-agent. These authors advocate its use in the form of inhalations according to the following formulae : Water, - - lOO. (3 %) Lactic acid - - 5. (i 1/4 5). As a gargle: Or, Water, 100. (3 5). Lactic acid, . _ _ - - 5. (1Y4 5). Syrup of orange, - - - - 30- (i §). Prof. Steiner has used this remedy with the atomizer, fifteen to twenty drops in 30. {}%) of distilled water. He has wit- nessed a preceptible improvement after each inhalation. Dr. Bruno Fehrmann used it for a year in the service of Prof. Wunderlich, at Leipzig ; he used it in the proportion of one-seventh, one-tenth, and even to one-fiftieth as a spray. He thought he saw the arrest of the process in some grave cases. Kiichenmeister, on the contrary, claims that lactic acid has no beneficial effect, and that it has the inconvenience of disgust- ing children and ulcerating the lips as well as the mouth. Gargles and inhalations may, indeed, produce these unpleas- ant results. The best mode of proceeding appears to me to consist in touching the false membrane frequently with a brush dipped in the following mixture : Glycerine 60., lactic acid 3. Acetic Acid. — The vaporization (spray) of solutions of acetic 432 DIPHTHERIA, CROUP, AND TRACH ICOTOMY. acid of different degrees of strength, is said to produce good results at the Charity Hospital, New York. No definite re- ports (N. Y. Med. Record, 1874, p. 144) are given in support of the assertion. 4th. Mercurials. — Red prcipitate and calomel have been used in some cases of pseudo-membranous affection. They have been thrown, in the form of powder, upon the diseased parts. The action of these remedies is unimportant. 5th. Brojjiine. — Independently of its internal use, bromine has been used locally. I have already indicated its use as a gargle in a '/soo solution as being prescribed concurrently with its internal use. Dr. Rapp paints the throat three or four times a day with the following solution : ^ Bromini, Bromidi potassii - - - aa O.50 (772 grs.) Aq. destill. - . . _ 100. (s'A, S). M. Dr. Schiitz, of Prague, had previously spoken highly of this remedy. Dr. Goltwald also praises it in the highest terms. These preparations exert upon the false membranes a certain solvent action, inferior in every respect to that of lime-water and of lactic acid. 6th. Glycerine of which the solvent properties have been an- nounced, has, really, no action. Antiseptics. These remedies are of incontestible value in the local treat- ment of diphtheria. They do not claim so much as the pre- ceding; they do not pretend to destroy or dissolve the false membranes; but when the latter are altered, when an abundant sero-purulent ichor, often mixed with putrefied blood, is dif- fused in the mouth, the absorption of these products by the digestive tract or by the denuded parts of the buccal mucous membrane, exposes the patient to putrid infection. It is then that antiseptics are highly indicated. They should be em- ployed largely by irrigations, following the method which I have already indicated. The injections should be frequent in TREATMENT. 433 order to neutralize, in the most complete manner, the incessant production of septic materials. Labarraque's solution and the permanganate of potash have been advocated for this purpose. Carbolic acid, this highly reputed disinfectant, has been em- ployed by several authors. Dr. Rothe, of Altenburg, uses it by painting on an alcoholic solution of one-fifth. ^ Tinct. iodini - - - - - 4. (l 5)- Acid, carbolici. AlcohoHs - aa 8. (2 5). Aq. destillatae - - - - - 40. (10 5) M. He thus obtained success in fifteen cases. Dr. Schlier used it exclusively in thirty-six cases, quite grave, either in the one-tenth solution used with the brush, or in one per cent, used as a gargle. The mortality was one-sixth. All the deaths were among children under 4 years of age. Dr. Giovanni, by applying a one per cent, solution every quar- ter of an hour to the affected parts, had but one death in fifty- eight cases. Dr. Brasch also recommends carbolic acid locally at the same time as the ferrated glycerine internally. In adopting this treatment he had not seen the mortality exceed 20 per cent., while in cauterization and mercurialization it had risen as high as 57 per cent. I dare not affirm that these figures have all the value that their author gives them. The conditions of comparison fail between the two series of cases. They are in every respect quite probable and worthy of attention. Dr. Cal- ligari has also obtained from it good results. Several of the authors whom I have cited are satisfied to employ the carbolic acid by painting it on. There is decided benefit in prescribing gargles or frequent irrigations with the one per cent, solution. Cliloral. — Since the antiseptic properties of chloral have been demonstrated, it has been suggested to use it in diph- theria. Dr. Accetella, (1873) considering diphtheria as a parasitic disease, treats it by painting four times a day upon the dis- eased mucous membranes the following solution: Chloral i. 434 DIPHTHERIA, CROUP AND TRACHEOTOMY. (15 grs.), distilled water, 5. (75 gtt.). gargles with a solution of one part to 23 of water are used for adults. Marc See, (1875) has quite recently extolled the use of chloral in diphtheria of the vulva. This local application, used by him at the suggestion of Bergeron, has given him the best results. The preparation used is a one per cent, solution. These facts should encourage the general use of chloral in all cases of diphtheria, and in angina in particular. This compound being antiseptic, equally energetic with carbolic acid, and of more convenient application, one should in all cases which present the indications for disinfectants, employ chloral in one per cent, solution as a gargle or by irrigations. [In a recent work on "Diphtheria, Croup, etc., also a delinea- tion of the new chloral hydrate method of treating the same, and its title to be considered a specific^' by C. B, Galentine, M. D., Cleveland, O., 1884, the following remark in the pre- face is found : "The writer has been led, or driven, into a new and hitherto untried (?) field of therapeutics in this destructive disease, and for several years, in the treatment of hundreds of cases has demonstrated to his entire satisfaction the claims of chloral hydrate to specific efficacy in the membranous diseases, diphtheria, croup, etc." Diphtheria and croup are spoken of as two diseases, but " that its (chloral hydrate's) therapeutic effi- cacy in croup is believed to be as rational and as well estab- lished as in that (diphtheria) disease." " To assure its greatest efficiency, it should not only be given early in the disease, but should be given freely and persistently, To a patient two or three years old either of the formulae (23 or 24) may be em- ployed in appropriate doses every hour or oftener when awake. The following are the formulae : B« Chloral, hydrat. Potass, chlorat. _ - - aa 40 grs. (3.20; Spts. gaulth. vel. Spts. menth. pip. - - - i 5 (4.00) Syrup, simpl,, aq. - - - aa 2 5 (64.00). M. Dose, a teaspoonful or a teaspoonful and a half every hour, when awake, to a child from 5 to 10 years old. TREATMENT. 435 J^ Chloral, hydrat, Brom. ammon. - - - - aa 70 grs. (5.00). Spts. chloroform. - - - 1-2 3 (4-to 8.) Syrup, simpl. Aquae - - - - - aa 2 5 (64.00). M. Dose, for an adult, two teaspoonfuls every hour. It is used also as a local remedy.] Salicylic acid. — The German school, persuaded of the para sitic nature of diphtheria, applies in this disease all the para- sitical agents. With this view, salicylic acid, vaunted at this time as antiparasitic and powerfully disinfectant, has been used by Wagner and Fontheim. The latter used a one per cent, aqueous solution as a gargle, and by painting it on. [Dr. Bedford Brown, of Alexandria, Va., recently in a report on the treatment of diphtheria recommended highly the following local application : Listerinei --- i6. ('/■■/|) Aq. cinnamomi, .-_-_-- 128. (4!^) Liq. sod. chlorinat.e, ------- 16. ('/2§) Acid carbol. gtt- 6. M To be applied to the nose and throat by means of the syringe or atomizer. In the hsemorrhagic variety he uses oil of turpentine, ergot and digitalis internally; and as a spray, a dilute form of Monsel's solution. 'Listerine is prepared by a pharmacal company in St Louis, and is, according to formula composed of the essential constituents of thyme, eucalyptus, baptisia, gaul- theria and mentha arvensis, together with refined benzo-boracic acid.] Emetics, — These, with cauterization, form the classic treat- ment of diphtheria. Without taking the emetic in contra- stimulant doses, many physicians prescribe one or more emet- ics. It seems as though the treatment would be regarded as in- complete without these means. One counts upon their me- chanical action to clear the throat of false membranes. It is for this reason that I have placed this method of treatment by the side of those which exert direct effects upon the false mem- branes. By admitting that this mode of action may indeed be beneficial, which is doubtful since the false membrane which separates is replaced by another, at least that the process itself is not arrested, by admitting, I say, this principle, two points present themselves, viz., the false membrane adheres firmly, or it is in process of separating. In the first, the emetic is cer- 436 DIPHTHERIA, CROUP AND TRACHEOTOMY. tainly insufficient ; in the second it is useless. Why make the patient vomit when it is so easy to complete the work com- menced by seizing the false membrane with the forceps. One spares the patient the unavoidable fatigue of vomiting (a mat- ter which is worthy of being taken into consideration in the case of diphtheria), as well as the diarrhoea, often very free, which is the consequence of it. For these reasons Barthez has for a long time, in such cases, renounced the emetic treat- ment. Conclusion. — It may be seen from this review that local modifiers in the treatment of diphtheritic angina are not want- ing. If the disease was purely local, one would find, without difficulty, in this therapeutic list, some means to master it. However, all are not equally good. Some, as cauterizations, are dangerous and worse than the disease. Others, more mild, are not always efficacious, and if they have an action suffi- ciently marked upon the thin, semi-transparent, soft false mem- branes, they effect but little those which are thick, opaque, and hard. Moreover, it is necessary, in order that their action be manifest, that their contact with the exudate be sufficiently prolonged. Now, this condition is not always easy to fulfil. But even when thus favored, one succeeds in attacking the exudate, thinning and dissolving it, he has not succeeded in preventing the one which he separated from being replaced by another ; neither has he prevented the extension of the disease ; he has only applied himself to the products while the disease itself was inaccessible. One no more cures diphtheria by de- stroying the false membranes than he cures small-pox by aborting the pustules. Therefore, we must recognize the fact that while the various local remedies, recommended in diph- theria, result in permitting the mild cases to recover, they do not prevent the grave ones from terminating fatally. None ot these means possess the power of limiting the diphtheritic pro- cess to the pharynx, and consequently of preventing croup ; no more can any of them boast of being an obstacle to general poisoning. Their use should be reserved for the cases in which the false membrane itself, constituting a danger by the mere TREATMENT. 437 fact of its situation, in croup, for example, should be promptly destroyed. In angina there is nothing similar, the danger is not in the false membrane itself but in the disease which pro- duces it and which poisons the economy at the same time that it provokes the fibrinous exudates. No rational indication de- mands, therefore, a destructive action of the false membranes. The antiseptics are an exception to this rule, and they may find, under certain circumstances, a useful application. Resume. Benign Diphtheritic Angina. — The indications are not numerous either on the part of the general or of the local condition. Gargles of lime-water diluted with one third of milk may be recommended. In young children we practice penciling with the saccharate of lime or with a mixture of lactic acid in glycerine, one to twenty. If the child refuses this treatment, it is better not to insist. If the disease is really be- nign it recovers itself; if it should become grave that is not the local treatment which will prevent it. Energetic means, such as cauterization, result only in extending the evil ; the re- sistance which one meets on the part of the patient, and the suffering which these applications produce, are positively in- jurious. The internal anti-diphtheritic treatment is useless, especially under these circumstances. The general condition should be carefully observed. Food should be recommended, even re- quired ; liquid food or of a soft consistency should be given by preference because of the difficulty of swallowing. We should insist upon the use of wine or beer, or coffee and qui- nine. Infections Diphtheritic Angina. — The local indications, even though secondary, should be taken into consideration. The abundance of the false membranes may be such as to become an additional obstacle to deglutition ; their alteration and the gangrene of the diseased parts give rise to an ichorous, san- guinolent oozing, the absorption of which may become the cause of septicaemic infection. In the beginning, the treatment is the same as in the benign form. When the thickness and extent of the false membranes, 438 DIPHTHERIA, CROUP AND TRACHEOTOMY. added to the adenitis, shall have shown the infectious form, we should give internally, in addition, a solution containing 4. (i 5) of chlorate of potassium, or 6 drops of bromine and 0.50 (8 grs.) ofbromide of potassium. Aside from the solvent action that they may have, these preparations have the prop- erty of being eliminated by the buccal mucous membrane and the saliva ; finally they possess the advantage of bringing in- cessantly into contact with the diseased surfaces a product which may modify and disinfect them. The alternating insuffla- tions of alum and tannin, and of flowers of sulphur, the inhal- ation of tannin, lime-water and lactic acid will also find their indications. If the false membranes are very thick and obstruct the isth- mus fauciiim, one removes them in whole or in part with the aid of the forceps. When they are altered, when the tissues, mor- tified or not, exhale a fetid odor, it is necessary to have re- course to irrigations. They constitute the best local treat- ment ; they wash the diseased parts even in the most distant recesses. They should be used according to the method indi- cated above, six or seven times a day, and more frequently still if the patient will permit it. A one per cent, solution of carbolic acid, chloral or salicylic acid should be used. In case of diphtheritic coryza irrigations of the nose should be prac- ticed also. The treatment of complications will be indicated hereafter. The general treatment should be provided for. Nourishment is more necessary than ever ; the taste of the child should be indulged, and if the object is not obtained by persuasion, re- course should be had to intimidation. Wine freely given, quinine in doses of 4. (i 5) of the extract in an infusion of cof- fee are of the highest necessity. Still the quinine may be ad- ministered in the form of a bolus of the extract containing i. (15 grs.) each, which is dissolved in a cup of strong coffee (without milk) at the proper time. These means, very useful in combating the infectious condition, should be aided by the internal administration of salicylic acid at the rate of 2. (30 grs.) a day. Collapse and adynamia demand cold lotions. TREATMENT. 439 Malignant Angina. — If the malignity is secondary the treat- ment should be commenced as in the preceding form. For the malignity itself, tonics, alcoholics, Spanish wines, sweetened spirits (grog) and cold lotions are the only means of safety. The malignity which is primarily manifested, is only amena- ble to the supporting and stimulant treatment, the local lesions being often insignificant in this case. § 2. — Croup, The present chapter takes the treatment from the moment at which the false membranes invade the larynx, whether the croup is announced primarily or consecutively to an angina. Asphyxia of various degrees being nearly always the fatal termination of croup, therapeutic efforts should tend to pre- vent this dreaded symptom, or to arrest it when it is produced. Medical and surgical means have been put in operation to ful- fill these two indications. Medical treatment. — Can croup be prevented ? Cauterizations and the local applications recommended with the object of preventing the propagation of the diphtheritic process from the pharynx to the larynx are unable to prevent the invasion. We proved that violent means result most clearly in diminish- ing the strength of the patient, and in rendering alimentation still more difficult. We may also demand whether, contrary to their purpose, they do not result, by denuding and irritating the healthy parts, in favoring the extension of the disease. From the appearance of the first symptoms of croup we should begin the battle. A material obstacle obstructs the respira- tion ; it should be surmounted. This is the principal indica- tion. In angina, the disease is everything, the false mem- brane is nothing or almost nothing ; in croup, on the contrary, the laryngeal exudate takes first rank, at least for the moment. This it is which is about to produce asphyxia,and we should re- move it. Medication thus understood does not reach the bot- tom, it attacks the lesion only. The obstacle when removed may be reformed ; that is true. But the cases in which croup has recovered after a single expulsion of false membranes are 440 DIPHTHERIA, CROUP AND TRACHEOTOMY. not rare ; if the obstruction should reform, one will always have gained time; he may hope to reach a time when, the process being exhausted, the production of false membranes will cease. The most urgent treatment, therefore, is that which is directly addressed to the false membrane. Several systems have been put into practice with the object of remov- ing the laryngeal obstruction. They all consist, either in de- stroying the false membrane by local changes, or by expelling it by means of sudden shocks (secousses) impressed upon the respiratory tract. For a certain time at the beginning of the disease, blisters to the front part of the neck have been prescribed, with the hope of overcoming the exudative inflammation and arresting the pseudo-membranous production. These means have no beneficial influence, but to the contrary. The irritated skin becomes covered, most frequently, with diphtheritic concretions. If the patient should be submitted to tracheotomy, the blister causes much difficulty in the per- formance of the operation. The tumefied and indurated tis- sues conceal the situation of the trachea; the land-marks be- come inappreciable, and the skin thus made slipper>-, offers no hold for the fingers. In short, the conditions are the most un- favorable under which the operation can be performed. Local Modifiers. We shall again meet all the modifiers proposed in angina, but as in croup the false membranes are not accessible to gar- gles, to penciling nor to insufflations, it becomes necessary to seek some special means to convey the remedy as far as the larynx. These are fumigations, inhalations and catheterism of the larynx. Fumigations constitute the most natural method of bringing the remedies in contact with the respiratory mucous mem- brane. Every volatile substance is conveyed by inspired air, and easily reaches its destination. The method most in use consists in placing by the bedside TREATMENT. 44-1 of the patient an apparatus in which water may be maintained in a state of ebullition during the entire time necessary. The substance, of which we desire the therapeutic action, is added to the water. A sheet arranged around the bed prevents the diffusion of the vapors ; those which emanate from the remedy, conveyed by those which arise from the water, form around the patient an artificial atmosphere, which is brought in constant contact with the air-passages. The vapors of pure water or charged with emollient plants, were at first employed, and this practice enjoyed a great run. Much was hoped from the prolonged bath of the respiratory mucous membrane which resulted from it. This is a rational means, but I do not believe that it ever prevented the develop- ment of the false membranes. Its true indication is found in stridulous laryngitis. Search also has been made for substan- ces the vapors of which might have a direct action upon the false membrane. However, amongst English physicians, the tent for inhalations still remains in favor. Fumigations of cEther, recommended at the beginning of the present century by Pinel and Alibert, have been brought again to light by Dr. Bisson. It is reported to have produced good effects ; in two cases of croup it is said to have aided in throwing off the false membranes. These cases are too few to enable the method to be judged of; besides, the use of the aether came in only after several other plans of treatment. Its action, it seems, is supposed to attack the spasmodic condition of the muscles of the larynx rather than the pseudo-membran- ous productions themselves. Iodine fiiniigations. — Being recommended by Warring Cur- ran, it is used in the following formula : ^ lodini. Potass, iodidi, aa - - - 0.20 (3 grs.) Alcohol, - - - - 12. (30) Aquae, - - - - - 120. (4§) Add to this mixture half a litre (pint) of vinegar and a hand- 442 DIPHTHERIA, CROUP AND TRACHEOTOMY. fulofsage. Take daily as high as a dozen inhalations of twelve minutes each for an adult. The dose of iodine should be rapidly increased according to the tolerance of the patient and other indications. In order to simplify the application of this process, the author recommends placing the mixture in a teapot, and breathing the vapor from the spout. A certain number of recoveries are said to have been the result of this method. It is to be feared, however, that the irritant action of the vapor of iodine might produce upon the respiratory tract injurious effects for which the theoretical advantage of the remedy would not compensate. This charge may be made in a general way against all irritating substances which are intro- duced into the respiratory tract. Should they be sufficiently diluted to be harmless, they lose their local action. Should they be sufficiently concentrated they irritate decidedly the lungs and become an active cause of pneumonia. This result is less to be feared with pulverizations (atomizations) which carry into the bronchi a homogeneous powder, while the fumi- gations carry mainly volatile substances ; these reaching the pulmonary mucous membrane almost in a pure state cauterize it. I shall place in the same category bromine fumigations recommended by Ozanam. Fumigations with sulphnret of mercury. — This system was conceived with the object of utilizing the solvent action which mercury exercises upon diphtheritic false membranes. Abeille placed at the foot of the patient's bed a wide-mouthed earthen vessel in which he kept, at the boiling point, water charged with emollient plants, viz., mallow, violets, poppies, and into which was thrown, every three hours, 2. ('/sO) of cinnabar. In nine cases of croup nine recoveries are said to have been obtained, and yet this treatment was seen to stop in the run of its recoveries ! It has been proved, in fact, that cinnabar does not emit vapors at the temperature of boiling water, but that it decomposes and eliminates sulphuretted hydrogen. The ap- paratus, therefore, furnishes simply vapor of water more or less charged with sulphuretted hydrogen, but none of the mer- cury. TREATMENT. 443 [NEW SPECIFIC TREATMENT OF DIPHTHERIA. By Dr. Dei/fhil. Presented to the Academy of Medicine, Paris, March 25, 1884, a dissertation in which he extols the use of fumigations of coal-tar and turpentine in the treatment of diphtheria. The conclusions of the memoir, in brief, are as follows; (Ann. des Mai. de I'ortille, der larynx, etc., Mai, 18S4. 1. The combustion, in the middle of the sick chamber, of a mixture of coal-tar (goudron de gaz) and of turpeniine in the proportion of about 200. of the former to 60. of the essence of tuipentine (lo to 3) or even turpentine alone, renewed every two or three hours, according to the gravity of the case, and at intervals according to the amelioration produced, is a specific medication in the treatment of diph- theria. 2. These fumigations are entirely inoffensive of themselves ; they are easily borne by the patient, and by the attendants, and they do not excite coughing. The amount may be varied considerably according to the indications and especially according to the size of the room occupied by the patient. I again repeat that Nor- wegian tar must not be used. 3. These anti-diphtheritic fumigations have for the false membranes disintegrating properties of a high order. 4. At the onset of the affection, they rapidly arrest the disease. 5. In a case in which the physician is called too late, they render eminently prac- tical the operation of tracheotomy when this latter becomes the last resort ; they transform this operation, palliative, expectant, and doubtful as it is in the immense majority of cases, into one with a well defined object ; they favor success. 6. These fumigations are prophylactic, protecting the attendants who wait on the p.itients; and by their microbicide or parasiticide and disinfectant properties, they re- move the danger of contagion. 7. They may, therefore, further be used to purify school-rooms,wards, public build- ings and hospitals. 8. Finally, this mode of treatment is recommended by its great simplicity, it can lie applied eveiywhere, and from the outset of the affection; in hospitals it will be easy to establish a room for fumigation. I shall conclude this communication by snyjig that I think the essence of turpentine alone or in combustion will probably s .nice.] Inhalations. — This method consists in making the patient in- hale vapors of volatile substances at an ordinary temperature, or liquids reduced by the atomizer to a condition analogous to that of vapor. The vapors of hydrochloric acid were employed by Bretonneau. Being partial to the action of hydrochloric acid upon false membranes of the throat, the physician of Tours thought that the vapors of this same product, conveyed into the air-passages, might have a similar effect upon the laryngeal 444 DIPHTHERIA, CROUP AND TRACHEOTOMY. false membranes. But this violent means, the irritant action of which could only favor the extension of the pseudo-mem- branous process and the development of pneumonia, has fallen into meiited neglect in spite of the ability which Homolle has displayed to rescue it. Inhalations of Ammonia recommended by Daguillon, of Oran, are practiced by means of a sponge dipped into ammonia and tied to a slender holder, and after being sufficiently pressed to free it of the excess of the liquid, it is passed between the tonsils without touching them. The heat of the region facili- tates the evaporation of the ammonia ; and the child is allowed to breath as long as he does not experience too much incon- venience. The operation is repeated three times in two hours. It is irnportant to follow it with washes, gargles and a drink of fresh water. At the same time the patient takes sulphuret of antimony, chlorate of potassium, and emetics; revulsives and discutients are applied to the neck. This treatment appears to me nearly as dangerous as the preceding and as every other which introduces irritant substances into the bronchial tubes. Pulverizations. Atomizing. — Barthez had the idea of apply- ing in croup the ingenious system invented by Sales-Girons for the treatment of chronic diseases of the air-passages. A solu- tion of tannin, one twentieth, or rarely one tenth, is the solu- tion used on this principle. The inhalations should be quite frequent, and should continue fifteen or twent)' minutes each time. The results obtained have been favorable. In the throat the false membranes are changed quite rapidly, and they be- come indurated, and as it were, tanned. In certain cases it was possible to obtain this action at the end of twenty-four hours. In patients attacked with croup the curative effect is mani- fest by the calming of the dyspnoea, and the disappearance of the attacks of suffocation. We have been able to find the air- passages absolutely clear, even when the diphtheritic poison- ing has produced death. Other substances have served for inhalations, among them the perchloride of iron, lime-water and lactic acid. Steiner has used lime-water and lactic acid TREATMENT. 445 largely; he speaks highly of their effects. Kiichenmeister, on the contrary, asserts that lactic acid has no beneficial action, ulcerates the lips and disgusts the children. The solution of bromine, i to 500, may also be employed by inhalation. It may be seen that there is not yet an agreement upon this point in therapeutics. In the meantime atomizations having, in general, no inconvenience, they may always be employed; we can obtain benefit from them in more than one case. The age of the children appears to me to have much influence in the difference of the results obtained. The atoms of water penetrate the air-passages so much far- ther when the patient submits readily. If we may admit, strictly speaking, though the fact has been denied, the en- trance of these preparations in the larynx in an atomized state, after having passed the nasal fossae, it is plain that the operation will give more definite results in a patient who would open the mouth largely and inspire strongly. In admitting that a part of the spray is condensed along the soft palate, we may acknowledge that a certain quantity pen- etrates the larynx. Children old enough to be reasonable, and adults, are, therefore, the only ones properly adapted to the operation ; one should explain the details to them and advise them to elevate the soft palate as much as possible. The so- lution of tannin, one part to twenty, lactic acid in the same proportion, and lime-water, appear to be the substances ofler- ing the most advantage. Lime-water, however, suggests to me a certain reserve. Injections into the trachea. — Two methods have been at- tempted for the introduction of lime-water into the air-pas- sages. Dr. Gottstein introduced it by the mouth. This method was quickly abandoned on account of the attacks of suffoca- tion produced by it. Dr. Albu, physician of the Saint Lazare Hospital, Berlin, conceived the idea of puncturing the trachea between two rings with a hypodermic syringe filled with lime- water, and injecting the contents into the trachea. Six pa- tients had, following the operation, violent attacks of coughing during which they expelled false membranes. 446 DIPHTHERIA, CROUP AND TRACHEOTOMY. This hazardous attempt gave only moderate results ; only one patient recovered. It may be remarked that the lime- water, applied by this method, could have no influence upon the false membranes of the larynx ; its action is limited to the trachea as in the instillations which are made through the can- ula after the operation of tracheotomy. These cases show that the injection had but one result, that of exciting a violent cough which might facilitate the expulsion of the false mem- branes. Catheterism of the larynx. — Formerly reserved for oedema- tous laryngitis, and to the asphyxia of the new born, this op- eration has been applied to croup by Loiseau, of Montmartre. This physician introduced directly into the larynx caustic or astringent substances. He announced a large number of re- coveries, the result of several years' practice. This communication created quite a sensation in the med- ical world ; it was tried on all sides. Large learned societies entered the subject in their order of the day. The Acadcuiie de medicine and the Societe medicale des liospitaux of Paris, caused the question to be examined by committees. Trousseau was the reporter for the first and Barthez for the second. Laryngeal catheterism proposes to apply to the false membranes which line the internal surface of this organ, substances capable of modifying them. The principal instru- ment is a laryngeal tube through which one may blow pow- ders and pass the probang carrying caustics, sponges, curettes, forceps, etc. The operative procedure is the following : the first phalanx of the left index finger, being guarded with a metallic ring about an inch in diameter, this finger is carried quickly to the bottom of the pharynx until it encounters the epiglottis which it raises and holds in this situation. The lar- yngeal tube, held in the right hand, is directed along the left index until it enters the larynx. The whistling escape of air through the tube proves that this has entered the air-passage. The following is a resume of the treatment of croup as pre- sented by Loiseau : 1st. Preventive treatment or in case of membranous angina TRKAIMENT. 447 the use of tannin and of alum as local applications ; tonic regimen, 2d. Membranous angina zvith commencement of aphonia or croupal voice : instillations of tannin and alum about the en- trance of the glottis added to the above treatment. 3d. Confiniied croup, but without the embarrassment oj the respiration : introduction of local styptics by the aid of cathe- terism. 4th. Confirmed croup tvith commencement of asphyxia : ex- traction of the false membranes by swabbing or scraping, and, above all, the introduction of astringents. 5th. Permanent asphyxia, but not yet threatening : endeavor to extract the false membranes, and perform tracheotomy if no beneficial change is obtained. 6th. Manifest [paraissaut) asphyxia presents imminent dan- ger: perform tracheotomy immediately, but if it is refused, practise catheterism as the last resource and endeavor to ex- tract the false membranes. This practice may be substituted for tracheotomy only when the latter is refused or contra-indicated. Local applications injected are, weak solutions of nitrate of silver, or astringent solutions of alum and tannin ; energetic caustics are proscribed. To the medicinal applications should be added the swabbing or scraping of the larynx with the dry sponge. All internal treatment, except quinine, should be abandoned. Food and wine are the only^ internal means ad- mitted. After having proved that, in a large number of the cases re- ported by Loiseau in support of his method, the diagnosis was very questionable, Barthez studied the results of this treat- ment. The operation is, generally speaking, easy ; however, difficulties are encountered in very young children of which the mouth may not always admit the protective ring, and in which the larynx is too narrow for sounding, Catheterism was nearly always well borne ; in cases, however, in which forced scraping or friction of the larynx has been practiced with a dry sponge, the patient complained of pain. In some 448 DIPHTHERIA, CROUP AND TRACHEOTOMY. circumstances a sudden amelioration, though transient, was noted immediately after the operation. Cauterization of the larynx with nitrate of silver is, of all the measures, that which produced most frequently a momentary improvement. But, more commonly, injections provoked fits of coughing or attacks of suffocation. Dr. Costilhes in this way lost one of his patients ; such an accident was near hap- pening to Peter. In a certain number of cases the asphyxia continued to increase and tracheotomy became necessary. This aggravation of asphyxia was sufficiently frequent to cause several physicians to take the precaution to make every pre- paration for tracheotomy, when a child was to be subjected to the treatment of Loiseau. Spasms of the larynx and rolling back of the false membranes by the instrument appeared to be the cause of these accidents. It is necessary, also, to mention the cases of pneumonia which were the consequence of injection of the bronchial tubes, with astringent solutions and especially with caustics. In 26 patients subjected to catheterism, Barthez witnessed 13 recoveries of which four only could be attributed to the treat- ment; in nine others it had to be abandoned, and recover}- was due seven times to tracheotomy, and twice to internal treatment. This question was recently studied in Germany by Schrotter and von Huttenbrenner. The conclusions of these authors are the same. Catheterism of the larynx may in some cases produce good results, but most frequently it brings onh' temporary allevia- tion. It has many disadvantages, to- wit, it may kill at once, or aggravate the oppression and cause paroxysms of suffoca- tion. When it is repeated frequently it is especially depress- ing to the forces. The introduction of the wedge between the teeth may injure the gums ; and also, the contact of the instru- ments with the mucous membrane of the larynx, especially when scraping is practiced, may excoriate this membrane ; thence extension of the false membranes. The doubt- ful advantages which this method of treatment produces are, therefore, fully balanced by the dangers to which it ex- TREATMENT. 449 poses. It is but right that it has fallen into desuetude after having enjoyed an ephemeral notoriety. In the same list with the method of Loiseau may be placed the cauterizations of the larynx practiced by means of a sponge dipped in a solution of caustic and attached to the end of a curved whalebone. This treatment which, without having any of the advantages of the former, increases the inconveniences and adds others still more serious, and should be absolutely banished from the practice. Local modifiers after absorption. — The chlorate of potassium, the balsams and the bromides have been administered in croup without very important results. The chlorate of potassium is eliminated by the saliva and by the buccal mucous membrane; it is without effect upon the respiratory passages ; its action is, therefore, nil upon the laryngeal false membranes. I have shown how questionable was the influence of the balsams, and will not recur to them. The bromine preparations, being eliminated by the air-passages, may have a modifying influence on the mucous membrane and on the false membranes. With that view their use is rational. Is it effectual ? Experience is not sufficient in this respect, but these means deserve a more extended trial. EMETICS. It is not sufficient to endeavor to destroy or to modify the false membranes; when asphyxia commences we must endeavor to expel them quickly. The violent efforts, the energetic con- tractions which accompany the vomiting facilitate and com- plete the separation of the exudates and then expel them. Ancient as well as modern authors recognize the benefit of emetics ; it is the only medication which has continued through the ages, was employed differently according to the theory which prevailed, and has never been abandoned. The emetic method, properly speaking, will be a special question ; the contra-stimulant method has heretofore been set forth. Tartar emetic was for a long time the only one in use. It is still given in doses of O.05 (Vi gr.) to .10 to .15 (172 gr.to 2 gr.) alone or combined A^ith ipecacuanha. The first dose is usually 450 DIPHTHERIA, CROUP AND TRACHEOTOMY. sufficient to produce vomiting ; the others often excite diar- rhcea and depression of the forces. These disadvantages are not always avoided even by the small doses, especially in children. Therefore, it is necessary to be very cautious with tartar emetic in early age. It would be better to renounce it absolutely. This is the course which I have taken ; such is also the practice of Barthez. It is well, when we have recourse to this remedy, to have the patient drink but little ; neglect of this precaution would increase the chances of intestinal symptoms. Sulphate of Copper. — This remedy has been largely used. It was advocated originally by Hoffmann in 1821, and by Zim- mermann, Droste and by Serlo, who appear to have employed it rather in stridulous laryngitis, and by Harless, Korting, Diirr and Beringuier. Prof. Stoeber, of Strasburg, spoke of it in the highest terms. Trousseau considered it the most certain of the emetics. It is given in small doses, from 0.20, O.30 to 0.40 (3 to 6 grs.) or more in divided doses. Notwithstanding the advantages which have been conceded to it^ this salt is quite an energetic irritant ; it provokes gastric pains, and quite frequently induces diarrhoea. Ipecacuanha. — This is the emetic which is best suited for children ; there is less risk of intestinal complications with it than with any other. Ipecac may be given in powder in a dose of 0.50 to 1. 50, (7 to 20 grs.) mixed with a little water. Other substances have been recommended as emetics, such as the sulphate of zinc, senega, violet root, etc. They were used only on rare occasions and are now out of use. To this list it is proper to add a medicine recently discovered — apo- morphia. I have not had occasion to use it in the case of croup ; I know not whether other physicians have tried it. It possesses properties which appear to recommend it in a very special manner in this disease. It is administered by the hy- podermic method which avoids the resistance which children so frequently make to taking emetics. It acts very quickly, in from three to five minutes ; it obviates or abridges very much TREATMENT. 451 the peroid of nausea. It often succeeds in cases where other emetics have no effect. Therefore, there is ease of ad- ministration, rapidity of action and exhaustion less decided. These reasons are of much value. The only obstacle to its general introduction is its difficulty of preservation. It changes very rapidly. Remedies to be employed in croup should be always within reach. Whatever remedy one may make choice of, it remains to be understood at what period of the disease it should be given and in what proportion. Emetics have been administered in all periods of croup. We should consider, however, that their action being purely me- chanical, they can only have effect at the moment when the false membrane begins to separate; the efforts then have the effect of facilitating its separation. They have still a useful result in these cases in which the exudate is thin, friable, slightly adherent and remain so. Now, it is not in the first period that the false membrane begins to be less adherent, so that it can be removed by an effort ; on the other hand, if it remains thin and friable, it rarely conducts the disease beyond the first period. Hence, it is at the beginning of the second, at the moment when asphyxia commences, that emetics ought to be administered. Later, at the third period, from the fact of diminished activity of absorption, or of anaesthesia of the gastric membrane, they remain without effect. In what proportion should they be prescribed ? Many au- thors have held that emetics act well only when given fre- quently dose after dose. Valleix and Bouchut have made them- selves particularly the champions of this method. Some fortu- nate series have been reported in its support, However,this sys- tem has disadvantages greater than its advantages. Under the influence of repeated emetics we see the patients grow pale, become depressed, and refuse food; in spite of all the prcautions uncontrollable vomiting and obstinate diarrhoea supervene. Tracheotomy, to which we nearly always come, at last, how will it be borne by a patient reduced to such a state of de- pression ? In this respect I support my opinion by that of 452 DIPHTHERIA, CROUP AND TRACHEOTOMY. two physicians of great distinction, Trousseau and Barthez, who have shown in many cases the fatal effects of repeated emetics upon the results of tracheotomy. These two masters have positively affirmed that, in cases of equal intensity, the results of tracheotomy are so much the more favorable in pro- portion as the patients have been less tormented by previous medical treatment. Repeated emetics have other dangers. It is not rare that the attacks of suffocation supervene while the patient finds him- self under the influence of the emetic ; death may be the re- sult of such an accident. There is, finally, a more frequent ac- cident than is generally believed. When one is lavish with emetics in all the periods of croup, the third having arrived, the economy no longer responds to these remedies ; I have in- dicated the reason of it. The emetic remaining without ef- fect another is given with the hope of seeing it act, and some- times several afterwards with no better results. Tracheotomy is performed, asphyxia is removed, anaesthesia disappears, and absorption is resumed. The emetics which have accumulated during the period of asphyxia begin then to act • thence general breaking down, prostration and symp- toms of great gravity which compromise the success of the op- eration. Emetics, are, therefore, useful, but only when given at a proper time, about the commencement of the second period, and wisely managed. I do not pretend that one should always limit himself to a single trial. If the first is well borne, and the indications are decided, nothing prevents the repetition. Dr. Fleischmann has recently produced statistics of a kind to show that this method of treatment has not always the advan- tao-es which have been attributed to it. Of thirty-seven chil- dren treated from 1863 to 1873 by emetics solely, and not m tracheotomized, he counted only three recoveries. Ster)iiitatori€s. — Advocated by some physicians, the use of these remedies has fallen into oblivion. It appears, a priori, says Barthez and Rilliet, that sneezing, which is only a sudden expiration, ought to be a valuable means for favoring the de- TREATMENT. 453 tachment and rejection of the false membrane. In this respect, this medication may be compared, to a certain degree, with treatment by emetics. If it is desired to have recourse to this treatment, we intro- duce into the nostrils of the child some snuff, or,what is better, the Saint-Ange powder, an officinal mixture of powdered asa- rum, betony, and vervain. Facts which may be cited in support of this method are rare and unsatisfactory. Antispasmodics, — Musk, camphor, opium, assafoetida, aether, belladonna and all the principles of the antispasmodic or cal- mative remedies have been used in the treatment of croup by the ancient authors : Millar, Thomson, Underwood, Cheyne, Vieusseux, Weichmann, Albers, Ruysch, Pinel, Jurine, Hen- drick, and others. It is proper to state that these remedies found their advantages at a period when croup was confounded with stidulous laryngitis ; since the differential diagnosis of these two diseases is definitely established, they are almost ex- clusively reserved for the latter disease. They are no longer directed against croup itself, but they may fulfill some in- dications when there is a predominance of the nervous ele- ment. Resume. A child is attacked with croup. What course should the physician pursue? The indications are general and local. The first should be met above all else, even to the disparagement of the second. Nourishment, tonics and rest combat, as far as it is possible, the depressing effects of the poisoning ; even in case of failure one may have the consciousness that these means were not in- jurious. I shall not say as much of the treatment which has for its end the fulfilling of local indications. Often ineffica- cious, they may be dangerous, for example, cauterization. It is necessary, therefore, to consider, first of all, the general condi- tion. Perhaps it would be paradoxical to sustain the absolute uselessness of local means. However, the reader could con- vince himself in following the long enumeration of modifiers of the false membrane, that there is none of them of which the 454 DIPHTHERIA, CROUP AND TRACHEOTOMY. action is certain. If he must not neglect them, because he should endeavor to equalize the respiration, he should be care- ful to avoid sacrificing the general indication. This would be to deprive the patient of his best chances for recovery. We shall, therefore, reject the barbarous methods of cauterization and of laryngeal catheterism, as well as the introduction into the bronchi, of irritant vapors of which the most certain effect is to set up broncho-pneumonia, that complication so fearful and so frequent. One should abandon those internal remedies of which the efficiency is always doubtful, however little they may be repugnant to the patient and diminish the appetite and offend the digestive apparatus. This is to acknowledge the little con- fidence inspired in us by the specific or local agents which we bring to bear against croup. This admission is painful, but it is useful. It teaches to be careful in the use of these remedies and to apply them only on condition that they do no harm : pfimnin non nocere. Observe then in what sense the treatment may be planned : In the first period, the local applications to be employed are inhalations of lime-water, lactic acid, bromine-water and solu- tions of tannin atomized. If the age of the patient will admit, the mouth should be held open during the inhalations ; if it is too young, we content ourselves with producing around the patient a medicated atmosphere. The applications should be continued long, and be frequent; ten or twelve times a day of a half hour each. At the same time we may administer internally the bromine solution, the formula of which I gave. If the child refuse it we shall not insist. In the second period, at the commencement, we administer fromo.50to 1.50 (7 to 20 grs.) of ipecac mixed inalittle water. If this first emetic produces the desired effect without fatigue, we may, if the disease continues its course, prescribe a second. It is rarely advisable to go beyond that; fatigue occurs as well as diarrhoea ; then the patients no longer respond to the action of emetics. If the occasion presents itself, one should give, in place of the ipecac, a dose of from 0.005 ^o O.O06 (Yisto '/u of a TREATMENT. 455 gr.) of apomorphia introduced by the hypodermic method on the posterior surface of the forearm, a part where the sensibil- ity is not so acute. This remedy would be especially indicated if the other emetics have failed. In the intervals between the emetics inhalation should be continued. Under the influence of this treatment it quite often happens that the disease is checked and the false membranes are expelled: but still oftener it passes to the third period \ then it is that the indication for tracheotomy is established. During the use of local remedies the general treatment will not be neg- lected. Food should be administered in all forms, following the directions that I gave when speaking of the general treat- ment of diphtheria. Tonics, properly so-called, cinchona es- pecially, at the rate of 4. (i5) of the extract daily, will not be forgotten. Results. By the use of this treatment we reach results worthy of being signalized. Whether one invokes the efficiency of therapeutics, or modestly refers the recoveries to the benign- ity of the malady, a certain number of recoveries have been ob- served. The other patients were operated on or died without operation, relief having arrived too late, or tracheotomy was contra-indicated by the intensity of the poisoning, and by the generalization of diphtheria. 456 DIPHTHERIA. CROUP AND TRACHEOTOMY. THE REGISTERS OF THE SAINTE EUGENIE HOSPITAL, KEPT FROM ITS FOUNDATION IN 1854, TABULATE THE CASES OF CROUP TREATED IN THAT ESTABLISH- MENT. AS FOLLOWS. Total Cases. CASES NOT OPERATED ON. Cases of Years Recovered. Died. Left not Re- covered. Croup Op- eration. 1854 17 3 5 — 9 1855 29 5 II — 13 1856 41 5 12 — 24 1857 54 9 14 I 30 1858 146 8 12 4 122 1859 150 20 20 I 109 i860 65 5 20 — 40 1861 75 4 7 — 64 1862 109 8 3 I 97 1863 121 13 2 106 1864 129 8 6 — "5 1865 162 13 II I 137 1866 140 9 15 I "5 1867 108 6 6 — 96 1868 167 14 17 I 135 1869 141 12 25 I 103 1870 149 5 13 — 131 1871 "3 9 9 2 93 1872 201 3 10 I 187 1873 230 2 II 4 213 1874 184 10 10 2 162 1875 278 33 28 6 211 2,809 204 265 28 2,312 TREATMENT, 45/ In 2,809 cases of croup, 204, that is i in 13, was able, there- fore, to avoid tracheotomy ; 265 died without operation ; and 2,312 required the operation. The number of croup cases ar- rested in their course is comparatively small ; it may be suf- ficient to encourage a commencement by medical means with- out falling into the great mistake [illusion) of the value of this treatment. One should, consequently, be very cafeful not to depress the patients, and submit them to surgical treatment when the strength is exhausted. Trousseau stated correctly that subjects who have reached croupal suffocation, free from previous treatment, have the most numerous chances allotted them for recovery after tracheotomy. Although true in prin- ciple, this precept cannot be applied without limit. The duty is incumbent to do whatever is possible to bring about recov- ery without tracheotomy. Bnt it is necessary to be very mod- erate in the use of emetics, local applications and so-called specifics. These means are often useless, and always depress- ing. Pushed to the extreme they do not prevent tracheotomy, but influence its results in a manner most deplorable. SURGICAL TREATMENT. TRACHEOTOMY. When nothing has been able to arrest the course of the dis- ease, and asphyxia, already commenced, threatens to become complete, there remains but one hope — recourse to tracheot- omy. This valuable operation has rescued from death a large number of patients otherwise irrevocably lost. Its populariza- tion will be Trousseau's highest claim to recognition by pos- terity. Coelius Aurelianus and Galen accredit Asclepiades with hav- ing extolled tracheotomy in angina suffocans at the time of Cicero. These authors transmit nothing of the operative pro- cedure which Asclepiades may have employed, nor has Are- taeus who unites with Coelius Aurelianus in severely criticising this operation. The first surgeon of antiquity of whose manner of operating we have any knowledge is Antyllus, cited by Paulus /Egineta. This surgeon points out very definitely that the operation has for its object the relief of suffocation caused by an inflammation seated in the pharynx (throat) above the larynx. He insists upon its advantage before the trachea is invaded. He makes the incision transversely below the third or the fourth ring of the trachea, being careful not to cut the cartilages, but the membrane which unites them. The recommendations which he gave concerning the details of the operation, the position of the patient, and the anatomy of the part have not fallen into oblivion, for the method was brought forward again a few years since by Miquel, of Am- boise. Rhazes, Mesne, and Avicenna spoke of bronchotomy as (458) SURGICAL TREATMENT. 459 a supreme resource in suffocative quinsy ; but they omitted the details of the operation. At the time of Albucasis, according to his statement, no one practiced tracheotomy. Avenzoar had the idea of trying the operation on a goat. The animal having recovered, he con- cluded that wounds of the trachea were not very fatal. In the Middle Ages tracheotomy had become a legend. It is neces- sary to advance to the middle of the sixteenth century to find an authentic example of it. We find one in 1546 by Ant. Musa Brassavolo, physician to the Duke of Ferrare, who suc- cessfully performed the operation on a patient who was at- tacked with a hopeless suffocative angina. About half a cen- tury later Santorio, as stated by Malavicini, first used, in per- forming the operation, a trochar of which he left the canula three days in the wound. This procedure — laryng.'Centesis — was again recommended in 1748 by Garengeot. This surgeon, however, recommended incising the integument previously, without disturbing the muscles, at least in thin persons. A little later, Heister recommended a mode of operating which approximated the one now employed. Decker, Bou- chot, Barbeau-Dubourg and Richter, invented special instru- ments for facilitating the puncture which wer« called broncho- tomes. But Van Swieten had criticised already this method of doing what he considered as very dangerous. Fabricius ab Acquapendente advised the use of a canula with wings {ailce), a simple canula being exposed to fall into the trachea. Casserio argued in favor of tracheotomy, from all the cases of wound of the trachea which had recovered up to that time. He gave a very complete description of the operation. Habi- cot recommended it in dangerous inflammations of the trachea. He had occasion to practice it in a case of a foreign body in the oesophagus which strongly compressed the trachea. Marcus Aurelius Severinus pronounced a grand eulogy on this opera- tion ; as well as did Rene Moreau, and the Portuguese,Thomas Rodriguez de Veiga. Bernard and Gherli both practiced it with success. Louis, in a celebrated memoir, contributed greatly to attract attention to the subject. 460 DIPHTHERIA, CROUP AND TRACHEOTOMY. Vicq d'Azyr, in 1776, published a work on crico-thyroidean laryngotomy. Crawford and Michaelis endeavored to estab- lish the indications for it. In this long period tracheotomy was probably performed in some cases of croup, but certainly also in many other affections. We do not possess data upon this point only from the time of Home (1765), the historian of croup. Without practicing the operation he recommended in- cision of the trachea as a dei-nier ressort, in the period of suffo- cation, either for preventing asphyxia or to favor the expulsion of false membranes. A little later, in 17S2, tracheotomy was successfully performed by John Andree, a surgeon of London. The report of this is given by Borsieri in his Institutes. Stoll (1786), also recommended the operation, but it does not ap- pear that he ever saw it practiced. At the commencement of the present century Chaussier recognized it as the only means capable of preventing suffoca- tion; and recommended not to wait till the lungs were en- gorged. Meanwhile it had furnished but few results, and it was very seldom practiced ; the discouragement was general. Also, at the time of the great competition of 1808 all the com- petitors and the secretary rejected tracheotomy. We must, however, except Caron, who sustained with great energy and indefatigable perseverance, the cause of the operation. But his arguments, however correct they may have been, required the support of successes ; but, instead of that, one tracheotomy, performed by him in the meantime tended only the more to the reverse. Nevertheless, he did not consider himself beaten. Encouraged by the fortunate result of a tracheotomy made for a foreign body in the air-passages, he offered a prize of a thousand francs to anyone who would cure a case of croup by the aid of this operation. England, in 18 14, furnished another case of cure of croup by tracheotomy performed by Thomas Chevalier, of London. In France, Bretonneau changed the status of things. Not satisfied with giving a full history of the disease, the celebrated physician of Tours was able, by his persevering firmness (" sa perseverant obstination ") to reanimate the confidence of phy- SURGICAL TREATMENT. 4^1 sicians, and to enable them to obtain unexpected results. After two unfortunate attempts, in 1818 and in 18 19, he had the happiness to save, in 1825, the daughter of his dear friend, the Count of Puysegur. If Bretonneau succeeded where so many others had failed, it was because he understood that it was not sufficient to make an opening, more or less narrow, for the air, and to maintain it with a canula formed from the end of a gum-elastic catheter,or to reclose it immediately after hav- ing extracted the false membranes which were immediately re- produced, but that it was necessary to incise somewhat exten- sively, and to keep the trachea open by means of a large can- ula during all the time necessary for the elimination of these concretions. His experiments on animals had shown him that the trachea could tolerate the contact of a foreign body for a sufficiently long time. This fact had an immense influence. Several tracheotomies were performed, but failing to observe the precepts of Bretonneau, particularly the use of the double canula, we see a new series of failures returning. In the mean- time. Prof. Stolz performed one successful operation at Stras- burg, in 1829. It was given to Trousseau to popularize tracheotomy. It is to this illustrious teacher, to his brilliancy, to the authority of his word, to the perfection which he added to the after- treatment, to the numerous successes of his practice that tracheotomy owes its extension, first in France and then abroad. His first success dates from 1830; he published it in 1833. After this epoch numerous operations were made ; Breton- neau and Trousseau continue to furnish examples. In 1839 a discussion arose in the Academy of Medicine in regard to a case of tracheotomy which terminated fatally, re- ported by M. Gendron. Bricheteau, the secretary of the commis- sion, proved that there could be counted eighteen recoveries in sixty operations. The debates which followed gave as re- sults the following figures : 462 DIPHTHERIA, CROUP AND TRACHEOTOMY. Operators. Messers. Amussat Number of Tracheotomies. 5 Successes. Baudelocque (operat. done at Hop des Enfants Malades) - lital 15 Blandin - 5 Bretonneau _ _ _ 17 5 Gerdy Roux - - - 6 4 4 Trousseau - _ 80 20 Velpeau _ _ _ 6 Total - - - - 1 38 29 This was, even then, an interesting result since it gave about one success in five operations, or, correctly, i in 4.75. Meanwhile, the operative procedure, and especially the after- treatment, was badly understood by many of the operators. We may, in this way, explain the terrible results of surgeons such as Velpeau, Blandin and Roux. In 1844 we can count 212 operations with 40 recoveries. When Trousseau, in 1848, took charge at Hopital des En- fants, the results of tracheotomy in that establishments were deplorable. Forty-nine operations had failed with the excep- tion of a single one, of which the report was not yet published at the time of his celebrate{^ report on catheterism of the lar- ynx (tubage de la glotte); it was communicated to the Societe Medicale des Hopitaux, at a later period by Roger. Thus disfavor was complete. One success obtained by Trousseau in his department aided him in overcoming the aversion of the other physicians of the establishment. The ice was broken ; a new era dawned. The operation was practiced on a large scale by Guersant and by the assistants at the hospital. Thanks to the improvements introduced by Trousseau in the after-treatment, and to the use also of the double canula, the results soon became very satisfactory. From 1849 to 1858 there were 466 tracheotomies performed, giving 126 successes, that is, more than one-fourth. SURGICAL TREATMENT. 463 At the same period the hospital Sainte-Eugenie, established four years previously, reported 198 tracheotomies, of which 39 recovered, that is, l in 5. It was at this time that the work of Bouchut on catheterism of the larynx appeared, a work in which the author, finding an increase in the mortality of croup at Paris for some years past, attributed this increase to trache- otomy without considering that the rise in the mortality coin- cided with the increase in the number of croup cases. Trous- seau, finding himself attacked on his favorite subject, assumed the defense of tracheotomy. His admirable report to the Acad- emy of Medicine was followed by a discussion which still re- mains celebrated. His powerful discourse, to which was added the argument so authoritative of Bouvier, had the effect of again placing the question in its true light. Vainly did Mal- gaigne, who had employed against tracheotomy all the re- sources of his able reasoning and his biting sarcasm, attempt to weaken the value of the figures presented by Trousseau by presenting such unfavorable statistics as the following : Number of Operators. Tracheotomies. Recoveries. Gosselin - - 23 Michon - - 20 2 Laugier - - 8 I Nelaton - - 36 3 Monod - (a bout) 40 Thierry < on on children adults - _ 37 3 3 Malgaigne - - 8 or 10 I . It was shown from the discussion that, though the efforts of these skilful surgeons had not been followed by better results, it should not be charged to the operation itself, nor to the manner in which it had been executed, but that these eminent surgeons, having completed the operation, considered their duty performed, and retired, leaving the patients in the hands of ordinary physicians who at that time were little acquainted with the necessary treatment of these patients. It was proved 464 DIPHTHERIA, CROUP AND TRACHEOTOMY. that if the tracheotomies performed in the hospitals most fre- quently by the assistants, gave such remarkable results, it did not depend alone upon the fact as had been insinuated, that the patients were operated on without necessity, but upon the fact that the after-treatment was performed properly in these institutions by attendants thoroughly trained. This was the explanation, at first, of these surprising differ- ences. The fact was so fully recognized that it became an established principle, still true to-day, that families, situated in straitened circumstances, give their children many more chances for recovery by having them operated on at the hos- pital. As proof of the difference in the results obtained by the op- eration followed by rational treatment, Trousseau cited the following statistics : I. Those of Bardinet, of Limoges, comprising the tracheot- omies done by himself and by several physicians of the same city : Operators. Boullaud Thouvenet Deperet Roche - Lemaiffre Saymondaud Y * * * "Mazard - - Bleynie - - Bardinet Total _ - - 58 17 of which the general result is i recovery in 3.41. 2. The reports of the operations performed by several phy- sicians from different parts of France : Number of Tracheotomies. Recoveries. 20 6 13 3 7 I I 3 I I 3 I 3 2 6 4 SURGICAL TREATMENT. 465 Number of Operators. Tracheotomies. Recoveries Saussier, of Troyes, 6 3 Beylard, of Paris, 13 4 Moynier, of Paris, 17 8 Archambault, of Paris, - 21 8 Perrochaud, of Boulogne, 3 2 Delarue, of Paris, 3 I Laloi, of Belleville, 6 3 Viard, of Montbard, 2 I Petel, of Cateau, 9 4 Baudin, of Nantua, 4 3 Dubarry, of Condom, - 5 2 Total - - - - 89 39 which gives i recovery in 2.28 operations. 3. Those of several distinguished surgeons of Paris, who had studied at the school of Trousseau, and comprehended the im- portance of the after treatment : Operators. Richet, Follin, Broca, Richard, Demarquay, - Total, - - - 39 17 that is, I recovery in 2.29 operations : The summing up of these three tables in 186 operations, gives 73 recoveries or i recovery in 2.54 operations. On the other hand the remarkable works of Barthez, Roger, and Germain See had demonstrated in an irrefutable manner a decided increase of croup since 1840. Therefore, the aug- mentation in the number of deaths corresponds to the consid- erable rise in the number of croup cases ; consequently tra- cheotomy, far from increasing the mortality, rescues from death a large number of patients. Number of Tracheotomies. Recoveries 9 5 7 2 12 6 5 2 6 2 466 DIPHTHERIA, CROUP AND TRACHEOTOMY. Erom this period, tracheotomy has extended not only in France, but to other countries. It is at present practiced in ever>' country of Europe where it has acquired the same claim to public recognition. It is interesting to state what we know of its results in the hospitals. French Statistics. Aside from the statistics of the hospitals, we have compara- tively few documents, but the former are of great importance. The following are such as I have collected from the regis- ters of the two hospitals for children in Paris : SURGICAL TREATMENT. HOPITAL SAINTE-EUGENIE. 467 CROUP CASES TRACHEOTOMIZED. Proportion of Years. Dismissed Cured. Died. Dismissed not Cured. Total. reco vertes to the whole number. 1854 2 7 — 9 I to 4.S0 1855 4 9 — 13 I to 3.25 1856 5 19 — 24 I to 4.80 1857 5 24 I 30 I to 6.00 1858 23 95 4 122 I to S.29 1859 17 88 4 109 I to 6.41 i860 7 31 2 40 I to S.7 I 1861 16 45 3 64 I to 4.00 1862 23 67 7 97 I to 4.2 r 1S63 35 68 3 106 I to 3.02 1864 26 85 4 IIS I to 4.42 1865 44 87 6 137 I to 3. 1 I 1866 36 76 3 IIS I to 3,19 1867 29 63 4 96 I to I.T, I 1868 31 lOI 3 135 I to 4.35 1869 31 70 2 103 I to 3.35 1870 42 85 4 131 I to 3. 1 I 1871 12 78 3 93 I to 7.75 1872 39 138 10 187 I to 4.79 1873 32 170 II 213 I to 6.65 1874 23 132 7 162 I to 7.04 1875 27 175 9 211 I to 6.48 509 1,713 90 2,312 I in 4.54 468 DIPHTHERIA, CROUP AND TRACHEOTOMY. HOSPITAL DES ENFANTS MALADES.i CROUP CASES TRACHEOTOMIZED. Proportion of Years. Dismissed Cicred. Died. Dismissed not Cured. Total. reco ver ies to the whole number. 1851 14 17 — 31 I to 2.21 1S52 18 43 — 61 I to 3.38 1853 9 52 — 61 I to 6.77 1854 14 29 — 43 I to 3.07 1855 12 34 — 46 I to 3.83 1856 16 33 3 52 I to 3.25 1857 16 54 — 70 I to 4.37 1858 34 73 2 109 I to 3.20 1859 41 "5 4 160 I to 3.90 i860 24 lOI 3 128 I to 5.30 1861 29 72 I 102 I to 3.49 1862 27 112 6 145 I to 5.37 1863 46 86 10 142 I to 3.08 1864 40 105 8 153 I to 3.82 1865 40 86 4 • 130 I to 3.25 1866 27 71 3 lOI I to 3.74 1867 15 57 4 76 I to 5.06 1868 26 36 — 62 I to 2.38 1869 12 54 — 66 I to 5.50 1870 21 43 — 64 I to 3.04 1871 16 27 — 43 I to 2.67 1872 30 71 9 no I to 3.66 1873 26 79 2 107 I to 4. 1 1 1874 23 81 4 108 I to 4.69 1875 38 130 13 181 I to 4.76 614 1,661 76 2,351 I in 3.82 'The tracheotomies were not borne on the register previous to 185 1. SURGICAL TREATMENT. 409 In 1864 Guersant reported that he had operated, in all, 156 times, from which he had 28 recoveries ; and he observed that up to 1845, the period at which he began to use the double canula and the cravat, he had only two recoveries in 32 opera- tions. His statistics may, therefore, be divided into two groups : Operations. Recoveries. 1st. Between 1834 and 1845, - 32 2 2d. After 1845, - - 124 26 Total. 156 28 In 1865, in the second edition of his Clinical Medicine, TxomlS- seau said he had performed two hundred tracheotomies, ot which more than one-fourth recovered. Statistics from the practice of other French physicians are to be found in medical literature. They are as follows : Number of Operators. Tracheotomies. Recoveries. Isnard, - - - 4 2 Baizeau, Paris, - - - 12 4 Lenantais, Nantes, - - 31 5 Calvet, Castres, - - - 16 8 Boeckel, Strasburg, - - 33 12 Ehrmann, Mulhouse - - 14 7 Klippel, - - 3 Battenburg, - - 3 I Werner, - - - 5 2 Koechlin, - - 6 2 Schoelhammer, (Haut Rhin) - 7 6 Belin, Colmar, - - - 4 I MuUer, - - - I Marquez, - - I I Macker, - - - I I Radat, - - - I I Duclout, - - 2 Godefroy, of Vienna, - - 12 2 Michalski, Charny, - - 3 2 Marc See, Paris (adult] 1- - I Total, - - > 160 57 470 diphtheria, croup and tracheotomy. Other Countries. Portugal. — The introduction of tracheotomy into Portugal dates from 1835, and it is due to Martiniano Nunez da Regate; this was a case of failure which passed almost unnoticed. In 185 1 da Silva adopted the operation, and had four rscov- eries in fourteen tracheotomies. The first three resulted in death. Prof. Antonio Mar, Barbosa had 6 recoveries in 15 opera- tions. From this date the Portuguese physicians have contin- ued to advance with equal courage and success. According to information kindly furnished me by Prof. Barbosa the pres- ent status of tracheotomy in Portugal is as follows : Since 1 863 Prof. Barbosa has performed 8 additional opera- tions, of which 3 recovered, which make a total of 23 cases and 9 recoveries. And Prof. Theotonio da Silva has now 21 cases, with 8 re- coveries. To these should be added 15 more caees with 4 re- coveries, in the practice of Messrs. Henriques Teixeira. Jose Gualdino de Carvalho, Teixeira Marques, and Alves Branco. In tabular form they are as follows : Number of Operators. Tracheolomies. Recoveries. Proportions. Antonio-Maria Barbosa, - - 23 9 I in 1.5s Theotonio da Silva, 21 8 I in 2.62 Other operators, ■ - 15 - 59 4 21 I in 3.74 Total, - - - - I in 2.80 These results, so remarkable, do great honor to our Portu- guese brethren, and worthily reward these able advocates of this operation in the Iberian peninsula. Spain. — The researches made by Prof. Barbosa in this country, at the time of his memoir on tracheotomy, show that this operation is rarely practiced in Spain. It has been tried five or six times only and then without success. The last was by Prof. Vicente Asnero, in 1859. Spanish physicians, little encouraged by these results, have, according to Barbosa's statement, but little confidence in the treatment of croup by tracheotomy. SURGICAL TREATMENT. 4/1 Belgium. — In i860, Dr. Henriet, of Brussels counted eight operations with four recoveries. According to a manuscript communication transmitted by the kindness of Warlomont, the statistics of tracheotomies per- formed from 1870 to 1875 in the practice of that distinguished physician at Saint Peter's Hospital in Brussels are as follows : Years. No. of Tracheotomies. Recoveries. 1870 - - - 3 I 1871 . . - 3 O 1872 - - - 4 * o 1873 - - . 7 I 1874 ... 9 4 1875 ... 9 ^ Total . - . 35 8 In adding these to the above we have twelve recoveries in forty-three operations, or i in 3.50. Dr. Henriet remarked that the cases operated on comprised in this report, in many instances, had been treated by the most irrational means, and nearly all were admitted to the hospital in an advanced stage of asphyxia. In private prac- tice the number of recoveries is perceptibly higher. Italy. — If we can judge from public documents, tracheotomy is seldom practised in Italy. It has been performed by Dr. Valerani, of Turin, who had one recovery in three cases. In Tuscany, where a severe epidemic of diphtheria has pre- vailed for ihe last ten years, tracheotomy is much dreaded, rarely practised and always at the last extremiiy. Prof. Rosati, of Florence has operated, or seen the operation in nine cases, only a single one of which recovered. He attributed this ter- rible mortality to excessive temporization — postponement. Germany. Slow to be adopted in Germany, tracheotomy is now in common practice in this country. The results there are very favorable. 472 DIPHTHERIA, CROUP AND TRACHEOTOMY. Germany. Operators and Country. No. of Tracheotomies. Recoveries. [Passavant, Frankfort, from 1851 to 1882 - 229 67] Baum, Goettingen, ----- 31 12 Fock and others, Madgeburg, - - - 43 18 Roser, Marbourg, -__-.42 19 Uhde and others, Braunschweig, - - - 81 21 Simon, Rostock, 22 j f"^ ^." ^" f "^^ I 6 ' |_termma d fat ly J Burow, Koenigsburg, ----- 59 7 Schmidt, Leipzig City Hospital, from 1878 to 15 2 1883 -__.-.. 310 67 Peltzer, Bremen, from Oct 1883 to Mar. 1884 88 12 Bartels, Kiel, ------ 61 17 Max Bartels, Berlin. Statistics of the opera- tions performed in the service of Prof. Wilms at the Bathanien Hospital, from 1861 to 1872 and comprise the 100 publish- ed by Giiterbock in 1867 - - - - 335 I03 Eberth, Berlin, 1857 to 1865 - - - 13 6 Busch, Berlin, ---__- 72 10 Von Kopl -------17 II Morath - ---.-i I Stelzner, Dresden, - - - - 12 4 Miiller, Cologne, 1862 to 1869 - - - 45 15 Molendzniski, Lemberg, . - . ■ 2 one an adult. o Oelschlaeger, Dantzig. 1856 to 1869 - - 12 I Reiffer, Frauenfeld, ----- 18 8 Hueter, Rostock, ----- 29 7 Birnbaum, Darmstadt, 1873 to '83 " " HO 47 [At Leipzig (City Hospital) from 1878 to 1883 inclusive, there were 310 operations of tracheotomy for diphtheria, of which 243 died. From October, 1883, to March, 1884, inclusive, there were 88 cases of tracheotomy during an epidemic, of which 76 (86.4%) died. The non-operated cases of diphtheria received at the same institution during the same period were mostly treated with turpentine — "a teaspoonful of a mixture con- t lining a little spirit of ether being given three times a day." — Van Arsdale. Ann, of Surg. Vol. L No. 2. 1885. Monti (1884) collected 12,736 cases with 3,409 recoveries. — Ann. of Surg. Vol, I. p. 581.] surgical treatment. 4/3 Bavaria. Operators. No. of Tracheotomies. Recoveries. Manner, Munich, -----17 2 [Fifty-eighth Congress of German Nat. and Physicians, Strassburg, Sept. 18 to 23, 1885 (Med. Record. Nov. 14, 1885). Ranke, of Munich, tracheotomy, 7V2 years, - - 45 19] Austria. [Monti, 1884, collected, - _ _ . 12,736 3»409] Wiederhofer, Vienna, 1864. Statistics of St Annen-Kinderspital [The latest statistics is that over 50% recovered (1884)] - - 19 2 Prague, statistics of Kinderspital, - - 24 6 Steiner, four years in Prague, - - - 52 18 [Ziemssen cyclopaedia, Children's Hosp., Prague, lOO 32] Balassa, Pesth, ------2 2 [The latest statistics of tracheotomy at St Annen Kinderspital is that over 50% of the cases recovered. — Brit. Med. Jour. July 19, 1884.] Russia. Operators. No. of Tracheotomies. Recoveries. Symwrhid, St. Petersburg, - - - - 4 2 Froebelius, " - - - _ 2 O Holland. Titanus, Amsterdam ----- 80 28 Switzerland. Billroth, Zurich, ------12 I Revilliod, Geneva, ----- 87 38 D'Espine, Geneva, ----- 15 6 Picot, Geneva, ------4 2 Rapin, Geneva, ------30 g The results, so brilliant in the Geneva practice, have been communicated to me, as well as a number of other valuable documents by my friend Dr. d'Espine, one of the most distin- guished pupils of Barthez. England. Tracheotomy is but little practised in England, where it has few recoveries as we learn from Dr. West. 474 DIPHTHERIA, CROUP AND TRACHEOTOMY. The followinfr figures which I take from the memoir of Dr. J. Solis-Cohen, of Philadelphia, while fully proving the first proposition above, do not equally establish the correctness of the second. Operators. No. of Tracheotomies. Recoveries. Spence, Edinburg, .-,--- 87 28 Buchanan, Glasgow, ----- 39 " ^3 Cruickshank, ------n 8 H. W. Fuller, statistics of, - - - - 7 3 Conway Evans, ------5 I Henry Smith, London, - - - - 3 o Ransom, Nottingham, ----- 3 o West, London, ------30 7 Total, 1S5 60 [In the report of the commissioners made to the Royal Med. Chirurg. Society (1879) on the relations of membranous croup and diphtheria, Dickinson, chairman, reports tracheotomy : Cases, 18. Recoveries, 6. Dr. Fagge, class I, ----- 24 2 Dr. Fagge, class II and III, - - - - 19 5 Dr. Gee's, from 1853 to 187S, - - - - 34 3 Total, - - 95 16 More recently R. W. Parker reports - - - 32 17] The proportion of recoveries would be i in 3.08. The hos- pitals of London furnish results unimportant numerically, and but little encouraging. Hospitals. No. of Tracheotomies. Recoveries. c /- > Tj -. 1 <; f I of the fatal cases'! » St. George's Hospital, - - - - 6 < ,^ r ^ > 3 o r > ^ -yyas 1 yrs 01 age. J "^ Dreadnought Hospitals hip, - - - i o Metropolitan Free Hos ital, - - - i O Hospital for Sick ChiKlien, " " - 3 o King's College Hospital, - - - - i o Middlesex Hospital, - _ . - 6 (one oper. on an adult) o St. Mary's Hospital, - _ . - i o Addenbrooke's Hospital, Cambriilge, - i I Total, -------20 4 America. The physicians of the United States practice tracheotomy largely. Some portions of the country are less favored than others. SURGICAL TREATMENT. 4/5 [The following two quotations are taken from the report of Dr. Wm. M. Mastin, of Mobile, Ala., on tracheotomy for croup in the United States: "Total number of operations tabulated amount to 863 (of these 296 were o'?///- t/teridc cronji, vfhh 41 cures and 2^^ deaths. \()<\psendo-iitemhranous troup,^\'On. 47 cures and 147 deaths. 373 croup in s^eneral (their i?.v(7(/ nature not being known), with 90 cures and 283 deaths; with 178 recoveries and 685 deaths; and include in their scope 26 states and i district, viz : Alabama 17, California 3, North Caro- lina I, South Carolina 4, Colorado i, Connecticut 4, Georgia 5, Illinois 34, Indiana 8, Kentucky 16, Louisiana 3, Maine 3, Maryland 17, Massachusetts 51, Michigan 8, Minnesota 5, Missouri 95, Mississippi 7, New Jersey 2, New York 432; Ohio 14, Pennsylvania 88, Tennessee 5, Texas 25, Vermont 3, Virginia 6, District of Columbia I, and unkiiou'ii slates 5." From a later article by the same author (Annals of Anatomy and Surgery, 1881 : "The total number of tracheotomies for croup in the United States collated by me to date comprises 903 operations with 195 recoveries and 708 deaths ; but of that number there were found 43 operations in which death was attended by such compli- cations as to justify their exclusion from the general list, and hence the true figures should read — whole number operations, 860 ; cures, 195, and deaths, 665, or i cure in a little over, every 41/2 operations (22.67 percent)." 476 DIPHTHERIA, CROUP AND TRACHEOTOMY. The following is a list of the operations reported by me in the State of Illinois (Annals of Anatomy and Surgery, April, 1881). OPERATORS. OPERA- TIONS. RECOV- ERIES. OPERATORS. OPERA- TIONS. RECOV- ERIES. Dr. E. Andrews, I Dr. R. S. Cowan, 3 I Dr. A. T. Bartlett, I Dr. F. B. Crummer, I Dr. F. H. Blackman, 2 I Dr. H. W. Chapman, I Dr. R, G. Bogue, 21 6 Dr. W. C. Day, I Dr. F. Brendel, I I Dr. C. W. Earl, 2 Dr. Ferd Brother, 3 Dr. J. G, Erhardt, 5 2 Dr. W. A. Byrd, 2 Dr. Christian Fenger, 6 2 Dr. L. Bremer, I I Dr. H. Z. Gill, 4 3 Dr. W. S. Caldwell, I Dr. D. W. Graham, I Dr. F. M. Casal, I Dr. E. L. Harriott, I Dr. W. J. Chenoweth, I Dr. E. F. Ingals, 3 I Dr. T. A. CoUett, 4 Dr. H. A. Johnson, 21 6 Dr. E. P. Cook, 3 Dr. W. H. KendaU, 2 Dr. F. Koeberlin, I I Dr. C. T. Parkes, I I Dr. G. W. Lasher, 2 I Dr. J. P. McClanahan, I Dr. — . Ledlie, I I Dr. A. B. Strong, I Dr. E. W. Lee. 32 8 Dr. J. L. White, I Dr. L. A. Mease, 2 I Dr. H. Wardner, 3 I D. J. P. Mathews, I Dr. T. Winston, I Dr. E. W. Mills, 2 I Dr. John Wright, I Dr. J. W. Newcomer, Dr. James Phillips, I 151 38 Dr. D. Prince, 6 25V6 per cent. Since the above list was published, 1881, the following operators have added to the number of their cases, with the following results : Dr. W. A. Byrd, 7 cases, re- covered, o ; Dr. Bogue, 9, recoveries, 3; Dr. Gill, 2, recoveries, o; Dr. Ingals, 10 or 12 cases, recoveries, 3. Some of the other operators report "no more cases." SURGICAL TREATMENT. SUMMARY OF TRACHEOTOMY IN ILLINOIS. 477 Length of time the patients had been sick before the operation. TIME. CASES. 2 days or less, - - - g 3 days - - - • - i6 4 days ----- 21 5 days 5 6 days ----- 5 7 days ----- 6 8 days ----- 7 10 days ----- 10 14 days ----- 4 Total reported - - - 82 AGES. CASES Under 2 years - - - II 2 to 3 years - 14 3 to 4 years - . - - 25 4 to 5 years - 20 5 to 6 years - 15 6 to 7 years - 5 7 to 8 years - 6 8 to 9 years - 8 10 to II years - 3 12 to 20 years . 2 Over 20 years • - I Total Age of I not given. Dates at Which the Patients Died After the Operations, so far as Reported. Within 12 hours (including those dying i Sixth day immediately) - - - 16! Seventh day From 12 to 24 hours - - - 19 From 24 to 48 hours Third day Fourth diy - Fifth day Tenth day Sixteenth day - Total reported I 2 I I 77 4/8 DIPHTHERIA, CROUP AND TRACHEOTOMY. THE TUBE WAS PERMANENTLY REMOVED AS FOLLOWS: DAY. NO OF CASES. 4th I 5th 2 6th- 7 7th 2 Sth 2 ' 9th I loth ------ 2 nth - - - - - - 2 1 2th - - - - . - I DAY, NO. Of CASES 14th ------ I l6th ------ I 2ISt ------ I 44th ------ I I20th ----- 2 128th ------ I Total re[joited - - - 27 In one case the tube still remains. The remaining cases are not reported as to this item. PROBABLE IMMEDIATE CAUSE OF DEATH. I. Lung Complications. — 1. Pneumonia or broncho-pneumonia, ----- 28 2. Accumulation of membrane and mucus in the trachea and bronchi, 10 3. Asphyxia (seat or mechanism of which not given, " " 5 II. Erysipelas and oedema. — ----__. _i III. Insufficient after-treatment. — 1. Dried and hardened accumulations around the end of the outer tube, forming a cap, -------- i 2. Other causes, ----------2 IV. General Effects. — 1. Exhaustion or blood poisoning, ------ ig 2. Syncope, ----------4 3. Collapse, "possibly hastened by haemorrhage" - - - i V. Immediate death (cause not given), ------ i Total, -- -!----_-- 72 Other Incidents. — Artificial respiration required at the time of the operation (all re- covered), ------___-j Complicated with whooping-cough (died), - - - - i Defective tubes (all died), --------3 Retention of the tube over 30 days. — 1. From exuberant granulations, ------ 3 2. From other causes, ---.«... 2 SURGICAL TREATMENT. 479 Operators. Cases. A. Jacobi,' New York, about 450 cases ; formerly 70%, lately 15% recoveries. L. S. Pilcher,! Brooklyn. (Of the first 20, 10 recov- 44 eries ; of the last 24, 4 recoveries.) John H. Ripley,! N. Y., 89 John T. Hodgen,! St. Louis, - - - - 92 H. H. Mudd,i St. Louis, 41 Harvy G. Mudd,' St. Louis 5 Geo. W. Gay,' Boston, 86 City Hospital, Boston, ----- 206 Daniel Ayers, Brooklyn, ----- 20 J. Pancoast, -------- 9 Henry O. Marcy,' Boston, ----- 62 Cheever, to 1874, Boston, ----- 9 Buck, New York, (Cohen) - - - - 2 Minor, " «-_--. 6 C. K. Briddon " " 5 Voss, " ------ 43 Krakowitzer, " "----" 55 Von Roth « « 48 D. C. Cocks,^ " - 15 John H. Packard,! Philadelphia, - - - - 10 Hodge, Maslin, - - - - - - - il Drysdale, " ------- 9 R.J. Levis, " -------17 Recoveries. 14 29 15 9 2 29 6S 4 4 8 6 2 2 (one an adult) o 10 16 II 8 I 2 3 2 The following table from Dr. Ripley is of too much interest to be omitted : 1 Letter from the operator. *Archi v. of Pediatrics. VoL L No. I. 48o DIPHTHERIA, CROUP AND TRACHEOTOMY. Age. ^ 1 ^ 1 .5 s. r .<3 1 •S ^ <4 Up to I year, 5 I I — I 5 Between i and 2 years, 5 6 — — — II Between 2 and 3 years. 7 8 4 4 8 7 Between 3 and 5 years, 20 12 9 4 13 19 Between <; and 7 years. 12 8 4 I 5 15 Between 7 and 9 years. I 3 — 2 2 2 At 17 years, I — — — — I 51 38 18 II 29 60=89 Causes of Death. Bronchial croup ---.---.-36 Erysipelas and bronchial croup -------i Toxsemia ----_----.. 6 Anaemia - - - - - - - - - - -4 Respiratory paralysis and ar.,x:iiia -.--.. 2 Respiratory paralysis -------.-2 Cardiac paralysis ----.-...j Pneumonia -----__. ___i Gangrene of wound ------,.-. i Accidental plugging of tube ----_._ ^ Acute tuberculosis ------. __i Total -._-..... 60 The following list, by Dr. Joseph Winters, kindly furnished by him, and cor- rected at my request, gives the largest number of recoveries after tracheotomy for croup on record, in children under one year of age. SURGICAL TREATMENT. 481 SUCCESSFUL TRACHEOTOMIES FOR CROUP IN CHILDREN ONE YEAR OF AGE AND UNDER. Case. Age. Disease. Operator. Authority. I 2 Weeks. 6 Months. 3 Croup. Croup. Scoutetten (1830). Annandale.^ Soc. Med. des Hop. de Paris, 1867. Ed. Med. Jour., vol. vii., part 2, June, 1862, p. 1121. 3 6 Croup. Kiister. Elias, Deutsche Med. Wochen., Nov. 9, 1S78, P- 555- 4 6V2 Croup. Jos. Bell. Bell : Letter to Brit. Med. Jour. April 8, 1871. 5 7 Croup. Tait. Brit. Med. Jour., April 15, 1871, p. 391. 6 7 7 7 Croup. Croup. • Lindner. Deutsche Zeitschrift f. Chir., Band xvii., Heft. 5 und 6. 8 7 Croup. Wegner. Kronlein: Archiv. f. klin. Chir., vol. xxi., 1877, ?• 266. 9 7 Croup. Kronlein. Rauchfuss in Gerhardt's Handb. Kind., vol. iii., p. 202. 7 Croup. .._5 Elias, op. cit. from St. Petersburg Med. Zeil- ung, 1877. II 7V2 Croup. Jos. Bell.» Syme: Ed. Med. Jour., vol. vi. part 2, April, 1 86 1, p. 956. 12 8-V3 Croup. Elias. Deutsche Med. Wochen., November 9, 1878. ' Child lived seven weeks after the operation. On autopsy lungs vv-ere found to be perfectly healthy. ^Name not given. 'Communication to Med. Chirurg. Soc, Edinburgh. Professor Syme thought that the operation would not do any good in this case, but yielded to Bell, the house-surgeon, who did the tracheotomy, which was followed by instant relief to the child. 482 DIPHTHERIA, CROUP AND TRACHEOTOMY. Successful Tracheotomies for Croup in Children. Case. ^^<r. Disease, Operator. Authority. 13 10 Croup. Day. Greenfield in St. Thomas' Ilosp. Rep., vol. viii., p. 263. 14 10 Croup. Baizeau,* Gaz. des HSpitaux, 1867, P- 397- 15 10 Croup. V. Winiwarter,^ Jahrbuch f. Kind., 3 u. 4, P- 337. 1876. 16 10 Diphtheria. Elias, Deutsche Med. Woch. November 9, 1878. 17 10 Croup. Bourdillat, L'Union Med.. 1872, vol. xiii., 3d series, p. 826. 18 II Croup. Geo. F, Shrady.8 N. Y. Med. Record, vol. xxii., Nov. 4, 1882, p. 512. 19 II Croup. Trousseau. Paris Theses, 1834, t. cclxxviii , No. 289.P.13, Aussandon's Thesis. 20 II Croup. Rauchfuss. Gerhardt's Handb. Kind. vol. iii., p. 202. 21 II Croup. J. Cooper Forster. Brit. Med. Jour., March 25. 1871, p. 309. 22 II Croup. Derby. Stevens : Boston Med. & Surg, lour., vol. Ixxi., Oct. 1869, p. 167. 23 12 Croup. Lindner. Deutsche Zeit. f. Chir., Band xvii., Heft 5 u. 6. 24 12 Croup. Trendelenburg. Gerhardt's Hand. Kind, vol. vi., p. 262. 25 12 Croup. A. T. Woodward. Mastin: Gaillard's Med. Jour., Jan. 1880, p. 30. 26 12 Croup. Dujardin. L'Union Med., 1872, 3d series, vol. xiv., p. 46. 'Twelve children under two years operated on, four got well. ''Respiration stopped and artificial respiration was performed for ten minutes, and had to be resorted to three times within the first hour. ^This is the youngest successful case operated upon in this country. This opera- tion was performed between the tenth and eleventh month. Child is still living. SURGICAL TREATMENT. 483 Successful Tracheotomies for Croup in Children from i to 2 Years of Age. Case. Age. Disease. Operator. Authority. 27 Months. 13 Croup. Wardner. Gill: 111. State Med. Soc. Trans., 1878, p. 164. Mastin : Gaillard's Jour., January, 1880, p. 30. 28 13 Croup. Barthez. Gaz. Hebdom., 1862, p. 806. 29 13 Croup. Trousseau.^ Jour, des Conn. Med.- Chirurg., September 3, 1834, t ii., p. I. 30 13 Croup. Archambault. Gaz, des H6pitaux, 1867, P- 307- 31 13 Uiphiheria. Steavenson.2 St. Barthol. Hosp Re- ports, vol. xviii, 1882, P- 313- 32 14 Croup. Cabot* Haywood: Boston Med. and Surg. Jour., vol. Ixii., p. 273, i860. 33 14 Croup. V. Langenbeck. Kronlein : Archiv. f. klin. Chi:,, vol. xxi., 1877, p. 268. 34 14 Croup. Rapin. Sanne: Trait6 de la Diph ■ therie, p. 481, Paris, 1S77. 35 14V2 Croup. Millard et H6mey. Sanne : op. cit,, p, 481, Jour, de Therapeutique, 1874. 36 15 Croup. Cabot. Boston Med. and Surg. Jour,, vol. Ixx., p. 61. 37 15 Croup. H61ie. Gaz. des Hopitaux, 1867, P-397 38 15 Croup. Baizeau. Gaz. des H6pitaux,p. 397, 1867. 39 16 Croup. Isambert Gaz. des H5p., 1867, p. 307. ' Operation same year as reported. * Child had scarlet fever and recovered. * Child had double pneumonia and recovered. 484 DIPHTHERIA, CROUl' AND TRACHEOTOMY. Successful Tracheotomies for Croup in Children. Case. Age. Disease. Operator. Authority. 40 16 Croup. Lindner. Deutsche Zeit. f. Chir., Band xvii., Heft 5 u. 6. 41 16 Croup. Wegner. Kronlein ; Archiv f. klin. Chir., vol. xxi., 1877. 42 17 Croup. Nathan Jacobson. N. Y. Med. Record, June 30, 1883, p. 705. 43 17 Croup. Vigla. Gaz. des Hopitaux, 1867, ?• 307- 44 18 Diphtheria. Bartscher. Deutsche Med. Wochen., 18S0, p. 29. 45 46 47 18 18 18 Croup. Croup. Croup. -C Wiihusen.i Dub. Med. Press, April 5, 1865, p. 320,froin Uges- krift for Larger, March 16, 1865. 48 18 Diphtheria. Josef Pauley. Berlin, klin. Wochen- schrift, February 25, 1878, p. 105-6. 49 18 Croup. George Rachel. Amer. Jour. Med. Sci- ences, July, 1S77, p. 95. 50 18 Croup. Collins. Mastin. Gaillard's Med. Jour., vol. Nxix., p. 30, January, iSSo. 51 18 Diphtheria. Voigt. Jahrbuch f. Kind., vol. viii., p 121, 1882. 52 18 Croup. Moutard-Martin. Gaz. des Hop., 1867, p. 308. 53 18 Croup. Potain. Gaz. des Hop., 1867, p. 308. 54 18 Croup. Archambault. Gaz. des Hop., 1S67, p. 307- 55 19 Croup. Roger. Gaz. des Hop., 1867, p. 30S. 56 19 Croup. Pan coast. Meigs : Amer. Jour. Med. Sciences, April, 1849. 57 19 Croup. Bose. Kronlein: Op. cit. ' One case died on eighty-first day of exhaustion from tubercular diarrhoea. SURGICAL TREATMENT. 485 Successful Tracheotomies for Croup in Children. Case. 5« 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Months 19 19 19 19 20 21 22 22 22 22 Disease. Croup. Croup. Croup. Croup. Croup. Croup. Croup. Croup. Croup. Diphtheria. Di[)h. second- ary to scarla- tina. Croup. Croup. Croup. Croup. Croup. Croup. Operator. Weber. Wegner. Trendelenburg. Jennings. Busch. Bose. Fitzau. Kronlein. T. Sendler. House-surgeon' A. J. Walter. >■ Dower. •< Isambert. Cushing. Laborde. Maslieurat-Lag6mard. Authority. Zeitschrift f. Ration. Med. Neue Folge i,Band iii., Heft I, p. 8, 1852. Kronlein . Op. cit. Vaneschi : Berlin klin. Wochen., April, 1872, p. 163. Archives of Pediatrics, vol. i., No. 9, Sept. 15, i884,p, 546. Vaneschi : Berliner klin. Woch., April, 1872, p. 163. Vaneschi . Berliner klin. Woch., April, 1872, p. 163. Berliner klin. Woch., April 25, 1S79, p. 223. Kronlein: Op. cit. Vierteljahrschrift f. Prak. Heil., vol. iv., p. 71. Poland, Brit. Med. Jour., Sept. 16, 1882, p. 523. R. and R. J. McCready, Am. Jour. Med. Scien., 1874. Brandt: N. Y. Med. Rec- ord, Jan. 13, 18S3, p. 54. Sanne : Diph., p. 481. Pacific Med. and Surg. Jour., vol. vii., p. 14. Gaz. Hebdom, 1862, p. So 7. Gaz. Med. de Paris. 1841, p. 380; 1842, p. 170. ^ Name not given. 486 DIPHTHERIA, CROUP AND TRACHEOTOMY. Successful Tracheotomif.s for Croup in Children. Case. Age. Disease. Operator. Authority. 74 22 Croup. Ferraux. Gaz. Hebdom. 1862, p. 807. 75 22 Croup. Johnson. 111. State Med. Soc. Trans., 1879, p. 120; re- ported by Gill. 76 22 Croup. Wegner. Kronlein: Op. cit. 77 22 Diphtheria. Mayer. N. Y. Med. Record, April 26, 1884, p. 457- 78 22 Diphtheria. Parker. Steavenson, St. Barthol. Hosp. Reports, vol. xviii., 1882, p 323. 79 23 Croup. Laborde. Gaz. Hebdom., 1862, p. 807. 8o 23 I'roup. Trousseau. Sanne ; Diph., p. 481. 8i 23 Croup. Bose. Kronlein : Op. cit. 82 23 Croup. Burland. Gaz. Hebd., 1862, p. 80S. Cases Exact Ages not Given. Years. 83 84 8S -2 1-2 Croup. V Croup. Krnckowizer. Korte, three cases. Jacobi : Am. Jour. Ob. May, 1868. Arch, fur klin. Chir 86 J Band xxv., p. 820. 87 to 1-2 \ Croup. Revilliod, six cases.i L'Union Med., 3d series 93 J L xxii., 1876, p. 136. ^Of sixteen children operated upon under two years of age, he obtained six cures that is to say, 37.5 per cent The youngest of his cases was fifteen months, the old- est twenty-three months. Monti, Ueber Croup und Diphtheritis, pp. 309— 311, has reported 158 cases of recovery under two years of age, in 1093 tracheotomies. Eight additional cases are, reported by Birnbaum. Arch f. Chirurgie, Bd. 31, Hft. 2, p. 346; Ann. of Surg. Vol. T.. p. 5S7. SURGICAL TREATMENT. 487 The statistics from various countries demonstrate to us but one thing, namel}', the benefit of tracheotomy; but now to compare tlie results obtained in different countries or in cer- tain regions of the same country, we must not be dreaming. These figures give only the statistics in totals, but they con- tain elements very dissimilar. Thus, as Bartliez has clearly shown, the statistics, compiled with the object of demonstating the value of various methods of treatment respectively in croup, should, to be decisive, con- tain only cases perfectly similar. How can we understand the action of a method of treatment when it is applied in one country to cases of simple benign diphtheria, and in another to the infectious or malignant form of the disease ? When we are told that tracheotomy succeeds less in one country than in another, if one can produce in support of the assertion only the total of the recoveries or their proportion to the number of operations in each place, we cannot deduce from this argu- ment any legitimate conclusion. It is necessary to know whether the conditions of age and season have been the same, and if the form of the disease has been similar, and whether the treatment has been applied at the same period and with the same care in one case as in the other. This information not being furnished by any of the statistics, we must abandon a comparison of the results from different countries. Let us content ourselves in knowing that in each tracheotomy has produced signal results. Some of the Causes which Influence the Results of Tracheotomy. Without speaking of the accidents which belong to the op- eration itself, nor of the complications which supervene after it, several causes of a general character have an influence on the results of tracheotomy. They are the form of the disease, the age of the patient, and the season of the year. Fat III of the disease. — Tracheotomy is not a method of treat- ment of croup, it is applied entirely to the laryngeal obstruc- 4^8 DIPHTHERIA, CROUP AND TRACHEOTOMY. tion — the cause of the asphyxia. This obstacle once removed, the diphtheria runs its course ; if it is benign, the asphyxia being removed, the patient recovers. If it is infectious and mahgnant the patient incurs all the dangers consequent upon these conditions ; he may succumb to the general poisoning or to a renewal of the asphyxia, this time irremediable, because produced by the extension of the false membranes to the bronchi. The infectious forms of diphtheria exercises on the results of tracheotomy a fatal influence so well demonstrated that it con- stitutes the principal contra-indication to the operation. Secondary cro7ip belonging nearly always to infectious diph- theria, is generally unfavorable. ■Age. — It was admitted for a long time, on the testimony of Trousseau, that tracheotomy should not be attempted before the age of two years. It was the rule not to operate below that limit, and still less below twenty months ; failure had always followed the violation of this precept. The statistics presented in 1858 by Roger and See, proved that the general average of recoveries being between 22 and 25 per cent., there was scarcely one per cent, below two years. Being presented before the Medicale Societe des Hopitaux of Paris, in 1867, by Isambert, on the occasion of a tracheotomy which had suc- ceeded in a child of sixteen months, this question called forth a discussion resulting in the proof of a considerable number of recoveries in children under two years. Already Scoutteten had reported the history (strongly contested, however, as to diagnosis,) of a successful case of tracheotomy in his own daughter of six weeks of age. Barthez had announced the re- covery of a child of thirteen months; Trousseau one of the same age, and MasHeurat Lagemard that of a child of twenty- three months. By collecting the known cases in France and in other countries we can present the following table : [See the later list by Dr, Winter's, p. 481.] We may add to that list the following : the case of a child of three months which lived six weeks after the operotion, re- ported by Dr. Annandale ; one of sixteen months which sur- SURGICAL TREATMENT. 489 vived four weeks and died of broncho-pneumonia, reported by Potain ; one from Millard of eighteen months, operated on at Necker Hospital by Collin (1857), and that lived to the twen- fifth day ; and finally one of twenty months operated on at Lille by Dujardin that lived to the twenty-third day. These recoveries, complete or incomplete, should evidently be taken only as exceptions, but they show that if recovery at this age is more rare, it is nevertheless not impossible. They did not, however, prevent an English author, Vincent Jackson, from condemning the operation of tracheotomy in children under four years of age. The facts can answer this evidently exag- gerated assertion. The rarity of recoveries under two years depends upon several causes. The operation is much more difficult, because of the shortness of the neck, its plumpness or fat, and the mobility and flaccidity of the trachea. Now, while tracheotomy well performed is not a dangerous operation, we must admit that at this age the accidents of the operation are much more common. The comparatively slight physical en- durance of the patients, their intractability, the difficulty of nourishing them, the increased chances of their contracting eruptive fevers after the operation, are so many obstacles to success. Research has been made equally as to whether, be- yond certain limits of age, tracheotomy was unfavorably in- fluenced. The age of seven or eight years has been consid- ered the limit at which this operation might be performed. In support of this, references have been made to cases at St. St. George's Hospital, and to others reported by Billroth and Wilms. Beginning in 1858, Millard, and in 1867 Archambault and Roger opposed this view of the case, because of its resting on facts not sufficiently numerous, while it was known that numerous recoveries were proved to exist at that age. It is certain, however, that failures are constantly occurring in tracheotomy of the adult. I know of but one case of recov- ery at this period of life. That was a patient of Legroux op- erated on by Robert in 1858. This man, aged forty-seven years, a copper-smith, presented the peculiarity of having his trachea ossified, so that it was necessary to use a strong pair of scissors to divide the osseous ring's. 490 DIPHTHERIA, CROUP AND TRACHEOTOMY. The following is a list of tracheotomies in the adult of which the results are known : Operators. Number of Tracheotomies. Recoveries. Deaths Legroux, I I Thierry, 3 Archanibault, 2 Burow, I Billroth, I Molendzinski, I Hulke, I Boiling, I Briddon, I Simon, I Total, 13 I 12 [Ferd. Brother, I I] [Cases of successful tracheotomy for croup in adults : Age. Legroux (operated by Robert, 1858), Sanne, - 47 Wm. Wallace (Brooklyn), Mastin, - - 52 D. Hayes Agnew (Philadelphia), Mastin, - 35 Cohen reports two English and one German=3. Internat. Ency. of Surg. Vol. V.] Trousseau gave a very plausible reason for these unfortu- nate results. The large dimensions of the larynx at that age, and the existence of the inter-arytenoidian glottis leave a pas- sage for the air sufficient for respiration even when the false membranes have diminished the caliber of the organ. As- phyxia is only produced when the bronchi become in their turn invaded. We can understand, then, how tracheotomy fails. After having established the rarity of the recoveries as well in early infancy as in adult age, let us ascertain what period of life offers the greatest advantages for the success of the opera- SURGICAL TREATMENT. 49 1 tion. According to Millard, ceteris paribus, the chances of suc- cess are in direct proportion to the age of the children. Peter is of the same opinion. Bourdillat has presented the following table. Under 2 years, average of recoveries, - 3 in lOO At 2 years, - - - - - 12 in lOO From 272 to 3 years, - - - - 17 in 100 From 3Y2 to 4 years, - - - 30 in 1 00 From 4'/2 to 5 \'ears, - - - - 35 in ] 00 From 572 to 6 years, - - - 38 in lOO Over 6 years, - - - - - 41 in lOO Dr. Jacobi, of New York, having obtained 13 recoveries in 67 cases tabulates them as follows : In 5 operations, from 272 to 3 yrs., i, that is 20 in 100 In 16 operations, from 3 to 4 yrs., 3, that is 16 in lOO In 23 operations, from 4 to 5 yrs., 7, that is 30 in lOO In 7 operations, from 5 to 6 yrs., 2. that is 28 in 100 The proportion is, therefore, about the same. Dr. Bartels gave a table also concerning the influence of ages, in the sta- tistics of the operations performed at Berlin in the service of Prof. Wilms, as follows : Age. Up to 2 yrs., Between 2 and 3 yrs.. Between 3 and 4 yrs.. Between 4 and 5 yrs.. Between 5 and 6 yrs., Between 6 and 7 yrs., Between 7 and 8 yrs., Between 8 and 14 yrs., Total, - - 335 103 37.5 Number of Tracheotomies. Recoveries. Proportion to the 100. 6 — 56 15 26 69 22 31 74 18 24 57 20 35 33 15 45 21 5 23 19 8 49 492 DIPHTHERIA, CROUP AND TR An anolagous table has been made at Paris for the Hbpital des Eufants, from 1858 to 1861. The results are: I Age. Number of Tracheotomies. Recoveries. Proportion to the 100. From I to 2 yrs., 10 I 10 From 3 to 5 yrs., From 6 to 10 yrs., - 359 122 68 68 18 55 From II to 15 yrs., 3 — — Number of TrachcoUnnies. Recoveries. Proportion to the 100. 653 88 13.62 1298 285 21.9s 335 127 37-89 I have done the same for all the croup cases operated on at Sainte-Eiigenie : Age, From I to 2 yrs., From 3 to 5 yrs., From 6 to 10 yrs., - From II to 15 yrs., 26 9 32.30 In these different series the figures lead to the same conclu- sion. The recoveries increase in proportion to the age of the patient. However, the statistics of the Sainte-Eugenie show that the proportion of recoveries is a little lower from ii to 15 years than from 6 to 10. Sex. — It has been observed at certain periods, that the re- sults of tracheotomy appeared to vary according to the sex of the patient. The recoveries were more numerous at one time with the boys, at another with the girls. Physicians who ob- served these series were led to consider success as favoring one sex to the disadvantage of the other. A favoring influence was attributed at one time to the male, and at another to the female sex. We are now in accord that sex exercises as little influence upon the results of tracheotomy as upon the etiology of diphtheria. The real obstacles to be surmounted in the cure of croup are numerous enough without creating any from the imagination. SURGICAL TREATMENT. 493 Tempef anient. — It is fully proven that vigorous children better support the depressant and anaemiant action of diphtheria, as well as the injury of the operation. But this condition is not invariable ; we see scrofulous, puny subjects attain re- covery. Previous Health. — Certain diseases, I mean the eruptive fevers and typhoid fever, exercise a considerable influence upon the development of croup. In fact if these diseases are so recent that the croup may be considered as secondary, most frequently the infectious element assumes an important rela- lation. The prognosis is narrowed down to the point that the operation was refused for a long time, and is still often refused in secondary croup, especially that which follows measles. When, on the contrary, the commencement of diphtheria has been preceded by the eruptive fevers by a considerable in- terval of time, the situation may be considered as better. In all probability these exanthemata will not intervene after tra- cheotomy ; i«i that way the patient will escape one of the most formidable causes of death. As to other diseases which pre- cede croup so closely that it may be considered secondary to them, viz., typhoid fever, whooping-cough, various cachexise, and tuberculosis in particular ; all these contingencies consid- erably diminish the chances of success. On this point one may refer to the chapter on secondary diphtheria. Among the preceding diseases we must also place croup. It is well known that this disease does return. It has in several cases required the performance of a second operation of tra- cheotomy in subjects operated on the first time for the same cause. These are, however, very rare cases. They are far from having the gravity that one might suppose. Of five cases reported by Millard one only succumbed. Perier recently cited the history of a child operated on, twice tracheotomized within one month's interval, and which he had the good fortune to cure. As to the operation itself this repetition may be a fortunate circumstance. The cicatricial connection uniting the skin and the trachea, serves as a certain guide and greatly fa- cilitates the operative procedure. Among the other diseases 494 DIPHTHERIA, CROUP AND TRACHKOTOMY. which may have a favorable influence when they precede croup, chronic bronchitis and whooping-cough have been men- tioned (Guersant, Cook, Millard). An habitual cough, con- tracted by the patient a long time previously, is supposed to facilitate the detachment of the false membranes. Of eighteen cases of diphtheria consecutive to this disease, twelve termi- nated fatally. Social Conditions, — It is understood that children whose parents are well-to-do are in better condition than others ; the diet and care in every respect are not wanting. Treatment in the family offers great advantages when it can unite all the needed resources ; moreover, in avoiding the stay at hospital the patient escapes the contagious diseases which act in such a fatal manner on the case. Previotis Treatment. — In speaking of the medical treatment I have shown the necessity of being sparing in the use of the means at our disposal. Tracheotomy has the best chances to succeed, said Trousseau, uninfluenced by all previous treatment. Without going so far, one may follow the course that I have indicated. The patients that we subject to tracheotomy, depressed by emetics too fre- quently repeated, by cauterization, by the struggles and suf- fering, are in a most unfavorable condition. Season of the year. — According to Fischer and Bricheteau, the influence of season upon the success of tracheotomy is re- markable. Winter and spring periods of the year which favor the development of pneumonia and broncho-pneumonia, are especially unfavorable ; summer and autumn, on the contrary, are propitious to recovery. The statement of all the tracheotomies done at the Sainte Eugenie up to the beginning of 1876 has given me the best re- sults for June and for August, to-wit : i : 3.31 and i : 3.56 re- spectively. November, December and January give 1:7.19, 6.18, 5.04 respectively. [See also the large table of cases, p. 321-2.] Pulmonary Injlatnmations. — It is by these that a large num- ber of the patients die who do not sink under the diphtheritic infection. SURGICAL TREATMENT. 495 Broncho-pneumonia is the scourge of the tracheotomized, but since the use of the cravat it is less frequent, without, how- ever, ceasing to be formidable. Eruptive Fevers. — The epidemic condition of the hospital wards frequently affects the convalescents who have not pre- viously had these diseases, and turns to failure cases which promised success. The most common of all. measles, is par- ticularly dangerous by its natural tendency to become com- plicated with broncho-pneumonia, a tendencx' which finds only too great a facility to develop itself in those operated on for croup. Scarlatina sometimes occasions a relapse of the diph- theria, often less severe than the former attack. Nevertheless it is dangerous of itself because of the soil on which it is im- planted. Other diseases, such as typhoid fever and variola, also very dangerous, are fortunately more rare. Indications for Tracheotomy. The only (unique) indication for the operation is asphyxia Agreement has always prevailed on this point. Differences have existed solely respecting the intensity of the asphyxia. Some have recommended surgical intervention during the second period, while asphyxia is still intermittent. Others have preferred to wait till asphyxia had advanced to its last degree, viz., the period of anaesthesia. The first of these plans is certainly the most brilliant, it furnishes numerous recoveries, but it might be accused of causing some patients to be oper- ated on who might have been cured by medical means alone. The. second is dangerous, exposing the patients to the peril of dying without the operation, and may also let them reach such a state of depression that they can no longer react after it, and thus result in no benefit. The early operation was recommended by Trousseau, and it remained for a long time the practice at the hospital in rue de Severes. " As long as tracheotomy was in my hands a treach. erous weapon," said Trousseau in 1834 and in 185 1, " I said, ' It is necessary to operate as late as possible ;' but now that 49^ DIPHTHERIA, CROUP AM) TRACHEOTOMY. I can count numerous recoveries I say, ' It is neceessary to op- erate as early as possible.' " Consequently, subtracting from this proposition, that which was too absolute, he modified it as follows : " The earlier the operation is performed the greater are the chances for success." Millard, who fully adopted the ideas of his [teacher, demon- strated by actual figures that tracheotomy furnishes results infinitely better when it is practiced in the second period rather than in the third. The preference shoulJ not always extend to exclusiveness. Trousseau says farther : " When the local lesion constitutes the principal danger of the disease, whatever degree the asphxia may have reached, if the child has but a few minutes to live, tracheotomy succeeds nearly as well as if it had been done three or four hours earlier." How- ever true in the main this remark may be it should not be taken literally. It would lead directly to the contrary of the first proposition, and serve as an argument to partisans of the late operation. To state the case in its true hght, we say : Asphyxia, to whatever degree it may have advanced, should never arrest the hand of the operator; and, as long as tiie patient is alive, it is a duty to operate. Therefore it is very different from sys- tematically letting the asphyxia reach an advanced degree. Whilst recommending tracheotomy in the second stage of croup. Trousseau did not, therefore, encounter the great incon- veniences belonging to the operation i)i extremis. The good results which early tracheotomy produces should not prevent our inquiring whether the patient might not ex- pect much more from a course which would give more impor- tance to temporization. Tracheotomy is the supreme therapeutic measure against croup ; it is, however, not the only one. Trousseau, who did not believe in the cure of croup by means aside from surgical intervention, acted correctly when he sought, first of all, to place his patients in the most favora- ble condition for a fortunate issue of the operation. This opinion, too exclusive, has found opponents. SURGICAL TREATMENT. 497 Barthez has demonstrated that croup will yield to medical means to an extent worthy of mention. Taking again the list of all the croup cases entered at the Sainte-Eugenie, I have reached the conclusion that in 2,809 cases, 204, that is, i in 13, have been restored to health without the operation. This pro- portion, even if it were still less, requires that we take it into consideration. To this objection it has been answered that tracheotomy, properly performed, is not of itself dangerous ; some have presented the harmlessness of this operation in the case of chronic or acute lesions of the larynx, other than diph- theria, and in that of foreign bodies in the air-passages. Now, admitting, if we will, that all the operators are equally ex- perienced in tracheotomy, we must acknowledge that very grave accidents have happened in the ablest hands, such as hiemorrhage, syncope and asphyxia, which are often followed by death. We may add thereto the influence of the wound which, in the very young, is not always exempt from dangers, as also the complications arising from the wound, viz., gangrene, diphtheria, erysipelas, etc. If then the cure can be effected by means which avoid the imminence of these dangers, no valid reason would justify the neglect of their employment. Moreover, why operate before the patient is in want of air ? Tracheotomy is not the treatment of croup, but of the as- phyxia ; it is, therefore, only applicable at a time when the latter is continuous and not at the time when relief of greater or less length follows each paroxysm of suffocation. However, from the moment when the paroxysms appear the patient should be closely watched. One paroxysm may be sufficiently severe to produce death. If the operator is within reach, he may save the life of the patient. Such cases are unique, when asphyxia alone is involved, which authorize the performance of tracheotomy during the second stage. We rarely find such a case ; therefore, the rule still holds to commence by medical treatment. But, having thus com- menced, it should be followed with prudence ; and, while tracheotomy should not be precipitated, we must be careful not 498 DIPHTHERIA, CROUP AND TRACHEOTOMY. to postpone it too long. This stumbling-block has not been appreciated by those who, exaggerating a truly wise precept, have extolled beyond measure the employment of medical means, and have postponed tracheotomy to the advanced period of asphyxia. Tracheotomy, practiced in extremis, has for it the authority of Archambault, but still we should know exactly the opinions of this able physician. The recoveries that he has had in mori- bund patients, have taught him that the operation, performed under these conditions, does not always involve the fatal con- sequences which he had at first dreaded. He, therefore, ad- vises not to withdraw from the operation in cases where the in- tervention of the physician has been asked only at the last stage ; but, as to advising to wait till that time to decide, he denies it most emphatically. Such a course would expose to painful disappointment. The decided depression, and some- times a condition of apparent death in which the patient is found, not only does not permit of delay, but exposes to the gravest accidents. Supposing the operator arrives in time, still he must operate rapidly. From this alone, the position given to the patient during the operation is very restraining to the respiration, and may soon cause a function to cease which is already imperfectly perforrned. Should now difficulties in the operation present themselves, its performance be protracted and difficult, and should the search for the trachea and the in cision not be made almost in the same moment, the patient will sink. This is one of the most frequent modes of death during the operation. In other cases the patient, half restored at the mo- ment of opening the trachea, sinks in a few moments, having no longer sufficient strength for reaction. Duhomme, on the authority of Claude Bernard, has showed that the effects of asphyxia are much less disposed to disap pear when it has existed a longer time. It vitiates the blood profoundly and even when air is supplied freely but slowly, the entire economy is so modified by the incomplete haematosis, that it is often found in a condition incapable of recovering. We can in this case say with the author, Snblata causa, non tollitur effectKs. SURGICAL TREATMENT. 499 When asphyxia alone is concerned, the dangers of prolonged delay are still not too great, as the recoveries of Archambault prove. But the situation is different when to the dyspnoea is added a profound poisoning. Completely depressed under the influence of these two causes, the patients operated on have no longer the power for reaction. Barthez has insisted upon this point ; and he has showed that these children make no effort to expel the false membranes ; and they permit in the bronchi and in the canula, the accumulation of the secreted fluids which dribble from the orifice of the tube, and they progress to an- haematosia, after the operation the same as before it. To wait for asphyxia before performing tracheotomy in the case of profound infection, is to expose this operation to be- come wholly illusory. The only chance for recovery is in re- moving one of the two factors which contribute to this lamen- table situation. Asphyxia is the only one over which thera- peutics has control ; this action it exercises by tracheotomy, provided, always, that asphyxia has not extended too far. By operating during the second period, before the asphyxia (I'anoxemie), and the poisoning have united their action, we have many chances of eliminating the former, and of having only the latter to deal with. hi conclusion, in a case where asphyxia predominates, it is too early to operate in the second period, and too late, very often, in the third. We should, therefore, endeavor during the first two periods, to provide for recovery by medical means If they produce no relief, we should not push their employ- ment beyond the second period, inasmuch as there is no bene- fit from them during the third. As heretofore stated, trache- otomy is so much the more successful in proportion as it is performed earlier ; so by uniting the two indications, we decide to perform the operation at the end of the second period or at the beginning of the third, at the moment when the first signs of continued asphyxia appear. When, on the contrary, the intoxication is the predominant symptom, it is necessary to operate during the second period. Nearly all authors are in accord with this precept formulated by Barthez: ''If it is in- 500 niPHTHEKIA, CROUP AND TRACHEOTOMY. fectious croup, it is preferable to operate iu the second period ; if it is not evidently the infectious form, it is proper to try medical treatment and to zvait to operate till the end of tJie second period, especially if the child be young." These rules are applicable in the majority of cases ; but they have exceptions. The violence of a paroxysm of suffocation may necessitate the performance of tracheotomy in the middle of the second period. At hospital it is seldom that aid cannot be summoned in time. In the practice of the city it is differ- ent. Whenever it is possible to leave with the patient a phy- sician experienced in tracheotomy, it is indispensable to do so in order to avoid being taken by surprise. When this resource fails, it is wise to take advantage of the moment when the operator and his assistants are present, to open the trachea, as soon as the paroxysms are seen to become more frequent and more severe ; for, when once separated, who knows whether the necessary aid can be reassembled in due time. It has hap- pened more than once that the disease, becoming suddenly aggravated when least expected, has taken everybody by sur- prise, and the necessity to operate occurred in the absence of the physician. Time being lost in hunting him, he arrives only in time to witness the death, A hasty operation, perhaps, might have saved the patient. Still other circumstances au- thorize the earlier performance of the operation. It is always an advantage to operate by daylight ; artificial light serves the purpose imperfectly, and requires an additional assistant. If then, a little while before evening the conviction is clear that the operation will become necessary during the evening or during the night, we will act wisely to take advantage of the sunlight. CONTRA-INDICATIONS. For some years past the range of contra-indications has be- come perceptibly restricted. Trousseau did not operate on croup secondary to measles or scarlatina. Pseudo-membran- ous bronchitis, broncho-pneumonia, and generalization of diph- SURGICAL TREATMENT. 5OI theria were considered as so many invalidating impediments. A discussion raised at the session of the " Societe Medicale des Hopitaux" in 1867, in which Isambert, Peter, Archam- bault, Roger, Potain, Moutard Martin, Vigla, and Dumont- pallier participated, showed the progress made. In the opin- ion of these eminent physicians there does not exist an abso- lute contra-indication to tracheotomy. Such a broad concep- tion of the situation is perfectly logical. As tracheotomy has become more common in medical practice, some of the bolder surgeons have operated without regarding the veto offered by their predecessors. Their efforts have been crowned with suc- cess ; and we have been able to cure patients which would have been, a short time previously, abandoned as incurable. In this way croup cases have been cured when attacked with broncho- pneumonia, and pseudo-membranous bronchitis, and croup cases following measles and scarlatina. Psejido-membranons bronchitis was considered as presenting a formal contra-indication ; but first of all, are we ever quite sure of its existence ? We know how treacherous are the signs furnished by auscultation in a subject attacked by croup. The feebleness of the vesicular murmur in certain parts of the chest, the presence of coarse crepitation, all these signs and many others prove nothing absolutely. The frequence of the respi- ration, beyond fifty in the minute, the slow increase of the as- phyxia, and above all, the cachectic palor of the surface taking the place of the cyanosis which indicates laryngeal obstruction, can furnish only presumptive evidence ; they indicate a pul- monary lesion without specifying what one. The only symp- tom that is conclusive is the expulsion of tubulated or ramified false membranes of which the form indicates the source ; we often see patients expel false membranes when they have ex- hibited no other signs attributable to the pseudo-membranous bronchitis. It often passes unnoticed; we operate on our patients without suspecting their having it. Should its proof stay the hand of the operator ? Certainly not. First, because the ex- pulsion of the arborescent fragments gives relief to the patient, and may have a favorable influence upon the course of the 502 DIPIIJIIERIA, CROUP AND TRACHEOTOMY. disease. Secondly, Millard and Peter report cases of recovery by tracheotomy with such coincidence. I have witnessed my- self the recovery of five operated cases of croup which had ex- pelled this variety of false membrane. In others I have seen death occur at the end of so long a period, a month for exam- ple, that the pseudo-membranous bronchitis could not be held responsible for this termination. The extension of diphtheria to the bronchi, is not, therefore, a contra-indication againt tracheotomy when it is accompanied by symptoms, indicating, at the same time, a laryngeal obstruction. Surgical interven- tion should be opposed only in the cases in which there is an evident predominence of asphyxia from the lungs. BfoncJio-pneinnonia, even more than pseudo-membranous bronchitis, has been dreaded by operators and has been placed among the positive contra-indications. Its gravity is beyond question, but its diagnosis is very difficult if not impossible. Auscultation and percussion furnish only uncertain results. The only symptoms on which we can depend are the extreme frequence of the pulse pointed out by Archambault, and the acceleration of the respiration indicated by Barthez. When- ever the respirations exceed fifty in the minute there is in all probability pulmonary inflammation. Let us add to these signs also the rise in the temperature in the body. Being but little elevated in the case of ordinary diphtheria, when inflammation develops it rises to about 40° (104° F.). Notwithstanding the aid that these facts may furnish we are still generally in almost complete uncertainty. However grave may be the prognosis of croup when broncho-pneumonia su- pervenes, strictly speaking, the diagnosis does not interdict tracheotomy ; the authors I have mentioned are in accord upon this point. In support of this opinion Peter has reported the history of a patient of Grisolle's who was tracheotomized, not- withstanding the existence of a clearly established broncho- pneumonia and who recovered. Why, indeed, not operate ? One says because these cases of broncho-pneumonia are always fatal from the beginning. The above case proves the contrary ; but, should not a case of recovery be known, still, the refusal, it appears to me, would not be justified. Respira- SURGICAL TREATMENT. 5O3 tion through the tube, says one, is likely to engender broncho- pneumonia or to aggravate it when it previously exists. If that were always so the cases of broncho-pneumonia which develop after the operation would never recover; but Millard, Archambault and Peter have cited cases of recoveries under similar circumstances. I have seen five cases recover in which broncho-pneumonia became apparent on the fifth day after the operation. Respiration through the tube is not, therefore, posi- tively fatal to the broncho-pneumonia, especially when proper precautions are taken. Suppose, on the other hand, a patient has two causes of asphyxia, to wit : a lesion of the larynx, and also one of the lungs, is not the indication clear to relieve him of one, the ef- fects of which we can instantly neutralize? Broncho-pneumonia is, therefore, not an irreversible contra-indication of tracheot- omy. Piieiwionia. — Lobar inflammation of the lungs being much more rare than broncho-pneumonia, we have seldom occasion to discuss the dangers arising therefrom in reference to the question of tracheotomy. Guersant was far from considering it as a positive contra-indication. He reports the history of two tracheotomies performed by his son in two cases of croup complicated with lobar pneumonia. Both patients survived ; the first to the eighth day, the second to the fourteenth, the wound being almost cicatrised. Millard remarks on this point that there does not exist in science a single authentic case of complete recovery of croup complicated with veritable pneu- monia at the time of the operation. I am prepared to cite one. The fact is all the more interesting, as the pneumonia inter- vened three times during the course of the same attack of croup. "A girl of 7 years of age (J. N.) was admitted to the Sainte-Eug^nie hospital, ward Sainte-Mathilde. No. 8, December 6, 1865, on the third day of croup, after several attacks of suffocation, and was at the time in the midst of the third period; retraction of the soft parts of the chest {tirage) considerable, laryngeal wheezing, palor with a slight cyanotic tint; voice still audible. Nothing in the throat; no submaxillary en- gorgement 504 DIPHTHERIA, CROUP AND TRACHEOTOMY. Auscultation, made at the time of her admission, revealed at the right posterior summit a well marked bronchial tone of the respiration, and at the same time a de- cided resonance of the laryngeal bruit. Resonance was diminished in the corres- ponding region. Tracheotomy was performed some hours after admission, and fragments of false membranes were expelled when the tube was introduced. Pneumonia of the summit of the right lung expressf d itself more clearly the follow- ing days, and the respiration assumed the cavernous tone, then the phenomena di- minished and the pneumonia improved and disappeared. During this time the croup had progressed towards recovery; the lube was removed on the seventeenth ■day; cicitrazation wes completed on the fortieth day, all of which did not prevent the reappearance of the pneumonia in the same place on the thirty-ninth day, and again the forty-sixth. Recovery was complete on the sixty-first day." Secondary Croup. — Measles and scarlatina have been re- garded as causing cases of croup always to be fatal. Trous- seau refused to operate on croup cases occurring under these conditions. However, Millard cites three cases of success ob- tained by tracheotomy in rubeolar croup. I am in posession of four observations of simlar facts. [Dr. L. S. Pilcher reports one.] Scarlatinous croup, which Trousseau and Millard consider as still more grave, tracheotomy having alwas failed, has fur- nished me also four cases of success It is different with small-pox. The general adoption of vac- cination makes this form of croup very rare. I have only known of two cases ; both terminated fatally, one after tra- cheotomy, the other without the operation. Diphtheria which follows typJioid fever is always fearfully grave. In eight cases of diphtheria supervening under these conditions, there was not a single recovery ; the tendency to infection and generalization was extreme. Of this number a single case of croup presented itself which could be operated on; that one succumbed. Whooping-cough does not seem to have a serious influence over tracheotomy, Millard speaks of three cases of croup fol- lowing this disease which were operated on and recovered. Archambault believed also in the favorable influence of whooping-cough. I do not oppose this opinion. In eighteen cases of diphtheria following whooping-cough, six recovered, and I can cite three cases of croup tracheotomized with sue- SURGICAL TREATMENT. 505 cess under the same circumstances. The cachexicB, especially tuberctdosis, have given me the following results : In nineteen cases of diphtheria consecutive to tuberculosis, death did not spare a single case ; six have undergone tracheotomy. Archambault has been less unfortunate. He cured by tra- cheotomy one tuberculous patient attacked with croup, and prolonged the life of another for six weeks. Of thirty-three patients attacked with diphtheria during the course of various cachexiae, two survived; three were tracheot- omized and succumbed. Diphtheritic infection, quite advanced, which appears, even for the most courageous a positive contra-indication, has still cures of the most desperate cases. I have also seen patients infected to the highest degree, having enormous glandular swelling, coryza, cutaneous diphtheria, angina and croup, not- withstanding, owe their lives to tracheotomy. We should not therefore, deny a patient the benefit of this operation because infection prevails in his case ; from the time that asphyxia by the larynx is manifest, we simplify the therapeutic problem by removing the asphyxia ; and we enable the organism to react against the infection. Conclusions : Among the conditions which exercise over tracheotomy the most disastrous influence, there is not one that can be regarded as a positive prohibition. All have had recoveries. ' The only contra-indication is the absence of laryngeal as- phyxia. If we can establish the fact, by the way, not an easy matter, that asphyxia has not its origin in the occlusion of the larynx, but in the obliteration of the bronchi, tracheotomy can be of no benefit ; it replaces the larynx, but is unable to supply bronchial tubes. Obstacles located in the trachea also justify tracheotomy ; they are ordinarily promptly expelled by the ar- tificial opening. But whenever one finds himself in the pres- ence of an asphyxia arising from stenosis of the larynx, whatever may be the complications which darken the progno- sis, he is under obligation to the patient to supply the air of which the latter stands in need. Tracheotomy does not pre- $06 DIPHTHERIA, CROUP AND TRACHEOTOMY. * tend to cure croup ; it removes the asphyxia, and destroys one of the most important elements of the morbid complex, and permits the economy and the therapeutics to combat the others. By acting thus we are exposed to numerous failures and obtain statistics not very flattering; but what value can this consideration have when we are enabled to restore to life, however small may be the number, patients doomed to imminent death. The action of the pioneers of tracheotomy was perfectly justified ; they desired to pave the way for an operation against which numerous prejudices were raised. They needed suc- cessful results, which they never would have obtained by oper- ating too frequently. Fully understanding that the interests of the small number should yield to that of the generality, they chose the cases which to them appeared favorable. By this course, laudably prudent, they succeeded in making tracheot- omy acceptable to such a degree that no one will longer se- riously question its benefits. We may not now act thus, we should, on the contrary, offer those advantages freely, endeavoring to make the best of the situation though in appearance the most desperate. Preparation. We are sometimes suddenly called to a patient that we find already suffocating. There is no time for details in the prep- arations, and inspired by the difficulties of the situation, we op- erate at once. These conditions are decidedly bad and may be causes of numerous accidents. It is true that the very gravity of the situation may aid the operator, and the state of relaxation {irsolutioii) and anaesthesia in which the patient is allows of operating almost as upon the cadaver. I have sev eral times found myself surrounded by similar circumstances. The case is not rare at hospitals ; children are sometimes brought there in a condition similarly unfavorable. Aided by one person who held the light, I have been able to operate on these patients on their bed, with the greatest facility. Those are exceptional cases. In ordinary practice we follow the SURGICAL TREATMENT. 507 case and observe the course of the disease, or are informed in proper time by the attending physician. It cannot be, more- over, too strongly recommended to the latter, that he shall not wait in calling for the operator till the case takes on a threat- ening action. At this period one can never foresee whether the disease will progress slowly or rapidly. We are sometimes surprised by a sudden acceleration which disappoints all ex- pectation, if it does not render the operation useless. There is every advantage in bringing the operator as soon as the di- agnosis is confirmed, and uniting with him in all proper meas- ures. Assistatits. — The first thing to be done is to find assistants. The success of tracheotomv often depends upon the manner in which one is aided. All other precautions are secondary to that. With experienced assistants we can always overcome the local difficulties of illumination and implements. Three as- sistants are necessary ; one stands in front of the operator, holds the light, passes the instruments, cleanses the wound, etc.; the second holds the head of the patient; the third holds the hands, the pelvis and the inferior extremities. It is infinitely preferable that the assistants should be phy- sicians, and, moreover, those who are posted in tracheotomy. But in an extreme case it may suffice that the principal as- sistant has these qualifications. The members of the family never fail to offer their services, but they nearly always have more of good desire than self control (qualification). The sympathy, the anxiety and the sensation so common in per- sons who for the first time witness a bloody operation, may cause faintness, the effect of which might be to seriously dis- turb or compromise the operation. Friends, neighbors and servants may render assistance, but we should be careful to inquire of and examine them to be assured that they will not give way. Females, even the nurse, should be displaced or put in a secondary position. Instnnncnts. — The operator should have at hand the follow- ing instruments. A bistoury brightened and very sharp. For the purposes of 508 DIPHTHERIA, CROUP AND TRACHEOTOMY. tracheotomy, a special bistoury has been made, with short blade and moderately convex. I find no advantage in it. On the contrary, I have observed in several cases its defects, and much prefer the bistoury with very sharp point. In adults, or in children of three or four years, any of the bistouries are good enough, but below that age the trachea is very small and yielding, and evades the instrument if it is not very pointed. In \h& post-vio)tein of a young child which died during the op eration without it being possible to open the trachea,one could recognize upon this very slender and very soft organ, the marks of the bistoury in real scratches. The operator, who used a convex bistoury had struck the trachea several times, but the trachea yielded and became depressed without being penetrated ! [Nota bene.] All authors recommend a blunt-pointed bistoury. This in- strument is of no use where the operation is regularly done ; it is rather an inconvenience as I'shall hereafter show. The dilator is still one of the instruments considered as in- dispensable by the majority of operators, especially by Trous- seau. The introduction of the canula into the tracheal wound, is, for the time being, regarded as the most difficult step of the operation ; one should surround himself with all the means adapted to facilitate this manoeuvre. This estimate is exag- gerated in the majority of cases. If in the operation practiced as low down as Trousseau did it, the introduction of the canula may offer difficulties because of the depth at which the trachea lies, it is not so when the incision is made from the inferior border of the cricoid. But in either case, when the operation is well done, the dilator rather augments than diminishes the difficulties. My friend Dr. Pouquet, in his excellent thesis, has treated this point with ability and with the authority which a large practice in tracheotomy has given him. When the in- cision in the trachea is central, straight and sufficiently long, it very rarely happens that the canula cannot be easily intro- duced without the aid of the dilator, especially when one uses the canula of Luer of which the end is cut slanting. Far from being useful, the dilator is often an obstacle on account of the SURGICAL TREATMENT. 509 space it occupies in the trachea, especially when this is very narrow ; hence, several physicians, expert in the matter of tracheotomy, have long since abandoned its use. My inten- tion is not, however, to entirely proscribe this instrument. But, while very simple, the direct introduction of the canula fright- ens beginners ; however, the dilator has its real advantages. If a false membrane, still partially adherent, should present itself at the moment of opening the trachea, the dilator, placed in the wound, may keep it open if necessary, while the trachea forceps is being used to search for the false membrane. If haemorrhage intervenes, or any cause whatever retards the in- troduction of the canula, the dilator supplies its place by hold- ing the wound open, and permits the patient to respire, while one provides against new difficulties; it also renders good ser- vice during the dressing which follows. For these reasons it should be retained among the useful instruments. The number of dilators which have been invented from time to time, proves the imperfection of the instrument. We may reckon two prin- cipal kinds : those which are applied to the inferior extremity of the wound, and those which are placed at the superior ex- tremity. The first dilators invented, especially the one by Trousseau, belonged in the former list; of all those the best is that of Luer. These instruments have a fault common to them all, it is that of requiring the canula to pass between two " rigid branches which remain too near each other when the in- cision is too short, or when the trachea is too narrow, and they slip too easily from the tracheal wound when this latter is too long or irregular. Finally, the canula often enough escapes between the branches of the dilator and passes in front of the trachea. To remedy this latter defect Laborde has invented a dilator with three blades. The third, situated at the anterior part, pre- vents the canula from escaping forwards, and serves to direct it. This ingenious instrument does not appear to me to ac- complish all that was expected. If the trachea is large and the incision sufficient it works admirably ; but then, one never experiences any difficulty. If, on the contrary, the trachea is 5IO DIPHTHERIA, CROUP AND TRACHEOTOMY. narrow, which condition is the source of the real difficulty, the three branches of tlie instruments occupy in the opening a space sufficiently large to prevent the canuhi from entering. The principal indications to be fulfilled by the inventors of di- lators, are to have an instrument with branches very thin, yet stiff, so as not to encumber the wound. The dilators which are applied to the superior angle of the wound are preferable. The canula is not required to pass between their branches, and it enters more freely. On this idea the one of Garnier is con- structed, the description of which he gives in his thesis. How- ever, this instrument has branches relatively thick, and still oc- cupy considerable space. I have sought to retain the advan- tages of this plan, and yet avoid its inconveniences. With this purpose I have taken the tenaculum of Langenbeck and have submitted it to some modifications. This instrument, intended to hold the trachea during the operation, is composed on the principle of two pointed, curved hooks, placed together, but separable at will and destined to hold the trachea as Chassaig- nac intended. By blunting the points of both branches and in- creasing slightly the curve of the extremities one has a real di- lator, with thin, resistant branches, which fixes itself firmly in the superior angle of the tracheal wound and never suddenly slips out. Ca/mlas. — First of all, by the example of Sanctorius, the canula of the trochar which was used to puncture the trachea, was left in the wound. Later, Fabricius ab Acquapendente spoke of a canula with 2i fla)igc (rim or plate), because of the danger that a simple canula offered of falling into the trachea. In 1730 George Martin, an English surgeon, carrying out the idea of one of his friends, invented the double canula, such as we now employ. Van Swieten recommended this instrument. B etonneau used, in his early operations, a double straight canula, which he soon replaced by a simple curved one. For some time this latter instrument prevailed in practice. Its numerous incon- veniences were soon recognized. Every time that the canula became obstructed it was necessary to remove it entirely or to SURGICAL TREATMENT. 5 i I push back into the trachea the obstructing material, which was not without considerable fatigue to the child, nor even without danger. These inconveniences disappeared with the use of the double canulas which Trousseau recommended. This inven- tion was suggested to him by an officer of the artillery, Gen. B., whose daughter he had operated on for a chronic laryngitis, about 1842. Impressed with the extreme inconvenience of the single canula this officer remarked to Barthez during a night which they both passed with the child, how much the after-treatment of the operation would be simplified if the canula was com- posed of two tubes, one inside of the other, in such a way that the products from the trachea or bronchi would pass by the central tube alone ; the latter becoming clogged, it would be sufficient to remove it without deranging the entire instrument, and to replace it after being cleaned. On the next day this idea was submitted to Trousseau who accepted it with thanks, and immediately had a double canula constructed. A quarter of a circle was the curve first adopted ; it was necessary to al- low one of the tubes to slip into the other without effort. But the result was that the lower end made a certain projection forwards, rubbing, compressing and often ulcerating the an- terior part of the trachea. The movable canula constructed by Luer, has removed these imperfections, as well by the mobility of the two pieces of the canula, one upon the other, as by diminishing the curve of the tube. Moreover, by the advice of Barthez the inferior extrem- ity has been beveled off (cut slanting) at the expense of the anterior aspect ; the instrument is thus much more easy of in- troduction, and is better borne by the trachea. It is really the best tracheotomy canula that we possess. I should also mention the canula of Bourdillat. In this instrument the outer tube, instead of being cylindrical, is formed of two valves which are introduced into the trachea upon an obturator, just as the speculum of Ricord. The canula being in place, the obturator is replaced by an inner cylindrical canula which separates the two valves [Fuller's bivalve]. Formed for the purpose of facil- 512 DIPHTHERIA, CROUP AND TRACHEOTOMY. itating the entrance of the canula into the trachea, this instru- ment has serious defects. Being presented at the wound closed it is impermeable to the air. It does not permit the pro- duction of the characteristic whistling sound which indicates the presence of the tube in the air-passage. Efforts at intro- duction are prolonged, and false routes are more com.mon. It does not, therefore, facilitate the introduction of the canula. As a compensation, it is very useful as a dilating body. I have shown the use that can be made of it ^ in cases wherein the wound contracts rapidly and refuses to admit an ordinary canula. [See description of canulas in Stirgical Anatomy, p. 32.3 We should always employ a canula as large as possible, in order that the respiration, and consequently the h^matosis, may be freely performed. As rational as this course may be, we must acknowledge that it is not always followed, and that the fear of difficulty in the introduction of the canula leads to the choice of one too narrow. We should oppose this tendency and understand fully that everything depends upon the man- ner in which the incision is made. When this is of proper di- mensions and direction the canula gives no trouble in entering. The precaution to assure one's self, before the operation, of the firmness of the canula to be used, might be regarded as unnec- essary. Several cases are cited, however, of the dropping of the canula into the bronchi ; the last one reported belonged to Legros, of Brussels. Some physicians, Maslieurat Lagemard, Miquel, of Amboise, and Tenderini, according to Fiorini, proscribe the canula ; they keep the trachea open either by means of a special separator — trachea stretcher — or by metallic hooks held by ribbons, or by the aid of threads passed through the edges of the wound. This hazardous practice has never prevailed. [The late Prof. Brainard, of Chicago, and Dr. Henry A. Martin, of Boston, strongly recommended dispensing with tubes ; also Roser, Chevalier, Dieffenbach, J. Pancoast, Hodge,Levis,DeF(>rrest Willard, Himes,Wm.Pancoast and (I.li. Smith. Substitutes for tubes have been proposed by Marshall Hall, Watson, ofNew York, Bigelow, Bird, of Birkenhead, Linhart and Packard. 'E'trude Sur le croup apres la tracheotomy, p. 97. SURGICAL TREATMENT. 513 Dr. John H. Packard in a report to the Pennsylvania State Medical Society, 1S85, "Suggestions as to substitutes for the tracheotomy tube," gives the following illus- trations : FUj.3 Fig. I represents an apparatus made out of bent wire which was found to be intro- duced in the cadaver wtih great ease, and to hold its place very firmly. As tried, it was not rigid enough and needed some arrangement to enable the surgeon to set it, and possibly in the living subject there might be some little difliculty in the introduc- tion. Fig. 2 represents an instrument for lateral dilatation of the tracheal wound. It is very easy of introduction, and being fixed at the proper degree of expansion by means of the bar, a, and the screw, b, may be kept in place by a strip of adhesive plaster, or by an elastic band fastened around the patient's neck. Fig. 3 represents the model by Dr. Ilopkinsof an instrument with separable blades. The lower one being inserted first, and then the upper one, the two are fastened to- gether by means of the screw. This appliance would hold its place in the trachea without any strap or confining band around the neck.] The canula selected should be supplied with a piece of tape in each eyelet, intended to be tied around the neck. A piece of oiled silk or thin rubber cloth with a slit near the upper edge should surround the canula. It is intended to protect the skin from contact with the plate, and from the pro- ducts which escape from the tube. A piece of tarlatan of which to make some cravats, and a piece of flannel for the same purpose, are equally necessary. These two accessories, so simple in appearance, are most for- 514 DIPHTHERIA. CROUP AND TRACHEOTOMY. tunate improvements added to tracheotomy. It is from their adoption by Trousseau that we date the restoration of the op- eration. The air entering directly by the wound without being either warmed or moistened in the nasal fossae, increases remarkably the tendency to broncho-pneumonia so natural to croup. The cravat remedies this unfavorable disposition. The tarlatan holds the moisture of the expired air, and the wool preserves the heat. The air enters the canula only after having passed through a strainer where it encounters heat and moist- ure ; the respiration is thus brought nearly to a physiological condition. The tarlatan should not be too fine; it would then have the disadvantage of muslin which, when wet, adheres to the mouth of the tube and prevents the circulation of the air. It should be stiff. One should be careful to rub it in the hands before applying it; its contact with the skin of the neck will then be less irritating. The piece of flannel may be substituted by a simple linen handkerchief. When one practices the operation by the process of Trous- seau, he must have some blunt hooks which may serve to sep- arate the tissues and to hold the vessels out of the way of the bistoury. They may be useful in the combined procedure which I employ. A forceps for false membranes, of the model of Luer, should be added to the other instruments. An inflating tube, such as is used to excite respiration in case of asphyxia in the new- born infant, may render important service when one operates on a patient in a state of apparent death. The canula being put into place, inflation is practised by means of this tube. In this way one avoids placing the lips upon the wound or upon the canula. [Parker, of London, has recommended an inflating tube by which dangers may be avoided, and yet the other objects of such an instrument fully effected.] Warm water, sponges and basins are placed at the service of the principal assistant. I do not speak here of artery forceps, threads, etc. The wounding of arteries is so rare that one never has occasion, so to speak, to ligate any of these vessels. SURGICAL TREATMENT. 515 As to the ligating of veins, it is difficult, dangerous and useless so far as the branches of the thyroid plexus are concerned. For the case of free haemorrhage which does not admit of waiting till the opening of the trachea and the introduction of the canula, I have had constructed by Collin haemostatic for- ceps reduced from those of Pean, but broader at the ex- tremity. Operatijig Table. — The patient should never be operated on while on his bed except in extreme emergency. It is too low or too wide, or inclosed by the walls, rendering the approach to the child difficult. The oval parlor tables, rather low, or the long narrow kitchen tables are a great aid, as well as the dining tables with folding leaves. The table being chosen it is covered with a mattress from the child's bed, and, spread over all, is a sheet. The patient's neck needing to be made quite prominent in front, a kind of bolster which one can make him- self is so placed as to support it. For this purpose the cushion should be quite firm. If it yields under the weight of the head and neck, the latter becomes relaxed and the trachea will be less accessible. One can make it with sheets not folded, which may be rolled up. Archambault ad- vised, in order to give more resistance, to introduce into the middle of the bundle a beer jug. I am in the habit of using an ordinary pillow, or one of hair if possible, which I roll upon itself, drawing it tightly and maintaining the constriction by tying it with bands of cloth like a sausage. If the bands are wanting, not to be had, I have recourse to pocket handker- chiefs which I draw firmly and tie tightly. Three will suffice, one in the middle and one at each end. One obtains in this way a cushion which is perfectly firm, and answers every pur- pose. When finished, the cushion is rolled in the upper end of the sheet which covers the bed. Upon this sheet is spread another folded double, which is intended to envelop the patient. Position of the Patient. — Formerly the operation was per- formed with the patient seated in a chair, the head thrown back. Trousseau himself, in the beginning adopted this plan. He soon abandoned it on account of its inconvenience, and be- 5^6 DIPHTHERIA, CROUP AND TRACHEOTOMY. cause it favored syncope, a complication which cannot be too much dreaded. A fatal accident of this kind led him to place the patient on the back. It is necessary, however, to avoid holding the head in forced extension ; the embarrassment of this position to the respiration may cause also serious conse- quences. Foville reports a case of almost sudden asphyxia in a female placed in this position. The dorsal decubitus with moderate extension of the head, recommended by Ledran, is the most favorable position for the patient and the most con- venient at the same time, both for the operator and his as- sistants. The sitting position is reserved exclusively for adults. Illtnnination. — When one operates by day-light the table is placed near a window so that the patient has his feet towards the light. In any other way the neck of the patient is hid by the shadow of the assistants. The table should not be placed at right angles to the window, else the shadow of the oper- ator's hand would fall upon the neck ; we place it at a certain angle so that the light will strike the hand which holds the in- strument obliquely. The assistant who has charge of the limbs and the trunk should remain stooping to avoid inter- cepting the light. No artificial light can take the place of day-light. The operation has certainly the advantage of safety by being performed during the day, especially when one has a lack of help. When we are sure the operation will become necessary, it is better to act a little sooner than to wait till night. All plans of illumination have been recom- mended when it is necessary to operate at night. Dining-hall lamps, and lamps suspended from the ceiling, expose the sur- geon and his assistants to injury of the head. If, to avoid this danger, one raises them too high they will not give sufficient light. Candles are easily extinguished, and drip upon the pa- tient ; lamps are heavy to carry, and the glass may crack, and the operation may be interrupted in the most unpleasant man- ner. The best of all the means, as it has always appeared to me, is the common wax taper of a large size, such as are used in hospitals. This kind gives a sufficient light and does not drip ; the assistant, standing in front ot the surgeon, holds it in his SURGICAL TREATMENT. 517 hand and approaches as near the wound as needed. A lighted candle placed near by enables it to be relighted in case the air escaping violently from the trachea should extinguish it. I have never employed any other plan, and have always been perfectly satisfied with it. Everything being thus prepared, the patient is divested of his clothing, even of the shirt, and placed upon the bed. He is placed upon his back, the neck supported upon the bolster, and quite projecting; he is rolled in the sheet which has been prepared for that purpose, being careful to bring the hands to- wards the pelvis. The assistant charged with this duty seizes with each hand, through the sheet, one hand of the patient and presses it upon the pelvis which he is holding. Leaning over strongly and almost lying upon the bed, he holds the in- ferior extremities of the patient by the weight of his body. The principal assistant stands opposite the operator, on the left of the patient; if it is night, he holds the light. The in- struments are placed within his reach which he passes when needed, as are also the sponges for cleansing the wound. An- other assistant holds the head by applying the hand on each side of the head near the angle of the inferior maxilla. He should be careful not to reach beyond this for fear of being in the way of the operator. The surgeon stands at the right of the patient, exposes the neck and proceeds to operate. Ancesthetics. — In England, in the United States, and in Ger- many the preparation is more simple ; the use of an anaesthetic is general. Drs. Howard Marsh, West, Jenner, Paget, the physicians of the Hospital foi Sick Cliildreti, Messrs. Holmes, Smith and Gee; Drs. Buchanan, .^f Glasgow; Parker, Voss and Jacobi, of New York; Braidwood, Kuhn, Roser, of INIarbourg, Wilms, of Berlin ; Llewellyn Thomas and many others give anaesthetics to patients whom they are going to operate on for croup. With them it is a quieting measure, as well as a means of calming the spasmodic element of the asphyxia. According to these authors chloroform should be given when we operate in the second period. Some even pretend that it Sl^ DIPHTHERIA, CROUP AND TRACHEOTOMY. does not embarrass respiration when asphyxia is advanced. Others, on the contrary, declare that they have seen its use considerably increase the symptoms of asphyxia. We can conceive of the use of anaesthetics when really nec- essary in operations during the second period ; the child is still disposed to resist, and sensation is intact; but we must stop the inhalations immediately after the incision through the integuments is completed — the only painful step in the opera- tion. After that they are perfectly useless, the asphyx.ia being sufficient to anaesthetize the patient, and to put him in a state of relaxation. Moreover, it is not proved that the use of these agents is as innocent as some would assert. We know there is danger of death by syncope in diphtheria ; and anaesthetics are among the well-known causes of that condition. [My experience with anesthetics, especially with chloroform, has been such as to make me extremely cautious in recommending their use in this operation for this dis- ease. In one case the patient came near being lost, chloroform being the anaesthetic used ; and in another, though given cautiously and suspended entirely at the begin- ning of the operation, I am inclined to think it had much to do in determining the fatal result. For years I have raised the note of warning against the use of chloro- form; and I now say that, generally speaking, under the conditions usually existing in this operation, it is better to dispense with the anaesthetic entirely.] The action of these substances upon the blood, insufficiently oxygenated, is of very doubtful innocence. Besides, the res- piratory mucous membrane when anaesthetized does not react sufficiently to expel the blood which is introduced into the trachea during the operation, nor to produce those violent paroxysms of coughing which, at the moment of opening the trachea, often favor the expulsion of false membranes. In France this practice is not common. We rarely operate in the second period, but at the commencement of the third, when resistance and sensation are often diminished. Besides, the little incision in the skin is never a cause of so severe pain as to demand the use of means which are not always without danger[!]. The following are the directions to be followed in the meth- ods which present themselves to the operator: surgical treatment. 5i9 Operation. Without speaking of the primitive processes, inconvenient, insufficient, dangerous and for these reasons fallen into desue- tude, three principal methods share the favor of operators. The first, that which Trousseau recommends, reaches the trachea below the thyroid body, often in the space comprised between the third and the seventh rings, as advised by Vel- peau. This is tracheotomy properly so called. I shall call it low tracheotomy. The second opens the trachea in its superior part, starting from the inferior border of the cricoid cartilage, that is, through the upper two or three rings. I shall designate it under the name of high ti'acJieotoviy. The third, indicated by Boyer, concerns the cricoid and the first two rings ; that is crico-tracheotoniy , (laryngo-tracheot- omy). The place of election is not the only point that has oc- cupied the attention of practitioners. Some have found ad- vantage in operating rapidly, others have advised deliberation. This question has been much discussed. The slow operation, so valliantly supported by Trousseau and Millard, still claims numerous partisans ; the rapid operation, on its part, has made important conquests. The operator, then, finds himself in the presence of several methods which difier respecting the region, and in reference to the slowness or the rapidity with which they should be com- pleted. The problem is less complicated than might appear. The method of Trousseau should be performed slowly for fear of accident. High tracheotomy may also be performed slowly and also crico-tracheotomy, but both these have the great ad- vantage of allowing promptness in their execution. When it is necessary to operate on a patient in an advanced state of asphyxia, it is necessary to proceed rapidly under penalty of exposing the patient to die during the operation. Still other considerations enter into the choice of method. They will be better understood after each procedure shall have been set forth in detail. 520 DIPHTHERIA, CROUP AND TRACHEOTOMY. Inferior Tracheotomy, (Low operation). This comprises, in its execution, three principal steps: i. Division of the soft parts down to the trachea; 2. Incision of the trachea; 3. Introduction of the canula. Division of the Soft Parts. — The operator, standing on the right of the patient, ascertains the position of the trachea ; that is one of the important preHminaries of the operation; it is not always easily accomplished. If the child is very young, if the neck is fat and the trachea compressible, we find difficulty. We should seek for the tuber cle of the cricoid cartilage as our guide. Under [the circum- stances to which I have just referred we do not always find it easily : it may be confounded with that of the thyroid, and this cartilage be divided in its entire length. The error has been committed several times and should be avoided. Peter gives excehent advice for this case. [In one case I found it verj' difficult to recognize the cricoid with any degree of certainty. It was rather by recognizing its relative oosiiion to other parts that I de- termined at what point to inti-oduce the tenaculum below it.] The patient being in the position desired for the operation, one should count the prominences which appear on the surface of the neck below the chin on the median line. The first is that of the os hyoid, the second that of the thyroid ; the third and last, that of the cricoid. This point being recognized it is marked either with the nail or with ink, and an incision is made on the median line, extending from this point to within a short distance of the sternal depression. It is absolutely necessary that the incision be central, in default of which one risks los- ing his course from the start, passing to the side of the trachea and, cutting on, reaches the cervical vertebrae, and is very fortunate if he does not injure, in making this track, some im- portant organ, a jugular vein, for example. To avoid this er- ror, one may, after the example of Trousseau, and before com- mencing the operation, mark out the track for the bistoury by making a line with ink or with a cork blackened in the SURGICAL TREATMENT. 521 flame of a candle. The nail of the left index finger often serves for the experienced operator to recognize the trachea. This finger answers as princal guide during the entire opera- tion, and it should frequently examine the position. The integument, the subcutaneous connective tissue and the cervical aponeurosis are to be successively divided. Reaching the median raphe, which separates the sterno-hyoid muscles, the bistoury is directed upon this line, and the incision is con- tinued by short strokes, while the left hand, armed with a blunt hook, draws aside one of these muscles. The assistant, armed with a similar hook, does the same with the other muscle. The sterno-thyroid muscles are to be separated in the same manner. During this time the assistant attends to sponging quickly and frequently so as to keep the bottom of the wound constantly quite clean. In this way we avoid the thyroid body, at least when it is not very large. In the latter case, even if the incision is exactly in the middle, we come down in front of the isthmus of this gland, ordinarily quite a thin strip, so . delicate that we may very frequently cut it without being aware of it. We next encounter the thyroid venous plexus, and the median thyroid artery (thyroidea ima, artery of Neic- batier and Erdmann^ the existence of which is quite excep- tional. This is really the critical moment in the operation, for these vessels are not the only ones which demand our careful attention. The left internal jugular vein, the left common ca- rotid which sometimes crosses the trachea, the left subclavian vein, and even the brachio-cephalic trunk, innominata, which sometimes rises considerably above the margin of the sternum, may be found under the bistoury. To wound them is to ex- pose the patient to certain death ; they are fortunately very rare cases. Notwithstanding, we must manipulate with great circumspection in this dangerous region ; each stroke of the knife should be preceded by a minute exploration with the aid of the finger and the eye. Every vein is dissected up and held aside by the blunt hook. Proceeding thus we arrive at the trachea; examine it with care; the rings present to the touch certain characteristics by which all error may be avoided. 522 DIPHTHERIA, CROUP AND TRACHEOTOMY. Without this precaution we are liable to mistake for the tra- chea one of the sterno-thyroid muscles, which in form *nd size very closely resemble this air-passage. In consequence of this en r I have seen this muscle pierced with thrusts from the bis- toury. 2, Incision of the Trachea. — When clearly recognized the tra- chea is to be exposed and punctured. Trousseau, without in- dicating exactly the point where the cutting instrument should be thrust in, advises it at some distance from the larynx. Vel- peau prefers to cut from the fourth to the sixth ring ; Guer- sant recommends to make the puncture between the fourth and the fifth. A hissing produced by the rapid entrance of the air indicates that the object has been reached. Without removing the knife from the wound the incision is to be pro- longed upwards or downwards according as the puncture has been made in the trachea in the inferior or in the superior part of the wound. If the puncture has been made at the in- ferior part, the edge must be presented upwards- This latter method, employed at one time exclusively, is generally aban-, doned. It has been, however, quite recently recommended again by Mr. Howse, of London.^ The incision should be about a centimetre and a half long. One should avoid having recourse to the probe pointed bistoury for the purpose of en- larging the incision. It is necessary, as far as possible, that the puncture and incision be made without removing the knife from' the trachea. It is the only method of making a straight tracheal incision. But if it is found that the incision is too short, or if it has been punctured by inadvertance, which often happens, and the knife is withdrawn from the wound, we should introduce the probe-pointed bistoury and remove the constriction upwards. This manipulation is not without dan- ger. Pouquet has showed its inconveniences. If, following the precept of Trousseau, the probe-pointed bistoury is carried to the bottom of the wound, there is often risk of pushing it in a different direction from the first and causing an irregular in- 'Guv's Hospital reports, 1875, P* 495* SURGICAL TREATMENT. 523 cision. This operative defect may be still more serious if, finding the incision too short while the dilator is in the wound, we attempt to divide the tracheal wall extended between the branches of the forceps. Under these conditions the normal di- rection ol the tissues is changed, and the second line of incision is almost i.ev.i' an exact extension of the first. Finally we ob- tain an irregular incision which dilates incompletely, and some- times tears under the efforts of the dilator. It is then that the canula encounters great difficulties in entering the trachea and may be inserted in the surrounding sheath of connective tissue. By making the puncture and incision at once this dan- ger is avoided. 3. Introduction of the Canula. — After the trachea is opened the tube must be introduced. The physician, taking the dilator in the right hand, introduces it into the wound by directing it upon the nail of the left index finger which holds one of the margins of the tracheal wound. At this moment it often hap- pens that false membranes present themselves at the wound, ' and a violent effort at coughing sometimes expels them, or if not, the physician siezes the tracheotomy forceps with the left hand and removes the floating material. Laying aside the for- ceps he takes the canula in the same hand and introduces it by presenting the bevel-edge in the side of the wound, then, tnrning a quarter of a circle, he makes it enter entirely into the trachea. The dilator which is applied at the upper part of the wound is now held in the left hand, and permits the ma- nipulations of the canula with the right hand. It is still better to dispense with the dilator. It is no more difficult than the other method ; a little courage and coolness suffice. The left index introduced into the wound catches the edge of the tracheal wound with the finger nail ; the canula, guided upon the finger, enters with facility into the trachea. Whatever method may be employed, it is necessary to act with gentleness ; if resistance is met with, one should stop, withdraw the tube a little, be sure of the condition of the parts, and recommence in the same manner. The employment of force leads only to making false routes; the canula imbeds 5^4 DIPHTHERIA, CROUP AND TRACHEOTOMY. itself by the side of the trachea surrounded by connective tis- sue. One supposes the instrument in place and yet the as- phyxia continues. He is quickly informed of this error by the aggravation of the patient's condition and by the cessation of the whistling which indicates the passage of air by the tube. In such a case he hastens to remove the canula and to com- mence again with more care. In fact this part of the operation requires the same dexterity as catheterism of the urethra. The false passages which oc- cur in both cases from the inexperience of the operator are equally fatal. I need not say what occurs in the case of a urethral false passage ; the tracheal false passage, even when it does not provoke immediate asphyxia, is the cause of sepa- rations (detachments) along the sides, and especially along the front part of the trachea. These separations are the starting points of abscesses of the neck, and sometimes of abscess of the mediastinum, which seriously compromise the success of the operation. While having a perfect steadiness of hand, the physician should manifest an unchangeable coolness during this part of tracheotomy. This is in fact an exciting moment; the patient is struggling, the air comes rushing from the tra- chea bringing a shower of blood, mucus and debris of false membranes which fall upon the operator, soiling his face, not excepting his eyes, nose or mouth. This scene is well calcu- lated to frighten beginners ; quite frequently it produces these unpleasant results greatly to the injury of the patient. It is necessary, therefore, to be forewarned and to remain undis- turbed. The canula being in place, the patient should be raised at once and seated upon the table, and the strings of the canula tied. The constriction should not be too tight, but should be sufficient to bring the canula well down and not permit it to escape from the trachea. One should see that the knot is suf- ficiently tight that it may not afterward become loose. The details, which appear perhaps too minute, have impressed themselves upon me by accidents resulting in death, of which I have been a witness. SURGICAL TREATMENT. 525 A cravat of tarlatan is put around the neck, and then a sec- ond of woolen. The patient is then washed with tepid water, cleansed of blood spots and returned to his bed where there is awaiting him a well warmed sheet in which he is to be wrapped, and dressed after the first sleep which usually follows the operation. To finish up he is to have a little sweetened wine to drink. Practiced according to this process, tracheotomy is what may be called a difficult operation. It requires of the surgeon extreme circumspection because of the nature of the region in which he operates. This vicinity is not without danger ; the risks of haemorrhage present themselves at every step, and the ability of the operator and the slowness of the operation do not always insure ag^ainst them. We know from Guerin that the left internal jugular has been wounded on several occa- sions. [!] Bichat cites a case of section of the left primitive carotid, and Axenfeld reports a case in which the innominate artery was injured. Pouquet found, in an autopsy, this artery in connection with the inferior angle of the tracheal incision ; the operation was made a little low because of the abnormal development of the isthmus of the thyroid. Afiditional diffi- culties of another kind are encountered still in this region. The older the child is, the larger is the trachea and the more easily recognized, but in a little child it is otherwise. The tube is narrow and its walls are thin and soft. However slightly fat the neck may be the trachea is movable, retreats before the finger that is seeking it, and moves to the left. The operation is then extremely difficult, the search is tedious, the surgeon, if he is not very expert, becoming embarrassed by the bleed- ing and by the increasing asphyxia, and losing his guide, punctures the sterno-thyroid muscle, and continuing to cut, goes down to the vertebral. This is the principal cause of death during the operation without reckoning the haemor- rhage which does not fail to add its share. I have often met with an anatomical peculiarity which places the operator in the same embarrassment. The trachea deviates towards the left, and the median incision does not 526 DIPHTHERIA, CROUP AND TRACHEOTOMV. strike it, the knife punctures it in the right half or leaves it to the side. The same thing occurs as in the case above, only in that the deviation is artificial and produced by pressure of the finger; in the latter case it is natural. To overcome these difficulties one has advised, after the cutaneous incision, to use almost entirely the grooved director to separate the tissues and hold them aside. This modus facioidi is advantageous so far only as the separation of the muscles and diverting the vessels is concerned. But if one wishes to divide the apon- euroses of the neck which are sufficiently resistant, he must employ considerable force, and risks making a mistake and producing extensive detachments which at a later period pro- duce abscesses, more or less extensive, and deep gangrene of this region. It is better when one encounters an aponeurosis to slip the director under it and divide the membrane upon it, and then continue the manipulations with the director. These remarks show that seeking for the trachea is the most difficult step of tracheotomy, and more trjang than the introduction of the canula, as has been stated. The patients which succumb during the operation nearly all die from asphyxia, in conse- quence of the delay in opening the trachea. When this is once opened the introduction of the dilator permits the entrance of the air and allows the patient to breathe ; and, in the absence of haemorrhage, nothing is lost, and in proportion as the in- cision is well made so will the canula enter with facility. The operation performed below the thyroid body offers, therefore, serious dangers, due to the vicinity of large vessels and to the depth and the mobility of the trachea. And how- ever experienced the surgeon may be, he may not flatter him- self that he can always avert them. [See Dr. Winters' report. Med, Record. Dec. 13, 1884; and p. 481. High Tracheotomy. The dangers of tracheotomy, properly speaking, have im- pressed all observers. Attempts have been made to remove these dangers, and with this object in view the incision has SURGICAL TREATMENT. 52/ been practised at the expense of the upper rings of the tra- chea. The objections which have been offered against this method of operating are purely theoretical. The only one which has been put into form is the inconvenience to the vocal cords from the prolonged retention of the canula in their vicinity. The objection is valid when the cricoid is divided, but when the in- cision is commenced below this cartilage I find it no longer well founded. The presence of the isthmus of the thyroid body may furnish an argument against this operation. But in the immense ma- jority of cases this portion of the gland is only a very thin strip which passes unnoticed. When, by chance, it is large, it bleeds it is true, but it is a haemorrhage which the press- ure of the finger or the blunt hook easily arrests. It is never comparable to that furnished by the thyroid vessels. These slight inconveniences are counterbalanced by impor- tant advantages. The veins are few and slightly developed, and one is certain not to wound either the jugular vein or the left common carotid, the innominate, nor the subclavian vein. The introduction of the canula is easier, the detachments are less frequent, and emphysema is more rare. Hence, all contribute to give preference to this operative procedure. In it there are two principal methods : the slow or deliberate, and the quick or rapid. The Slow Operation. I have nothing special to say upon the manner of operating under these circumstances. The course to follow is exactly the same as in tracheotomy, properly so called. The incision in the integument should be made higher; it commences from the superior border of the cricoid cartilage and extends about 4 centimetres (i^/^ in.). The subjacent tissues are to be di- vided and separated with the same care, the vessels held aside with the same precautions, which from their small number give little trouble. Finally, the trachea being exposed, {denudce) 528 DIPHTHERIA, CKOUP AND TRACHEOTOMY. is to be punctured immediately below the tubercle of the cri- coid, the bistoury having the edge directed downwards and being guided by the nail of the left index which rests upon this tubercle. The puncture is immediately followed by the in- cision to the extent of about 0.015 (Ysin.); then the canula is to be introduced either with or without the dilator, following the rules given for the preceding operation. The Rapid Operation'. The model of the rapid operation is the process of Chas- saignac. This surgeon found first the tubercle on the cricoid, then held it by pressing it a little upwards by means of the nail of the left index finger. Now taking in the right hand, as one would hold a carving knife, a tenaculum with a groove on the back, he places this instrument at right angles to the trachea and punctures this tube. He then gives to the handle of the tenaculum a circular movement which brings it upwards and parallel to the trachea. When once in this position the handle is to be seized by the left hand and drawn strongly upwards. The right hand armed with a bistoury, introduces the point of this instrument into the groove of the tenaculum, and thence, without hesitation, by one stroke into the trachea at the point where the tenaculum is implanted. The operation is com- pleted by cutting at the same time the skin and three or four rings of the trachea. The canula is finally introduced by aid of the dilator. This process is very brilliant, but it succeeds especially in the easy cases, where it is of little use ; it exposes to unforeseen accidents in the difficult cases in which it would be especially applicable. In the easy operations, that is to say, when the neck is moderately fat, when the trachea and larynx make a strong projection, it is easy to find the cricoid tubercle and to insert the tenaculum there. But when the neck is fat, when the larynx and trachea are deep and movable, it is difficult to recognize the tubercle and still more difficult to catch it. After numerous experiments made upon the cadaver I am convinced SURGICAL TREATMENT. 529 that it is not always easy to catch the tubercle by means of the tenaculum through the skin, even by making previously a slight incision in the integument. Several observers have wit- nessed this fact. Some operators have seen the bistoury, when conducted by the tenaculum hooked in some other part than the trachea, carried astray in a most unfortunate manner. Analogous observations have been made abroad. Dr. Marsh reports three cases of the operation made according to this process in which the canula was placed by the side of the trachea. In another case of the same kind, cited by Dr. Thomas Green, the trachea was untouched and the canula lay on the outside of it. This mode of operating, therefore, does not always meet the very important indication of holding the trachea in the cases in which it is deep and movable. Other objections have been of- fered to it. Sometimes it subjects the trachea to a twisting movement, which requires that the incision be not made on the median line. In children in which the trachea is very narrow one runs the risk of transfixing this tube and incising the oesophagus. Peter has witnessed such an accident in an operation performed ac- cording to this process. The canula was introduced into the oesophagus, and the patient died at once asphyxiated. It has been strongly accused of hastening asphyxia by immobilizing the trachea. This objection, it seems to me, is based rather upon theory than practice. The time during which the trachea is held is very brief, and it is difficult to admit that it can really hasten asphyxia. It has also been charged, without much evi- dence, with favoring hsemorrhage by division of the thyroid body. Generally speaking, it exposes but little to haemor- rhage ; the vessels are few in this region, and the elevation given to the trachea causes those which might be found in front to slip to the sides. As to the section of the thyroid body it is trifling if the incision is exactly in the middle. More- over, the best means for arresting haemorrhage being the in- troduction of the canula, as we shall see hereafter, this method 530 DIPHTHERIA, CROUP AND TRACHEOTOMY. of operating has nothing to envy (desire) of the others in this respect. The process of Chassaignac gave rise to that of Langenbeck. The tenaculum is composed of two hooks in juxta-position, separated by a groove as far as the point. At this point they are apphed accurately one against the other in such a manner as to make a single point. The Berlin surgeon does not apply his instrument to the trachea only after the latter has been ex- posed by the ordinary method. He then inserts it between two rings, holds the trachea, separates slowly the two hooks by means of a screw and makes the puncture of the trachea be- tween the two, and then the incision as in the process of Chas- saignac. The two branches which remain fixed, one in each side of the incision, are separated by the action of a spring {pedal); each one holds a lip of the wound; this is dilated and the canula is introduced. Hence, this instrument serves at once the purpose of a tenaculum and a dilator. Its application is far from being simple ; it is not easy to catch with the hook the trachea at the bottom of a wound somewhat deep, nar- row and full of blood, while the patient is struggling and con- tracting the muscles of the neck, the trachea often small and slippery with blood. It is a quite useless complication of the operation. If the fixing of the trachea before the incision of the integuments is a logical and accessible thing, it is very difficult and without object, after this step, in tracheotomy. At this time the tube is under control, and it can be punctured easily, and the operation terminated by the ordinary method with much less difficulty. Isambert comprehended the defects of this mode of oper- ating ; he gave to the instrument a larger curve, and at the same time it was made stronger and sharper. Thus modified the instrument is inserted into the trachea through the integument, the same as with Chassaignac's instrument. The puncture with the bistoury is made between the slightly separated branches ; then the skin and trachea are divided at a single stroke. The action of the pedal (spring) subsequently sepa- rates the margins of the wound, as well those of the trachea SURGICAL TREATMENT. 5 3 I as those of the integument, and then the canula is to be intro duced. The author is very much pleased with this improvement. It is, without question, very ingenious. I do not hesitate to recognize with the author that this in- strument may present advantages in civil practice, and princi- pally in the country where one is compelled to operate with an insufficiency of assistance and light. Other instruments have been invented by Marc See, Maisonneuve, and, recently, by B. Anger, for performing tracheotomy mechanically. These instruments comprise the knife and the dilator. Like all in- struments of this kind, they give brilliant results on the cada- ver and upon the adult ; but acting as if the relation of the parts was invariable, their range of application is very limited, especially in children. Bourdillat has proposed another rapid process of operating. Instead of operating at a single step, like Chassaignac, he fin- ishes all in two steps. The first divides the integuments down to the trachea, and the second incises the trachea. The cricoid tubercle being recognized, a line is drawn with ink as a guide to the incision. The larynx is then held between the fingers of the left hand; the knife divides at a single stroke all the tis- sues in front of the trachea to the extent of from 0.015 to 0.02 (Ys to Ys in-)- -^^ t^^" makes the puncture and the incision into the trachea. The depth of the first incision should be about O.oi (75 in.) ; in a child less than two years the depth is less. As a guide the author recommends that a mark be made on the blade of the bistoury o.oi (Ys in.) from the point. He also advises to endeavor to enter the trachea at once through the integuments. From the fact that it requires no special in- strument, this process should be preferred to the preceding ones. But how can one be certain to cut at one stroke all the tissues lying in front of the trachea ? The guide or land-mark on the blade of the knife often leads to error; one risks punc- turing the trachea without desiring it, or missing it a certain distance. In the first case, the tracheal incision must be en- larged, which exposes to an irregular incision and to em 532 DIPHTHERIA, CROUP AND TRACHEOTOMY, physema; in the second the wound in the soft part must be more or less deepened, the operation looses its character of a rapid process or method. Besides, the wound in the integu- ments being very small, the examination with the finger and eye is imperfect. For a long time I have adopted a combined process which approximates the rapid method, but which does not sacrifice everj'thing to rapidity. It permits, to a certain extent, the su- pervision of the progress of the operation. While the rapid- ity with which the canula is introduced quickly arrests the ex- isting hsemorrhages, it enables one very greatly to prevent them. The cricoid tubercle being recognized, the larynx is firmly held between the thumb and middle finger of the left hand, while the nail of the left index holds firmly this prominence and does not let it escape. Thus grasped the larynx is slightly elevated in such a manner that the trachea forms an elevation under the skin. The incision of the integument is made, com- mencing from the nail of the left index, to the extent of about 0.64 (lYs in.). The skin only is divided at first; the assistant sponges the wound, and the operation is rapidly continued. If any large vein appears it is pushed aside ; then, when the tra- chea is quite or nearly reached, as nearly as can be judged, it is punctured, always directing the knife along the same finger nail. The noise of the escaping air announces the entrance into the trachea, and the division is to be completed to the desired extent. The canula may be introduced without removing the left hand from its place, and without the dilator. The parallelism of the lips of the wound facilitates this step when the incision is well made. The left index finger may still be introduced into the wound, the margin of the tracheal incision be caught by the nail serving as a guide to the canula. Should one pre- fer to use the dilator it may be introduced, guided by the nail, an*^ the canula may be made to enter by the usual means. surgical treatment. 533 Crico-Tracheotomy. Several authors have advised including the cricoid cartilage in the incision. The late Prof. Hueter, of Greifswald, advised cutting the cricoid cartilage from below upwards, avoiding the crico-thy- roid membrane, and extending the wound if necessary, by di- viding one ring of the trachea. Saint Germain punctures the ctico-thyroid membrane through the skin, and divides at one stroke the integuments, the cricoid cartilage and the first ring of the trachea. This process is of still more easy execution than JiigJi tracheotomy. This simplification, however, does not appear to me necessary. High tracheotomy is very easily performed, and obviates the passage of the canula through the larynx, interference with which may be a disadvantage to the vocal cords. Besides, when when the patient is somewhat advanced in age, the cricoid car- tilage offers resistance, and frequently difficulty is experienced in separating its edges ; sometimes this is even impracticable. In young children the latter inconvenience is not present, but one is not always sure of avoiding haemorrhage. Frightful hasmorrhages do occur. Choice of Methods. — From what has been said, it follows that loiv (inferieure) tracheotomy is a difficult operation, and even dangerous ; it should always yield the precedence to high tra- cheotomy, which I also prefer to crico-tracheotomy . As to the rapidity or the slowness of the execution I believe the rapid operation is the better ; it is much less fatiguing, it exposes far less to death during the operation, and to syncope; it should especially be preferred when the patient is in an ad- vanced state of asphyxia. It exposes more, it is true, to haem- orrhage, but it permits an immediate remedy to that disad- vantage. The introduction of the canula being the best haem- ostatic, the rapidity of the process permits an arrest of the evil as soon as it occurs. But, in order that it may be so, it is necessary that the operator should be experienced in tracheot- omy. If haemorrhage occurs it causes delay in finding the tra- 534 DIPHTHERIA, CROUP AND TRACHEOTOMY. chea, in opening it and introducing the canula, and all is lost; the operation is prolonged, and the patient succumbs to as- phyxia or haemorrhage. It is of importance that physicians who have not frequent occasion to practice tracheotomy, should choose the slow method which permits them to proceed prudently, layer by layer, according to the precept of Trousseau, and thus avoid the accidents which the other process may involve. As to transfixing the trachea, which has been charged to the rapid process, it has been seen more than once in the course of the slow operation. We should concede, however, that the pro- cess of fixing by the tenaculum exposes to this complication more than the other, in consequence, probably, of the eleva- tion given to the trachea, and causing the posterior wall to be no longer supported by the cervical column, but held in space. Thermic Tracheotomy. 4 Several surgeons, engrossed with a desire to avoid hjemor- rhage, have endeavored to substitute these cauteries for cut- ting instruments. The application of this principle to tracheotomy was made in 1870 upon a child of 16 years of age, by Amussat. It was in a case of a foreign body in the trachea. In 1872 Verneuil oper- ated on an adult. His example was followed by Krishaber, Tillaux, Voltolini, of Breslau, and Victor Burns. A number of these cases have been collected in a valuable monograph by E. Bourdon, and some others in a thesis by Heral. The gal- vano-cautery was the instrument employed by these surgeons. I shall not give a detailed account of this method, consider- t ing that it is inapplicable to children. It is, says Verneuil, a i method for the adult. It is, moreover, impracticable when the case is one of croup. Tracheotomy in this case is an opera- j tion of urgency ; it should be performed with instruments which may be always at hand, and always ready to be used. We may add that the operation by the galvano-cautery often requires considerable time. Moreover, if the temperature of the SURGICAL TREATMENT. 535 cautery should be even a little too high, haemorrhage will su- pervene. On several occasions it was necessary to finish the operation with the knife. We must not ignore either the con- siderable eschars which are the consequence of continued ele- vation of the temperature. The serious inconveniences of this method have caused it to be abandoned. Another has been sought by which the haem- ostatic properties of heat might be utilized without its having the dangers of the galvano-caustic. Saint Germain proposed first to perforate the crico-thyroid membrane with a pointed actual cautery, heated to a dull red, then to introduce immediately the dilator and the canula. The burning of the larynx and the dangers of letting the cautery slip upon the sides of the trachea caused the abandonment of this process which, besides, has only been employed upon the ca- daver and the dog. DeRanse and Muron incline more to the operative process of Verneuil. They divide the tissues with a knife heated in the fire instead of being reddened by the battery. They em- ploy for this purpose the ordinary bistoury, simple table or dessert knives with rounded end, or the handle of a spoon. Finally Muron imagined an instrument formed of an elliptical plate of iron fastened to a roughened shank, which enabled the apparatus to be held between the blades of a forceps ; one extremity of the ellipse was narrower and thicker than the other. The instrument being raised to a white heat, the broader end is applied to the skin, about o.oi (Vs in.) below the cricoid cartilage; the division of the integuments and superficial parts is then effected. The temperature of the instrument during this time having fallen to a dull red, it is turned and the operation continued with the thick narrow end. The operator proceeds cautiously, drawing aside the tissues, if it is thought best, with the aid of a spring forceps in such a manner as to stop as soon as the trachea is recognized by its white surface. It was recom- mended to avoid touching this air tube with the cautery for fear of subsequent necrosis ; the tube is opened with the knife 53^ DIPHTHERIA, CROUP AND TRACHEOTOMY. and the canula introduced. A fundamental precept of this process consists in dividing the deep tissues with the cautery at a dull red heat. It is known that this temperature exerts pow- erful haemostatic properties, while the white red causes ha:m- orhage. This operative process, which already constitutes an advance beyond the preceding one, has not been applied to man. It is, therefore, difficult to judge of it. We may, how- ever, foresee all the precautions that it requires. It is neces- sary to know how to get the exact degree of temperature at which one may prevent haemorrhage. Is not the patient ex- posed to considerable eschars which retard and make the cica- trization of the wound irregular? Following this line, Saint Germain has simplified and ren- dered this process easier of application. He uses a bistoury rounded like a table knife, and therefore not probe-pointed. This able surgeon says : "I attach to it, at the heel, to an extent of about 0.015 (^/s in.,) a band of moist thread. This device is intended to enable me to hold the knife in my hand without burning me. That done I hold it in the jet of an eSlipile flame, or alchohol lamp, and bring it to a white heat; then I plunge it in perpendicularly on a level with the crico-thyroid membrane. It penetrates the tissues with the greatest ease, and the sensation of resistance overcome, when it has arrived within the larynx, is still more distinct than with the ordinary bistoury. This first step being executed I proceed as I have already described, and cut through {scie, saTv) the cricoid and two rings of the trachea; then I cut obliquely in such a manner as to divide the integument a little more extensively than the trachea itself. I have applied this process in one case, upon a child of from three to four yea'-s, and, I should say, it succeeded perfectly in the sense, first of having had no bleeding, and that we were able to complete our operation entirely; and secondly, when, after eight days the child sank under diphtheritic invasion, I was able, by post mortem examination, to exhibit his lar- ynx to the Societe de Chirurgie absolutely free from cauterization, either of the posterior wall or of the sides. It has been well observed that the heat may ex- ercise a deleterious influence upon the vocal cords ; I patiently await a case of success by this process, and I hope to remove the objection which has been offered by exhibiting a speaking patient." In fact, in order to render an opinion we must aA'ait the re- sults of a larger experience. In the mean time we may present several objections. In the first place, the direct puncture of the larynx, made with the SURGICAL TREATMENT. 537 bistoury, which already occasions serious disturbance when the instrument goes astray, will be still more dangerous when it shall be performed with the aid of the cautery. It was to avoid this difficulty that Saint Germain attacked primarily [d' emblee) the crico-thyroid membrane, the larynx being more superficial and more easily held than the trachea. But then the second objection presents itself, that of burning the larynx; that is one of no less importance. These disadvantages were fully appreciated by this able surgeon, and he has, for the present at least, abandoned this process. Accidents of Tracheotomy. The difficulties which arise at every step in the performance of tracheotomy I have pointed out. If the operator has not reached a position in experience from which he can meet them, they become so many sources of real accidents, capable of destroying the patient suddenly by syncope or by asphyxia. Syncope has for its origin the haemorrhage, or sometimes simply the depression of the powers which renders the patient incapable of surviving the injury of the operation. Asphyxia is the termination of all causes which prolong the operation or retard the introduction of the canula. The inten- sity of the dyspnoea, the uncomfortable position in which the patient is held, unitedly demand a prompt supply of air. These various accidents are : hcBiuorrhage which, according to the manner in which it acts, may produce asphyxia as well as syncope, and the defective incision of the tracJiea. We should add thereto _/h:/.y^ membranes in the trachea, traumatic emphy- sema, and wound of the oesophagus. Hemorrhage. Haemorrhage shows itself at the time of the operation or a short time afterwards. It is, accordingly, primary or second- ary. Primary Hceniorrhage. — It is almost always venous. Arterial 53^ DIPHTHERIA, CROUP AND TRACHEOTOMY. haemorrhage is extremely rare, and presents nothing special. I will not insist upon the gravity of a wound of the carotid or of the innominate trunk. It has already been shown that these accidents have occurred. The veins most frequently wounded are branches of the thyroid plexus. The division of one of the internal jugular veins is so exceptional that it is sufficient to point out its possibility. The slow operation has the ad- vantage of rendering the injury of important vessels uncom- mon ; we must not think, however, that they are always avoided. It is sometimes difficult not to wound some deep vessel in spite of the greatest care. In proceeding rapidly one runs greater risk, but it is remedied by the prompt introduc- tion of the canula, which arrests, as by enchantment, the es- cape of blood, as well by the compression which the canula exerts upon the patulent vascular orifices as by the equaliza- tion of the circulation. Inferior tracheotomy exposes much more to hccmorrhage than the high operation; the same is true of too lengthy incisions, and of dividing constrictions down- wards. It is not rare, after the trachea has been exposed with- out trouble, with the last stroke of the knife, intended only to enlarge the incision, to encounter a thyroid vein. The section of a vessel gives rise to a jet of blood, in size proportioned to the caliber of the vein. If the trachea is already opened, the blood runs into it and provokes cough which expels it forcibly, and sprinkles it upon the operator and the assistants hke a shower. It is a spectacle most dramatic ; the fate of the patient is decided in a few moments ; every- thing depends upon the time that is occupied in introducing the canula. Besides, when the vessel is important, the inter vention of this instrument may be insufficient. 9 Sanguineous oozing sometimes comes from the thyroid body. When the incision is on the isthmus, this being most frequently very thin ; it bleeds but little if at all. When, as an exception, it is voluminous, or the incision is made upon one of the lobes of the gland, the result is a heemorrhage no longer in jets but like a wave. The most common is that which occurs during the operation at the moment of the division of a vessel. Or, ACCIDENTS OF TRACHEOTOMV. 539 • again, it may occur only a few minutes after, when the opera- tion has been nearly bloodless. The rapid process is particu- larly liable to this condition. But should the division of integ- uments and trachea be made by a single stroke, the concur- rence of asphyxia and the operative celerity prevents all im- mediate escape of blood, even when an important vessel may have been cut. But, after the respiration has been restored, the vessels bleed freely. When supervening in spite of the presence of the canula, this haemorrhage is very serious and often fatal. When the sanguineous discharge comes on after the intro- duction of the canula, and persists after this step of the opera- tion, the blood escapes externally, most frequently by the in- ferior angle of the wound or by the canula; the haemorrhage is visible, and one may meet it by appropriate means. In other cases the blood escapes externally and internally. Then it is we may have to combat a most formidable accident. Besides, by entering the air-passages, the blood excites cough which expels it partly through the tube, but the concussion revives the haemorrhage, and so on continuously. Ordinarily the cough becomes quiet in a short time, and the bleeding ceases , but it does also occur that the escape continues till the child sinks from anaemia or from asphyxia. All the causes which induce cough concur in aggravating haemorrhage. The most powerful is the presence of floating false membranes behind the canula. I reported the case of a patient who, finding him- self attacked with a severe haemorrhage, coughed violently and caused a rattling behind the tube, which indicated the pres- ence of a false membrane. Notwithstanding the extraction of numerous fragments, it was impossible to arrest the discharge ; the child became cold, pale and sank. Asphyxia is also a result of blood entering the bronchial tubes. The cough does not always suffice ,tov empty the chest, the dyspnoea augments, anxiety increases, the patient makes extraordinary efforts to expel this new obstacle, and succumbs when the small bronchiae become filled. During the struggle auscultation detects fine, Hmited rales in the inferior portion of 540 DIPHTHERIA, CROUP AND TRACHEOTOMY. • both lungs. When the haemorrhage decreases, and the dysp- noea diminishes, all goes well. The expectoration contains only traces of blood during twenty-four or thirty-six hours after the cessation of haemorrhage. Asphyxia may occur suddenly when the blood expelled through the tube ceases its obstruction. I have reported the history of a case which fell as if struck by lightning a few min- utes after the introduction of the canula. I discovered that the inner tube was filled by a plug of coagulated blood and fibrin introduced from the inside by the force of the cough. The entire removal of the tube, quickly, could alone restore life. These facts are fortunately rare, but it is important to be aware of them; they may serve as a key to difficulties. The amount of the sanguineous discharge is variable ; some- times it is insignificant. I have seen it reach six to eight ounces. When the termination is favorable the haemorrhage ceases most frequently not to return ; in other cases it returns in sev- eral attacks, either every day or at intervals. One patient could not remain relieved of the canula without a stream of blood appearing. In the intervals between the dressing there was sometimes a slight discharge through the canula. Seeondary Hcemorrliage. — Haemorrhage occurs not only at the time of the operation. It is not very uncommon to see bloody discharges appear at the time of changing the canula, even when the operation has not been especially bloody; again, it may occur at a still later period, at the fifth, seventh, eleventh or fifteenth day. The most frequent time is the first dressing. I have collected twenty-two cases of haemorrhage of this kind, and Andre, Boeckel and Wilks each report one. These haem- orrhages occur externally or internally. They are often less abundant than the primary. Nevertiieless Wilks speaks of a patient who sank under a sudden haemorrhage fifteen days after tracheotomy. In the twenty-two cases of secondary haemorrhage, the operation was quite bloody in thirteen ; in three the details were omitted. Secondary haemorrhages are due to several causes. The ACCIDENTS OF TRACHEOTOMY. 54 1 most frequent is the reopening of a vessel which had ceased to bleed by being compressed by the canula, but whose obhtera- tion was not permanent. It opens at the time of removing the tube. The same disposition may persist for several days. The necessary manipulations in the dressing constitute the second order of causes, either by removing the false membranes or eschars, or by the introduction of the canula, a vessel may be wounded or one opened which had been momentarily occluded. This mechanism has been shown in one case. Compression exerted by the canula may become a source of haemorrhage by ultimately ulcerating the walls of the vessels spared by the knife. [Secondary hsemorrhage from the innominate artery, resulting from ulceration due to the pressure of the canula, proved fatal in two cases reported to the An- atomical Society of Paris, and referred to in the British Medical Journal for April, 1881 Hsemorrhage from the tracheal mucous membrane proved fatal in one of my own cases, by giving rise to bronchial pneumonia. — Ashhurst^ Finally, diphtheritic poisoning, which is_ of itself a cause of hsemorrhage into the tissues which have not suftered from op- eration, acts still more energetically upon those of the wound. When the loss is but slight it produces no unfavorable con- sequence, but if it has been copious it increases the disposition to anaemia, already so decided in diphtheritic patients, and ag- gravates the prognosis even when it does not directly cause annoying accidents. In twenty-two cases of secondary haemor- rhage, twelve induced death rapidly, or through the influence of anaemia. Haemorrhages should be energetically suppressed. In case of arterial injury one should endeavor to ligate imme- mediately both ends of the vessel. This operation is not very difficult if one has to deal with a transverse artery such as the thyroideal of Neubauer. When it is a case of venous lesion produced at the begin- ning of the operation, the best means, the means almost infal- lible in overcoming it, is the introduction of the canula. If, however, haemorrhage occurs before this time to an annoying degree, one may apply with advantage the haemostatic for- ceps at the point where the blood escapes. 542 DIPHTHERIA, CROUP AN'D TRACHEOTOMY. Pean uses this method with advantage in tracheotomy, as in many other operations I have had made by Collin small forceps fashioned after the model of dissecting forceps; their extremities are widened in the form of a T so as to sieze a certain amount [masse) of tissue. Avoid the application of the perchloride of iron to the in- terior of the wound ; it produces a black coagulum which later penetrates into the trachea and increases the asphyxia. If the haemorrhage arise from a lesion of the thyroid body, compression, exercised by the finger or by the blunt hooks, suffices, most frequently, for its arrest. The introduction of the canula does not always stop the sanguineous discharge. Several processes may be put intq. operation. If it be slight, a little pressure upon the wound is sufficient in all cases. The best expedient consists in dressing the inferior angle of the wound with bits of agaric, or better, wadding, introduced un- der the patch of oiled silk or gummed cloth. When the first bit is saturated with blood, a second is added and so on until the haemorrhage is arrested. It forms a bloody crust, com- presses the wound slightly, and stops the bleeding before there is occasion to apply a large quantity of wadding. This sub- stance absorbs with great facility, and ought for this reason to be preferred to agaric. If the haemorrhage is more intense, direct compression of the inferior angle of the wound with the finger may be useful; but as this manoeuver is fatiguing to the patient as also to the physician, the finger is withdrawn when the haemorrhage di- minishes, and we have recourse to pledgets of wadding. If this method does not succeed, we apply on the wound a dossil of lint saturated with perchloride of iron. But this is a very painful application, and may be the starting point of an abscess. It has also been advised to withdraw the canula in order to seek to ligate the divided vessel. This is a practice which we must guard against following, we would thus abandon the only effectual compressive means to devote ourselves to a search, very long if not fruitless, during which the patient ACCIDENTS OF TRACHEOTOMY. 543 would have ample time to expire. Better replace the canula by one larger. We obtain frequently by this plan excellent results. If it does not suffice, we endeavor to place one or more haemostatic forceps upon the divided vascular extremi- ties, and replace the tube besides. In case of impossibility we hold the trachea open with a dilator. All these means, the canula excepted, are applicable only to discharge of blood oc- curring by the external orifice of the wound ; it is necessary, therefore, in case of internal haemorrhage, to seek a process which possesses rapid and general haemostatic action; the em- ployment of alcohol in large doses combines these conditions. While it renders great service in the large haemorrhages, es- pecially in those following delivery, this agent is of excellent use in the sanguineous losses which complicate tracheotomy. I have cited some cases in which the use of the wine of Bap-- o noles in a large quantity was followed by the immediate arrest of the haemorrhage; rum, in doses of 6o. to 8o. (2 to 2'/^ 5), has also produced remarkable results. Alcohol should be given largely; full doses are surest; one need not fear going too far. Persons are much concerned about the results which may follow the entrance of blood into the trachea, and have advised as a preventive measure the aspiration of the effused fluid, either with the mouth directly or with the elastic tube. This method is very popular in England and in Germany. Many physicians of these countries, among others, Roserand Hueter, so much dread this accident that they recommend not to open the trachea till after the cessation of haemorrhage ; the effects following the introduction of the canula is to them still little known. However, Dr.Durham, of London,has protested against this practice of his countrymen, and showed that the want of air exposes patients to far greater dangers than the presence of blood in the bronchial tubes. Besides the suction is useless. When the sanguineous exudation is comparatively slight, the efforts of coughing quickly expel all that has been diverted into the air-passages ; this manipulation is then superfluous. If the hc-emorrhage is abundant and continued, aspiration is un- 544 DIPHTHERIA, CROUP AND TRACHEOTOMY able to relieve the bronchi, the blood that is removed being constantly resupplied. There is no time to intercede with any- chance of success, only after the haemorrhage has ceased, if the patient has been able to survive so long. Moderate cough- ing should be excited, and if the child has retained some strength and still reacts, he will expel the excess of liquid contained in the bronchi. The position given to the patient must not be neglected. So long as the loss is moderate he may sit upon his bed supported by pillows in order to avoid the entrance of the fluid into the trachea. On the contrary, if syncope appears imminent he is laid down, and sinapisms are directed to be placed upon the body, at the same time that the face is vigorously slapped with a towel wet with fresh water. But why dread the syncope since it would have the effect very likely of arresting the hsemorrhiige ? This objection might have some weight if it were a case of ordinary haemorrhage, but in a disease infectious like croup, and in which sudden death is not very rare, we should dread syncope and avoid it by all means. In order to prevent the blood entering the respirarory passages. Dr. Hil- ton advises placing the patient in the prone position, when one has reason to fear that accident. It is useless to point out the folly and the danger of this practice ; the prompt introduction of the tube is preferable to it in all cases. Imperfect Incisions of the Trachea. A median tracheal incision of proper dimensions, that is, about 0.015 (^/s in.) long, at a sufficient height, is that which we should endeavor to obtain. One or several of these condi- tions, and sometimes all, are deficient. It happens in some cases that the air comes hissing through the wound at a moment least expected. The trachea has been wounded unin- tentionally by too deep a cut with the knife before the air tube was exposed. This mishap is sufficiently common with beginners, and startles them very much. Two plans may be adopted to obviate the consequences, that is to say, to prevent ACCIDENTS OF TRACHEOTOMY. 545 the traumatic emphysema, which would result from a too long continued passage of the air through the tissues. The first consists in placing the left index finger over the little opening, continuing the operation, exposing the trachea and finally en- larging the small incision. In the second, we introduce directly into the wound a probe- pointed bistoury, and then divide the strictures. If we find it without difficulty, and that the incision is straight and in the median line, the danger is easily repaired, but it does occur that this prolongation is made obliquely or in a different direc- tion from the first incision ; the result then is an incision in an irregular line. It also happens that the accidental orifice is not easily found ; it may be even undiscoverable. In that case a second puncture is made and extended by an incision ; the trachea is opened then twice. From these errors arise sometimes emphysema, at others, difficulties in the introduc- tion of the tube. An incision too short renders the introduction of the tube im- possible. The incision is then extended with the probe- pointed bistoury, sometimes even on the dilator. From this come irregular or V-shaped incisions, which often cause insur- mountable difficulties in the matter of introducing the tube. An incision too long permits the canula to pass easily, but is frequently accompanied with haemorrhage ; it is seldom that the last stroke of the knife does not injure some important ves- sel. If this misfortune is avoided it may be only to fall into another. The canula is retained with difficulty in incisions of this kind. However tight the tapes may be tied, the instru- ment escapes from the wound of itself at the end of some hours, or in less time. If it is not replaced at the time there is danger of asphyxia or emphysema. The only means of pre- venting the recurrence of this accident is the introduction of a longer tube. A lateral incision is produced when the trachea, being very mobile and displaced by the finger, is punctured upon the side, while the skin has been divided in the median line. If the op- erator then withdraws his finger the trachea returns to its 546 DIPHTHERIA, CROUP AND TRACHEOTOMY. place ; the incision is hid under the soft parts and becomes in- accessible. The efforts at introduction of the canula are fruit- less, the dilator even does not enter the trachea. In these at- tempts both instruments produce separation of the tissues ; the canula is placed in front of the trachea, and, to conclude, the patient suffocates. Not discovering again the tracheal incision, the operator makes another which is parallel to the first, at other times ob- lique, so as to form a V at the superior or at the inferior angle. The introduction of the canula by this second passage is very- difficult, often impossible. When it is effected, another gaping incision remains through which the air escapes into the con- nective tissue where it soon produces emphysema. All incision too low exposes to the same dangers as one too long. Afi incision too high constitutes laryngotomy instead of tra- cheotomy. A mistake in the situation of the land mark (the cricoid tuburcle) has caused more than once the division of the thyroid cartilage in its entire length. In this case the in- troduction of the canula is nearly always impossible; the pa- tient dies asphyxiated. When one does succeed in introducing the canula it is at the cost of considerable laceration which does not improve the matter. l^hQ perfotation of the trachea through and through (transfix- ing) has been reported by several authors. Millard cites two cases, Peter reports one. [I believe I saw one case of this kind.] Of these three patients, only one survived, the other two died asphyxiated during the operation. I have met also three such cases ; all were fatal. This accident is, therefore, one of the most serious that can happen during the operation. In fact, it destroys rapidly by asphyxia, or gives rise to emphy- sema. In the first case it may happen that the two openings, being wide, the canula passes through them both and the extremity lodges posteriorly in the peritracheal connective tissue, or in front of the oesophagus. The patient is suddenly suffocated. ACCIDENTS OF TRACHEOTOMY. 547 In the second case, the posterior opening being too small to transmit the canula, it enters the trachea. But a certain amount of air escapes by the second incision and is diffused into the connective tissue. The operation made with the tenaculum is the most com- mon cause of transfixion of the trachea. False Membranes of the Trachea. When one operates on a patient having the trachea lined with thick false membranes, these sometimes cause serious accidents. In puncturing the trachea the bistoury would penetrate a thicker wall than usual. Most frequently the instrument passes beyond, but sometimes it remains on this side of the membrane ; the hissing is not heard ; one believes himself in error; another puncture is made, hence two incisions. It happens also that the trachea only being incised, the canula separates and crowds the membrane before it, and remains outside the respiratory cavity. The air cannot penetrate ; asphyxia supervenes rap- idly if the error is not recognized, which, moreover, is very difficult. One is rather tempted to suspect a false route, the canula is withdrawn and again introduced in the same place without obtaining any favorable change. Dr. Jacobi, of New York, reports a case of this kind. If the false membrane is re- sistant it opposes the entrance of the canula. When one is quite certain of having incised the trachea, he must direct the dilator into the wound upon the left index ; if there is a false membrane plugging the wound it is seen, and it may be seized and extracted with the forceps. I have seen this procedure suc- ceed in three cases, in causing the canula to enter after several fruitless attempts. The following case is an interesting exam- ple of the kind : I The child being operated on was four and a half years old, in the third period the trachea being punctured and incised I was surprised at not hearing the characteristic sound. The finger, introduced into the wound, enabled me to ascertain that the tra- chea was incised. I hastened to introduce the canula; the air still did not pass ; res- piration was suspended; the child fell into a state of apparent death. Inflaiions through the tube were at first fruitless. However, before long they were followed by 548 DIPHTHERIA, CROUP AND TRACHEOTOMY. spontaneous inspirations. The child revived, But in a few minutes suspension of respiration returned. I then withdrew the canula, introduced the dilator, and I saw a large false membrane completely occluding the opening in the trachea. I immedi- ately removed it with the aid of forceps. It adhered strongly by its lower extremity. Its dimensions were 0.05 (2 in.) in length, and 0.02 (^/s in.) in breadth. Under other circumstances the false membrane is largely separated and thrust back by the canula which detaches it, and it falls into the inferior part of the trachea which it closes, and the patient immediately sinks from asphyxia. In a similar case the respiration ceased at the moment of the introduction of the canula. It returned after a violent ex- piration had thrown a considerable patch of false membrane into the canula which was removed by the forceps ; another smaller piece followed soon after, and the respiration became perfectly free. False membranes, formed in the trachea or in the bronchi, may cause asph}'xia by a different mechanism. When they are detached they are carried by expiration, and principally by the cough, towards the exterior. They then present themselves at the extremity of the canula, or become engaged in the inner tube. Dyspnoea with true paroxysms of suffocation, even asphyxia, are the result of these qiigrations. The respiration becomes embarrassed, noisy, tl:e canula whistles or causes a flapping sound like a valve or waving body; the cough becomes incessant and suffocative. If the false membrane is small and loose, a fit of coughing expels it, and the respiration becomes established ; but if it should be adherent by one extremity, and rather large, the respiratory disturbance becomes aggravated, the face becomes anxious and red, and the signs of asphyxia appear. At this point it does happen again that a violent fit of coughing may detach the concretion and expel it through the^anula, but the pow- ers of nature are not always sufficient. It is in such cases that prompt relief becomes necessary, under penalty of inevitable death. What is to be done in such cases ? If the suffocative attacks are moderate, we commence by irritating the tracheal mucous membrane by means of a feather passed through the canula. ACCIDENTS OF TRACHEOTOMY. 549 If this measure does not succeed we may introduce into the can- ula the tracheotomy forceps in search of the false membrane There are several forms of these forceps ; the one which suits me the best is that of Luer. This attempt may be made and be repeated a number of timer, before meeting with any success. Often it fails entifely. It is a means from which little is to be expected. If asphyxia is imminent, the only thing to do is to remove the canula. Sometimes this simple act is sufficient to excite the expul- sion of the false membrane ; in the opposite case we introduce the dilator ; entrance of air into the trachea widely opened, gives rise to a paroxysm of coughing, frequently ending in the expulsion of the foreign body. Sometimes one sees, float- ing at the bottom of the wound, the false membrane ; it is then easy to seize it with the forceps and extract it. If it is loose, the extraction is easy ; but we may also find that it is still ad- herent to the trachea by one of its extremities ; then it is nec- essary to use sufficient force to remove it piecemeal. We thus may bring out pieces 0.05 or 0.06 (2 in.) or more in length. If the paroxysms of cough, excited by the dilator, do not throw out the exudate ; if it is not visible, one finds it expedi- ent occasionally to introduce the forceps into the trachea ; re- newed fits of coughing are thus excited, and we may succeed in seizing some fragments of false membrane. These expedients should soon produce satisfactory results ; otherwise it is useless and even dangerous to continue them ; they contuse the edges of the wound; and, moreover, the cold air which they introduce freely into the trachea, may be the starting point of one of the pulmonary inflammations which carry off so many patients attacked with croup. If they re- main unsuccessful, we hasten then to introduce the canula. This means is still more powerful than the preceding ; we con- stantly see the false membrane driven violently through the canula at the moment when this is replaced, after they have resisted all attempts at extraction. But all efforts may be ren- dered unavailing ; the false membranes situated too low or being too adherent, remain firm and the patient dies asphyx- iated. 5 so DIPHTHERIA, CROUP AND TRACHEOTOMY. I close this chapter by a few words upon the care given in case of syncope or asphyxia. One should endeavor to equal- ize the circulation. Besides, for syncope he should employ a horizontal position, mustard plasters, slapping the face with a towel wet in cold water, etc.; and for asphyxia, revulsives, elec- triciry to the phrenic nerve and its branches to the diaphragm, and above all, inflation. This last operation should be practiced by means of a tube introduced into the canula. It is very important to execute this manoeuvre with care, for by blowing with energy one is liable to produce pulmonary emphysema, and even to rupture the lung. I have seen a case of double pneumo-thorax produced in this manner, as well as a case of subcutaneous emphysema in which the air had reached the neck and as far as the nipple after having penetrated the mediastinum by a pulmonary fissure. The inflation, therefore, should be performed gently, and at sufficient intervals so as not to fatigue the lungs, and to allow them to react. It is preferably peformed through the canula ; if one is obliged to do it through the wound, he should be sure that the elastic tube enters into the trachea, for fear of pro- ducing subcutaneous emphysema. [R. W. Parker's " trachea aspirator" consists of a small glass cylinder to one end of which is attached a flexible tube, to the other also a tube and a glass mouthpiece. The glass cylinder can be half filled with antiseptic wool, and thus all risk of in- fection is prevented. — Lancet. Nov. 15, 1884. p. 897. An aspirator of any form may be attached to the elastic catheter or tube, and made to answer well for suction purposes.] Subcutaneous Emphysema. This infiltration of air into the connective tissue is an acci- dent of the operation quite uncommon. In 766 cases I have met with it twenty-two times. Millard and other observers have cited soine examples of it. It is due in the great major- ity of cases to a faulty operation, i. The most frequent cause without question, is the detachment (decollement) of the tra- chea produced by ineffectual efforts at introduction of the can- ula. Should the operation have been a little tedious, and, ACCIDENTS OF TRACHEOTOMY. 55 I above all, if the canula has remained for some moments in the false passage, the air is propelled into the loose connective tis- sue of this region by inspiration and expiration, and emphy- sema soon appears. In these cases it is not rare to find, on post mortein examination, an abscess of the mediastinum, as well as emphysema. 2. K faulty incision of the tracJiea, the grave consequences of which I have shown in respect of the introduction of the canula, is a cause no less effectual of em- physema. Latei'al Incision. — The parallelism between the incision in the integuments and that in the trachea is not maintained. Double Incision. — The trachea may be transfixed, and that in two ways. The second incision is carried directly back- wards in the median line, or in one side of the trachea. Some- times the canula passes through the second opening, and lodges in the connective tissue surrounding the trachea or be- tween the trachea and oesophagus. The patient dies before there is time for the emphysema to occur. When, on the con- trary, the canula enters into the trachea, the air, drawn by en- ergetic efforts, enters forcibly into the air-passages. A part of the air escapes by the second opening and diffuses itself into the connective tissue. An Incision too Long. — The canula escapes from the trachea in a short time, and lodges in the connective tissue, where it soon produces emphysema by the air which it conducts there, whether it has escaped entirely from the trachea, or that its in- ferior extremity rests astride of the inferior angle of the tra- cheal incision. If it escapes entirely from the trachea it forms an incomplete obstruction which impedes the escape of the air and facilitates its spreading into the connective tissue. If it rests upon the inferior angle of the tracheal incision, the air coming from without escapes in two currents, one remainino- in the trachea, while the other enters the connective tissue. I have reported one case of emphysema caused by the incision including five rings and a half An Incision too Short. — It sometimes happens that the tra- chea is simply punctured, and we then endeavor to enlarge the 552 DIPHTHERIA, CROUP AND TRACHEOTOMY. opening by means of a probe -pointed bistoury. From this re- sults a certain delay during which the little tracheal opening, deeply situated and often quite difficult to find, transmits the air into the surrounding tissues. 3. Too Short a Camda. — The instrument should be suffi- ciently long for its inferior extremity to enter completely into the trachea. Too short a tube will certainly produce emphy- sema. It is therefore necessary to select one with reference to the age of the child. This even is not an infallible precau- tion ; certain conditions may exist which will render a canula insufficient, which, under ordinary circumstances, would be suitable. They are : An Incision made too Low. — If, instead of commencing the incision immediately below the cricoid, a point where the tra- chea is superficial, and where the vessels are less numerous, the operator should neglect this precept, he is liable to find, among other accidents, that the canula which he has selected becomes too short. The production of emphysema is the con- sequence. Tumefaction of the tissues ixonx the most diverse causes, to- wit : abscesses, erysipelas, etc., may act in the same way even when the operation has been regularly done. The canula, which at first had the desired dimensions, becomes too short in consequence of the lengthening of the track; then it escapes from the trachea and emphysema results. We can comprehend that emphysema, when it has been pro- duced, also increases the thickness of the pretracheal tissues and perpetuates itself by virtue of the same mechanism. Too great looseness of the tapes which hold the canula acts in the same way by not holding it down sufficiently, and thus exposing it to escape from the trachea. The /^r;« ^/"//zf <:^w?//rt has a similar influence. In order to spare the anterior wall of the trachea, the inferior extremity of the tube has been (in some instruments) beveled off at the ex- pense of the anterior aspect. This improvement may, how- ever, have some inconveniences. It may happen that the tra- cheal incision being too long, the superior part of the bevel ACCIDENTS OF TRACHEOTOMY. 553 (slant) may be outside of the trachea, A part of the air which circulates in the canula escapes by this opening and diffuses itself into the connective tissue. Formerly the bevel or slant was made too long; this disposition increased the danger. 4. Inflation Practiced TJuoiigh the Wound. — In certain tedious operations which cause long delay in opening the tra- chea, as well as operations performed in extremis, the patient falls into a state of suspended animation ; and immediately on opening the trachea one hastens to apply inflation through the wound. I have previously showed that this manoeuvre re- quires great care. I have reported, in confirmation, some cases of emphysema, and a case of pneumo-thorax due to this cause. Commencement. — Emphysema often appears during the op- eration ; one may observe it in a few minutes or some hours after. Several times it was not discovered till the next day, but we may suppose that its existence was not noticed during the first night. In a case reported by Millard it developed at two different times with an hour's interval ; the second was probably caused by the escape of the canula, an escape which the first puncture had caused. Seat. — Sometimes limited to the region of the wound, it often extends to the angles of the inferior maxillary ; more rarely it is seen invading the face, the eyelids and the hairy scalp. In serious cases it descends in front of the sternum to spread itself all over the chest, and even to the shoulders, the arms and the back. Finally in some cases it becomes almost general. Symptoms. — I shall not tarry upon the well known symp- toms of emphysema. If it occupies a large surface it becomes the cause of dyspnoea, and of considerable anxiety. The local symptoms which it causes about the wound are of much inter- est. The tissues sometimes become distended in such a man- ner that the canula becomes too short. Occasionally, it is even pushed out of the wound. As a consequence we have to fear, on the one hand, the increase of emphysema, and on the other, asphyxia, which the difficulty causes, and sometimes the impossibility of finding a canula sufficiently long. 554 DIPHTHERIA, CROUP AND TRACHEOTOMY. The rapid death of the patient often prevents the observa- tion of all the phases of emphysema ; but in cases in which death is more gradual, and in those cases of recovery, we re- cognize that its duration is in proportion to its extent and to the persistence of the cause. Thus it is that one may see it disappear the next day in some, the third day in another, and that it still did exist in one patient on the ninth day, the time of death. Treatme7it. — The best treatment is the removal of the cause. If the canula is too short, substitute a longer one. But the tumefaction may be so great that all the ordinary canulas are insufficient. Millard reports a very interesting case in which emphysema made such progress that the canula, becoming too short, one attempted, unsuccessfully, the introduction of the gum tube and variously modified canulas. It was necessary to hold the wound open, first with the dilator, which it soon be- came necessary to abandon, and then with a long tracheotomy forceps ; the entire duration lasting several hours, till one was able to introduce a proper canula. Such cases, however rare they may be, prove that the prac- titioner, in order to avoid being surprised and having the pa- tient die in his hands, will do well to have in his operating case a canula long enough to meet such an emergency. In a case in which emphysema appeared to be caused by the bevel of the canula, Barthez had recourse to an ordinary canula, and the infiltration ceased immediately. After being developed, emphysema, consecutive to tracheot- omy, is amenable to the usual treatment of an emphysema developed in the different regions of the body, under the in- fluences of various causes. In case the gaseous infiltration is hmited to the vicinity of the wound, it is an advantage to cover the tumor with a coating of collodion. The compression which results from it is found to be quite rationally indicated. Injury of the QEsophagus. The injury of the oesophagus has been regarded as an acci- ACCIDENTS OF TRACHEOTOMY. 555 dent possible to tracheotomy. I have never met with it, neither have the great majority of observers. The flaccidity of this tube, and its deviation to the left, shelter it almost absolutely from the cutting instrument. The long list of difficulties and accidents of every kind which may complicate tracheotomy, is of such a character as to intimidate those who are called upon to perform this opera- tion. This is not because it is always of difficult execution. Often, on the contrary, it is of extreme simplicity. We may assert that it is either vciy easy or veyy difficult. What con- veys the thought better is the uncertainty in which the opera- tor is nearly always placed at the time of making the first stroke of the bistoury. So an operation, which might appear to be done without trouble, may offer the greatest difficulties, and vice versa. When anyone commences tracheotomy, he should always be upon his guard and expect some surprise. Because of the numerous variations, which the region in which we operate presents, tracheotomy cannot be brought under invariable rules like other operations. It requires of him who would practice it large experience and a tested coolness, qualities which ena- ble him not to be taken unawares. However well qualified one may be in these respects, he never feels, at the moment of performing tracheotomy, free from experiencing to a certain degree, the apprehension which the unknown produces. SEQUELS OF TRACHEOTOMY. I The patient upon whom tracheotomy has just been per- formed finds himself placed in new conditions. The laryngeal obstacle having been not surmounted, but rather set aside and made of no effect, croup, properly speaking, no longer ex- ists. Diphtheria, as a general disease, resumes the first place. Recovery will in great measure depend upon the degree of in- fection, the tendency of the false membranes to spread, and the intervention of complications proper to diphtheria. On the other hand, the patient finds himself, like all who have under- gone an operation, exposed to the accidents which menace wounds in general, and th(jse of the neck and trachea in par- ticular. The direct introduction of air into the chest, without its having been previously warmed and moistened in the upper passages, singularly facilitates the development of pulmonary inflammations, the cruel enemies of those who have been oper- ated upon for croup, and so much the more formidable, as they too often chipose their victims among those who have es- caped the dangers of infection. It was these which harvested almost all the patients before Trousseau had, by the invention of the cravat, enabled respiration to perceptibly approach nor- mal conditions. What croup becomes when thus modified in its natural course is what I am about to examine. Recovery may be obtained in two ways : In the first, the patient having to do with a benign diphtheria, gradually im- proves when the respiratory difficulty has disappeared, and re- covers of his croup, as of a pharyngitis. In the second, acci- dents or complications intervene which compromise the cure more or less, but which nevertheless end by subsiding. These (556) SEQUELS OF TRACHEOTOMY, 557 symptoms may finally become worse, and a fatal issue should then be feared. Among these complications some depend upon croup in so far as it is a diphtheritic affection. These have no special relation to tracheotomy, and I have examined them already. Others are the immediate consequence of the operation, being pro- duced during its performance or continumg afterwards. I have already detailed them. A third group includes those which, while they are the result of the operation, do not ap- pear until after a variable time. These are the only ones which should find place here. The history of the sequelae of tracheotomy may thus be divided into two parts : The first will be devoted to the evolution of croup after tra- cheotomy when it results in recovery without complications. The second will include the complications, but only those which are attributable to tracheotomy, and the care which they require. PART FIRST. The Evolution of Uncomplicated Croup to Recovery. The After-Treatment of Tracheotomy. I left the patient just after the operation, replaced in bed, after having swallowed a little warm, sweetened wine. He should be carefully tucked into his bed, which should have been previously warmed. If necessary he may be surrounded by bottles of hot water, and even sinapisms may be ordered upon his skin, all for the purpose of combatting the tendency to chill which always follows the operation, especially when asphyxia has progressed far, and when haemorrhage has been abundant. After a short time the face recovers its natural color, respiration becomes regular, the pulse resumes its ful- ness, and the child falls into a calm slumber which lasts for one or more hours. During this time the dressing should be watched so as to be sure that there is no discharge of blood. Traumatic Fever. — After a few hours the traumatic fever ap- 558 DIPHTHERIA. CROUP AND TRACHEOTO'^IY. pears. The time of its beginning varies with the condition of the patient at the moment of operation. The more he has un- dergone the influence of asphyxia and of blood poisoning, the more blood he has lost, the more enfeebled and chilled he has become, the later is the appearance of reaction. It may su- pervene four hours after the operation or not until the day fol- lowing. In the opposite conditions the child reacts rapidly, and the fever appears without delay. Apart from these considerations, the traumatic fever which follows tracheotomy has no special features. The pulse reaches 140, or more rarely 160 pulsations. The temperature rises to about 39°. It often exceeds this degree, and remains at about 39.5° or 39.8° (103.1° to 103.6° F.). Sometimes it reaches 40° (104° F.), and I have even seen it once at 40.4° (F. 104.7) without there being reason to credit the existence of a pulmonary inflammation. It is not the intensity of the febrile movement which should inspire fears in regard to it, but its prolongation. It does not ordinarily last more than one or two days. When it persists longer, it gives reason to fear a complication. There are cases where the reaction comes on violently, the thermometer reaches or exceeds 40° (104 °F,) and death supervenes within twenty-four hours. If, in such a case, the autopsy shows only unimportant lesions, we are right in attributing the fatal issue to the intensity of the reaction. Expectoration. — In the first moments following the operation the liquids thrown out through the canula contain a greater or less quantity of blood, according to the amount of bloody dis- charge which has found its way into the bronchi. After a short time the expectoration changes its character, becoming mucous, thick and opaque, so as to form large nummular sputa, somewhat ragged and not unlike the sputa of consumptives. Sometimes they are so dense that when the sponge pushes them from the canula into the spittoon, they are moulded within the tube and assume the appearance of cylindrical false mem- branes. It is sufficient to turn them into a glass of water, to cause them to resume their true character. The mucus be- comes diluted or remains transparent, while the false membrane ^ SEQUELAE OF TRACHEOTOMY. 559 preserves its form and its opacity. In other cases the expec- toration, while remaining mucous, continues transparent and more fluid. Such are the characteristics of laudable expectoration. It would be of bad character if it should consist of a liquid which is purulent or serous, grayish, fetid, unaerated and frothy. It should always arouse anxiety if the patient operated upon does not cough. It must be concluded therefrom that the bronchial fluids are being imperfectly discharged and that as- phyxia is gradually coming on. The absence of expectora- tion and dryness of the canula, are of unpleasant prognosis, for they indicate the existence of a bronchial inflammation. False membranes, completely or incompletely detached from the tracheal or bronchial walls, and floating in the air-passages, are often thrown through the canula by coughing. The presence of these products in the metallic tube, as well as their absence, is indicated by the different noises made by the air passing through it. When the expectoration is abundant the canula is noisy, it is the seat of a real gurgle. When it is moderate the canula is quiet or gives rise to a slight snoring sound ; when it is absent or very slight, quite an acute whist- ling is made. If a false membrane presents itself at the inner end of the canula, a characteristic flapping sound is heard, ac- companied by rough and shrill noises. The respiration be- comes painful, the child coughs and makes energetic efforts, which usually bring about the expulsion of the concretion. The canula should, therefore, be watched with great care. When the gurgling noise is heard the inner canula must be re- moved, cleaned with a sponge and its contents thrown into a vessel of water, in order to render the inspection of the sputa and false membranes easy. If we recognize by the noise which characterizes the presence of a false membrane below the canula, that its expulsion is delayed, and that difficulty is arising in the respiration, the child should be made to cough, and the cough should be aided by means of a feather, or a curved forceps which is introduced into the canula after re- moving the inner one. If this means does not suffice, a few 56o DIPHTHERIA, CROUP AND TRACHEOTOMY. drops of tepid water should be instilled into the canula by- means of a pipette, every quarter of an hour. This manoeuvre has the advantage of provoking a cough and of aiding in the detachment of tracheal and bronchial products. In urgent cases, of great distress and marked excitement of the patient, it might be necessary, as I have before indicated, to introduce the trachea forceps and even to withdraw the canula. When, after an attack of coughing, a false membrane becomes en- gaged in the instrument, we are apprised of it by an immediate embarrassment of respiration. The inner tube is then to be removed and cleansed as before. These important attentions should be given pro re nata. It is also injurious to run to the canula after the manner of the inexperienced, to cleanse it at the least noise which it produces. All this is a great detri- ment to the child whom these unreasonable manoeuvres often irritate and whose rest they disturb. So, also, the attendant should know when it becomes noisy in such a continuous man- ner as announces asphyxia. The latter is, in fact, all the more promptly produced and increased as the respiration is effected only through a relatively narrow channel, the calibre of which may be easily reduced or obstructed. Circumspection is still more necessary when a false membrane presents itself below the canula. If we must, in fact, avoid uselessly tormenting the child by making it cough and tickling the irachea for the pur- pose of bringing out an imaginary false membrane, we must, on the other hand, know how to recognize the presence of this foreign body and to aid in its expulsion. By reason of these difficulties assistants attached to hospitals for children should, when possible, be placed in charge of these patients. THE FIRST CHANGE OF THE CANULA. When twenty-four hours have expired after the operation, it is well to consider a change of the canula already soiled by blood and sputum. The period which I have assigned for the first change of SEQUELAE OF TRACHEOTOMY. 56 1 canula may perhaps appear too early, and I am not ignorant that many physicians even among those who are famihar with diseases of children, notably Trousseau, are not willing to make this first dressing except at a later period. I should except Millard, who recommends the change at the end of twenty- four hours. Such is also the opinion of Barthez. By this time the track of the canula is perfectly formed, and while its walls do not yet possess all the firmness that they may acquire, they are, nevertheless, firm enough to permit the tube to pass easily and without fear of going astray. I have always found this practice easy of execution. It also allows the inspection of the wound and its surroundings, and giving them in good sea- son the attention which they require. Moreover, it facilitates marvelously the expulsion of the false membranes. The wound is in contact with a foreign body, which irritates it and against which it reacts. In uncomplicated cases the in- flammation remains localized in the track whose formation it aids. But in others, and unfortunately the most numerous cases, diphtheria, gangrene, erysipelas, and other accidents arise to change the character of the wound. These complica- tions, if they are not apparent from the first day, are, neverthe- less, in embryo, and in process of development from that mo- ment. It is useful, therefore, that attention to cleanliness, aided or not by various topical applications should be used as early as possible to check the march of the disease. On the other hand, it often occurs that a false membrane, one or more, comes in contact with the posterior orifice of the canula, or into its neighborhood, and gives rise to symptoms which are often disquieting. It is then that the removal of the canula often renders a well marked set vice. Scarcely is it re- moved when a violent effort at coughing shoots the false mem- brane to a distance, and, moreover, if the desired effect is not obtained, recource can be had to holding the wound agape with the dilator, a proceeding which gives free access of air and provokes an energetic cough,which often drives the foreign body out. We are still further enabled to search for the latter with the forceps, which manoeuvre is singularly simplified by 562 DIPHTHERIA, CROUP AND TRACHEOTOMY. the absence of the canula. Should all these means fail, then let the canula be returned, and a fresh attack of coughing is produced which throws out the false membrane in a vast ma- jority of cases. The changing of the canula, therefore, at the end of the first twenty-four hours, seems to me to be justified. It is well un- derstood that this limit is not absolute, and that it may be shortened or lengthened according to circumstances. If that period is about to expire, for example, during the evening, it would be better to put off the dressing till the next morning. An hour must also be chosen which is remote from the last meal. Without this precaution the necessary manipulations will not fail to bring on vomiting, and, however small the amount may have been, alimentation is too necessary not to enforce the avoidance of that accident. The necessary ma- terials are : a canula to replace the first, a dilator, forceps for false membranes, quill feathers, a basin full of tepid water, compresses, dressing forceps, olive oil or cold cream and collo- dion. The fatty substances and the collodion are for the pur- pose of protecting the skin from the liquids which discharge from the wound. I advised, in 1869, the substitution of collo- dion for the fatty materials. This agent applied about the wound forms a thick coating over the skin, a sort of cuirass which protects it from the liquids discharging from the wound, while at the same time it exercises a slight compression very useful for tissues so exposed to swelling. When it is neutral, this composition is not at all irritating. The canula ought to be of the same calibre as the first. If, however, too small a canula has been used at the operation, it should be replaced by one of larger calibre at the first dress- ing. A narrow canula places the respiration in unfavorable conditions. The assistants may be less numerous than for tra- cheotomy. It is sufficient to have one to hold the hands and another to hold the lower extremities. The child soon becomes accustomed to the dressing, and after two or three days the surgeon can almost always do it by himself. For the first time the patient may be replaced upon the operating table, but it SEQUELS OP' TRACHEOTOMY. 563 almost always is sufficient to leave him upon his bed, which should be placed facing the light. At the instant when the canula is removed an attack of coughing is produced which throws out mucus, blood, false membranes, etc. If no com- plication exists the metal of the canula is unchanged. It may be soiled with pus, blood, mucus, etc., but it ought not to be blackened. Every alteration of the canula indicates a patho- logical condition of the parts in contact with it. The skin should be carefully washed with a compress or a sponge dipped in tepid water. The exploration of the wound should then be undertaken. To examine the deeper portion well, a bit of charpie or wadding dipped in tepid water is passed along the divided surfaces. If the wound is healthy its borders and surroundings preserve their normal color. They are sup- ple, or there exists merely a slight induration in the subcuta- neous cellular tissue, which diminishes neither the suppleness nor the mobility of the skin, while the walls of the wound are partly separated so that the air passes freely through. In some cases the walls and the edges are softer, and the canula is hardly removed when they fall together into the wound and close it. The air no longer penetrates, and the child suffocates. In this case the dilator is speedily introduced into the wound, which is held agape during all the time neces- essary. This manceuvre gives a double advantage. It per- mits the child to respire freely during the whole time of cleans- ing, and, on the other hand, the free entrance which it gives to the air, excites coughing and aids in the expulsion of tracheal or bronchial products. The walls of the wound are rose col- ored, and present here and there small ecchymotic points formed by certain vessels cut during the operation, and often a little pus is beginning to exude. Trousseau, and several phy- sicians after him, advise cauterizing the wound with nitrate of silver immediately after the operation, for the purpose of pre- venting diphtheria in it. This practice has been abandoned, for it is powerless to prevent the wound from becoming dis- eased and may aid in producing consecutive inflammation. When the wound is simple it is left to itself. Diphtheria of 564 DIPHTHERIA, CROUP AND TRACHEOTOMY. the wound is no more frequent for it. Attention to cleanliness^ slightly stimulating and disinfectant topical applications, such as a I per cent, solution of carbolic or salicylic acid, consti- tute the therapeutics of the wound which is thus assimilated to simple wounds. While the child is still without the canula, the condition of the larynx should be ascertained. For that purpose the lips of the wound are approximated with the iingers in such a way as to prevent all access of air through this passage. Another method of exploring the larynx consists in stopping the orifice of the canula with the ball of a finger before it has been re- moved or after it has been replaced. This procedure is less trust- worthy than the former, for on the one hand the finger is often too large to lodge firmly in the orifice and seal it hermetically, and, on the other hand, air may pass between the walls of the wound and the canula. These are two causes of error which are avoided by the first method. If the larynx is becoming free, an inspiration more or less whistling, according to the degree of freedom from obstruc- tion, is accomplished through the mouth, but if the obstacle persists the child makes vain efforts to breathe, becomes agi- tated, its face becomes cyanotic, and the signs of asphyxia ap- pear. In the first case the patient is left without a canula so long as is possible without fatiguing him. During this time the trachea and the wound are at rest. The child begins to form the habit of remaining without its canula and is preparing for its final removal. In the second case we hasten to re-open the wound, and re- insert the tube after taking pains to cover the surrounding skin with a coat of oil of sweet almonds, of cold cream, or bet- ter of collodion. Finally the neck is surrounded with the double cravat. After the canula has been replaced, the con- dition of the respiration, of the circulation and of the tempera- ture should be ascertained. The respiration should extend to the whole chest, and be without intermingling of rales. The number of respirations varies, and should be carefully noted. There are cases, in fact, SEQUELS OF TRACHEOTOMY. 565 in which the child is calm and is making no apparent effort to breathe, but on closer examination it is perceived that each respiration is very short and that the inspirations are numerous, depth being supplemented by frequency. When there are more than forty-eight inspirations per minute, there is almost complete certainty of a pulmonary complication or the pres- ence of either loose or adherent pseudo-membranous products in the air-passages. The origin of the respiratory trouble must then be sought by careful auscultation. According as the disease progresses toward recovery, the number of respirations diminishes little by little, and soon re- turns to the normal. Care should be taken to determine this number during the sleep of the patient, in order to avoid the acceleration which follows the slightest emotion. Circulation follows the respiration exactly. We have seen that in the period directly following the operation, traumatic fever lights up and is then confounded with the fever which pertains to the diphtheritic affection. The febrile movement is maintained in the neighborhood of 120 to 140 pulsations, to subside after a few days according to the duration of the dis- ease. The temperature does likewise, and subsides sometimes sud- denly, sometimes gradually, while preserving a rise in the evening. Acceleration of the pulse up to 160 or 180 pulsations per minute, and frequency of respiration beyond 48 respirations per minute, joined to an elevation of temperature to about 39.5° or 40° (103° or 104° F.) indicate with certainty that a complication is coming on. Final Removal of the Canula. After the first changing of the canula the same dressing is repeated every day, and the same precautions are used. When the air begins to pass through the larynx, the trial is made of leaving the child a few moments without the canula. At this time, and until complete recovery, vigilance is more 566 diphthp:kia, croup and tracheotomy. necessary than ever. The patient should not be left a single instant. Some one who is able to replace the canula should be with him constantly. A few moments are sufficient for a child yet unused to breathing without aid to be taken with suffocation and to die, unless the instrument can be im- mediately restored to its place. The recognized causes of this accident are : incomplete permeability of the larynx, mucous concretions or fragments of false membrane which come and lodge in the wound or in the larynx ; laxity of the borders of the wound which fall together and close the orifice ; fungous granulations and the progress of cicatrization which contracts the wound, and very often the fright which the child experi- ences on finding itself without the canula; it becomes agitated, coughs, the muscles of the larynx contract spasmodically, and finally respiration ceases. These causes will be studied in de- tail when 1 take up the difficulties met with in removing the canula. As seon as the patient appears fatigued the canula should be replaced. Little by little its removal is attained, first for a few minutes, then for several hours, then a whole day, and finally, once for all. A good sign of the recovery of the larynx is the passage of the tracheal sputa by way of the mouth. During the time that the child remains without the canula, care should be taken to place over the wound a piece of fine linen to receive the products of secretion, and to support it by a woolen cravat. Cautious, progressive removal, based upon repeated explo rations of the larynx, is condemned by Battels, of Berlin, who charges this practice with irritating the parts. He advises that the canula be finally removed from the fifth to the eighth day. These scruples of the Berlin physician seem to me exagger- ated. When cautiously made, exploration of the larynx is of no danger whatever. As to the removal of the canula upon a set day, without any notion as to the permeability of the lar- ynx, it would not be justified by a single consideration. Here are the periods at which the canula could be finally removed in 134 children, both in the hospital and in my private practice : SEQUELiE OF TRACHEOTOMY. 567 No. of] cases. I At end of ist day - - - i M 3i " - - - - 3 « 4th « .... 8 « 5tli " - - - - 14 4< 6th " - - - 18 M 7 th " - - - - 16 M 8th " - - - 18 <t 9th .... 7 « loth « - - . 8 l< nth " - - - - 4 « 12th "... 5 It 13th " - - - - 6 " 14th " - - I <l 15th «... . - 4 " 1 6th " - - - 3 At end of 17th day " 1 8th " " 19th " " 20th " " 2ISt " ■ « 23d " " 24th " . '* 25th " •' 30th " •' 32d " " 34th « ■ " 35th " " 4Sth « ■ " 126th « Total No. of cases. 3 134 Dr. Jacobi obtained the following results which differ perceptibly from the pre- ceding. Time. 17th day 1 8th " 20th " 27th " 29th " 30th " No. of cases. Time. 35th " 42d « 44th " 46th " 54th « Total No. of cases. 2 - I I - I I 13 The shortest delay was 17 days. Dr. Max MuUer produces figures which seem truly surprising: 568 DIPHTHERIA. CROUP AND TRACHEOTOMY. Time. 13th day 15th " 25th « 27th « 42d " 44th « 51st « 69th " No. of cases. Time. 70th day 79th " 105th " 1 1 2th " 1 20th " 203d " Total No. of cases. 14 [See also reports of Illinois cases, page 478. The question arises, by virtue of what causes, in so large a number of cases was the removal of the canula so long de- layed ? The author, indeed, informs us that in one case there occurred, nineteen days after tracheotomy, a return of the fever followed three days afterward by the expectoration of a mem- branous tube coming from the bronchi, but that fact does not explain the general delay appertaining to the removal of the canula. An early removal is the fortune of simple croups, dependent upon a benign diphtheria and not retarded by complications- The late removal is the result of the complications which em- barrass the course of the disease. These complications will be treated of later. Cicatrization of the Wound. In the natural course of the disease, many days elapse be- tween the removal of the canula and the complete cicatrization of the wound. This latter gradually contracts and ends by be- coming completely closed after a few days. The regularity and rapidity of the cicatrization are constant in simple cases, but the least complication, on the contrary, suffices to disturb them. The examination of the wound is, therefore, valuable for prognosis. Whenever cicatrization occurs regularly, the SEQUELiE OF TRACHEOTOMY. 569 prognosis is favorable. On the contrary when, in the absence of apparent cause, cicatrization is arrested or retarded, a com- pHcation is to be dreaded, such as an eruptive fever, paralysis, broncho-pneumonia, etc. When the wound is simple the role of the physician is limited to directing the cicatrization. For a long time custom prescribed that after the removal of the canula, a tight dressing made of strips of diachylon or court plaster should be applied to the wound. That procedure had very serious inconveniences. The patient, in fact, is far from being out of danger at the time when the canula is removed. Attacks of suffocation supervene under the influence of any mental emotion, of sputum which is thrown out with difficulty, or by the simple impression of cold air, even when the freedom of the larynx has been fully ascertained. When in such cases the wound is hermetically sealed, the patient becomes as- phyxiated and quickly dies, if there be no one present who can render him effectual aid. On account of many accidents that practice has been given up. It is best to leave the wound to itself, and cover it with a simple dressing or a piece of fine linen which will protect it from the rubbing of the clothing while permitting it to close spontaneously. This method allows all the attention which the wound may require, and leaves to the air-passages for sev- eral days the help of two orifices which supplement one an- other to the advantage of both respiration and expectoration. Thus are avoided attacks of suffocation caused by sputum re- tained in the larynx. During this time that organ becomes accustomed to functional activity and has become already ex- ercised when the wound is finally closed. We are, therefore, limited to watching the cicatrization and to stimulating the wound, if the progress be a little slow, with appropriate topical apphcations. The one which has suc- ceeded best in my hands is a i % solution of carbolic acid, with which the wound is touched several times a day by means of a pair of forceps. If this means does not suffice, a pencil of nitrate of silver is to be passed hghtly over the surfaces. This agent should also be employed to repress the exuberance of 570 DIPHTHERIA, CROUP AND TRACHEOTOMY. granulations. It is important that the cicatrix should be reg- ular. It is situated, in fact, upon a prominent point. This precaution should be taken into consideration, particularly with female patients. In 92 patients the cicatrization of the wound was completed at the following periods : Period. No. OF CASES. Period. No. OF CASES. At the end of 7 days - - I At th s end f 23 days 4 « 8 " - - I " 24 « - 2 « 9 « - - I « 25 u 5 u 10 « - - 3 M 26 « - 3 M II « - - 4 .( 27 « 4 H 12 - - 6 <( 29 « - 2 « •3 (( - - 6 t( 30 " - - - I «< •4 « - - 5 4< 33 t' - I « J5 « - - 6 l< 35 l< 1 W 16 « - - I « 36 " - 1 « 17 " - - 3 » 3!^ " 1 « 18 " .- - 5 « 40 « - I <l '9 " - - 3 « 43 M 1 M 20 « - - 7 M 80 « - - - I U 21 'C - - 6 (1 128 X I " 22 <( - - 5 Total - - 92 Hygiene of Patients Who Have Undergone Operation. The general treatment, the hygiene of those who have been operated upon, is of the greatest importance. Every one agrees that if tracheotomy gives more numerous successes in private than in hospital practice, that difference should be at- tributed to the superiority of the resources which the former SEQUEL.E OF TRACHEOTOMY. 5/1 furnishes in care of every kind : personal attention, food, reg- ularity of temperature and ventilation, clothing, etc. These different departments of hygiene have all great value. They form a whole, no part of which can be subtracted with impunity. Alimentation. — The nourishing of those who have been tra- cheotomized should be attended to with great care. It is an indispensable condition of success, and yet this part of the treatment is one of the most difficult to direct. The appetite of the little patients is often irregular. While satisfactory dur- ing the first two or three days, it often diminishes about the fourth or fifth, and remains poor up to the time when the fever subsides or the false membranes cease to be formed. Some- times even the child refuses all nourishment. I have already insisted upon the necessity of a supporting diet for subjects af- fected with diphtheria. These precepts which I need not re- produce in detail find their application more than ever, when we have to deal with patients who have undergone tracheot- omy. Temperature. — From the first the desired precautions have been taken to restore the warmth which is often deficient at first. It is also important, for fear of thoracic complications, to keep the external temperature at a proper average. The child should be protected from the first by ample clothing. Its room should be large, airy, and of a southern exposure if possible. It should always be kept at a temperature of i8° to 19° cen- tigrade (65° to 70° F.). See page 508, application of cravat. Aeration. — The septic nature of diphtheria makes of the pa- tient a morbid focus which infects the patient himself and the persons who are about him. This aggravation in the situation is avoided by free ventilation without giving opportunity for chilling. It would be, therefore, of advantage to have an- other well warmed apartment beside the one in which the child usually remains, and into which he can be carried while the first is being ventilated. When this is done and the tem- perature restored to the proper point, the child should be re- turned to its former room. For the same reasons the number 5/2 DIPHTHERIA, CROUP AND TRACHEOTOMY. of persons who remain in the room should be hmited to those who are strictly necessary. Mental Managejiient. — Calm and quiet are indispensable dur- ing the first few days. Immoderate demonstrations of tender- ness and of feeling fatigue the patient. All persons who can not avoid such exaggerations should be excluded. The mother even should be no exception. The physician should interpose his authority and oblige her to look at her child from a distance without showing herself. This exclusion, which at the first glance may seem severe, is justified by necessity first, and by this consideration also, viz., that the child is much less sensitive to it than is generally believed. For a while it may perhaps cry and ask for its mother ; but after a very short time, if the instructions are faithfully ob- served, it will completely forget this source of annoyance. More- over, parents who are too feeble or too much overcome by the affliction, lose their authority over the child and become an obstacle to its cure. At the hospital especially, where we have to deal with a public usually less enlightened than that in private practice, great strictness should be exercised with regard to the visits of parents. To those who have attended croup patients at the hospital, it is evident that every visit of the parents is followed by an aggravation. The child becomes agitated, cries and asks for its mother, the fever and oppression are augmented, and the same scene is repeated every day without reckoning the dainties of bad quality with which it does not fail to gorge itself, to the detriment of its appetite for more nourishing food. It is not rare to see certain children take a dislike to the hospital, refuse to eat, grow pale and thin and finally succumb. The lack of intelligence of certain people, moreover, surpasses anything that can be im- agined. I have reported how the parents of a child, operated upon in the service of Barthez, kept ceaselessly repeating to the little patient that, "He would not recover," and expressing before him with many demonstrations the grief which they felt at his death. They ended by removing him from the hospital in spite of Barthez, for, they said, they could not do without SEQUELiE OF TRACHEOTOMY. 573 their son, but they allowed him to die for lack of care. Diversion is necessary for these patients. It is important to have the child get up as soon as possible after the time when the cessation of the fever,the disappearance of the false membranes and the commencement of the cicatriza- tion of the wound are established; otherwise it grows pale and gloomy, appetite diminishes, cicatrization becomes slow and its general condition which was satisfactory becomes depraved. If, on the contrary, it gets up, all this disappears as if by en- chantment ; it becomes cheerful, color reappears and the ap- petite returns. His sitting up, if well borne, should be grad- ually prolonged, and soon should be regulated by his previous habits. After a few days, governed by the season, the child can go out, when comfortably clothed, even before the wound has wholly recovered. Treatment of Croup After Tracheotomy. It is customary, when once tracheotomy has been done, to leave the pharyngo-laryngeal manifestations of diphtheria to themselves. It seems, as Trousseau said : "That we need no longer worry about the pharyngeal or laryngeal diphtheritic manifestations which up to this time called for such vigorous resistance. It seems as if the disease on its arrival at the air-passages had exhausted all its action, and if, by giving access of air to the respiratory apparatus by means of tracheotomy, the pa- tient is prevented from dying, recovery will come on ol itself." These words are true and stamped with the practical tact which so well characterized the illustrious professor. Expe- rience has given grounds for them. Chlorate of potassium, recommended by Isambert, Andre and Millard, acetate of po- tassium counselled by Labat, of Bordeaux ; the balsams, tried by a great number of physicians upon the indication of Tri- deau, kermes mineral, etc., have been recognized as useless. It is well, therefore, to abstain from them, for if they are use- less they may become pernicious by injuring the patient's ap- petite and causing diarrhoea and nausea. For the purpose of preventing bronchial inflammations, and the extension of the diphtheria to the bronchi, inhalations have been tried of the vapor of pure water or of water charged with medicaments • 574 DIPHTHERIA, CROUP AND TRACHEOTOMY. great jars filled with boiling water into which emollient plants were thrown, were placed about the patient's bed. The re- sults obtained by this method do not appear to have been equal to the hopes which were entertained with regard to it. Since the invention of the cravat it has become more embar- rassing than really useful and is generally abandoned. In En- gland, however, it is much used, and the patients are placed under a tent in which a vaporarium is placed. — Howse. PART SECOND. Complications. The accidents which occur after tracheotomy are of two kinds. Some are of traumatic origin and are due to the oper- ation; others are dependent upon the diphtheritic infection and are observed equally in croup when not operated upon, and in angina. The first alone will be examined in detail. The sec- ond have already been studied as complications of diphtheria and of croup. Certain of them, viz., the pulmonary inflamma- tions, however, deserve mention, for the reason that tracheot- omy, while it is not their sole or principal cause, nevertheless exercises a certain influence in their development. The modifi- cations which they impress upon certain symptoms of the normal evolution of croup after operation, deserve to be pointed out. I will close by indicating the causes which retard the re- moval of the canula. Accidents of Traumatic Origin. As the incision involves the integuments and the trachea, the complications have, consequently, the former or the latter as their theater. The accidents dependent upon the wound in the soft parts are haemorrhage, subcutaneous emphysema, abscess of the me- sequels: of tracheotomy. 575 diastinum, phlegmon, erysipelas, gangrene and diphtheria of the wound, to which I shall add irregularities of cicatrization. The accidents which relate to the trachea are ulceration, stricture, polypi and fistulae. CHAPTER FIRST. Accidents Dependant Upon the Wound in the Soft Parts. H(Bmorrhage and subciitaiieous emphysema appearing oftenest during the operation, their history has been given with that of the accidents of tracheotomy. Secondary haemorrhage and emphysema which supervene after the operation, have been described in the same place as the former. Abscess of the Mediastinum. This accident of tracheotomy is but httle known. Hardly appreciable by its symptoms, it is rarely recognized except at the autopsy. It is found mentioned for the first time in the thesis of Millard, then in that of Crequy (1858). The follow- ing year Pelletier de Chambure collated some observations, one of which belonged to Barthez and two to Roger. I have been able to collect eleven cases which were observed in the service of Barthez. I shall notice also a case belonging to Boeckel, of Strasburg, recorded in the thesis of E. W. Boeckel. The rarity of this lesion is, therefore, incontestable, and per- haps the number of cases has been lessened by the difficulty of diagnosis. Etiology. — Just as subcutaneous emphysema, and a certain number of the complications which follow tracheotomy, inflam- mation of the mediastinum is often caused, not by the opera- tion but by the operator. In every case observed the acknowl- edged causes of the abscess were accidents in operation, which have the closest relation to those which engender em- physema. This community of origin is not surprising when we bear in mind the frequent coincidence noted in these two complications. Tedious operations, numerous and incautious (576) SEQUELiE OF TRACHEOTOMY. 577 attempts at introducing the canula, false passages, contusion and dissecting up of the peritracheal cellular tissue, are the usual causes. It is the same with vicious incisions of the tra- chea, perforation of its posterior wall, double or lateral in- cisions, all of which serve to complicate the introduction of the canula. These manoeuvres result in inflammation or gangrene of the wound. The inflammation, developed in the wound and around the trachea, rapidly reaches the cellular tissue of the mediastinum. This process has been manifested in every case. Moreover, it is interesting to observe that the same diseased conditions of the wound when it is unaccompanied by denuding (detach- ment) of the trachea, remain limited to the wound in place of spreading into the mediastinum. In one patient, whose history I have cited in detail, the abscess of the mediastinum had an exceptional origin. It seemed to result from the action of the actual cautery upon a wound affected with gangrene. Symptoms. — It is usually impossible to assign special signs to abscess of the mediastinum, for the autopsy only reveals it. In fact this lesion almost never exists alone, for generalized diphtheria, broncho-pneumonia, or pneumonia are rarely want- ing and their symptoms overshadow by far those of the medi- astinal inflammation. There are, however, autopsies in which abscess of the mediastinum has been found alone. In such cases it has been remarked that after a few days, at a time when the condition of the patient seemed to be improving, there came on an intense fever accompanied by dyspnoea and agitation, and which ended, without delay, in death. Pelletier de Chambure has well presented that peculiarity. I have been able, in other observations, to verify the accuracy of his state- ment. The diagnosis is evidently almost impossible. Yet if it can be shown that in a tracheotomized subject the operation was tedious, that false passages were made and that the wound has been the seat of phlegmon, of erysipelas, of gangrene or of diphtheria ; if then, after a remission of several days, a return of the fever is noted,and of the dyspnoea together with accelera- 5/8 DIPHTHERIA, CROUP AND TRACHEOTOMY. tion of the respiration, we may suspect the formation of an abscess in the mediastinum. Yet the rarity of this accident should be always kept in mind, and the thought that the chances are much more numerous in favor of a broncho-pneu- monia or some other pulmonary inflammation, which compli- cations are much more common. The chest of the patient should, therefore, be carefully examined before pronouncing an opinion, and then even, when the evident signs of respira- tory inflammation fail to be confirmed, we should be none the less very reserved. It will suffice, in fact, to have a slight ex- perience with patients with croup to know how difficult and uncertain auscultation is with them. How many pulmonary lesions are found on autopsy which the most attentive auscul- tation was not able to discover ! Treatment. — The difficulty in diagnosis usually prevents the application of any treatment. But admitting that the diagno- sis has been settled, what treatment should be employed? The only rational means is to trephine the sternum ; but who would dare to employ such a procedure in a patient operated upon for croup ! [The abscess, when located, might be opened from the side of the sternum.] Phlegmon of the Wound. When all the causes of inflammation to which a wound of tracheotomy is subjected are examined, the wonder is that the condition is not constant. Under these conditions the wound is rarely simple, and in- flammation of the walls and surrounding tissue is almost inev- itable. In place of furnishing the physiological inflammation necessary to cicatrization, the wound becomes phlegmonous. The beginning occurs at the end of the first twenty-four or thirty-six hours. Up to that time the edges had remained soft, the walls rose-colored, the surrounding tissues supple or very slightly indurated deep down, but the skin has remained movable. The walls grow pale while they become indurated in such a way that the opening of the wound, instead of being SEQUELAE OF TRACHEOTOMY. 5/9 almost linear, becomes gaping and elliptical, while the subcu- taneous cellular tissue swells around the wound to an extent which varies from half a centimeter to several centimeters. However intense the tumefaction may be, the tapes and the plate of the canula leave their impress upon the skin, and it may be so developed as to augment the depth of the wound to such a degree that the canula may become too short, which exposes the patient to emphysema and to suffocation. It fur- ther happens that in consequence of the tumefaction the skin becomes too tight, and no longer completely covers the sub- cutaneous cellular tissue which it leaves uncovered in the form of a border on a level with the edges and the angles of the wound. That cellular margin often serves as a starting point for a new complication, viz., erysipelas or diphtheria of the wound. The skin becomes tense, immovable and red. This discoloration which occupies a quite large zone or forms simply a narrow border about the wound, shades off insensibly and becomes confounded with that of the healthy skin. Quite frequently the inflamed skin becomes covered with little vesicles like those of miliary fever, and filled with a white opaline liquid. Sometimes few in number but often very numerous, they may be situated above the wound but oftener below it, at that portion which is exposed to contact with the liquids which flow out of the canula ; it is not rare to see them forming a sort of crescent which follows the contour of the shield of court plaster. They are quite confluent at this point, but become more scattered above and below. After they have matured they dry up and the epidermis forms again beneath. In less fortunate cases, which are quite common, the floor of these vesicles is formed by a minute false mem- brane which often enlarges and, by uniting with those of the neighboring vesicles, forms patches of cutaneous diphtheria. This form of inflammation of the wound rarely ends in sup- puration. In five cases only have I seen abscesses formed. Two of them were situated above the wound. The third was dis- covered at the autopsy, and was found between the os hyoides and the thyroid cartilage on the one hand, and the thyro- 580 DIPHTHERIA. CROUP AND TRACHEOTOMY. hyoid membrane and the sterno- and thyro-hyoid muscles on the other, a fourth had formed below the inferior angle of the wound. With the last patient quite a large number of ab- scesses were met with upon the neck and face. Termination by nlceration is more common, by reason of the general alteration of nutrition in diphtheria. The process is usually limited to the angles and edges of the wound, espec- ially at its lower half Sometimes it extends to the surround- ing skin where it produces quite extensive losses of tissue. The ulcerated parts usually present a rose-colored floor, rarely gray, and its edges are regular and slightly salient. The metal of the canula is unaltered. When the patient is to recover, these disorders, after lasting for some days, subside, the red- ness diminishes, the induration undergoes resolution, the ulcer- ated parts are repaired, the wound becomes smaller and the work of cicatrization recommences. The inflammatory com- plication is never very severe of itself. It is almost inevitable and recovers perfectly when no other accident occurs. Treatmeiit. — An inflammation of moderate intensity demands more than ever, attention to cleanliness. The skin about the wound should be frequently cleansed and coated with some fatty substance, such as oil of sweet almonds or cold cream. If the tumefaction is somewhat considerable, applications of collodion will be of great service. If the inflammation is more extended, recourse should be at once had to the same care, and every topical application containing any irritant substance should be rejected. Then, as the canula is the most efficient- agent in producing the irritation, the attempt should be made to relieve the child of it as soon as possible. The induration of the borders of the wound, by making an almost rigid duct of the passage, favors the introduction of the air and facilitates leaving out the canula. While he is in this situation, he should be very closely watched, for, during the first few days, he tol- erates it with difficulty ; the respiration becomes easily ob- structed and suffocation comes on rapidly. The canula should be replaced at the end of half an hour, a quarter of an hour, or less. If the swelling of the cellular tissue is considerable, a longer canula than the first may be needed. SEQUELiE OF TRACHEOTOMY, 58 I The tendency to ulceration should be combated with the solution of carbolic acid, and if necessary, by nitrate of silver. Erysipelas of the Wound. Erysipelas recognizes the same apparent causes as simple phlegmasia. As to the essential cause of that inflammation we cannot penetrate it in the case of tracheotomy more than in any other. I have seen tracheotomized children affected with erysipelas of the wound, when there was not a case of that disease in the hospital. Its almost constant coincidence with gangrene of the wound should, however, be noted. This complication is much the less frequent, and several years may go by without its being met with. I have already recorded thirteen cases, and another has been cited by Blanchetiere. It begins most frequently at the end of one or two days, but in the instance of Blanchetiere's it was postponed till the fifth day. Prodromata are almost always wanting ; the general symp- toms disappear in the group of symptoms which characterizes croup. Blanchetiere's patient had a very high fever during the entire period following the operation. The temperature re- mained constantly above 40° (104° F.) and rose to 40.1°, while the frequency of the pulse corresponded with the elevation of temperature. The local symptoms are, at first, the same which character- ize simple phlegmasia, viz., induration of the tissues, pallor of the wound, which becomes gaping, a red zone around its bor- der, and sometimes little phlyctenules full of yellow fluid ap- pearing upon its borders. The next day the redness has ex- tended and is bounded by the hard, salient, fimbriated border which characterizes erysipelas. The phlyctenules are repro- duced and increase in volume, while the skin is hard, painful and tense. The exanthem may remain limited to the neigh- borhood of the wound, but in certain cases it assumes the ser- piginous form and overruns the whole body. The surrounding parts are usually healthy. It is not rare, 5^2 DIPHTHERIA, CROUP AND TRACHEOTOMY. however, to observe around the wound, before the appear- ance of the erysipelatous patches, a soft swelHng which has a great tendency to spread to a distance. It succeeds very often in reaching the jaws and the sternum, when the projection of the angle of the jaw is obliterated, the glands become indu- rated and painful, as in the case of pharyngitis. The sternal fourchette disappears, while the presternal cellular tissue in- creases in volume, and that of the chest and of the back may be invaded in its turn. The tumefaction of the cellular tissue is soft and distinguished from that of emphysema by the ab- sence of crepitation. It is painless and forms, in some sort, the advance guard of the erysipelatous swelling proper which is characterized by redness, hard swelling, pain, phyctenules, etc. If erysipelas alone prevails, the walls of the wound are pale and suppurate but little, and the canula is clean; but if to the erysipelas is added gangrene of the wound, which is very com- mon, the wound alters its character and the canula becomes blackened. The course of the erysipelas offers nothing worthy of special mention. The prognosis is unfavorable, and patients who undergo this complication rarely escape death. In thirteen I saw but three recover. The gravity, however, does not always correspond with the extent of the surface invaded. I have noticed recov- ery in a patient where the erysipelas had overrun the whole body ; and, per contra, cases of quite limited erysipelas have resulted in death. We find a satisfactory explanation in that general patholog- ical law according to which malignant exanthems are often distinguished by the slight extent of their cutaneous manifes- tations. Treatment. — Attention to cleanliness, applications of starch, fatty substances or collodion, together with removals of the canula as frequent and as prolonged as possible, are the only measures to be recommended. Gangrene of the Wound I have drawn attention to the frequency of this accident and i SEQUELiE OF TRACHEOTOMY. 583 have shown that it is often confounded with diphtheria of the wound. In fact, gangrene of the wound is not only that which is characterized by phlyctenules and by large black es- chars, but it also presents itself under the form of thin, gray patches which have a certain resemblance to the pseudo-mem- branous exudate. It is the most frequent of the complications which follow the operation. It is rare for a tracheotomy wound not to be affected to a certain degree with gangrene, varying from the mortification of a few isolated points to an extensive destruction of the coverings of the neck. Gangrene of the wound is of two varieties : 1. Superficial gangrene if the internal surface of the wound. — A frequent, benign form due almost wholly to the pressure of the canula upon the already inflamed tissue. 2. Extensive and deep gangtene of the track of the wound zuith or without extension to the skin, enlarging beyond measure the opening and the track of the wound, and caused at once by diphtheritic infection and by compression ; a grave and rarer form. The causes are at once local and general. The local cause is the presence of the canula which acts in a manner easy to understand. The divided tissues contract by virtue of their elas- ticity, against the canula, a rigid body which constantly tends to separate them. The best demonstration of this mechanism is given by the rapidity with which haemorrhages produced by the operation are arrested as soon as the canula is put in place. To this purely dynamic cause are added general conditions, i. e., the diphtheritic infection which alters the economy to a great degree, and diminishes the activity of nutrition. This influence is of great weight. Vigorous subjects, with whom the vitality of the tissue is energetic, are less subject to spread- ing gangrene than children who are thin, pale and scrofulous, or deteriorated by bad hygiene. It is also among those who show the most manifest signs of septicaemia that the cases of deep gangrene are met with. These two classes of causes are reciprocally supplementary. 584 DIPHTHERIA, CROUP AND TRACHEOTOMY. while singly they are less active. Those who have undergone tracheotomy for a non-infectious laryngeal lesion, oedema of the glottis, for example, wear their canula for a very long time, often for years, without experiencing the least gangren- ous alteration of the wound. The same fact occurs even among those who are operated on for croup, when, after the fever has subsided, and the diphtheritic affection has recov- ered, any cause whatever obliges them to retain the canula after the ordinary time. I observed a child of 5 years, who, after tracheotomy was obliged to retain the canula for 126 days on account of a spasm of the glottis which arrested res- piration at every attempt at removal, and throughout this long space of time the wound remained healthy. In superficial gangrene the dynamic element preponderates, while the gen- eral element overbalances in deep and diffuse gangrene. Superficial gangrene begins about the third or fourth day after the operation. At this period the change is difficult to recognize, for it is situated upon the walls of the wound which are already colored white or yellowish gray by the pus which they discharge, a tint which is confounded with those of the mortified part. Moreover, the beginning passes unnoticed, at least if we are not guided by one sign which is never wanting. I refer to the alterations on the surface of the canula. It does not apply, however, except to silver canulas. When the wound is healthy or simply inflamed, the metal remains white and polished. It may be soiled with blood, pus or some other substance, but washing restores its brightness. The chemical reaction which takes place on this occasion appears peculiar to gangrene. The contact of the air is not sufficient to impress upon the pus such modifications as will enable it to blacken silver. Aside from the gangrenous con- dition, the canula is never altered even when it is worn for several months. The disengagement of sulphurated hydrogen by organic bodies is one of the phenomena of their putrefac- tion, and in the case of gangrene it bears witness to the inten- sity of the infection, and of the disturbance which it brings about in the vitality of the tissues. From the time when the SEQUELS OF TRACHEOTOMY. 585 slightest mortified point is found upon the walls of the wound, a black stain is produced upon the corresponding portion of the canula. This extends with the gangrene, and its daily variations indicate the progress of the disorganization. At the beginning, if the gangrene is at first limited, a small, dark stain is formed on the portion of the cylinder which lies near the flange. This stain is slight, iridescent rather than black, and the silver still preserves its brightness. In proportion as gangrene progresses, the stain extends, becoming of a deep black and altering the polish of the metal. It may thus spread over the upper half or two thirds of the canula. It rarely passes this limit, and the lower half remains unchanged, at least unless an ulceration of the trachea supervenes, caused by the friction of the lower end of the canula, in which case that extremity becomes blackened in its turn. It is very rare, however, to see the canula entirely black, for there always re- mains an unchanged zone between those which are altered. Deep and generalized gangrene forms an exception to this rule. Thus the site and extent of the eschar will be revealed with precision by the alteration of the metal of the canula. When the canula has been found to be blackened, the wound should be carefully examined, after first washing it by passing a bit of charpie or moistened wadding over its walls. When the surfaces have been thoroughly cleansed, one or more patches of variable extent are perceived. Sometimes they are only the size of millet seeds, slightly salient and of a gray or yellowish color. They are also met with either upon the edges of the wound or upon its angles, but they choose as their place of election the angles, and especially the inferior angle ; at a distance they show a very great resemblance to false membranes. Sometimes the tract is carpeted with a pulpy, grayish and adherent coating. Fragments of these patches, torn off with a pair of forceps and placed under the microscope reveal their origin by their structure which includes elements of striated and muscular tissue. Superficial gangrene does not extend far. The canula re- mains slightly blackened. The exudation which arises from 586 DIPHTHERIA, CROUP AND TRACHEOTOMY. the surface of the wound is sero-purulent or serous, and of a yellowish gray color. The odor is often faint, but sometimes really gangrenous. The period of elimination comes on promptly, the eschars become detached, the track of the wound resumes the appearance of a simple wound, and as the loss of substance has been slight, the configuration of the parts is but little modified unless the edges were themselves affected, in which case the orifice becomes irregular. Deep Gangrene. — But often the gangrene extends and the wound becomes covered little by little with a uniform, thick, adherent layer of a yellowish brown color, which reaches be- yond its circumference at one or more points. At the same time the walls are bloody and a grayish or reddish, fetid, san- ious pus oozes out. The edges become indurated and irregu- lar. The surrounding, tissues are swollen and hard, the skin is no longer movable upon the connective tissue. It assumes a livid tint and sometimes the epidermis is lifted up by phlyctenules filled with a reddish serous fluid. When these phlyctenules break they reveal the derma already disorganized in part and taking on the aspect of a brown eschar. Little by little the lesion extends and may attain a distance of several centimeters from the wound in one direction or in another or in all directions at once. It penetrates into the trachea and attacks the mucous membrane and the cartilages ; sometimes it even invades the mucous membrane and the cartilages of the larynx. In very rare cases it extends as far as the parenchyma of the lungs. The patient's breath exhales an odor peculiar to gangrene. The canula becomes blackened over its whole surface. Such extensive disorganization is not common, either be- cause it limits itself or because the patient dies before, as unfor- tunately, frequently is the case, whenever lesions attain a cer- tain depth. The period of elimination is marked by losses of substance which are often considerable. The wound is filled with frag- ments of eschars, with shreds of mortified cellular or muscular tissue, and sometimes with cartilaginous debris coming from SEQUELAE OF TRACHEOTOMY. 587 the rings of the trachea, all bathed in a brown and fetid serous ichor. There has even been observed a very extensive des truction of the thyroid and cricoid cartilages as well as a com- plete elimination of several rings of the trachea. If the patient resists, this stage follows its habitual course : the eschars are thrown off, suppuration becomes normal again, and we find ourselves in the presence of a simple wound. It is evident that the opening is enlarged in consequence of the destruction of a portion of its walls, and what remains of them is irregular, and anfractuous. The edges have become sinuous and are re- moved from their primitive situation. The denuded surfaces become again covered with a layer of granulations secreting a healthy pus. Cicatrization is in its turn resumed and follows its regular course, unless other obstacles arise to prevent it. It is marked by contraction followed by vicious cicatrices which are the more marked in proportion as the loss of substance has been more considerable. Strictures of the trachea and of the larynx are the consequences of these accidents. The general symptoms present nothing peculiar. As the gangrene is the expression of a grave general condition, its symptoms are confounded with those which correspond to that condition, viz : high fever, anorexia, agitation, etc. At the moment when the stage of elimination arrives if there be no other complication, the general condition improves. It would be nearer correct, in certain cases,to reverse the prop- osition, and to say that the gangrene is arrested when the general condition of the patient becomes more favorable. The prognosis always presents a certain gravity from this fact alone, that the gangrene is the index of an advanced in- fection. The absence of gangrene is a very favorable sign. The gravity varies with the extent of the lesions. Partial, superficial gangrenes are the least severe for they show a low degree of blood poisoning. Those which are extensive and deep are, on the contrary, very formidable, while the deformi- ties of the cicatrix, and especially the laryngeal and tracheal strictures which follow them, add still further to the dangers 5^8 DIPHTHERIA, CROUP AND TRACHEOTOMY. of this accident by causing grave inconvenience to patients who have survived the acute stage. Diagnosis. — Ulceration and diphtheria of the wound may be confounded with gangrene. When the wound is inflamed and becomes converted into an irregular ulceration, limited to the track or not, when its sur- face becomes grayish and secretes a serous pus, it assumes an aspect which is not unlike that of gangrene, especially in the deeper parts. But the difficulty disappears if care be taken to wash the wound thoroughly with a moistened hair-pencil, for the absence of any eschar is then recognized. The canula is unaltered in the majority of cases. But it is not so easy to distinguish gangrene from diphtheria. When the false membrane is situated externally, around the edges, and in the neighborhood of the wound, the diagnosis is more easy, for the well-known differential features of gangrene and of cutaneous diphtheria are amply sufficient. But the difficulty becomes real in cases where the lesion appears upon the walls of the wound at a certain depth. Under these cir- cumstances the false membrane and the eschar present some resemblance which renders the inquiry very delicate and has, many a time, led uninformed observers into error. Thence comes the exaggerated predominance for a long time assigned to diphtheria of the wound. Nevertheless, a diagnosis may be arrived at by means of the following features : In gangrene the swelling of the tissues is more intense than in diphtheria. They are also of firmer consistence, and the skin is no longer movable upon the sub-cutaneous tissues. However small in extent the gangrene may be, the character- istic fetid odor of the wound is striking. A gray or brown sero-purulent discharge oozes out or is brought out by the hair pencil. In diphtheria the odor is entirely different. The false membrane is smooth, thin around its edges, adherent, ir- regular and usually white, though its transparency sometimes makes it appear slightly brown when it rests on the sanguin- eous base. Fragments can, moreover, be torn off with forceps, which present very clearly all the features of diphtheritic false SEQUELS OF TRACHEOTOMY. 589 membrane. The eschar is rugose, unpolished, more salient than the false membrane, and with ragged edges ; while its color which at first is yellow verging toward brown, afterwards assumes a dark brown tint. It can also be torn off in frag- ments by means of a pair of forceps ; but it brings with it pieces of mortified connective tissue. The canula which in gangrene is profoundly blackened re- mains intact when diphtheria exists alone. In cases where the eschars are small and deep down, or the peculiar odor and color of the discharge are lacking, the black tint of the canula is often sufficient to diagnosticate gangrene, for if not path- ognomonic it at least belongs almost exclusively to that le- sion. In doubtful cases the microscope gives the final de- cision. The course and duration may also furnish elements in the diagnosis, for, if diphtheria and gangrene appear at the same time, the duration of the former is less than that of the latter; on the other hand gangrene does not reappear when it has once disappeared, while diphtheria, on the contrary, may give rise to several attacks, and it is not, like gangrene, confined to the beginning. So then, when one of these comphcations appears at an advanced stage of the disease, whether the wound have been healthy up to that time, or whether it have been diseased, all the probabiHties are in favor of diphtheria. In those quite frequent cases where gangrene is associated with diphtheria, the diagnosis becomes more difficult, and often, when the le- sions are situated in the deeper portions of the wound it is not easy to determine the part which is referable to each. The indisputable presence of false membranes upon the edges, or upon the circumference of the wound, is at once a strong pre- sumption in favor of diphtheria, and in cases of doubt the mi- croscope will decide. Treatment. — The surfaces in the neighborhood of the eschars should be cauterized with nitrate of silver for the purpose of modifying them and opposing the extension of the disease. Washing with disinfectants should be frequently practiced by means of a hair-pencil dipped in a i % solution of carbolic or salicylic acid. 590 DIPHTHERIA, CROUP AND TRACHEOTOMY. The patient should be left as long as possible without the canula. Gangrene of the edges and of the neighborhood of the wound demands the same attention. If, though such cases are very rare, the lesions extend beyond the surface of the shield of court plaster, this can be enlarged ; or it is well to place over the diseased parts leaves of blotting paper covered with cerate or cold cream to diminish the friction from the tapes. When the eschars have been detached, the wound is found in ordinary conditions; and there remains nothing more than to direct the cicatrization according to the principles which I shall indicate hereafter. In the midst of the attentions which the local condition demands, those must not be forgotten which are demanded by the general condition. Alimentation, quinine and generous wines form an indispensable supplement to the treatment. Diphtheria of the Wound. We know the tendency which diphtheria has to every point of the cutaneous surface, which is deprived of epidermis, and with what facility the false membranes extend over blistered surfaces and over ulcerations of every kind. Diphtheritic com- plication of the wound, therefore, appears to be the fatal con- sequence of these two causes united, viz., diphtheria and tra- cheotomy. But it is not so, for diphtheria of the wound is not as common as we would be tempted to believe. The false membrane appears more readily upon a cutaneous surface which is ulcerated, or only deprived of its epithelium, than upon a wound involving the deep parts. From this result the infrequency of diphtheria of the wound and its tendency to settle upon the surface, on a level with its edges, where the skin is cut, rather than upon the walls themselves. The an- atomy explains this peculiarity, for the histological elements which furnish the pseudo-membranous exudate are the epi- thelial cells and those of the rete mucosum of Malpighi. These do not exist in the depths of the wound, hence the rar- SEQUELAE OF TRACHEOTOMY. 59 1 ity of the false membrane in those regions. In a case where it should really form 'rt would be at the expense of the cells of the connective tissue which, moreover, is rare in the deep por- tions. If it has appeared common to many authors it is be- cause they have often confounded it with gangrene. Diphtheria of the wound begins from the second to the fourth day after the operation. The wound swells, its walls become indurated and the opening enlarges. The aspect of the lesion varies according to its site. Upon the walls of the wound it appears under the form of white patches, sometimes slightly yellow, adherent and thin about the edges. The su- perior and inferior angles, and particularly the superior angle, are its habitual site. We remark that the points where diph- theria is encountered are those where the compression of the canula is the least felt, and of all these points the superior angle is certainly the one which is the least compressed. After that comes the inferior angle, and finally, the walls. Would compression be an obstacle to the development of diphtheria? If it fixes upon the edges, it disposes itself about the wound under the form of a narrow border, which is oftenest encoun- tered at the level of the angles, and especially that of the su- perior angle, from whence it descends along the edges, form- ing a sort of crescent. Diphtheria of the wound has little tendency to spread and in this respect it differs from diphtheria of the mucous mem- brane. The marginal false membranes are perhaps those which have the greatest tendency to gain ground. They be- come, moreover, cutaneous diphtheria. But this accretion is not very great and, besides, we should not allow ourselves to be deceived by the ulcerative inflammation which often devel- ops about the false membrane; for the pus which the ulcer se- cretes, and its slightly grayish floor, by being confounded with the tint of the false membrane, seem to augment the territory of the latter. A careful examination made after washing the surfaces allows the situation of the respective changes to be exactly recognized. When diphtheria alone is present in the wound, the canula 592 DIPHTHERIA, CROUP AND TRACHEOTOMY. remains bright, but since it is very rare that a slight amount of gangrene is not associated with it, the black discoloration of the metal is quite often observed. The general condition pre- sents nothing special to be noted. Prognosis. — Diphtheria of the wound, is not, of itself, an in- dication of great gravity, for of all the complications which affect this region, it is, to a certain extent, the most natural one, since it is only a slightly important localization of the dis- ease, and has not, therefore, in many cases other than a local importance which is proportional to the extent of the surfaces invaded. Nevertheless when it persists for a long time, and when it assumes a tendency to propagate or reproduce itself, the prognosis becomes more serious, for it is, in fact, a proof of the intensity and tenacity of the general affection. It has, moreover, the inconvenience of becoming often complicated with gangrene. Diagnosis. — Diphtheria of the wound can only be con- founded with gray ulceration and with gangrene. The dis- tinctive signs of these three morbid conditions have been given in the article gangrene. Treatment. — What I have previously said of the local treat- ment of false membranes is applicable here. Caustics should be ruled out as in every other case. Recourse should prefera- bly be had to astringents, e. g., alum, tannin, or better still, to solvents of the false membrane, such as lemon-juice, lactic acid, and lime-water. A hair-pencil lightly dipped in one of these liquids should frequently be passed over the walls of the wound. If there be gangrene at the same time, recourse should be had to the appropriate treatment. When the false membrane has extended to the surrounding skin, a coating of glycerate of tannin should be spread over the diseased parts, or, indeed, they may be powdered with a mixture of equal parts of starch powder and tannin. They may also be cov- ered with a pledget of charpie dipped in a solvent liquid. The dressing should be renewed two or three times a day. When the canula is to be put in place the surfaces should be pro- tected by sliding pieces of the dressing underneath the tapes. sequels of tracheotomy. 593 Irregularities of Cicatrization. We have seen how the cicatrization of the wound behaves when recovery is obtained without comphcations. I have in- timated that numerous causes might influence the progress of this work, either by retarding it or by preventing its progres- sion in accordance with the permeabihty of the air-passages. In the natural order of the disease there is a parallehsm be- tween the cicatrization of the wound and the clearing up of the larynx, i. e., when the latter has become permeable to the air, the wound tends uninterruptedly toward cicatrization and becomes closed in a very few days after the final removal of the canula. By virtue of numerous causes, this equilibrium may be destroyed, and hence we see the wound delaying cica- trization after the respiratory passages are already free, or tending to close before the air-passages have become unob- structed. We have thus to consider a tardy cicatrization, and a rapid cicatrization. Tardy Cicatrization. — Causes of any kind may retard cica- trization. Among them, we must record in the first rank, le- sions of the wound, viz., phlegmon, erysipelas, gangrene and diphtheria. Cicatrization retarded by a cause of this class usually re- sumes its regular course when the cause has disappeared. In other cases, on the contrary, in spite of the cessation of the in- itial influence, the wound remains at the point where the com- plication left it, and shows no tendency at all toward recovery. Often, moreover, there has been no lesion at all of the wound, the respiratory passages are free, the canula has been removed, but the wound remains the same as on the first day. It is pale, soft, without granulations, and does not make a single effort toward cicatrization. With other patients, finally, the work of reparation after having begun, and given hope of an early recovery, is suddenly arrested. These difficulties of cicatri- zation are never manifested without grave cause, and the patient under the influence of a complication, either apparent or hid- den. By complication I mean not the lesions of the wound 594 DIPHTHERIA, CROUP AND TRACHEOTOMY. which habitually present themselves shortly after the opera- tion, but affections which are more general and of a very dif- ferent kind, such as inflammations of the respiratory apparatus, eruptive fevers, diphtheritic paralysis, diphtheritic cachexia, alterations of the digestive functions, etc. When a cure is about to be obtained, cicatrization resumes its course, and the wound promptly closes. But there are cases where this work is never completely revived and the patient remains with a tracheal fistula. These instances are happily extremely rare. Treatment. — Since the delay in cicatrization is the expres- sion of a more or less extensive general trouble, the cause, when sought for and discovered, should be the object of ap- propriate attention. The local treatment consists in stimulating applications. The wound should be touched several times a day with a pencil dipped in a I % solution of carbolic acid. This means has fre- quently given me excellent results. If it be not sufficient re- course should be had to superficial cauterizations with nitrate of silver. Premature Cicatrization. There are cases where the wound tends to close before the respiratory passages are free. This want of equilibrium, while indeed it becomes a true complication by reason of the troubles, often grave, which it causes, is in reality only the normal course of cicatrization. If, in the greater number of cases, cicatrization follows the recovery of the larynx, this occurs only by virtue of the morbid condition which involves the whole economy. In a subject who undergoes tracheotomy for a lesion foreign to any general affection, in cases of foreign bodies in the air-passages, for example, cicatrization is pro- duced with very great rapidity and it is the same in other in- juries of the larynx. Just as slowness of cicatrization indicates a profound im- pregnation of the economy, so rapidity of cicatrization corres- SEQUELS OF TRACHEOTOMY, 59$ ponds with an intoxication which is feeble or already neutral- ized. A favorable prognosis can be given in such a case. The local condition often remains, it is true, difficult to manage, and requires minute attention ; but we should deem ourselves happy when diphtheria loses its infectious character to be- come, after a sort, transformed into a local lesion, accessible to treatment. In some cases, very rare ones, however, cicatriza- tion may, by reason of the slight importance of the intoxica- tion, and by reason of the vigor of the subject, precede the clearing up of the larynx, even when the lesions of this organ show neither exceptional intensity nor persistence. With other patients priority of cicatrizaticjn reveals itself later, after having been retarded either by the low general condition or by local complications, e. g., diphtheria, gangrene, etc. In other cases, finally, while cicatrization follows a regular course, the larynx is slow in becoming permeable again. Whatever be the cause, the symptoms and the treatment are the same. Whether the wound be still recent and healthy, or of long standing and has remained healthy, or has become clean, it granulates actively and rapidly closes. Every time the canula is withdrawn, the skin contracts little by little and narrows the lumen of the wound, so much so that often in a very short time the air can no longer pass through this opening without diffi- culty. Respiration becomes embarrassed, the face blue and anx- ious, retraction is produced, and an actual attack of suffocation comes on, so intense at times that if it be not relieved, the child succumbs without delay. Sometimes this occurs with such rapidity that if, unfortunately, the patient be alone or those about him be unable to replace the canula (an opera- tion which in such circumstances may become difficult) as- phyxia comes on and destroys a child who was already nearly well. If the canula have remained a short time out of the wound and the latter have undergone but a moderate con- traction, a certain resistance is experienced on reintroducing it which is quite easily overcome, but if the contraction has been pushed further, the obstacle becomes more serious ; for the opening, reduced to a very narrow passage, refuses to distend 50 DIPHTHERIA, CROUP AND TRACHEOTOMY. and admit a canula of the same calibre. We will oftenest suc- ceed, however, after several unsuccessful attempts, by pressing the end of the canula against the wound and especially by giving the instrument a double rotary movement, as in the management of an awl. It will then be noted that the resis- tance is superficial, and that when once the cutaneous ring is passed, the canula glides easily along the rest of its course. This, is at least, what I have observed in every patient, and the elasticity of the skin, much more energetic than that of the sub- jacent tissues, explains this peculiarity. In one case I met with a second obstacle a little distance from the sk^n, which, perhaps, was due to fibrinous bands in front of the trachea. It is not unusual that, in spite of repeated trials, the canula which the patient has habitually worn cannot be made to re-enter, and we are compelled to take a smaller size ; but in some cases the resistance is so great as to necessitate its removal by incision. This situation persists up to the time when the larynx has returned to its normal condition, provided always, that the general condition of the child remains satisfactory ; if not, the wound relaxes and cicatrization is arrested until the new mor- bid element has disappeared when it resumes its course with the same tenacity. I have published the history of a child in whom the wound had an extreme tendency to become obliter- ated, measles intervened, the wound at once reopened, became soft and allowed the canula to enter easily ; and when the ex- anthema disappeared the wound began to recontract. From the time when the state of the larynx at last permits the final removal of the canula the wound closes as if by en- chantment. In a day or two it becomes covered with a scab, beneath which cicatrization is perfected. Granulations may, by their volume and mobility, precipitate the occlusion of a wound which is already cicatrizing too rapidly. In the little patient of whom I have just spoken, the superior angle of the wound gave rise to a large mass of fungous granulations which being free below, was a fair representation of the form of the uvula, and possessed a like mobility. As soon as the child SEQUELS OF TRACHEOTOMY. 597 was without the canula, the air passing through the wound drew the mass toward the trachea, making a stopper of it, which checked the respiration. Treatment. — The causes which retard the permeabihty of the larynx should be the object of the first attention. See, laryn- geal complications. We should watch carefully to see that the child does not re- main without the canula long enough for the contraction to be- come insurmountable; but with a little experience the mo- ment will be recognized when the wound, although contracted will yet admit the canula without great difficulty. But there are wounds which do not allow even this latitude ; for scarcely is the canula removed before the skin contracts and the orifice closes. It is then necessary to cleanse the wound speedily, to take a canula and replace it ; for all delay will be the cause of new obstacles. If the constriction of the wound is energetic enough for asphyxia to become imminent, a dilator should be rapidly introduced into the wound ; the separation which is obtained, is enough to allow the respiration to be established, but is too little to permit the passage of the canula. The di- lator should then be kept in the wound for some moments to allow the patient to become tranquillized, and the occasion should be improved by opening several times forcibly the jaws of the instrument, in such a way as to overcome the resistance of the tissues. The trachea is then seized between the thumb and middle finger of the left hand and slightly lifted up, then the canula is applied with the right hand and entered without violence, and always with a rotary movement. Inconsequence of these maneuvers, the skin gradually relaxes, and when it finally yields, a sensation of resistance overcome, is felt. The dilator which is of great service in the matter of partly open- ing the wound, and even of dilating it, becomes useless and in- convenient in the introduction of the canula. It should be laid aside. We are no longer, in fact, in the situation of tracheotomy,when the freshly cut tissues are supple and easily yield to pressure ; the borders of the wound have lost their flexibility and offer resistence to dilatation. The result is that 59^ DIPHTHERIA, CROUP AND TRACHEOTOMY. the forceps not only separates them but little, but its blades occupy a space which still further diminishes the room left for the canula ; so, instead of aiding, it hinders. By this procedure we often succeed in replacing a canula of the same size. There are circumstances where all efforts re- main ineffectual; and then it is that the valvular canula ot' Bourdillat has been of great service to me. This instrument is introduced like the bivalve speculum of Ricord, to which it has a great analogy ; while its almost linear extremity often per- mits it to overcome the stricture. When once the external canula is put in place the internal canula, which is cylindrical and rigid, is introduced and it neer's only to be pushed forcibly into the external canula whose valves it separates. When it is introduced completely the valves are separated and the track from the skin to the trachea is reestablished. To give more power to it, I have had made, by Collin, an obturator with wooden handle large enough to be grasped by the whole hand, like that of a trocar for paracentesis of the abdomen. The in- strument thus modified affords a firm hold which permits it to pass strictures before which it formerly recoiled. When the passage has been forced, this canula can be with- drawn and replaced b>' an ordinary canula, which maneuvre is accomplished without difficulty. But dilatation may remain insufficient, the necessary instruments may be wanting und we have as a last resort the division of the stricture in the wound. To perform this operation the patient is placed in the proper position and secured as for tracheotomy, but left upon his bed. If the wound will admit the dilator it is well to introduce that instrument. Its jaws are slightly separated and then, with a probe pointed bistoury which is passed between them, the stricture is cut, care being taken to include in the incision the whole thickness of the tissues, from the skin to the trachea in- clusive. This precept is indispensable. If, in fact, the inci.s- ion stops in front of the trachea, risk is run of a difficult intro- duction of the canula, and of false passages in the peri-tracheal connective tissue. This accident has happened several times, and I have found it related in two observations. If the wound is too narrow to allow a dilator to enter, the SEQUELAE OF TRACHEOTOMY. 599 probe-pointed bistoury is at once introduced and pushed care- fully from before backward until it encounters a resistence. When it is quite certain that this resistance is due to the pos- terior wall of the trachea, the cut should be made. If there be doubts as to the depth of the incision the dilator should be in- troduced and the wound inspected, and if the trachea has not been included in the incision it is easy to complete it by re- peating the former procedure. In what direction should the incision be made? That is almost a matter of indifference and depends on circumstances. Whatever be the direction of the cut, it should be made in the median line in order to avoid ir- regular wounds of the trachea out of line with that of the soft parts. The extent of the cut in the greater number of cases, should not exceed half a centimeter. The introduction of the canula is usually very easy and it enters without the aid of a dilator. This instrument would be, moreover, of more harm than use for the reason previously indicated. Bourdillat's canula would be very useful in case of difficulty. When the respiration is obstructed by large, moveable masses of granulations, they should be thoroughly cauterized every day. This means is often insufficient, especially when the granulations are deep in. In such a case they should be torn off by means of forceps introduced into the wound at the instant when expiration forces the tumor outward. After be- ing torn off, the stump should be cauterized. Accidents Subsequent to Cicatrization. All has not yet been said with regard to the wound in the integument when it has cicatrized. Contractions and deformi- ties result from considerable losses of substance occasioned by gangrene. Moreover, the newly formed tissue is exposed to ulceration and even to destruction. It has been seen that cer- tain morbid general conditions retard or interrupt the work of reparation. Their influence may be felt, even after cicatriza- tion is complete. Eruptive fevers, or pulmonary inflammations which arise shortly after this stage, often ulcerate the cicatrix 6oo DIPHTHERIA, CROUP A\U TRACH KOTOMY. and even reopen it completely so far as to include the trachea. With one child, the wound which had been cicatrized for sev- enteen days, reopened under the influence of a pleurisy and laid bare the trachea. The same accident occurred in another, two months after cicatrization, and was occasioned by pneu- monia. A third, who had gone out of the hospital sev^eral months before, returned with an abscess developed without apparent cause at the level of the cicatrix. The abscess dis- charged itself, but ulcerated the cicatrix. The ulcerative process gained in breadth and depth till it reached the treachea, which in its turn reopened. After some days cicatrization resumed its work ; and the wound finally closed in fifteen days. Of these three patients, only one succumbed to the inter- current disease, and that was the one who was attacked with pneumonia. The other two recovered rapidly and completely as soon as the influence which compromised the nutrition of the tissues disappeared. CHAPTER II. ACCIDENTS WHICH DEPEND UPON THE TRACH- EAL WOUND. Ulcerations of the trachea,tracheo-laryngeal strictures,polypi of the trachea, and fistulae, ULCERATIONS OF THE TRACHEA. The anatomico-pathological division of this question has been treated at the beginning of this work. The symptoms, the diagnosis, the etiology,the prognosis and the treatment,re- main to be pointed out. SYMPTOMS AND DIAGNOSIS. Since ulcerations of the trachea are inaccessible to sight, tney are perceptible only by means of rational symptoms. As they are most commonly produced in consequence of trache- otomy, the sii n ; by which they are recognized are inferred from the condit on of the canula, and from the quality of the expectoration. These are: ist. TJie black discoloration of the beak of the canula. — The tracheal ulceration being of a gan- grenous nature, it blackens the lower end of the canula just as gangrene of the wound blackens the upper portions. This is a sign which is never wanting ; and on the other hand, the end of the canula does not change when the tracheal wall is not ul- cerated. When gangrene attacks the wound and the trachea at the same time, it is not rare to see the two extremities of the tube blackened and separated by an intact zone. This is the best sign of tracheal ulceration. The canula is the reagent which discloses the lesion. 2d. The expectoration of sanginneous mucous sputa thrown ofp (6oi) 602 DIPHTHERIA, CROUP AND TRACHEOTOMY. sevetal days after traclicotoniy. — These should be distinguished from the sputa mixed with blood which follow tracheotomy during the first few days. The latter are, in fact, the conse- quence of an oozing of blood, which persists at the level of the wound, or of an effusion of blood into the trachea at the time of operation. Those which come from an ulceration only ap- pear several days after the expectoration has become free from blood. 3d. A fetid, gang7'e7io2is odor exhaled by the 100201 d, may be a good sign of ulceration, but it is very often liable to lead into error. If the wound be gangrenous it may produce this odor. It has no value respecting the existence of an ulceration unless it is perceived when the wound is healthy. In this case it can be perfectly ascertained every time the canula is introduced ; for after the wound is well washed, and free from odor, at that moment a puff of fetid air is perceived to pass through it. 4th. Paiji in the anterior cervical region notedhy Toulmonche. The child frequently carries its hand toward the neck with a very evident expression of suffering. This sign may be valid, as I myself have verified. But it has no value unless the ex- ternal wound is healthy, and when there is neither inflamma- tion nor erysipelas in its neighborhood. The bad condition of the wound, and of the soft parts of the neck, their tumefaction, and their gangrenous or ulcerated condition indicated by Roger as one of the signs of tracheal ulceration, may coexist with this ulceration, but it appears in too many cases where the ulceration does not exist, to give it the claim to be regarded as of importance. The same is true with regard to dysphagia. Etiology. General and local causes influence the formation of these ul- cerations. Locally, the pressure of the canula is the usual agent. As the surface of the tube produces necrosis of the walls of the wound by the pressure which it exercises upon them, so also the beak of the instrument causes that portion SEQUELAE OF TRACHEOTOMY. 603 of the tracheal wall in contact with it, to mortify. In fact, the ulcerations almost always occupy this situation, and when they extend around the whole circumference of the trachea, their maximum depth is found upon the anterior portion. Formerly the ulcers were more frequent at the back part, on account of the construction of the canulas. The curve of the metallic tube being copied after the quadrant ot a circle, presented posteri- orly a quite salient convexity which, bearing against the pos- terior wall of the trachea, pressed upon it, and of necessity ul- cerated it. The immobility of the two pieces of the canulaone upon the other, /. c. the soldering of the tube to the flange, favored ulceration by exposing the trachea to friction against the canula during the movements of ascent and descent which result from respiration, cough and deglutition. The exterior flange being held immovable by the tapes, the vertical portion, in place of following the trachea, resisted and rubbed against it. Large sized canulas, too large for the calibre of the trachea, have a similar action. As they are in more complete contact with the mucous membrane, they exercise a more continuous pressure and may ulcerate the trachea over a large surface and in every direction. The inferior orifice of the canula, when it is circular and perpendicular to the axis of the tube, forms in front, an almost cutting edge which rapidly abrades and per- forates the anterior wall of the trachea. The effect of the local cause is still further shown by an instance cited by Hayem. Tracheal ulcerations were found in a man who was operated upon for compression of the trachea due to a glandular tumor. In this case the influence of the general condition could not be assigned. But if mechanical action is evident in the pro- duction of tracheal ulceration, that of the general condition is none the less so, and may even be sufficient to account for it. In fact, ulcerations do not always form in proximity to the canula, and there are those which appear beyond the reach of the instrument, ulcerations of the larynx, for example, which could not be attributed to compression, are found at the same time. Moreover, a goodly number of tracheal ulcerations co- incide with gangrene of the wound of which they are some- 604 DIPHTHERIA, CROUP AND TRACHEOTOMY. times the evident extension. If pressure of the canula were the sole cause of the ulceration, no one who is operated upon could avoid this lesion. Yet, it is very rare in the absence of diphtheria. Patients tracheotomized for oedema of the glottis, syphilitic lesions or polypi of the larynx wear their canula for months or years without the trachea becoming necrosed. Finally, among the ulcerations which are verified post mottem, the deepest are not always those which coincide with the longest retention of the canula. Thus Roger cites two perforations, the one accomplished in five days and the other in thirty-six hours. On the other hand, in a patient who died at the end of twenty-seven days, there was found only a very slight erosion. There are then two influences, one local and efficient, the other general or predisposing, which unite in engendering ul- ceration. The most powerful one is certainly the second, as the long sojourn of the canula without accident in non-infec- tious cases, and on the other hand, the lesions which super- vene after a very short sbjourn in cases of profound blood poisoning, fully prove. The predisposing causes are : diphtheria in its infectious or malignant forms, gangrene of the wound, diseases of the res- piratory passages which predispose the mucous membrane by inflaming it and altering its nutrition ; and tender years — ul ceration is especially encountered among patients aged about 2 years. The type of the prevailing disease (epidemic or meteorological influences) is also of great importance, for in certain epidemics tracheal ulceration is rare, while in others it is frequent. Frequency. Ulceration of the trachea often passes unnoticed during life, the autopsy alone disclosing it. The conclusion must not be drawn from this that the lesion is extremely rare. It must often escape notice among patients who recover, in view of the SEQUELiE OF TRACHEOTOMY. 605 insufficiency of the means of diagnosis. Everything leads to the belief that it is more frequent than the cases collected at the autopsy would seem to indicate. Prognosis. Tracheal ulceration is curable, and the gravity of the cases in which it is encountered, depends not on the ulceration, but upon the intensity of the diphtheritic poisoning. It is no lon- ger so when the cartilaginous rings are eroded, and when the c inula bears against a membrane which has grown very thin for perforation is imminent and is effected, unless another and graver complication precedes it. The perforations which I have observed did not appear to have of themselves fatal con- sequences, and death did not seem to be properly attributable to them. Yet, one of them coincided, as in a patient of Roger's, with a pretracheal abscess. In four of my cases, the ulceration showed a curious relation ; it corresponded with the innominate trunk, from which the canula was separated by only a very thin membrane. In one case the lower end of the instrument was in direct relation with this vessel. It is proba- ble that if the disease had lasted longer, the ulceration would have extended to the vascular walls and perforated them, giving rise to a frightful haemorrhage. There have been cited several cases of haemorrhage of this kind, supervening in adults who had worn a canula for several months after tracheotomy performed for organic lesions of the larynx. Roger cites two remarkable examples of this kind. This termination is extremely rare in children, and the only two cases I know of were quite recently reported by Howse ; haemorrhage came on suddenly and was fatal. Can the inflammation developed in the mucous membrane serve as the point of origin of a bronchitis ? I reported a case in which, from the ulceration, this membrane was inflamed as far as the minute bronchi, while the portion situated above the ulceration remained healthy. It may be asked whether the irritation provoked by the canula upon a predisposed mucous membrane was not the determining cause of the inflam.matory process. 6o6 DIPHTHERIA, CROUP AND TRACHEOTOMY. When recovery is reached in spite of a somewhat extensive ulceration, the cicatricial contraction gives rise to strictures of the trachea which are encountered in certain autopsies made a long time after tracheotomy. They are often slightly marked and do not produce any functional trouble whatever ; others, on the contrary, are more decided and become the cause of accidents. Treatment. The really important part of treatment is prophylaxis. When the lesion is once produced, curative treatment is very limited in default of feasible topical medication. General and local measures concur in preventing it. General medication is necessary to meet the general predis- posing influence. Alimentation and tonic and ferruginous preparations hold the foremost place. The few local measures which are at our disposal are likewise valuable. The canula, the immediate cause of the ulceration, should befixed in such a way as to diminish, as far as possible, its friction against the mucous membrane. Since the principal causes which make this instrument the offending agent are, the immobility of the collar upon the tube, the curve of the latter in the quadrant of a circle and the salient edge of its lower border, modifications have been made in its construction. Luer has disposed of the first by making canulae, the two pieces of which are moveable. The vertical portion is easily carried along by the trachea in the ascending movement and falls back by its own weight in the descending movement; but sometimes when the canula is too large and too long, the room given to the vertical portion is not enough and the canula continues to wound the trachea. The same maker has remedied the second cause by enlarg- ing the curve; the lower end being carried further back is in less close contact with the anterior wall. Barthez provided for the third inconvenience. (See p. 511 and 552). The custom of removing the canula as soon as possible is SEQUELS OF TRACHEOTOMY. GO/ an excellent prophylactic measure. When ulceration has been produced and diagnosticated, what should be done ? All local treatment, such as cauterization of the trachea, should be avoided. This expedient, already dangerous of itself, cannot be applied except haphazard in view of the ab- sence of precise notions as to the site, the extent and the depth of the ulceration. The only rational treatment consists in removing the canula every day as long as the patient can permit it, and in taking it out altogether as soon as practicable. Tracheo-Laryngeal Strictures. These are caused by losses of substance produced by ulcer- ations of the trachea, or by certain errors in operation. Tra- cheal ulcerations are sometimes accompanied by considerable destruction of tissue, the most dangerous being those which occupy the edges of the incision, for they enlarge it by exca- vating in its lips notches of more or less depth. Cauterization of the larynx produces the same results. In a case cited by Bouchut, a child attacked with membranous pharyngitis was subjected to cauterization of the tonsils with a pencil saturated with hydrochloric acid. A drop fell into the larynx and pro- duced such suffocation that it became necessary to perform tracheotomy. The patient was obliged to retain his canula because of the stricture which was produced in consequence of this burning of the larynx. The errors in operation consist in multiple incisions of the trachea made during difficult operations. If they are deep enough they result in detaching more or less extensive frag- ments from the cartilaginous rings. In either case there is a loss of substance in the circumference of the conduit, whence there often results cicatricial contraction followed by stricture. The corresponding symptoms vary with the tightness of the constriction. When this is very close, dyspncea is intense, and respiration cannot be carried on without a canula without dan- ger of suffocation. When more moderate it allows the child to breathe without aid, but inspiration is accompanied by a 6o8 DIPHTHIERIA, CROUP AND TRACHEOTOMY. wheezing which lasts a great while and which augments under the influence of the least congestion of the mucous membrane. The same cause brings on attacks of suffocation. When the lesion affects the larynx the wheezing is accompanied by hoarseness of the voice. Three patients suffering from these sequelae of croup have passed under my observation. The first, a girl of 2^2 years old, operated upon two months and a half before, presented retractio 1 accompanied by a quite intense laryngo-tracheal wheezing. The second, a girl of the same age, could not contract a cold, a year even, after tracheotomy, without bting exposed to attacks of sufiocation. The third, a girl 6 years old, was subject, for two years following the croup, to at- tacks of suffocation which returned each winter. In the intervals her voice was clear. It seemed that the trachea was contracted and the slightest tumefaction of the mucous membrane sufficed to render its ca.ibre too narrow. Tracheal strictures always possess a certain gravity. When tight enough they force the patient to retain the canula, and when less marked they expose him to attacks of suffocation and to other troubles in breathing and phonation. Sometimes, even, a simple cold and a little excitement, suffice to deter- mine an attack of suffocation which has, in several cases, been followed by death. A child whose history Blachez relates, had, for six weeks following the operation, resisted every at- tempt to remove the canula. At the beginning of the seventh week Blachez removed the canula from the larynx, but left it in the wound for the purpose of deceiving the patient. Half an hour afterwards, while at play, he pinched his finger in a door, when the anger and excitement brought on an attack of suffocation to which he succumbed in a few minutes. The au- topsy revealed a slight stricture with induration of the vocal cords. The anatomical lesion which was already troublesome to his breathing, had been suddenly complicated by a spasm which rendered it fatal. Polypi of the Trachea. Gigon, of Angouleme, reported the history of a child from SEQUELS OF TRACHEOTOMY. 609 whom the canula could be removed at the end of fifteen days, but whose breathing was incompletely reestablished. Attacks of suffocation came on and necessitated a second tracheotomy forty-five days after the first. There were then perceived at the level of the tracheal cicatrix, some rounded, reddish, mov- able bodies, the size of peas, whose mass diminished the cali- bre of the passage. They were excised. The canula could be removed the third day, and the recovery was permanent. Bergeron presented to the Societe niedicale des hbpitaux the history of a child who, after several unsuccessful attempts at removal of the canula, died of pneumonia the twenty-third day after the operation. The autopsy brought to light, on the an- terior aspect and just at the lower extremity of the larynx, at about I centimetre above the incision in the trachea, a small polypus on a pedicle. It was recognized that this polypus was the obstacle which prevented the removal of the canula and which must have been the cause of several attacks of suffoca- tion mistaken for attacks ot laryngismus stridulus, which had twice recurred several months before the invasion of croup. This eminent physician insists upon the difficulty of diag- nosis, and shows that little confidence can be placed in the use of the laryngoscope in young children. Krishaber's patient has been the subject of a thorough dis- cussion from the standpoint of diagnosis. The conclusion is that the polypus had existed before the tracheotomy, and that he had not had croup. Krishaber based this opinion upon the existence of a jerky and dry cough dating from far back, upon the absence of false membranes, and upon the very clear intermittence of the symptoms during the three months which followed tracheotomy, an intermittence which is found among patients affected with polypi of the air-passages. Of the two patients cited by Bouchut, one did not present a single symptom peculiar to polypus, and the autopsy disclosed it by chance. The other remained for six years with his canula, for at each attempted removal an attack of suffocation supervened. The canula, moreover, did not serve at all for the passage of air, for it was very small, the size of a goose quill, and it could even be stopped with a cork without causing the patient trouble in breathing or in speaking aloud clearly OlO DIPHTHERIA, CROUP AND TRACHEOTOMY. and distinctly. This instrnment had, apparently, no other use than to depress a tumor which without that compression be came elevated and took a position in the trachea which ob- structed the air-passage. Exploratory manoeuvres had to be quickly interrupted every time, because of the imminence of suffocation. Calvet, of Castres, operated in 1869 upon a child 8 years old affected with croup. False membranes were expelled after the operation. The removal of the canula took place the eighth day, and six days afterward the wound was covered with a scab. One month after complete recovery the little girl was taken, while asleep, with a snoring which increased day by day, and became so loud that persons sleeping in the adjoining rooms were discommoded by it. Little by little res- piration became difficult and wheezing during the day. One night (about 2 o'clock in the morning) the child awoke in a start, called her father while arising in her bed, in great ter- ror, and fell back dead upon her couch. Tracheotomy which was proposed when the symptoms assumed a serious character, had been refused by the parents. No autopsy could be obtained. 'm It is difficult to explain these symptoms ohterwise than by I the development of a tumor at the level of the cicatrix or in its ji vicinity. Dr. Jacobi, of New York, reports that in four cases the abla- tion of the canula was rendered impossible by polypoid ex- , crescences, sometimes numerous, the size of which varied from '^H that of the head of a pin to that of a pea and larger, implanted |lr on the border of the tracheal incision and coming, in one case, i from the inferior portion of the larynx. Numerous applica- tions of nitrate of silver and sulphate of iron brought about their destruction. Their disappearance at once removed the obstacles to the final withdrawal of the canula. j Prof. Steiner mentions voluminous vegetations arising from the edge of the tracheal wound and forming a tongue-like pro- tuberance in the air-passage. I observed in 1871 a similar case of which the following is the resume: SEQUELAE OF TRACHEOTOMY. 6ll Ren6 B , aged 3 years, entered Saint Eugenie's Hospital, ward S'. Benjamin No. 14, on account of croup in its third stage. Tiacheotomy was immediately per- formed. As the incision was too small it was enlarged with the bistoury, and there- from an abundant hemorrhage resulted. The patient, however, rallied. '1 he phy- sician who had attended the child before his entry into the hospital called to see him, and claimed to have seen upon his tonsils false membranes which he had cauterized with nitrate of si'ver. I will add, to thoroughly establish the diphtheritic character of the disease, that duiing the hrst few days after the operation fragments of false membrane were expelled through the wound and through the canula. Several pieces of cartilaginous debris belonging to the rings of the trachea and doubtless detached by the second cut of the bistoury, were also expelled with the sputa. At the expiration of a month the canul 1 could not yet be removed, for voluminous vegetations were perceived which appeared to come from the trachea, and obliterated the wound as soon as the canula was taken away. These productions had the most complete resemblance to large masses of granulations. Cauterization with nitrate of silver brought temporaiy relief; the patient could remain two or three hours without the canula before the granulations reappeared and suffocation returned. Everything tended to the belief that the laiynx was free, for the voice was clear and the ai cir- culated freely when the wound was closed with the finger, but suffocation soon re- turned. Then violent retraction [tirage) was produced, and attacks of coughing, during which the tumor was driven into the wound of the soft parts with such a force that it was ]iossible to seize it with forceps and tear it off. When the canula was in place, respiration was always easy, even when the instrument was closed with the ball of the linger. The vegetations certainly did not arise from the soft parts, for they were seen to emerge from ibe trachea, and they appeared to be planted upon its edges. It seemed that the canula when put in place, compressed them, which ex- plained why they did not appear in the first few moments following its removal and why the breathing was then easily carried on, becoming difficult and even impossible when on resuming their volume they projected into the trachea. Removal, combined with cauterization with nitrate of silver an 1 with chromic acid, was ineffectual. After each operation there was a respite of several days followed inevitably by a relapse. At the expiration of seven months the child left the hospital without being cured, or being able to go without the canula. His mother brought him to me at my office three months after his departure. His condition was the same, but the wound was considerably contracted and it had become very difficult to introduce the canula, for, during the short time it was withdrawn the orifice became unusually contracted, and it was necessary to have recourse every time to the dila- ting canula of Bourdidat. I recommenced the treatment by removal and cauterization combined. I had a pair of forceps made with spoon shaped jaws with cutting edges which easily enabled the seizure of the tumor and cutting of it off. I several times removed tumors the size of a large pea, soft, friable, red and like granulations in evety respect. Having proved that breathing was carried on easily when the canula was closed with a stopper, I had the canula closed permanently. By fullowing this course persistently, the child was able to remain some days without a canula, but it could never be jjermanently removed. I regret that I have lost sight of this interesting patient and that I have remained without information as to what became of him. 6l2 DIPHTHERIA, CROUP AND TRACHEOTOMY. There is every reason to suppose that the symptoms were due to the production of a polypus on the surface of the tra- chea about the wound. There was nothing to give rise to the supposition that the tumor had existed before the operation. This case presents a remarkable likeness to one of those which Bouchut cited, for the compres.-^ing action of the canula was exactly reproduced in it. [D. E. Beaty, Jr., aged 3 years and i month, operated for croup, March 22, 1877. The details have been published and need not be repeated here. The tube was per- manently removed after the operation on the sixth day. On the eighteenth day I find the following note : "Wound nearly closed ; air escapes through the wound only on coughing; speaks aloud with little effort; appetite good." Saw the case on May 6. Inspiration was difficult, especially so when sleeping or resting, and in the latter part of the day and at night. This condition had showed itself for some days, but when he was thoroughly awake and playing, i attracted but little attention and pro- duced but little embarrassment. On May 7 he was quite bad. Prescribed for him, but did not see him again until May 10, considerable relief having been obtained. From this time the obstruction became more marked, and inspiration more difficnlt when droiusy or 7vhen sleepini^. Remedies produced little or no effect. The ex- piration seemed to be but slightly affected ; no paroxysms occurred ; the condiiion grew slowly worse. At times the child being weary and sleepy from the long-con- tinued and laborious efforts at inspiration, there would be several fruitless attempts at inspiration, repeated until he would arouse himself and take a deep, forced in- spiration. Even this condition grew worse, and I presented the only remedy which offered any hope, viz.. tracheotomy. I regarded it, at the time, as paralysis of the muscles of the glottis, the dilators in particular, or, at least a loss of balance (syn- ergy, correlation) between the dilators and the contractors, possibly spasm of the latter, and expected immediate relief by opening the trachea; and I did not intend to let the child die without the operation, unless opposed or over-r ded. Dr. J. L. White, of Bloomington, 111., having been telej^raphed, was in consulta- tion, and fully concurred in the necessity of the operation, which, at il a. m,, I pro- ceeded to ■^e.xioxxa., Jifty-on e days after the first operation. In the latter part of May the respiration seemed to be entirely clear, with the tube in. June 20 — " Cannot sleep with the tube out it the opening in the trachea is entirely covered and closed. The same difficulty exists widi inspiration as formerly." In July I used electricity, and stimulating applications to the larynx. On November 2 I s^layed with him till midnight, leaving the tube out all night. There was no special trouble in respira- tion. The parents had not expected to leave the tube out permanently, fearing a re- turn of the former trouble, and the next day I found considerable difficulty in rein- troducing it. Some weeks later I made the trial again, remaining with the patient SEQUELS OF TRACHEOTOMY. 613 all night About midnight the difficulty of inspiration became so great as to neces- sitate the re-introduction of the tube. Respiration afterwards has been carried on with the fenestrated tube in, and about as well when it was closed as when open. The father had a shorter tube made, which the boy. now nearly 12 years ohl, has contin- ued to wear. I am now decidedly of the opinion th it the case was one of polypoid or exuberant granulations (which, late in the observation of the case I attempted to remove), and connected with that, a spasmodic condition of the parts. He became greatly attached to his tube and seemed to be afraid to be without it. He still wears the tube — now over eight years. I>r. R. W. Parker, of London, gives, in his work on tracheotomy, four illustrations of I lapillomata and polypoid granulations of the larynx and trachea, preventing the permanent removal of the tube. The following case with illustration is given in abstract by my friend Prof. Isaac N. Himes, of Cleveland, O. Eddy Biittner, aged 4 years. Diphtheria. Saw the patient in consultation in De- cember, 1883. Membrane was developed on both tonsils and on the pillars. At- tended him for five days during which time his breathing and cough were croupy. On the filth day of the consultation he began to show signs of asphyxia. During the preparation for operation asphyxia increased, producing unconsciousness. Re- traction of the chest walls was well marked. Death seemed to be imminent. The operation was performed without difficulty. The cricoid cartilage and the crico-thyroid membrane were divided making an opening of about ^/i of an inch long. No tube was used. A heavy plaited surgical silk thread was passed through the end of the cricoid cartilage on each side. This was passed well through the tissues, but not through the skin, but was allowed to ride upon it. Tapes were attached to these cords and tied behind, encircling the neck. After the operation the atomizer was used occasionally during the night with lime-water spray. Sponges wrung out of hot water were allowed to rest over the orifice, and for some days these were removed every fifteen minutes. Salt water was used as often as the trachea showed dryness, being thrown into the opening and down towards the lungs by means of a small rubber syringe. The patient was fed on beef extract and milk. In swallowing, some of the milk would appear at the opening in the trachea. Thirteen days after the operation the wound was almost healed ; he could then make a vocal sound. Pulse 105 ; respiration 25 in the minute. On the twenty-second day after the operation he was sitting up eating his dinner and he was beginning to articulate very well. Forty-one days after the operation he could talk plainly. At night, however, he seemed to be croupy and to breathe with difficulty. Nearly two months after the operation the doctor was called to see him again. " Inspiration was made with tolerable freedom, but the breath after inspi- ration seemed to be held and slowly expired with a cooing sound when listened to with the stethoscope." The breathing had been worse during the night. There was no willingness to submit to any operative treatment. About thirty-six hours late 6i4 DIPHTHERIA, CKOUP AND TRACHEOTOMY. Dr. Sykora was called to see him in the mornin , when the patient suddenly died, apparently trom spasm of riie glottis. / E^pi^lollis, /The specimen X9 v\ / ^ofn ali}ds poinl- ^\ / /^corjiu of ^ "^T Cifisoii aarlilaqe- Polypoid , or jranulalion qnWlk Polypoid ^rowvlh Wilkin ihe. larynx^afterharyn^o^aoheolomy in a alild foUT years olc',. Fig. 35. Posf mortem examination was reluctantly permitted. The cicatrix of the original incis.on was very small, scarcely noticeable, and the skin was movable over the deeper structures. " Within the lumen of the larynx and the trachea at the spot / SEQUELAE OF TRACHEOTOMY. 615 where the wound had been made, at the crico-thyroid space, there was a small polyp-like structure about the size of a soup bean, attached by a small fibrous ped- icle. This structure had developed in the process of healing of the wound. When the glottis was open in inspiration it did not present a great obstruction to the en- tering air, but in the relaxation of the glottis in expiration, when the lumen of the larynx, small and soft as this organ is at this age, was diminished, this growth, which in the expiration was moved upward towards the narrow chink of the relaxed glottis, produced greater obstruction At the time of death it is probable that this growth, acting like a foreign body, with the addition of some increased irritability, produced spasm of the glottis and the sudden fatal termination. The lungs were distended with air and filled with blood, but not dark. The right side of the heart was com- pletely relaxed and empty of blood ; the left side was in a state of firm contraction and also empty."] These instances, small in number, but significant, show that polypi of the trachea n:ay manifest themselves either before or after the removal of the canula ; [or when no canula has been used.] The former oblige the patient to continue this artificial mode of respiation. Every time the attempt is made to do without it, respiration becomes gradually or rapidly difficult, a violent cough is produced, and suffocation is imminent. When the tumor is on a pedicle and floating, the cough pro- jects it through the wound, but during inspiration it reenters the trachea. Those which are somewhat large and attached by an elongated pedicle, project as far as the external orifice of the wound, but the majority scarcely pass the orifice of the trachea. On separating the lips of the wound, a small red, rounded body is perceived which in every respect resembles a mass of granulations. Its removal is always followed by re- lief. While the canula is in the wound, breathing goes on easily, however narrow be the canula, and even when it is closed. The instrument has a double action. It depresses the polypus which rises up, and resumes its position in the trachea as soon as the pressure ceases to be maintained, while it also compresses it and flattens it to that degree that when the canula is removed it often happens that respiration remains perfectly free for a certain time, which the tumor needs in order to resume its volume. When the foreign body is formed after the wound has closed 6l6 DIPHTHERIA, CROUP AND TRACHEOTOMY. and cicatrized, respiration does not return completely to its former condition, while in other cases it remains easy for a certain time, a month for example. (Calvet) [and H. Z. Gill.] The beginning comes on insensibly. At first there are slight symptoms, limited to a moderate snoring during sleep, then progressive augmentation, laryngo-tracheal wheezing, nocturnal at first, then diurnal ; and, finally, attacks of suffoca- tion, more and more intense, becoming fatal if surgical aid does not promptly combat them, while the first one may be fatal (Calvet). They occur suddenly, in the middle of the night or oftener, as the result of excitement, such as fear or anger. After the attack, matters return completely to their usual order. The remission, however, may be incomplete, and some respiratory troubles may persist with an intensity corre- sponding to the size of the tumor, such as snoring, whistling, wheezing and hoarseness of voice. The course of these symptoms, however continuous it may be, simulates intermittence. Two factors, indeed, are neces- sary to the production of grave troubles. The first is irritation of the mucous membrane caused by a cold or by the contact of the tumor with a foreign body ; the second is spasm of the glottis aroused by mental emotions and by the inflamma- tion itself. The structure of these vegetations does not war- rant the thought that mental impressions provoke the attack by developing the tumor by producing a rapid vascular tur- gescence, for they are not erectile in character. Spasm of the glottis is the only tenable hypothesis. Diphtheritic in- flammation, or irritation caused by the presence of the canula, is their probable cause. These productions may be formed about the point where the canula passes, just as large excres- cences are developed about drainage tubes, setons, etc. The diagnosis is often difficult. Certain polypi are over- looked and are recognized only at the autopsy. This singular toleration of the trachea is probably limited, and a time would have arrived, had life continued, when symptoms would have been rapidly produced. Disorders like those which polypus causes, have sometimes SEQUELiE OF TRACHEOTOMY. 617 as their only origin, spasm of the glottis. The diagnosis is very difficult if the attack of suffocation be regarded as the principal symptom, for there is nothing to prove that the at- tack was produced by spasm rather than by polypus. It may appear superfluous at first to differentiate polypus of the tra- chea from the neurotic spasm of the glottis which is observed in very young children or during the course of whooping- cough, but when we examine the course of croup after opera- tion, we recognize that one of the greatest obstacles to the re- moval of the canula is this very spasm of the glottis. The dis- tinction has, therefore, its practical side. Spasm pertains especially to excitable children who dread the removal of the canula and are persuaded that they cannot breathe without its aid. This trouble, which is entirely emo- tional, ceases under the influence of mental treatment. The tracheal polypus, even when it does not project into the wound, behaves very differently, and moral measures and patience are not enough to overcome it. When dyspnoeic symptoms arise after the cicatrization of the wound, their commencing with snoring and their gradual increase mark them as dependent upon polypus. The integ- rity of the voice distinguishes tracheal from laryngeal polypus, when a layngoscopic examination is impracticable. It may be useful, finally, when the existence of a polypus is admitted to know whether it came before or after the tracheotomy. The verification of a dry and jerky cough for a long time before the operation, intermittence of the symptoms, and the fact that no false membrane at all has been perceived, give a strong presumption in favor of the pre-existence of polypus. The prognosis is grave. Polypi which have appeared after the cicatrization of the wound, have brought about death or the necessity of a second tracheotomy. In these conditions a cure may be obtained, as Gigon's case proves. Those which appear early retard or prevent the removal of the canula. In these cases cure is not impossible. Treatment. — Polypi which develop while the wound is still open should be followed up by removal and cauterization com- bined. 6l8 DIPHTHERIA, CROUP AND TRACHEOTOMY. It is not always easy to grasp these excrescences, for they are deep down and often do not project into the wound except during efforts at coughing, and in order to seize them we must hold the forceps open in the wound, make the patient cough and close the instrument quickly at the instant when the tu- mor appears. Their slippery surface allows them often to es- cape from ordinary forceps, and their friability is the reason why only small pieces can be caught at a time. I have facili- tated this manoeuvre by having forceps made with jaws broad- ened, rounded and hollowed out like a spoon, and at the same time having cutting edges. This arrangment allows a larger portion of the polypus to be seized and cut off at the same time. Cauterization with nitrate of silver or with chromic acid should immediately follow the removal. Caustics running into the trachea should be avoided. For this purpose care should be taken in the first instance to immediately touch the cauter- ized surfaces with a pencil dipped in a saturated solution of chloride of sodium. When the polypus develops after the occlusion of the wound, a second tracheotomy is imperatively indicated as soon as snoring or whistling during respiration, or, with much greater reason, when attacks of suffocation shall have created suspicion as to the nature of the disease. It is better to oper- ate than to await these attacks, for the first one may prove fatal. After the trachea has been opened we manage, as be- fore, if the polypus projects, which feature may be wanting. The patient must then retain the canula until cured. When the simple means which have just been indicated are not enough to destroy the polypi, we are often obliged to have recourse to operations which are employed in laryngoscopy and whose complete description is found in special treatises Tracheal Fistula. This form of lesion is extremely rare in the absence of pol- ypus or of stricture. I know of but two cases, one cited by SEQUELiE OF TRACHEOTOMY. 619 Trousseau and the Other by Dujardin, of Lille. These authors do not inform us by what cause the fistula was produced. All that we know is that Dujardin's patient wore his canula for eight months, and that asphyxia returned at every attempt to remove it. After three years and a half there still remained a capillary tracheal fistula. The cause of that persistence re- mains unknown to us in these two cases. The most probable hypothesis is that of a loss of substance suffered by the tra- cheal rings at the site of the incision. Ulceration of the edges of the wound or multiple incisions made during the operation are the conditions which best explain a loss of substance of that kind. When the fistula is simply linear, and when it is not accom- panied by polypus it causes no disturbance at all in either res- piration or phonation. If larger it may bring about certain troubles in the emission of the voice. The authors just cited do not tell us what was tried to remedy this condition. Cau- terization of the track with a red hot iron would perhaps has- ten the reunion of the surfaces by augmenting the vitality of the tissues, while autoplasty has been also advised by several authors. CHAPTER III. ACCIDENTS REFERABLE TO THE DIPHTHERITIC INFECTION. The only ones which deserve mention are convulsions and pulmonary complications. I — Convulsions. I have spoken of those which manifest themselves at the be- ginning of diphtheria. There are others much more interest- ing which break out in consequence of tracheotomy. These are the most common. They begin a short time after the op- eration, and during the first thirty-six hours. They are en- tirely included within these limits in such a manner as to clearly show the influence of the traumatism. Often the convul- sion is single. Its duration is variable and it may last for five hours. In other cases they recur several times after quite brief intervals. Certain ones appear at a stage more remote from the opera- tion. They are not produced, like the preceding, from a traumatism, but from the action of an accidental cause, as an emotion or a fright. A little girl of 2 years had a convulsion nine days after being operated on for croup from having re- mained too long a time without the canula. The fright, the agitation, and perhaps a slight suffocation, brought on the ac- cident, which passed off, however, and never reappeared. Other cases, finally, are observed at a still later stage, but they depend upon a complication or upon albuminuria. They are of extreme rarity. The prognosis varies according to the stage and the case. Convulsions which come on at the beginning are without grav- (6ao) 4 I SEQUELiE OF TRACHEOTOMY. 621 ity. Those which develop under the influence of the traumatism of the operation are always fatal. The patient is carried off in one of the convulsions or succumbs a few hours afterwards. As to those which come on later, they are almost always of evil augury because they announce that a complication is im- minent. If the patient does not succumb to the convulsion, he has many chances to be carried off by the recent accident. An exception may be made in favor of those which are due to an emotional disturbance. II. — Pulmonary Complications. These depend, for the most part, on the diphtheritic infec- tion. This fact is now beyond doubt, and I have already given the reasons for it. The opinion which considered them as the exclusive result of tracheotomy has justly been aban- doned. I have recognized, however, that the operation might play a part in their development on account of the direct in- troduction into the trachea of air which is still cold and dry. They were formerly the most dreaded of the causes of mor- tality. Their influence was not lessened until after the inven- tion of the cravat by which Trousseau restored the air entering the trachea, to physiological conditions. Though much more rare than formerly, they are still very frequent, and should be reckoned among the accidents which follow tracheotomy. It only remains now for me to indicate the physiognomy which they present in those who have undergone the operation. The fever, the oppression and the frequency of respiration, have nothing peculiar. It is on the part of the canula, and in the expectoration that certain special phenomena are found. I have heretofore examined the features of the expectora- tion when the disease progresses without hindrance toward re- covery. During the first few hours which follow the operation the fluids thrown out through the canula are tinged with blood and the intensity and duration of that discoloration are depend- ent upon the quantity of blood thrown into the bronchi. It the loss of blood continue after the operation and it penetrate 622 DIPHTHERIA, CROUP AND TRACHEOTOMY. into the pulmonary cavity, the blood is thrown out through the canula, either mixed with sputa or pure. Laudable expectoration is formed, after the disappearance of the blood, by mucus which is transparent and tenaceous or opaque ; in the latter case there are found in the vessel which receives it, thick, rounded, yellow or greenish sputa, lighter than water. When the trachea and the larger bro?ichi are the site of an intense inflammation, the expectoration ceases to be mucous ; it diminishes and dries up, or becomes purulent, oftener sero- purulent, and sometimes grumous, and of a yellow color which is sometimes bright and sometimes verging toward gray. It is abundant. Its odor is unpleasant. The canula is noisy and emits a gurgling noise which is audible at a distance. It be- comes easily obstructed, respiration is embarrassed, the child coughs frequently and each attack is accompanied by redness of the face. The cloths placed before the canula are soiled by the matters expectorated, and must be frequently renewed. This kind of expectoration should convey a grave prognosis; if the child coughs vigorously it may succeed in driving off this mucosity ; but if the cough is feeble, fluids accumulate little by little in the bronchi and give rise to asphyxia. Repeated cleaning of the internal canula and changing of the cloths which surround the neck are indispensable, for we can conceive the inconvenience which would result from con- tact with the skin of these wet bodies rapidly becoming cold, and which are charged with matters whose exhalations cannot but become a new element of infection. It also indicated to sustain the general condition, in order to give the patient the strength necessary to throw off" the bronchial fluids. Generous wines should be insisted on, or, indeed, rum can be given in quantities of from 30. to- 40. grammes (15 to io5) a day by taking care to give not more than ten drops at a time in a spoonful of milk. Pulmonary inflammations impress other modifications upon the expectoration. When they come on in a subject whose sputa present the preceding features, no important change is 1 1 SEQUELS OP^ TRACHEOTOMV. 623 produced. But if the expectoration has been satisfactory at first, it is seen to diminish and almost cease at the moment w'len the oppression and the fever appear. The canula re- mains noisy, but all bubbling noise vanishes and gives place to a whistling which is often intense. Gangtene, when it attacks the trachea or the lung gives rise to a semi-fluid expectoration, of a grayish-brown or greenish color and exhaling the characteristic odor of gangrene. The canula is blackened, whet .er the wound be gangrenous or not; ;ind since the disengagement of septic products is taking place through the lungs, the metal is altered throughout its whole surface, even parts not in contact with the wound, and as the black discoloration of the lower extremity is proof of ulcera- tion of the trachea, so the production of sulphide of silver over its whole surface and upon those portions which do not touch the wound is a sign of gangrene of the lung. Hcsmorrhages. — If the blood, after having ceased at the usual epoch, reappears in the sputa after a few days, recur- rence of the haemorrhage may be feared, especially \{ it be abundant and but slightly mixed with mucus. But if it be scarce and intimately incorporated with the sputa so as to give them a slightly brown discoloration, there are many probabili- ties in favor of an ulceration of the trachea, especially if, at the same time, the lower extremity of the canula take on the black color which it assumes in case of gangrene of the wound. CHAPTER IV. CAUSES WHICH RETARD THE REMOVAL OF THE CANULA. The tables in which I have arranged the dates of removal ol the canula in a large number of cases collected in France and in other countries, bear witness of an excessive discrepancy be- tween the extreme limits which are actually known. Though the canula might need to remain in the wound only a day, it was, in one case, necessary to retain it there for 203 days. Numerous causes are responsible for these variations. The complications of croup, the accidents during or following tra- cheotomy, the intensity of the disease, its duration, its re- lapses, its sequelse, diphtheritic paralysis among them, are in the list. There are patients, and they are the most numerous with whom there is no material lesion to account for the delay. Nothing can be assigned except a spasmodic condition de- pending almost always upon the emotions of the patient. The morbid conditions which postpone the removal of the canula may, therefore, be grouped as follows : 1st. Duration of diphtheritic intoxication. 2d. Lesions of the respiratory apparatus. 3d. Accidents of the wound. 4th. Diphtheritic paralysis. 5th, Spasmodic or emotional conditions. I. — Duration of Diphtheria. This disease has no fixed limits. Its evolution often ends in a few days, but it may last for several weeks. Besides, it is subject to reappear, and it is not rare to see several relapses succeed one another. The period of removal of the canula is influenced by these variations and is postponed so much the (624) SEQUELiE OF RTACHEOTOMY. 625 longer as the tendency of the economy to exude the false membrane is the more lasting, while relapses also postpone still further. In fact, as long as this disposition exists, the lar- ynx partakes of it. While it happens that the false mem- bi'anes cease to be produced on the day after the operation, they are also encountered at still later epochs, and I have cited a case where they appeared as late as the thirty-second day. Between these two extreme points there are numerous intermediate ones ; yet, in favorable cases the duration of the evolution of false membrane hardly exceeds the first week. Production which is prolonged beyond that may be considered as causing delay in the removal of the canula. The rejection of pseudo-membranous debris through the canula, and the ex- istence of false membranes at divers points of the economy, at the same time that the larynx is impermeable, constitute strong presumption in favor of the persistence of the pseudo- membranous covering of the walls of this cavity. The only position to take, in such a case, is to patiently wait till the pro- duction of false membrane ceases. Guersant has advised a manoeuvre which he designates by the name of sweeping the larynx ; but it is, to say the least, useless. II. — Lesions of the Respiratory Apparatus. 1st. — Laryngeal Lesion. {a) Tumefaction of the Laryngeal Mucous Membrane. — In two patients, who could not go without their canula without res- piration becoming embarrassed and without asphyxia becom- ing menacing, death supervened under the influence of a broncho-pneumonia. The autopsy disclosed that the mucous membrane was red and hypertrophied. and formed, at the level of the inferior vocal cords, salient, non-oedematous folds which obstructed the glottis. These patients had thrown off false membranes, and no laryngeal accident had been noted before the invasion of croup. We had, therefore, to deal not with an old alteration, but rather with a recent lesion resulting from 626 DIPHTHERIA, CROUP AND TRACHEOTOMY. the phlogosis which had given rise to the exudation. It is this tumefaction which, between the successive attacks of diphtheria upon the larynx, may render it impermeable to air as though the false membranes remained permanently. {d) Qidenia of the Glottis. — In several patients a true oedema of the glottis has constituted the obstacle to the removal of the canula. {c) Polypi. — There exists no authentic example of a polypus which has grown in the larynx in consequence of croup, and has furnished the symptoms characteristic of laryngeal tumors. Those in question came from the inferior portion of the larynx, and fell into the tracheal incision which put them, as regards symptoms and treatment, under the same head of tracheal polypi, {d) Alterations of the Muscles. — Lesions of the laryngeal muscles, and especially of the thyro -arytenoids, are very probably of great causal importance in the delays which now occupy us. The functions of the larynx, compromised by the paresis of the muscles, are incompletely performed. Since these muscular alterations are not rare, it is legitimate, when we find no other explanation, to attribute to them the attacks of dyspnoea, the snoring or the whistling which supervene at the moment when it is desired to remove the canula. Laryn- goscopic examination would be of great use in supporting or refuting the data of pathological anatomy ; but unfortunately it is of extreme difficulty in the child. [Other causes are : In- turned cartilage retained in position by inflammatory products^ tendency on the part of the trachea to collapse. — Passavant^ Electrization of the lar^-ngeal region through the skin, or carried directly to the muscles in the cavity of the pharynx may modify their nutrition in a happy manner, and regulate their functions. {e) Necrosis of tJie Cartilages. — In certain cases of gangrene, mortification has reached the cartilages. These lesions, in general quite considerable, and allied to a profound infection, have always been fatal. If, as an exception, a cure were ob- tained, grave disorders might be present which would certainly condemn the patient to retain the canula. SEQUELS. OF RTACHKOTOMV. 62/ 2nd. — Tracheal Lesions. Strictures of the trachea and polypi formed about the wound are powerful causes of respiratory troubles which oblige the patient to retain the canula. Their history has already been given. 3rd. — Accidents of the Wound. Vegetations. When the wound granulates too rapidly, there are some- times formed voluminous, pedunculated vegetations which float in the wound similar to polypi. Rouziez Joly cited an interesting case of this kind. The excrescences, which must not be confounded with polypi of the trachea, are attached to the superior angle of the wound, and float into its track. They have the form, size and mobility of the uvula. Inspiration draws them into the trachea, whence comes suffocation. Confusion is easy between these vegetations and polypi of the trachea. To avoid error we must carefully search for the point of insertion, and when this is not clearly perceived, every- thing leads to the belief that the tumor comes from the tra- chea. In case of polypus of the wound removal and cauteri- zation immediately terminate all the symptoms, while in that of the tracheal origin, the impossibility of seizing the whole of the tumor makes the relief temporary and the repetition of treatment necessary. 4th. — Diphtheritic Paralysis. The laryngeal muscles may become enfeebled in their ac- tion by the extension of the paralysis to the' nervous trunks which animate them, as well as by fatty, degeneration. Phy- siology teaches that section or paralysis of the recurrent nerves is accompanied by a complete loss of voice and a res- piratory disturbance which extends to asphyxia in young ani- mals, by reason of the small dimensions of the inter-arytenoid portion of the glottis ; this narrowness, in fact, deprives the animal of the safety valve which that portion of the glottis af- 628 DIPHTHERIA, CROUP AND TRACHEOTOMY. fords the adult, when the inter-ligamentous portion is closed. But the occlusion of the inter-ligamentous portion of the glottis is the direct result of paralysis of the posterior crico-ary- tejioid muscles, the sole antagonists of the rest of the muscles of the larynx, all of them constrictors, and of the atmospheric pressure which tends naturally to approximate the inferior vocal cords during inspiration. These physiological data fully account for the respiratory troubles which diphtheritic paralysis can cause, when, after having affected the sensitive portion of the pnemogastric rep- resented by the superior laryngeal, this causing troubles in deglutition as well as hoarseness of voice, it reaches the motor portion represented by the inferior laryngeal. By virtue of these data, when a tracheotomized patient who is affected at the same time with diphtheritic paralysis, cannot go without his canula, the laryngeal symptoms may be charged to the ac- count of paralysis, when neither a spasmodic condition nor an organic lesion can be found to explain them. It is true that it is not common for diphtheritic paralysis to act in this way, for it more readily attacks the external respiratory muscles. It plays, however, its part, together with stricture and with pol- ypus, in the production of dyspnoea, of wheezing and of hoarse- ness of voice, which sometimes persist a very long time after the cicatrization of the wound. The agents employed against diphtheritic paralysis, viz., sulphate of strychnine and faradization are indicated here. Potain has cited a child in this difficult situation, who was cured by electrization at one sitting. 5th. — Spasmodic or Emotional Condition. The patient has reached a condition of health which is sat- isfactory in every respect ; the voice is clear, the air passes freely through the larynx, no lesion can be suspected, for the false membranes are no longer reproduced. There is no paral- ysis, the general condition is excellent, and yet the chlid can- not remain without the canula. Accustomed to this aid, he SEQUELiE OF TRACHEOTOMY. 629 refuses to go without it. It seems to him that respiration is impossible without this assistance, and he refuses to try his own powers. As soon as the canula is removed he becomes agitated, struggles, and his countenance expresses terror or anger. Respiration, which for the first few moments went on freely, becomes embarrassed, and suffocation comes on without delay. We are compelled to reinsert the instrument as quickly as possible. In other cases, very well described by Millard, the emotional influence, though acting less rapidly, is none the less at fault. The fear of suffocation is extreme, and one of his patients could not lose sight of her canula for an instant, and was quickly attacked with suffocation upon simply the threat, made in jest, of carrying the instrument out of the room. It was necessary to hang it about her neck. I saw a patient in whom the complete permeability of the laiynx authorized at- tempts to remove the canula. Left alone for a few moments one day when he was without a canula, he was taken with such fright that a convulsion came upon him, which lasted about ten minutes and from which there was much trouble in restoring him. I think I ought to reproduce here a curious observation which I have already had occasion to cite. It relates to an extremely nervous and hysterical little girl who could not be separated an instant from her canula without suffocating, yet this did not prevent her uttering piercing cries and exclaiming in a loud voice, "My canula I my canula!" The wound contracted with very great energy and the reintroduction of the canula became very dillicult. The laryngoscope demonstrated the integrity of the lar}'nx and there was no gross lesion save a vegetation which was removed sev- eral times, and whose disappearance brought only a slight amelioration, while diph- theritic paralysis had ceased. The period came when I had barely time to make the applications. As every means had failed, antl prolonged observation of the patient had left no doubt as to the neurotic character of these symptoms, it was resolved to deal sharply with the pusillanimity of the patient. The hundredth day after the operation in ihe morning, I withdrew the canula and remained beside the child, ready to perl- form tracheotomy again, if necessary, but resolved to triumph over the fears or the ill will of my little patient. Success, beyond all th t had been hoped for, crowned my effort. The agitation and the usual contortions were not wanting; the child asked tor her canula, cried and begged; the oppression was very intense, accompan- ied by retraction (lirage) but without extending to asphyxia. The spasmodic and really hysterical stamp of these phenomena became more manifest. Each inspira- 630 DIPHTHERIA, CROUP AND TRACHEOTOMY, tion was accompanied by a violent sob and the face contracted energetically, espe- cially on the right side. After a short time, calm returned for an interval which varied from a few minutes to an hour, and then the agitation was resumed with the same characteristics. The day passed in this way. In the evening as the child was very much fatigued and the oppression was increasing, the canula was replaced, but with extreme difficulty. It was necessary to dilate the wound for a long time, and then only a small canula could be made to enter ;. 008 ('/sin ) in'place of. 010 (^5 in,) which she had habitually worn. The experiment was continued on the next day and the spas- modic movements diminished On the third day the child passed the night without the canula. She had difficulty in going to sleej), and although the sleep went on without interruptiou, the same spasmodic movements of the inspiratory and facial muscles were noted. The wound, however, contracted more and more and scarcely admitted the canula, which, as a precaution, was replaced at night for four days, and finally withdrawn the hundred and twenty-sixth day. On the next day the wound had coiri- pletely closed. The spasmodic movements persisted for a few nights more, and the child was able to leave the hospital completely cured. Another patient whose history Bergeron has kindly allowed me to relate, presented similar features. He could not remain without the canula more than a few minutes, yet after forty days he was able to go without it a day and a night, but on the morrow he was taken with such an attack of suffocation that it was necessary to perform tracheotomy again. After this time the canula could not be left out over a quarter of an hour every day. To enable him to speak, the use of a canula fenestrated on its upper curve, was tried, as well as the canule a bonle of Luer. He went on in that way until the hundred and fitty-fourth day, when he died of a broncho-pneumonia following measles. The autopsy did not reveal any lesion which could account for the obstacle to respiration. It is difficult not to refer the suffocation in these children, especially in the first one, to the emotional condition and to spasm of the larynx. This influence is still more striking in Blachez's patient who succumbed to a laryngeal spasm pro- duced by a violent fit of anger. Whooping cough, a typical spasmodic disease, prevents in the same manner the removal of the canula, as I have been able to assure myself with regard to one patient. Another was taken at each dressing with an attack of convulsive cough which occasioned a long delay. It has been said that the emotional condition should be held SEQUEL.E OF TRACHEOTOMY. 63 I responsible in those cases only where the obstacle yielded after a quite short time. According to Boeckel, the author of that theory, prolonged respiratory troubles correspond with the duration of the sojourn of the false membranes in the lar- ynx. They proceed from a lack of correlation (synergy) be- tween the extrinsic muscles of respiration and those of the larynx proper. These latter remaining inactive all the time the patient breathes through the canula, and losing little by little the habit of acting in concert with the extrinsic group. The facts often contradict this theory. In the cases of delayed removal which I have encountered, the false membranes had not remained in the larynx beyond the ordinary period ; and still further, in several cases where their reproduction had been very active, or their presence had been verified for a very long- period after the operation, to the twenty- eight day, the canula could be removed on the next day or the day after that. Two patients only retained it longer ; but in one the delay could be explained by the fits of anger to which he gave way as soon as it was removed ; and in the other an attack of whooping cough was the cause of the delay. Another patient, it is true, who submitted twice to tracheot- omy,presented false membranes up to the thirtieth day from the first tracheotomy, which was also the thirty-fourth day from the outset of the disease, and the fourteenth from the second tracheotomy. Complete recovery was not obtained until the expiration of three months, reckoning from the beginning ; the canula could not be removed without attacks of suffoca- tion. Would it not be more easy in this case to suppose either a persistent obstruction of the glottis by tumefaction of the mucous membrane, a fact whose reality I have shown, or an alteration of the muscles of the larynx, rather than a want of synergy of the respiratory muscles. In brief, the final removal of the canula may be sometimes delayed for a long time by a nervous state which reveals itself by a spasm of the glottis brought on by the least emo- tion. That condition is a veritable psychical trouble which recognizes as its usual cause fear of the removal of the canula 632 DIPHTHERIA, CROUP AND TRACHEOTOMY. which engenders fits of anger or fright quickly followed by laryngeal spasm and by suffocation. Nervous, excitable chil- dren are more subject to this than others. Other affections of spasmodic character, like whooping cough, also retard recovery by energetically inviting laryngeal spasm. The means to be employed in such cases demand much tact. It is the emotion, in fact, which must be attended to. The physician and those who assist him must put under contribu- tion all the resources which their imagination and their knowl- edge of the character of the child furnish. Mildness and pa- tience or authority and intimidation, may be employed as needed. Excellent results are obtained from a great variety of subterfuges born of the occasion, which, moreover, often sug gests happy expedients. Millard reports very interesting instances which I have al- ready cited (see page 629). I have seen patients become reassured provided the canula was hung in full view at the head of their bed. But there are children whom these means will not persuade, and who abso- lutely will not remain without the canula. The larynx should then be carefully explored while the edges of the wound are approximated with the fingers, or the canula is closed. If the larynx be not free, the trial should be repeated at intervals of one or two days, but if it be clear, let the child struggle, while you are ready, canula in hand, to give it succor in case of real danger. Millard advises not to push the experiment far enough to allow the child to get a real attack of suffocation, for he thinks that the terror which would follow would add another difficulty to those already existing. I subscribe fully to this precept in cases where the outset is still recent ; but where the disease is of long standing, we only succeed, by ob- serving it, in protracting the obstacle and in prolonging in- definitely an abnormal and uncomfortable condition. With the patients whose history I have reported, I have only to con- gratulate myself on having hastened its termination. When the preceding methods have failed, it will be found of advantage to withdraw the canula while the patient is asleep. SEQUELiE OF TRACHEOTOMY. 633 This expedient which requires certain precautions, often suc- ceeds very well, provided the child is not waked up while doing it. The attempt has been made to obtain the same re- sults by means of various modifications in the canula. I will not speak of those which are fenestrated on their convex sur- face. While they allow the air to pass through the larynx and sometimes permit the patient to speak, they are of no other use, for they are retained as long as the others. Moreover, the superior orifice is often plugged by the mucus or by folds of swollen mucous membrane, and in either instance the patient is deprived of speech. Laborde contrived very short canulae, penetrating so slightly into the larynx that the least shake would displace them from it, when they would remain in the wound in the soft parts, having no action upon respiration, but the child would feel that he was wearing a canula and would be at ease. This mod- ification was useful in one case reported, but its employment is difficult to extend to other cases, for few children will allow themselves to be deceived by it. The accompanying cut — FiG. 36 — illustrates a tube inv ntjd and used success- fully by Dr. Hendrix, of St. Louis, Mo., for the gradual withdrawal of the tube in tracheotomy in these complicated cases. Blanchet, of Montet, (AUier) used a different artifice, but of more certain effect. Having to deal with a very excitable lit- tle girl who very much feared the removal of the canula, he strove for a month, employing without success the most various means, when he conceived the idea of introducing every morning a narrower canula than the former one. Suc- cess was soon attained, and after tlie fourth day the last canula, ^34 DIPHTHERIA, CROUP AND TRACHEOTOMY. which, moreover, was no longer of use, was removed and the child did not notice it. [A short conical "plug," just long enough to reach but not enter into the trachea, attached to the metal collar as a substitute for the tube, is recommended by R. W. Parker.] Catheterism of the Glottis. Necessity, in making the history of croup complete, has con- strained me to say a few words about a system of operation devised and recommended by Bouchut. Attributing a baleful influence to tracheotomy, this author endeavored to find a method capable of replacing with advantage that operation. The idea of laryngeal catheterism had occurred to several au- thors at a period already remote. Desault had succeeded in leaving catheters in the larynx, and like procedures had been recommended by Green, Chapman and Loiseau. Bouchut in- vented straight, cylindrical ferrules of silver .015 to .02 (Ys to ^/s in.) in length, provided at their upper extremity with two flanges .006 (7* in.) apart and pierced with an eye for the pas- sage of a silk thread for the purpose of holding them up or re- moving them {retejiir au dehors). The mouth was held open by means of a peculiar wedge. The index finger of the left hand, protected by a metallic ring, elevated the epiglottis. The right hand introduced into the larynx a male catheter of variable size, upon which the ferule was guided as far as the lower portion of the larynx, in such a manner that the upper flange was placed below the superior vocal cord. In that position the ferrule held itself without pre- venting the play of the epiglottis or of the arytenoid cartilages. It was left in place until the asphyxia ceased. The results were not very encouraging. The apparatus clogged easily, and the asphyxia was relieved so little that tra- cheotomy had to be performed /// extremis, where the ferrule had proved itself powerless. It was, moreover, far from being exempt from danger. The experiments of Trousseau and Bouley upon animals disclosed in the larynx, after forty-eight SEQUELAE OF TRACHEOTOMY. 635 hours of catheterism, grave disorders, such as ulceration and destruction of the mucous membrane, denudation of the carti- lages, etc. Trousseau and Bouvier presented objections [porterent des coups) to catheterization from which it will not recover. It was abandoned by its author himself Intubation of the Larynx. • [The recent re-introduction of this subject to the notice of the profession and into practice, and the application of improved instruments in the operation, as a substitute for tracheotomy in many cases of laryngeal obstruction, are due, first, to Dr. Joseph O'Dwyer, physician to the New York Foundling Asy- lum : and, in the same field, to Drs. F. E. Waxham and E. F. Ingals, of Chicago, and others in this country. The reports of cases to which this method, as now practiced, has been applied, are becoming too numerous and too impor- tant to be omitted here.' Though the range of its application, as a substitute for tra- cheotomy, may not yet be established, it has a just claim to the attention of the profession, and seems rapidly to be gain- ing favor. Its exact status, as to the cases in which it should, as a procedure, be preferred to tracheotomy, or vice versa, has not been formulated, but probably soon will be. The following is a summary of Dr. E. F, Ingal's description of the technique of the operation : " The child should be wrapped in a sheet or shawl, which will pinion the arms, and then be held upright in the nurse's lap. An assistant holds the child's head. The 'Med. Record, February 21, 18S5. Chicago Medical Journal, June, November, December, 1885 ; and March, 1886. Archives Pediatrics, November, 1885, New York Medical Journal, November 28, 1885, and April 3, 1886. Journal American Medical Association, February 6, 13 ; July 10, 17, 1886. Medical and Surgical Reporter, March 20, 18S6. American Journal of Obstetrics, June, 18S6, p. 657. Private letter from Dr. Waxham, June 20, 1SS6. ^3^ DIPHTHERIA, CROUP AND TRACHEOTOMY. gag is then introduced between the jaws, far back on the left side of the mouth, and opened as wide as need be, but not with great force. The physician sitting in front of the patient passes his left index finger over the base of the tongue and down be- hind the epiglottis, and with it guides the end of the tube into the glottis. The end of the tube, having reached the pharyngeal wall, is directed downwards and forwards along the index finger into the larynx, 'under and not over the finger' — JVax/iam. Unless he is careful to carry the handle of his instrument high and thus bring the tube as far forward towards the base of the tongue as possible, the tube will be passed into the oesophagus. Too great haste should be avoided. If the tube is not intro- duced in ten or-twenty seconds, it should be removed for a minute or two to allow the child to breathe, and then the operation maybe repeated; but if the tube seems to be in the proper position, whether the operator is certain of it or not, the slide should be crowded forward so as to disengage the obturator, which is then with- drawn. Some cough will occur at once, and if the tube has not been inserted into the larynx, or if it has not been passed down so that the rim rests on the vocal cords, it is likely to be expelled, and may be seen or felt in the back part of the mouth. If the tube has been properly inserted respiration will become easier in a few minutes. The operator then cuts one end of the silk thread attached to the upper end of the tube, passes his fingers behind the epiglottis and holds the tube while the thread is withdrawn. The tube may remain in the larynx as long as necessary to secure per- fect respiration, as it causes little if any irritation. No anaesthetic will be needed for the introduction of the tube, but one will occasionally be required for its removal. Looking at the intubation of the glottis from our standpoint, it seems well adapted for the following cases : I. For diphtheritic and croupous stenosis of the larynx occurring in children under 3^/2 years of asje. 2. For cases of these same affections in older children in which from any cause the physician wishes to defer the operation of tracheotomy. 3. For those cases in which consent to tracheotomy cannot be obtained. 4. For those cases in which proper nursing could not be secured. 5. For severe cases of spasmodic croup in children less than 10 years of age. 6. For simple stenosis of the larynx, not diphtheritic, in children. 7. With proper sized tubes it may be of value in the treatment of various forms of laryngeal stenosis in adults." The following are illustrations of the instruments used by Dr. O'Dwyer, the plates of v/hich were, by his permission, fur- nished by George Tiermann & Co. : Fig. a — Forceps for extractinc: or removing Tube. SEQUELiE OF KTACHEOTOMY. 637 G.TIEMANn'&CI)! III fer'tS;. ■7 -^ if it Fig. C — Scale, actual size — - The numbers give the length of tubes required for children of corresponding ages. Fig. D — O'Dwyer's Tube and Introducer. 638 DIPllTHIERIA, CROUP AND TRACHEOTOMY. Fig. B — Mouth Gag as used by Dr. O'Dwyer. Less than half size. A. Extractor, about two-fifths normal size. B. Gag, two-fifths normal size. C. Scale of the actual sizes of tubes. D. Tube and introducer. The calibre is oval and is Vs by 7* inches in the largest one, and half that size in the smallest. Each tube has at its upper extremity an eye for the silk thread used when it is being introduced. There are jointed obturators which fit each of these tubes and hold them while being introduced. They are jointed in order that they may be more readily with- drawn when the tube is in the larynx. "Statistics of tracheotomy and of intubation of the larynx in the treatment of diphtheritic croup in Chicago, 111." (In abstract.) Tracheotomy. In tracheotomy there were fifty-two operatoi-s, or reporters who report from one lo thirty three operations each — twelve operators reporting one each ; the others re- porting numbers varying to the highest number. Total operations 306, recoveries 58, percentage of recoveries 18.95. In 138 cases in which the age was known, the average was 5 years and i month. Intubation. Of intubation there were 83 cases, 3 were reported by Dr. C. P. Caldwell, 5 by Dr. E. F. Ingals, 7 by Dr. A. B. Strong, 10 by Dr.J.R. Richardson, and 58 by Dr. F. E. Waxham. The results were as follows : SEQUELiE OF TRACHEOTOMY. 639 Cases. 7 2 2 2 3 I 12 I I 14 II I 3 10 7 Total, 83. Ages. 9 months II " 13 " - 14 '• 15 « - 16 « 17 " - 18 « Recoveries. o o o 2 years - - 2 years, I mon:Ii 2 " 2 " - 2 " 2 « 3 6 « 3 years 3 years 4 months 3 " 6 « - 4 years 4 years 9 months 4 years 6 months 7 years 7 years 6 months 8 years II years ? Average age, 3 yrs. 7 mos. 23 The percentage of recoveries from intubation, 27.71, represents the percentage of entire recoveries from the disease, and not simply recoveries from the operation. Of the 58 cases coming under my care, 20 were actually moribund when the ope- ration was performed, many of them entirely unconscious, and 40 were bad cases of diphtheria, characterized by extreme exudation in the pharynx as well as in the lar- ynx. In 18 cases the exudation in the phaiynx was slight. In every case the ope- ration was performed to avert impending suffocation, and false membrane was ex- pelled either in the form of muco-pus, shreds or casts. 640 DIPHTHERIA, CROUP AND TRACHEOTOMY. In addition to the 23 perfect recoveries from the disease the operafo 1 was per- fectly successful in 18 others, although the patients -'ied. Thus 4 died perfectly easy before the removal of the tube, from the severity of the diphtheritic disease; 3 died easily, from one to several days after the tube was removed, from exhaustion inci- dent to the disease. One died of paralysis of the heart, i from uraimic convulsions. Ix-.^^c/r^'T-i! Antero-Posterior Section cf the Head, showing the combined direction of Spray Producers Kos. 2, 3, 4 and 5 in the local treat- ment of the pharyngo-nasal and nasal cavities. No. 2 is introduced into the anierior nares (Rujibold) . Fig. 41. 3 from pneumonia, resulting from hypostatic congestion of the lungs, and 6 from pneumonia, resulting from unfavorable surroundings. These cases, added to those where perfect recovery resulted, and the total, 41 or 49.39 per cent., represents the I SEQUELAE OF TRACHEOTOMY. 641 proportion of cases in which the operation was successful and entirely satisfactory; the remaining cases dying, generally, from extension of the membrane into the bron- chial tube. — F. E. Waxh"am.] Diphtheritic Coryza. Antero-Posterior Stction of the Head.— Showing the combined direction of Spray Producers 1, 6 and 7. No. 8 throws the stream on the base of the tongue. These Instruments treat the pharynx, larynx and base of the tongue (Uumbold) . Fig. 42. Insufflations of tannin, alum, flowers of sulphur, or better stiil, injections of lime-water, of solutions of lactic acid, car- ^42 DIPHTHERIA, CROUP AND TRACHEOTOMY. bolic acid, salicylic acid [and biniodide of mercury, ^/som] also peroxide of hydrogen, 20 grm. — Nunn],etc.,are the means to be employed in diphtheritic coryza. The injections should be re- peated four or five times a day. They should be abundant and made by means of an irrigator or siphon. A canula of waxed leather, or better still, a special canula of ivory, of the shape of the nostril should be employed. With a little practice on the part of the patient the velum palati contracts in such a way that the liquid introduced by one nostril runs out by the other without running into the fauces, provided always that the ob- struction be not complete. In such a case it -would be neces- sary to wash the two nostrils alternately. [The spray appa- ratus with double bulb is in these cases very convenient and efficient.] PsEUDo- Membranous Bronchitis. When the diagnosis can be positively settled, it is useful to treat the bronchial and tracheal false membranes. Internal measures which operate by bronchial elimination demand too long a time. Emetics may render service, but they should be given with caution for fear of diarrhoea and depression of vital- ity. However feeble, in such cases, its action may be, it is still preferable to have recourse to topical medication. The vapor of water charged with emollients acts as a local bath, but this action is insufficient in the case in question. Such substances as modify the false membranes are more indicated. Inhalations of atomized lime-water or dilute lactic acid may be employed, and the atomization made in front of the wound, if the patient has been tracheotomized. But the most efficacious means consists in instilling through the canula modifying fluids. Instillatio7is were at first made with tepid water for the purpose of softening the false membranes and aiding in their detachment. Trousseau, who recommended this treatment, employed the water in quite large quantity, a teaspoonful at a time. Struck by the inconveniences of t^is method which, in place of relieving patients, frequently au;'- mented their dyspnoea, he renounced it. SEQUELS OF TRACHEOTOMY. 643 Barthez took up the same idea again, and, desirous of re- moving its dangers, adopted the following procedure: The water is warmed to a temperature between 30° and 40° C. {86° to 104° F.) and a few drops are drawn into a pipette and allowed to drop into the canula. A paroxysm of cough- ing succeeds this instillation, during which the child often ejects pseudo-membranous debris. This is repeated about every half hour, except when the patient is asleep. Aside from the softening of the false membrane which it may bring about, the action of the water is indirect rather than direct, and it has little effect except in exciting cough. It has also been sought to bring to bear upon the bronchial and tracheal exudations, agents capable of destroying them. Cauterization of the trachea and injection of a solution of nitrate of silver have been tried; but these useless and dangerous methods were very quickly renounced. Barthez, utilizing the solvent properties of the alkalies, had the idea of instilling them into the trachea in the form of solu- tion. After several trials he settled upon chlorate of sodium, whose action is more rapid than that of chlorate of potassium. The solution employed is saturated. The instillations are ef- fected by the procedure above indicated. Cough comes on as after the instillation of tepid water, but with greater energy. The action of the chlorate of sodium is not limited to that. In children submitted to this treatment for several days, the false membranes are found at the autopsy to have been softened from the incision in the trachea down to the bifurcation of that passage. The action of these instillations does not appear to extend farther: for the bronchial false membranes, in fact, preserve their form and consistence. While this desideratum may be regretted, it is none the less true that chlorate of sodium by instillation constitutes a treat- ment which can render service against the generalization of the false membranes, whether by the cough which it excites, or by its immediate action upon the exudate. The perfect harmless- ness of this agent has, likewise, its value in such cases. ^44 DIPHTHERIA, CROUP AND TRACHEOTOMY. Barthez has also tried ammonia in solution, one in twenty, but the cough was so violent that he had to renounce this ir- • ; ritant substance. |ll Lime-water and lactic acid may also be used, but it must ^} not be concealed that the action of these substances upon the false membranes of the bronchi is, so to speak, nil. [Neurin and papyotin have been recently recommended on account of their dissolvent action.] §5 • BlEPH ARO-CONJUNCTIVITIS. Cauterization and blood-letting should be proscribed. The latter, aside from the harmful effect which it has, in general, upon diphtheria, finds no special indication in this particular case, for the conjunctiva is rather anciemic than congested. Cold, and even iced compresses, frequently renewed, and cool irrigations are of great service against the pain which is often intolerable. The false membrane should be touched with lime- water, or dilute lactic or citric acid. After each application the eye should be washed with cold water. The washing should be very abundant, and repeated three or four times a day, and at each operation the contents of a large irrigator ] should be used. When the elimination of the false membrane ' is accomplished, resolution should be hastened by the instilla- tion of slightly astringent collyria of nitrate of silver, of sul- phate of zinc or sulphate of copper. Cauterization with nitrate of silver should be avoided as it endangers damage to the cornea, already considerably affected in its vitality, and inclined to mortification. The period of cicatrization should be watched to prevent, as far as possible, vicious adhesions as symblepharon and entropion. It is of great advantage to pro- tect the healthy eye by thorough occlusion. §6. — Diphtheritic Otitis. Otitis media, supervening by the propagation of the diph- theritic process from the pharynx to the tympanic cavity, SEQUELiE OF RTACHEOTOMY. 645 along the Eustachian tube, almost always goes on unperceived in the midst of the symptomatic complexus of which it is one of the elements. Otorrhoea is almost the only symptom which calls attention to this part, but the evil has already been done, the tympanic membrane is perforated, and the entire surface of the cavity and the external meatus is often covered with false membrane. The indication for treatment, therefore, gen- erally remains hidden, but that, however, is a point of mediocre importance. We cannot flatter ourselves, in fact, that the pro- cess could have been prevented had it been recognized from the beginning. The false membranes can no more be pre- vented gaining the cavity of the tympanum than they can be stopped in their descent to the bronchi. When they reach the external meatus, frequent and abundant injections of a solution of carbolic acid, one to five hundred, should be employed. Four injections a day should be given, and each one should comprise the contents of a large sized irrigator. The patient should hold his head strongly inclined toward the side of the diseased ear, and over a basin. After the separation of the false membrane, the situation no longer differs from that presented by ordinary otitis media ending in suppuration and perforation of the tympanum. The treatment is the same. An attempt is made to arrest the dis- charge. For this -purpose injections of simple or carbolized water made in the same manner are continued, but they are followed each time, after having the diseased ear inclined far enough to empty it, by instilling a few drops of a solution of sulphate of zinc, 1%, of sulphate of copper, 1-2%, or of pure sulphate of aluminum, i to 10%. The patient should be care- ful to retain the liquid for a few moments in contact with the cavity of the ear, which will be accomplished by holding the head inclined toward the side opposite the diseased ear. Af- ter each operation the ear should be dried and then stopped with a cotton tampon. After a certain period of this treatment, the discharge di- minishes and finally disappears, and the hearing may return to nearly normal. But as the tympanic membrane is absent the 646 DIPHTHIERIA, CROUP AND TRACHEOTOMY. floor of the ear is sensitive to atmospheric changes. Cold and moisture cause a return of the discharge and of the deafness. The patient should avoid these relapses as much as possible by protecting the cavity of the tympanum by a tampon of cot- ton placed in the external meatus. §7. — Diphtheritic Stomatitis. Chlorate of potassium internally, and applications of lemon juice, lactic acid, saccharate of lime, etc., bring it easily to an end. §8. — Cutaneous Diphtheria. The diseased surfaces should be dusted with bicarbonate of sodium, calomel, tannin, flowers of sulphur, etc., or better, cov- ered with pledgets of charpie dipped in lime-water or dilute lactic acid. DiphtJieria of the genital organs is combated by the same means. THIRD CLASS. Treatment of Certain Symptoms, Complications and Sequelae. Some of the symptoms of diphtheria assume occasionally sufficient importance to demand special treatment. Hemorrhage. — The means of combating losses of blood de- pendent upon tracheotomy have been indicated above. Inde- pendent of any operation other hemorrhages may proceed from the mouth, or nose, which have for their causes profound in- fection, the elimination of eschars, denuding of vessels, etc. The ansemic condition of the patient demands that we arrest this new source of destruction of vitality as quickly as possible. The hemorrhage which is seen oozing from the mouth, and whose source is accessible, should be met by styptics, and es- pecially by applications of perchloride of iron combined with the i SBQUELiE OF TRACHEOTOMY. 64/ internal employment of that salt. Epistaxis may be attacked by injections of perchloride of iron, and even, as a last re- source, by tamponing. But these methods are not without in- convenience, and often remain useless. It is not without dan- ger to practice tamponing the nasal fossae, covered perhaps with false menibrane,and whose mucous membrane bleeds easily. Cold applications are more advantageous and are entirely harmless. In case of buccal hemorrhage, and even of epistaxis, the pa- tient should be made to take a teaspoonful of pounded ice every five or ten minutes. Under the influence of this very simple means, the bloody discharge is rapidly arrested. Epi- staxis may be directly combated by repeated injections of ice- water. Alcoholic liquors internally in the form of strong wines, such as Marsala, sherry, etc., are useful as adjuvants. Syncope. — That which comes on where there is no operation is amenable to the same means as that which complicates tracheotomy. Gastro-Intestinal Dishirbances. — We will, as far as possible, avoid producing them, by being very cautious in the use of remedies which disturb that organ, to-wit, emetics, mer- curials, balsamics, etc. If their employment has been be- gun they should be immediately suspended. In case this pre- caution does not suffice, the use of bismuth, of diascordium (an aromatic electuary or confection of laudanum), enemata, etc., should be prescribed. Adenitis. — During the first stage, recourse should be had to cataplasms or to oily embrocations, after which the neck should be surrounded with a layer of cotton wadding. But when suppuration has appeared, exit must be given to the pus. The necessity for this is so much the more pressing as we of- ten find ourselves in the presence of two abscesses, one in the glands, and the other in the surrounding cellular tissue. While the glandular abscess progresses quite slowly and shows but little tendency to spread, it is not so with the other. It extends itself rapidly and sends out burrows which produce extensive 648 DIPHTHERIA, CROUP AND TRACHEOTOMY. separations, and dissects the muscles of the neck. The pus should, therefore, receive a prompt exit. Its quantity varies with the time of openin^r. But we must not think that every- thing is ended because the incision has been made and the pus discharged. Certain peculiarities and difficulties are to be counted upon, which it is well to know. It is quickly perceived that the abscess is composed of two cavities, one superficial and subcutaneous, and the other deep, and formed at the expense of one or more glands. These two pockets are united by a narrow channel through which the pus makes it^ way with difficulty. Moreover, while the superficial collection discharges itself easily, pus accumu- lates in the other, and does not run out except on pressure. Further, a grooved probe must be introduced into the fistula, the groove facilitating the exit of pus. This is the form of ab- scess called, boiiton de chemise. If this condition is not rem- edied the collection increases and separation of tissues (bur- rowing) is produced. The enlargement of the outlet by incision has only a tem- porary influence. It is found closed the next day even when it is attempted to maintain the dilatation with a tent. More- over, the tent has the disadvantage of acting as a plug and preventing the exit of the pus. It is useful when the cavity is considerable, to make one or more counter punctures into which drainage tubes are passed. But this procedure is scarcely applicable except to the superficial cavity. The un- dertaking is more difficult when it is a matter of going deeply into the glandular mass. It is not always prudent to push a trocar far in the neighborhood of organs which must be re- spected. I have found it well, in several cases of this kind, to dilate the opening with a bit oilaviinaria digitata. A piece must be chosen which has been formed into a tube. This arrangement prevents the retention of the pus while dilation is going on. The opening contracts quite promptly and one operation rarely suffices ; so recourse must again be had to laminaria. This quite painful procedure should not be repeated except at the SEQUELiE OF RTACHEOTOMY. 649 moment when it becomes absolutely necessary. To avoid this alternative I have taken the position of managing the discharge ofthepus, by means of a kind of permanent canula. This is how I proceed : I take a gum catheter of proper size and leave it of such a length as will reach to the bottom of the pocket and extend some millimeters ('/g inch) beyond the ori- fice in the skin. I cut it off at both ends, as the pus passes more easily through a circular orifice situated in the axis of the instrument, than through lateral eyes. Finally, I fasten a stout thread to the end which is to project externally, which thread is there fastened to two pieces of tape just as in a tracheotomy canula. The catheter, previously oiled, is introduced into the fistula, the tapes are then tied around the neck just like those of the canula for tracheotomy. The whole is covered with a poultice. This dressing is not painful ; and it retains its place perfectly when care is taken not to leave the external end too long, otherwise it works out of the wound. The pus dis- charges with the greatest facility, the pocket empties itself, shrinks, and a cure is rapidly obtained. Pulmonary Inflammations. — Vesicants should be shunned, at least during the first stage of the disease. As long as the economy remains under the diphtheritic influence the denud- ed surface is liable to become covered with false membrane. This is an aggravation which should be avoided. Internally, sulphuret of antimony may be given in small doses, .05 ('Yi gr-) at most, discontinuing it, however, if it cause nausea or anorexia or produce a purgative effect. The medication which has the most rational basis is the treatment by alcohol. The tendency toward depression which lies at the base of diphtheria demands this method of thera- peutics. From 40. to 6o. (lO to 153) of brandy should be given according to age. The proper dose is such an amount that the alcohol shall stimulate, not depress. Pulmonary complications such as gangrene, apoplexy, oedema, etc., are not usually recognized except at the autopsy. I will not speak of their treatment which, however, presents nothing peculiar in this instance. 650 DIPHTHIERIA, CROUP AND TRACHEOTOMY. Diphtheritic paralysis. — When the paralysis is slight and confined to the velum palati, the only proper treatment is electrization. The affected muscles should be excited by means of the induced current. Care should be taken, at the same time, to allow the patient but little drink or liquid food. These substances are thrown out through the nose or into the air-passages, at every move- ment of deglutition, whence there arises on the part of the child, an intense disgust and dread which makes him refuse all nourishment. Solid food should be discarded also, for the patient, in fact, masticates poorly and sometimes allows bits of meat or other substances to fall into the trachea, causing death by suffocation. Bits of unmasticated meat have been found in the bronchi of paralytics who had died suddenly. The meals should be composed of thick soups and panadas, or of very thick porridges of pea soup containing also a large proportion of meat finely chopped and pressed through a sieve. For the purpose of facilitating deglutition in case of paraly- sis, Perrin recommends placing the child flat on its belly, over the knees of the person who is feeding it, in such a way that the face of the patient shall be inclined and turned toward the floor. In this position a flat plate full of any liquid, milk, broth, porridge, etc., is brought close to his lips. Then the plate is gradually removed in such a way as to oblige the pa- tient to stretch his neck and elongate his lips so as to practice a 'real suction of the liquid. Applied to a patient of four years that expedient was crowned with success. It was the same in another case with a little patient aged twenty-three months, who had been operated upon, and whom the author, in con- cert with Archambault, was attending. The method of pro- cedure was still more simple, for we were content with placing the body of the child in supination, the head situated lower than the shoulders, and making him drink slowly and carefully from a spoon. Tonics, such as Peruvian bark, the bitter and the ferruginous SEQUEL.E OF TRACHEOTOMY. 65 I tonics of every form, together with sulphur baths, should be added to the preceding measures. When the paralysis has be- gun to decline, preparations of nux vomica are of service in exciting muscular contractility. We must avoid giving them at the beginning, for they then do more harm than good. However advantageous these therapeutic agents may be, one only is indispensable, and this is electricity. The induced current should be applied to the velum palati, by means of special electrodes. Still further, one of the electrodes can be placed upon the velum palati, and the other upon the m.astoid process. Onimus advises the application of the two electrodes of a continuous current either upon the anterior portion of the neck, or one upon that part and the other upon the nucha. Every time that an interruption of the current, and especially a change of the polarity is made, there is produced a complete movement of deglutition. When the paralysis affects the muscles of the eye, and even those of accommodation, the continuous current gives also ex- cellent results. Care should be taken to place the negative pole upon the nucha and the positive pole at the orbit. Cam- uset has reported a case of success obtained by this method. When the paralysis becomes general, other means should be associated with the foregoing. Hydrotherapy, which, accord- ing to H. Weber, succeeds still better than electricity, gives good results and may be employed. Sea bathing is also of use in perfecting the cure. In grave cases the pointed cautery applied along the vertebral column, has been used with success. and likewise application of ice in the same region (David Eas- ton). Billiard notes good effects from sinapisms and vesicants upon the chest, to combat the paralysis of the respiratory muscles. To prevent the extension of the paralysis to the heart, Duchenne, of Boulogne, advises faradization of the precordial region. PROPHYLAXIS. Are there any means of preventing diphtheria? As the disease is epidemic and contagious, we should at- tempt to arrest the development of the epidemic. The only- rational and effectual means is the isolation of the patients and their sequestration in a remote place. Though practicable in hospitals and in small localities where the cases which arise are immediately recognized, this system is almost illusory in the great centers where numerous cases may remain unknown. Theory demands isolation in these cases, as in the preceding, but, unfortunately, these measures of precaution have not en- tered into practice [not fully] and diphtheria has become en- demic in the large cities, It would be advisable to have isola- tion rigorously enforced in hospitals. There are too many patients who enter for various diseases, and who contract in the wards a diphtheria which is often fatal. The physicians of the hospitals of Paris, and of most of the large cities of France, are perseveringly demanding the application of these meas- ures, to all contagious diseases. Their efforts have not yet succeeded in overcoming deeply rooted customs. Yet, in presence of the growing ravages of diphtheria, it is fitting that these sanitary safeguards should be adopted as soon as possible. What cannot be obtained in large, crowded populations, nor as yet in the hospitals, should be enforced in families. It is a fact that one case of diphtheria is almost always followed, in such circumstances, by one or more others when the members of the family, especially the children, remain in communica- tion with the patient, while those who are removed in time, are oftener spared. All authors, ancient as well as modern, agree (632) SEQUELAE OF TRACHEOTOMY. ' 653 upon this point. Those whom it is desired to protect should be sent off, not to a neighboring room, nor in the same house, but to a distance, and as far as possible. When it is desired to have them return to their dwelling, care should be taken to submit the apartment to thorough disinfection. Furniture, carpets and hangings, which serve as receptacles for the mor- bific germs, should be beaten and cleaned, and disinfectant fu- migations should be rigorously made. Floors and painted (wood) work should be washed. Return should not be al- lowed until after the strict application of these measures. Be- yond that, it is necessary to wait long enough to be sure that the persons who have remained in contact with the patient do not themselves take the disease. But as the incubation of diphtheria may last for eight days, those who have been sent away should not be allowed to re-enter their dwelling under eight days at least. If possible the period of delay should be prolonged. But certain persons, the physician and the pa- rents, remain in contact with the patient; have they any means of preventing the disease? The first of the precautions is to allow to remain only as many persons as it is strictly necessary in the patient's room. In that way each one will not remain so long in contact with \.\\<t fojuesniorbi. The patient himself will profit by this meas- ure by escaping the inconveniences of crowding. Parents must avoid holding the child constantly in their arms, embrac- ing him every moment, and directly inhaling his breath. This is one of the points upon which the physician will meet the strongest opposition. Maternal tenderness refuses to listen to the advice of prudence. She is determined to give herself en- tirely to the suffering child, and, always ready for sacrifice, she is reckless of the danger. Wounds, chaps or denuded surfaces should be carefully pro- tected. Free ablutions with water, or better still, with a solu- tion of carbolic or salicylic acid are indespensable to those :ontaminated by diphtheritic products, especially when these TiAterials have been received upon mucous surfaces, in the 6S4 DIPHTHERIA, CROUP AND TRACHEOTOMY, mouth, upon the hps, in the orifice of the nostrils, or upon tlie conjunctiva. These recommendations apply particularly to the physician who operates and attends to the dressing of the patient; for we know how frequently they are soiled with blood and with fragments ^ false membrane. Although neglect of this pre- cept is not always followed by accident, it is not right to neg- lect it. Cases of diphtheria developed by contact with the false membranes are too well established not to be taken into account. To act otherwise would be exposing oneself gratiu- tously. [See pages 539-540.] I shall say as much for that heroic, but useless as well as dangerous act, of applying the mouth to the wound for the purpose of sucking out the blood which has flowed into the trachea. Preventive properties have been attributed to several sub- stances. Bicarbonate of sodium has been advised by Moure- mans and by Baron ; sulphur was recommended by Duche, and bromine by Ozanam. The worthlessness of these means is everywhere recognized. Racle, of Constantine, (Algiers), considers acetic acid as a very sure preventive. It would be very fortunate if acetic acid should be found possessed of these valuable properties. I have seen this agent employed only once. It was in a family where I had performed tracheotomy upon a child with croup. Gargles of vinegar did not prevent the father from contract- ing the disease, which killed him after extending rapidly from the tonsils to the larynx and the bronchi. The conjectured inoculability of diphtheria has been the oc- casion of imitating in this disease, that which has been done for small pox. Doctor Mazotto performed inoculation fifteen times as a curative measure, at the beginning of the disease, and twenty times as a preventive measure upon subjects liv- ing in a diphtheritic focus. The patients of the first series were affected with benign forms only ; while those of the sec- ond class, it is said, were spared, all except two ; but these latter had only very slight manifestations, (See p. 332 et seq.) SEQUELS OF TRACHEOTOMY. 655 We would greatly deceive ourselves in founding any hopes whatever upon these instances. It is known how questionable the experimental inoculation of diphtheria is. There is noth- ing to prove that the inoculation was effective in a single one of these patients, for no valid scientific proof has been pro- duced to sustain it ; and further, in the two cases where diph- theria followed the supposed inoculation, the disease declared itself twenty and twenty-two days after the puncture. The ex- aggerated duration of the incubation gives reason to believe that the disease emanated quite in the usual manner from the morbid focus in which the patients were living. We do not know, therefore, any drug which will certainly prevent diphtheria, and. a preservative from that disease is, like its specific, wanting up to the present time. [E. M. Hunt recommends internal administration of chlorate of potash, combined with local applications of chloride of iron.] [The Council of Hygeine of France has voted the following instructions (Jour, de Med. et de Chir.) Jour. Am. Med. Assoc, vol. iii. No. 19, Nov. 8, 1884). They contain so much in so brief a space that I shall insert them here. The Illinois State Board of Health issued a circular on diphtheria in 1883, con- taining the same, and other points more elaborately set forth. The Council of Hygiene says : Preservative Measures. — Diphtheria is a contagious affection. All association of children with persons infected by it should be interdicted. No medicine is known to-day that is protective against diphtheria. It is important, particularly during the prevalence of epidemics, to nourish children as carefully as possible, and to see that they are not subjected to the pro- longed influence of moisture and cokl. It is very important to tend to all throat affections at their onset. Measures to be taken zvhen a case of diphtheria appears in a family. — It is indispensable to remove the case at once from all communication with other persons, especially children, who are not concerned in the treatment of the disease. Those who wait upon the case should not embrace the patient, inhale the 656 DIPHTHERIA, CROUP AND TRACHEOTOMY. breath, or stand in front of the mouth of the patient during at- tacks of coughing. If they have any cracks or sores on the hands or face, they should cover them carefully with collo- dion. They should be well nourished and go out into the fresh air several times every day, taking the precaution of first washing the hands and face with water containing to the quart about three teaspoonfuls of crystalized boracic acid, or 15 grains of thymic acid. They should be careful not to remain night and day in the room of the patient. Measures of disinfection in the course of the disease of in the case of death. — i. The matters discharged by cougiiing or vomiting should be destroyed by the aid of a solution contain- ing 50. (5jss) of chloride of zinc or sulphate of copper to the quart of water. The soiled linen, clothes, etc., should be im- mediately washed in one of these solutions, and then plunged into water which is kept boiling for an hour at least. The spoons, glasses, etc., after being used by the patient, should be plunged into boiling water. 2. Whatever be the result (or cause) of the disease, disin- fection is indispensable. Fumigations with sulphur are to be conducted as follows : After closing all openings, an earthen pan containing hot coals is to be placed upon sand, and on it powdered sulphur to be placed proportional in amount to the size of the room (20 grammes, or 5v, to the cubic metre). The chamber must remain closed for twenty-four hours, and then be freely aired. The clothes, linen and other cloths used by the patient are to be disinfected by the solutions mentioned before being sent to the wash. The mattress should be opened and left in the chamber during the fumigation.] The only measure which deserves confidence is the prompt removal of healthy subjects who are in morbific foci (a con- taminated locality). I therefore repeat with Alaymo, "Caveant angue pejus parentes suos filios secum gerere, ubi puerulus hoc modo infirmatur ; et, si in domo ejus continget, statim alios pueros valetudine fruentes separent;" and with Carne- vale, *' Cede cito, longinquum abi, seriusque reverte." UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. Lib. 1939 n^(^»^^■ vw. xsSS BIOMQ DEC 02 BIOMFD ' 1" BEC 1 3 1985 R£CD BiOMED DEC 16 •8/1 8101(01 tfcE'&'BT 115 Form L9-30)«-7r**(C824s4)444 m 3 115801085 9717 i i : ( ^IB