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DIPHTHERIA: 
 
 ITS NATURE AND TREATMENT, 
 
 AN ACCOUNT OF THE HISTORY OF ITS PREVALENCE 
 IN VARIOUS COUNTRIES. 
 
 BY 
 
 DANIEL D. SLADE, M. D. 
 
 BEING A SECOND AND REVISED EDITION OF AN ESSAY TO WHICH 
 WAS AWARDED THE FISKE FUND PRIZE OF 1S60. 
 
 PHILADELPHIA: 
 
 BLANCHARD AND LEA. 
 
 1864. 
 
The Trustees of the Fiske Fund, at the annual meeting of the Rhode 
 Island Medical Society, held ia Newport, July 11, 1860, announced that the 
 premium of one hundred dollars offered by them on the subject of '"Diph- 
 theria, its nature and treatment, with an account of the history of its pre- 
 valence in different countries," had been awarded to the author of the 
 dissertation bearing the motto — 
 
 " Felix qui 2^01 uit rerum cognoscere causa s.'''' 
 
 And upon breaking the seal of the accompanying packet, they learned that 
 the successful competitor was Daniel Denison Slade, M. D., of Boston, Mass. 
 James H. Eldridge, M. D., East Greenwich, 
 Charles W. Parsons, M. D., Providence, 
 Henry E. Turner, M. D., Newport, 
 
 Trustees. 
 S. Aug. Arnold, M.D., Providence, Secretary of the Fiske Fund. 
 
 Pnil.ADKLPHlA : 
 COLLINS, 1' lU N T E R . 
 
O .-b .3 
 
 buP 
 
 -^ 
 
 ^^xX-*^ 
 
 PREFACE. 
 
 5 
 
 The publication of another edition of this essay 
 
 has afforded an opportunity for its thorough re- 
 
 visal, and for such additions as experience and 
 
 observation have taught us. Our knowledge of 
 
 the nature, causes, and treatment of diphtheria is 
 
 still lamentably deficient, and it is only by the 
 
 \ most diligent study, and by the most careful ob- 
 
 j. servation, that we may hope to arrive hereafter at 
 
 '^o more satisfactory results. 
 
 Boston, October, 1864. 
 
 ^ 
 
 P^i352839 
 
DIPHTHERIA 
 
 No diseases of late years have awakened more atten- 
 tion, both among the profession and the public gene- 
 rally, than those which have been classed, more or less 
 correctly, under the term diphtheritic. ISTor is this to be 
 wondered at when we consider the distressing nature of 
 the symptoms, and the terrible fatality with which the 
 epideitpics of malignant sore throat have so often been 
 attended. 
 
 Diphtheria is a synonyme of the word Diphtherite,^ 
 originally used by M. Bretonneau in his treatise on this 
 subject, which appeared in 1826, and which is chiefly 
 made up of his own observations on the epidemics of 
 malignant sore throat prevailing at Tours and in its 
 neighborhood in 1818, and again in 1825 and 1826. 
 
 The following are the specific characters of diphtherite, 
 according to M. Bretonneau : — ^ 
 
 At the commencement of the disease a circumscribed 
 
 ' Ai<p^Bpa and At<j>'^£f£? liave botli the same signification, the pre- 
 pared slvin of an animal ; Ai<p9ipirn<: and Ai<i>6s^U(; botli signify that 
 which is covered with skin. 
 
 2 Traite de la Diphtherite, Paris, 1826, p. 49. 
 9 
 
14 DIPHTHERIA. 
 
 redness is seen, covered with a semitransparent coagu- 
 lated mucus. This first layer, which is slight, supple, 
 and porous, may be still further raised up by portions 
 of unaltered mucus, in such a manner as to form vesicles. 
 Frequently the red spots perceptibly extend from one to 
 another, either by continuity or by contact, like a liquid 
 which is spread out upon a flat surface, or which runs 
 by streaks in a tube. The concretion becomes opaque, 
 white, and thick, and assumes a membranous consistence. 
 In this stage it is easily detached, and does not adhere 
 to the mucous membrane, except by some very delicate 
 prolongations of concrete matter which penetrate into 
 the muciparous follicles. The surface which it covers is 
 usually of a fliint red tint, with points of a deeper red ; 
 this tint is brighter at the periphery of the spots. 
 
 If the false membrane, in detaching itself, leaves the 
 mucous surface uncovered, the redness which the exuda- 
 tion has concealed returns, and the points of a deeper 
 red allow blood to transude. The exudation is renewed 
 and becomes more and more adherent at the points 
 which were first attacked ; it often acquires a thickness 
 of several lines, and passes from a yellowish-white to a 
 l)rown-gray or black color. At the same time the 
 transudation of blood becomes still more free, and is the 
 source of those stillicidia which have been so generally 
 noted by authors. At this time the alteration of the 
 organic surfaces is more apparent than at the beginning ; 
 often portions of concrete matter are effused into the 
 very substance of the mucous tissue. A slight erosion 
 
SPECIFIC CHARACTERS. 15 
 
 and sometimes even eccbymoses are observed at those 
 points which, by their situation, are exposed to friction, 
 or from which the avulsion of the false eschars has been 
 attempted. It is especially just at this period that the 
 pellicles which are undergoing decomposition give out a 
 foul odor. If they are circumscribed, the oedematous 
 swelling of the surrounding cellular tissue makes them 
 appear depressed, and from this appearance alone we 
 might be led to believe that we had before us a foul 
 ulcer with a considerable loss of substance. If, on the 
 contrary, they are extended over large surfaces, they are 
 partly detached, hang in shreds more or less decom- 
 posed, and simulate the appearance of the last stages of 
 sphacelus. But when we open the bodies of those who, 
 after some days of sickness, die of tracheal diphtherite, 
 we shall find in the air-passages all the gradations of 
 this inflammation from its first stage on the portions 
 recently attacked, up to that which by the aspect of a 
 gangrenous alteration at the points which were first 
 afiected, is most likely to deceive us. 
 
 Diphtheria, according to M. Bretonneau, is a specific 
 disease. Its specific character consists, anatomically, in 
 the formation of a false membrane of definite structure 
 — pathologically, in the power of reproducing itself. 
 " Nothing is diphtheria that has not a pellicular exuda- 
 tion; no such exudation is diphtherical which is not 
 capable of acting as a virus or contagion." 
 
 These were the views expressed in the treatise of M. 
 
16 DIPHTHERIA. 
 
 Bretonneau, and to these be still adheres, with some 
 modifications, in a paper published in the Archives 
 Generales de Mklecine, 1855. 
 
 Under the term diphtheria, Bretonneau, however, has 
 connected several affections, which in the prevailing 
 nosology are separated from each other by wide inter- 
 vals. This point will demand of us especial considera- 
 tion. 
 
 How far his description of diphtheria is to be con- 
 sidered a faithful representation, how far it is to be taken 
 as a universal type of the disease, are questions to be 
 answered only by a careful comparison of the accounts 
 of the epidemics of " sore throat" or " angina" w^hich 
 have invaded various portions of the world, at longer or 
 shorter intervals, particularly during the last two centu- 
 ries. On making such comparison it will be found that 
 they exhibit marked differences in their characteristic 
 symptoms and dangers, having been frequently regarded 
 as different diseases. We shall, however, not only be 
 satisfied of their identit}^, a fact so well established by 
 Bretonneau, but also of the common character by wdiich 
 this identity may be recognized, viz., the existence of 
 the exudation of false membrane. 
 
 As regards the special virulence of the diphtheritic 
 exudation which constitutes an important feature in M. 
 Bretonneau's views of diphtheria, it will be seen, as we 
 proceed, that so far from inoculation being the only 
 mode of propagation, there is no suiTicient reason to 
 suppose that a concrete virus exists; that epidemics of a 
 
HISTORY. 17 
 
 rapidly fatal character have occurred, where the exuda- 
 tion has been extremely liimted and where death has 
 been brought about solely by the constitutional disturb- 
 ance. 
 
 History. — We can undoubtedly trace back the history 
 of this affection to a period almost contemporary with 
 Homer. Whether such be the case or not, certain it is 
 that, ten centuries later, we find distinct descriptions of a 
 form of malignant sore throat in the writings of Aretseus, 
 under the name of Egyptian or Syrian ulcer. This 
 prevailed in the two countries, more especially among 
 children. It was characterized by the appearance of 
 •ulceration in the throat, by fetid breath, and sometimes 
 by great dyspnoea. 
 
 Macrobius speaks of a similar epidemic at Eome, A.D. 
 880, during which sacrifices were offered up to a certain 
 Goddess — "ut populus Eomanus, morbo, qui angina 
 dicitur, promisso voto, sit liberatus." 
 
 A fatal epidemic of sore throat occurred in Holland, 
 in 1337. Hecker,^ in his account of the " Sweating 
 sickness" of England, in 1517, says that — 
 
 "In January of that year, there appeared in Holland 
 another disease whfbh, from its dangerous and inexpli- 
 cable symptoms, spread fear and horror around. It 
 was a malignant and infectious inflammation of the 
 throat, so rapid in its course that, unless assistance was 
 procured within eight hours, the patient was past all 
 
 • Hecker's Epidemics, p. 224. 
 
 2^ 
 
18 DirUTHERIA. 
 
 Lope of recovery before the close of the day. Sudden 
 pains in the throat, and violent oppression of the chest, 
 especially in the region of the heart, threatened suffoca- 
 tion, and at length actually produced it. During the 
 paroxysms the muscles of the throat and chest were 
 seized with violent spasms, and there were but short 
 intervals of alleviation, before a repetition of such 
 seizures terminated in death. Unattended by any pre- 
 monitory symptoms, the disease began with a severe 
 catarrhal affection of the chest, which speedily advanced 
 to inflammation of the air-passages. 
 
 " The physicians had recourse to venesection and pur- 
 gatives. Moreover, the employment of detergent gargles, 
 whereby the extension of the affection to the lungs was 
 prevented, as also of demulcent pectoral remedies, was 
 decidedly beneficial. . . Most of those affected were 
 taken ill at the same time; and eleven days of suffering 
 and misery had scarcely elapsed, when not another case 
 occurred. It spread, however, no doubt, beyond Hol- 
 land, for in the same year we find it in Basle, where, 
 within eight months, it destroyed about 2000 people, 
 and its symptoms would seem to have been more 
 strongly marked. 
 
 "Eespecting the intermediate countries, which it is 
 highly probable that the disease passed through from 
 Holland before it reached Basle, we unfortunately have 
 no information. The tongue and gullet were white, as 
 if covered with mould ; the patient had an aversion to 
 food and drink, and suffered from malignant fever, 
 
niSTORY. 19 
 
 accompanied witti continued headache and deliriam. 
 Here, in addition to an internal method of cure not de- 
 tailed, the cleansing of the mouth was perceived to be 
 an essential part of the treatment ; the viscous white 
 coating was removed every two hours, and the tongue 
 and fauces were afterwards smeared with honej^ of 
 roses." 
 
 In 1557, a similar epidemic appeared in Holland, 
 which proved very fatal, and Vvdiich spread to other parts 
 of Europe. It has been described by M. Forest. He 
 says :— 
 
 "It was not so rapid in its course as in 1517, but 
 began with a slight fever, like a common catarrh, and 
 showed its great malignity only by degrees. Sudden 
 fits of suffocation then came on, and the pain of the 
 chest was so distressing that the patients imagined that 
 they must die in the paroxysm. The complaint was 
 increased still more by a tight convulsive cough. Death 
 did not take place till the ninth or fourteenth day. The 
 painful affection of the stomach was, in this epidemic, 
 very distinctly marked, so that a sense of pressure at the 
 precordia, accompanied by continued acid eructations, 
 continued to exist even after a succession of six or seven 
 fits of fever ; and convalescents were troubled with dys- 
 pepsia, debility, and hypochondriasis." 
 
 In 1576, there was a very malignant form of throat 
 disease prevalent in Paris. In fact, from the end of the 
 16th century, we find that epidemics of angina have 
 shown themselves almost constantly to a greater or less 
 
20 DIPHTHERIA. 
 
 extent, in some portions of the old or new world. In 
 the beginning of the 17th century, an epidemic of angina 
 occurred in Spain, which received the name of ''Garo- 
 tillo," because those who were attacked by it perished as 
 if strangled by a cord. This has been described by 
 Mercatus, Yillareal, Nunez, and by others. In 1618, the 
 same disease appeared at Naples, which the inhabitants 
 termed " male de canna," disease of the trachea. It raged 
 here to a greater or less extent for twenty years, and has 
 been described by several writers, among whom we may 
 mention Nola, Carnevale, Syambati, Zacutus Lusitanus, 
 and Marcus Aurelius Severinus. Carnevale, in par- 
 ticular, has given us full data of this epidemic in his 
 treatise entitled, "De Epidemico Strangulatione Affectu." 
 The children were first attacked, the disease afterwards 
 spreading among the population generally, and proving 
 very fatal. The disease commenced by a mild inflam- 
 mation of the throat; soon the affected parts presented 
 a whitish exudation; the breath became fetid; degluti- 
 tion impossible; the respiration embarrassed, and the 
 patient died of suffocation. This writer also gives us 
 the different appearances which the pharynx presented 
 in this epidemic ; he also speaks of the extension of the 
 disease to the trachea, oesophagus, pituitary membrane — 
 of the diagnosis, prognosis, and the topical remedies, all 
 of which are quite in accordance with modern views. 
 
 In 1632, Alaymus published a treatise upon "Syrian 
 Ulcers." He prefers this term, he says, inasmuch as it 
 applies to all forms of the disease, which he describes in 
 
HISTOKY. 21 
 
 a similar manner with Carnevale. No writer of this 
 age, however, speaks of cutaneous diphtheria in connec- 
 tion with the other sj^mptoms which thej describe, 
 although most of them particularly notice the extension 
 of the disease to the air-passages. 
 
 From the middle of the seventeenth century up to 
 1740, we find but little mention made of the prevalence 
 of malignant angina. But very shortly after this, in 
 1743, the disease made its appearance in Paris, where it 
 prevailed until 1748, and has been described by Malouin 
 and Chomel. At about the same time a similar 
 epidemic appeared both in England and at Cremona, 
 accounts of wdiich are recorded by Fothergill, Starr, and 
 Ghisi. 
 
 In England these epidemics proved very destructive. 
 The epidemic described by Fothergilh is, without doubt, 
 closely allied with scarlatina. He says : — 
 
 "It generally comes on with giddiness and chills, which 
 are soon followed by great heat ; these states alternate 
 for a few hours, until, at length, the heat becomes 
 constant and intense. Then follows acute pain in the 
 head, heat and soreness, rather than pain of throat, 
 stiffness of the neck, commonly great sickness or 
 purging, or the two combined. The face soon after 
 looks red and swelled, the eyes inflamed and watery, as 
 in measles, restlessness, anxiety and faintness. If the 
 mouth and throat be examined soon after the first attack, 
 
 ' Account of tlie Sore Throat, attended with Ulcers. London, 1748. 
 
22 DIPnTHERIA. 
 
 the uvula and tonsils are found swelled ; and these parts 
 together with the velum palati and pharynx appear of a 
 florid red color, which is most marked on posterior edge 
 of palate in the angles above the tonsils, and upon the 
 tonsils themselves. Instead of redness, a broad spot or 
 patch of an irregular form and of pale white, is 
 sometimes seen surrounded with florid red, which white- 
 ness appears like that of the gums immediately after 
 being pressed with the fingers, or as if matter ready to 
 be discharged was contained beneath. Generally on 
 the second day of the disease, the face, neck, breast and 
 hands, are of a deep erysipelatous color, with a 
 sensible tumefaction. A great number of small pimples 
 of a color more intense than that which surrounds them 
 appear on the arms and other parts. (In a note, he says, 
 the eruption and redness have not so regularly ac- 
 companied the disease during the latter part of this 
 winter, 1754, as they did last year. In some cases they 
 did not appear at all, in others not till the third or 
 fourth day.) 
 
 " The appearances in the fauces continue the same, 
 except that the white places become more ash-colored ; 
 and it is now found that what might be taken for the 
 superficial covering of a suppurated tumor is really a 
 slough concealing an ulcer. Instead of the slough in 
 mild cases, a superficial ulcer of an irregular form ap- 
 pears in one or more parts, scarce to be distinguished 
 from the sound, but by the irregularity of surface which 
 it occasions. Towards ni2;ht heat and restlessness 
 
HISTORY. 23 
 
 increase, and a peculiar kind of delirium frequently 
 comes on. The pulse is generally very quick ; in some, 
 hard and small ; in some, soft and full. The tongue is 
 generally moist, and not often found. In some it is 
 covered with a thick white fur ; and these generally com- 
 plain of soreness about the root of the tongue." 
 
 Fothergill also speaks of an acrid discharge from the 
 nose, and remarks that there was sometimes epistaxis at 
 the commencement of the attack. He describes faint- 
 ness as a common symptom, also diarrhoea at the outset. 
 He is very positive about the separation of sloughs 
 which leave ulcers. Although he does not mention 
 dropsy as a sequela, 3^et he evidently had entertained the 
 notion of the disease beins^ allied to scarlatina ; but, he 
 remarks, it differed from the sore throat and scarlet 
 fever described in Edinburgh in 1733. 
 
 Ghisi, after having given a detailed description of the 
 epidemic of sore throat which commenced at Cremona 
 in 1747, remarks that the disease proved fatal by suffoca- 
 tion, even in those cases where the attention of the 
 patient had not been called to the condition of the 
 throat. This absence of difficulty in deglutition has 
 been constantly observed, however, according to M. 
 Bretonneau, in all the epidemics of malignant angina, 
 particularly in those of Tours. Ghisi describes cases 
 which appear to be primary and not secondary to scarla- 
 tina. He especially indicates the peculiarity of the 
 pseudo-membranous concretion which lines the air- 
 passages. 
 
24 DIPHTHERIA. 
 
 In 1747; M. Arnault, of Orleans, mentions cases of 
 malignant sore throat which carried off the patient in 
 twenty-four hours. At the autopsies of two children 
 dead from this disease the mucous membrane of the 
 trachea was found detached to the extent of several 
 inches. It was of the consistence of parchment, and of a 
 white color. 
 
 In 1708, ^NTartcau de Grandvilliers published descrip- 
 tions of cases of gangrenous angina, which he had 
 observed for many years in Picardy. These observa- 
 tions, according to M. Bretonneau, would have con- 
 tributed essentially towards a right understanding of the 
 several mooted points, had not the writer confounded 
 scarlatinal with diphtheritic angina. 
 
 Iluxham^ describes an epidemic in 1757, prevailing 
 in England, which was also closely allied with scarlatina. 
 He says : — 
 
 " Most commonly the angina came on before the cx- 
 anthem, but many times the eruption appeared before 
 the sore throat, and was sometimes very considerable, 
 though there was little or no pain in the fauces ; on the 
 contrary, a very severe angina seized some patients that 
 had no manner of eruption ; and yet even in these cases 
 a very great itching and desquamation sometimes 
 ensued, but this w^as chiefly in grown persons, very 
 rarely in children." 
 
 ' nuxlinin, I'is.scrt:iUoii on the Malignant Ulcerous Sure Throat. 
 London, 1707. 
 
HISTORY. 25 
 
 The eruption was sometimes pustular, sometimes 
 erysipelatous. He alludes to some cases in which there 
 were signs of croup, but the symptoms were not well 
 marked ; the peculiar breathing and suffocation were 
 wanting. He remarks that "in all sorts of fevers about 
 this time there was a surprising disposition to eruptions 
 of some kind or other, to soreness of throat, and apncea." 
 His attention was chiefly directed to the condition of the 
 fauces, and he does not at all seem to appreciate the 
 tendency of the disease to extend to the air-passages. 
 Yet, by his own statements, some of his cases must have 
 terminated with laryngeal symptoms. 
 
 "Not only," says he, "were the nostrils, fauces, &c., 
 affected, but the windpipe itself was much corroded, and 
 pieces of its internal membrane were spit up." 
 
 Dr. Starr, of Liskeard, published a paper in the 
 Philosophical Transactions, upon the malignant ulcerous 
 sore throat epidemic which appeared in that place in 
 1749. In this paper, besides other details of the 
 epidemic, he gives the full data of a case in which the 
 false membrane, commencing in the fauces, extended to 
 the larynx. He particularly dwells upon the physical 
 properties of the exudation, its adherence to the sub- 
 jacent surface, its frequent detachment and reproduction. 
 In fact, he gives a complete picture of Bretonneau's 
 diphtheria. 
 
 In 1761, Kosen gives an account of an epidemic which 
 prevailed in Sweden. 
 3 
 
26 DIPHTHERIA. 
 
 Dr. Samuel Bard' published a dissertation upon the 
 nature, causes, and treatment of suffocative angina, as it 
 appeared in New York in 1771. To this writer we shall 
 have occasion to revert more particularly when we come 
 to trace the history of diphtheria in our own country. 
 
 From this period the disease and the writings which 
 the subject had called forth, seem to have been laid 
 aside, and almost lost sight of, when, in 1826, the 
 treatise of Bretonneau made its appearance. This we 
 may truly consider the first connected and practical 
 research upon the nature of the affection. Of late, the 
 disease has become firmly established in France, and it 
 ■would seem, judging from the experience of the last few 
 years, that it has also prevailed, to a greater or less 
 extent, in England and in our own land. It has been 
 described by many French writers, among whom we 
 may mention Guersant, Isambert, Chomel, Andral, 
 Itilliet, Barthez, Trousseau, and Bouchut. 
 
 It is by a careful study of the most characteristic and 
 important researches into these epidemics that we are 
 enabled to gain at least a partial insight into the nature 
 of the disease, and to contrast the present with the 
 earlier accounts of its character. 
 
 The epidemic at Tours, in 1818—1821, so vividly 
 described by Bretonneau, first broke out in the barracks, 
 amongst the soldiers, and thence spread to the surround- 
 ing quarters. Among the military the gums were the 
 
 ' Rosearclies on the Nature, Causes, and Treatment of Suflbcative 
 Angina, &c. By Satuuel Bard, M. D, New York. 
 
niSTORY. 27 
 
 portions most frequently attacked, the air-passages being 
 rarely affected. As it spread into the city, the larynx, 
 however, was the portion which the disease selected, 
 wdiile the gums were unaffected; children being, in most 
 cases, the victims. 
 
 Those who were thus attacked rarely complained 
 much at the outset of the attack, although deglutition 
 was slightly interfered with. On examination of the 
 throat it was found to be somewhat inflamed ; shortly a 
 yellow-grayish patch could be seen upon the tonsils, 
 which spread rapidly over the soft palate, the mouth, 
 and the pharynx ; the cervical and submaxillary glands 
 became swollen and inflamed. The outward appearance 
 of the patient, the leaden aspect, the dulness of the eye, 
 the uncertain step, bore evidence of the severe character 
 of the disease, while the hoarseness of the cough, the 
 change in the tone of the voice, the extremely fetid 
 breath, and the grayish-black exudation upon the 
 pharjmx, were speedily followed by suffocating dyspnoea 
 and death. 
 
 From Tours the epidemic spread to two small hamlets. 
 La Fevriere and Chanusson, to which places it was for a 
 time confined. 
 
 "From this time it continued to traverse the depart- 
 ments of France, passing mainly from the southern 
 littoral districts towards the centre. It did not seem 
 possible to ascribe its visitations to any particular 
 
 ' See cases reported by Bretonneau in his Treatise, 1826. 
 
28 DIPHTHERIA. 
 
 climate or meteorological conditions ; for historical 
 documents show that while it raged with terrible 
 violence amongst the towns and hamlets of the Loiret, 
 remarkable for their salubrity and the advantages of 
 their geographical position, it passed over the villages of 
 Sologne, seated amidst marshes; while elsewhere it 
 seemed to select marshy and ill-drained districts, and to 
 spare those which were in a better sanitary condition. 
 Again, while in the year 1825, a year remarkable for its 
 extreme dryness, the communes north of Orleans were 
 laid waste by diphtheria, it made as many victims in the 
 damp and warm year 1828, in the country south of 
 Orleans.'" 
 
 In this year Trousseau saw thirteen out of seventeen 
 individuals die in the same farm-house, all attacked with 
 diphtheria. 
 
 In 181:1 an epidemic occurred in the Children's 
 Hospital at Paris, which has been described by M. 
 Becquerel.^ In this many of the children were attacked 
 with sore throat, sometimes false membranes being pro- 
 duced, and at others sloughs and gangrene, the one 
 running into the other. The pharynx, larjnix, and 
 blistered surfaces were the parts attacked. In all the 
 cases tliere was a want of coagulability in the blood, and 
 pulmonary apoplexy often accompanied the malady. 
 
 In the Archives Gentrales de Medecine, M. Empis' 
 gives a most valuable paper upon an epidemic of diph- 
 
 ' Report of the Lancet Sanitary Commission, 1859. 
 
 « Gazette Medicale de Paris, 1843. ^ March, 1850. 
 
HISTORY. 29 
 
 theria whicTi occurred at the Hopital JSTachez, in 18-i8. 
 Both the mucous and cutaneous surfaces were attacked, 
 in many cases conjointly. 
 
 There was a very virulent epidemic in Paris in 1855, 
 attacking the rich and poor indiscriminately ; carrying 
 off adults, but expending itself more particularly upon 
 children. 
 
 From the early part of 1855 to March, 1857, a serious 
 epidemic prevailed in Boulogne, during which 366 
 persons died, of whom many were English. A greater 
 portion of those who were carried off were under ten 
 years of age. 
 
 M. Lemoine has described an epidemic at Nievre, in 
 which the air-passages generally escaped. 
 
 In the department of the Haute Marne, the diphtheria 
 had a decided predilection for the nasal fossce, the 
 larynx, for the most part, escaping. This epidemic was 
 described by M. Jobert. M. Lespiau has given an 
 account of an epidemic which occurred among the 
 military at Avignon, in the autumn of 1853, and in 
 which the false membrane usually spread to the air- 
 passages. Of 1796 soldiers, 195 were attacked; and of 
 22 children belonging to one regiment, 4 suffered. In 
 the cases secondary to other diseases nearly all died, 
 while in the primary cases only 6 per cent. died. 
 
 Such is a concise history of the epidemics of malig- 
 nant angina which have been observed in Europe, and 
 more especially in France, during the present century. 
 Before giving an account of the history of diphtheria in 
 
 3* 
 
80 DIPHTHERIA. * 
 
 England, let us compare more closely the experience of 
 FrencTi practitioners during the epidemics of the last 
 few years with the observations of Bretonneau. AYe 
 shall confine ourselves to a few of the most important 
 points. 
 
 In his Tmite de la Diphtherlte, Bretonneau says 
 little of the constitutional symptoms which accompany 
 diphtheria, probably because he did not attribute to 
 them anything more than a secondary importance. 
 He says : — 
 
 "At the onset of diphtheria, the organic functions and 
 those which belong to the life of relation, are so little 
 disturbed that children who are already dangerously 
 affected by malignant angina, generally retain their 
 
 habitual appetite, and continue their play 
 
 The disease only becomes mortal when the membranous 
 layers which line the interior of the air-passages, form, 
 by their accumulation, or by their adherence, a mechani- 
 cal obstacle to respiration If a topical treat- 
 ment modifies the diphtheritic inflammation, the return 
 to health follows immediately on the cessation of the 
 local disease.'" 
 
 In a recent paper in the Archives Genemles de Mede- 
 cine, to which we have before alluded, Bretonneau has 
 somewhat modified his idea that diphtheria is essentially 
 a local disease. In the recent epidemics in France, the 
 disease has come on insidiously, and hastened to a 
 
 ' Addition suppleuieutairo au Traite do la Uiplitherite. 
 
NATURE. 31 
 
 fatal termination in a manner not to be explained by 
 such a theory. Still maintaining the opinion that the 
 constitutional state of diphtheria is secondarj^ and 
 incapable of existing independently of the local changes, 
 he assumes that whenever the disease takes on a sud- 
 denly fatal form, whenever the constitutional seem to 
 precede the local symptoms, an explanation is to be 
 found "not in the antecedence of a morbid diathesis, but 
 in the secret development of diphtheria in the nostrils." 
 And this assumption seems to be founded solely upon 
 the fact that in some cases coryza and glandular swell- 
 ings have preceded the graver symptoms. 
 
 Although we cannot by any means agree with the 
 distinguished observer in views which are so much at 
 variance with modern experience, we must do him the 
 justice to say that the characters of the disease, as 
 observed by him in 1826, were undoubtedly as he has 
 described them, but that, during the last few years, 
 the disease has assumed new forms and been attended 
 with new dangers. Trousseau has most distinctly 
 admitted this change of type of diphtheria, in the 
 Gazette des Hopitaux, 1855 : — 
 
 " There is a form of diphtheria to which, for seven or 
 eight years past, innumerable victims have succumbed, 
 which differs so completely from all others in the 
 general aspect of its symptoms, that one would be 
 tempted to establish a line of demarcation; but in direct- 
 ing our attention to its mode of invasion and etiology, 
 we have no difl&culty in recognizing conformity and 
 
82 DIPHTHERIA. 
 
 even identity ; tLe difference being that the diphtheritic 
 disease assumes a character of exceptional gravity, and 
 kills at once by the constitutional affection without the 
 participation of the larynx. Usually the sore throat 
 seems to be the first symptom ; but sometimes it is pre- 
 ceded by a coryza of great severity, as if the pituitary 
 membrane had been attacked before the fauces." 
 
 *' There is also swelling of the lymphatic ganglia of 
 the neck, which is sometimes so enormous as to extend 
 beyond the jaw. 
 
 " Join to this acute pain in the head, extremely intense 
 fever (excessive frequency of the pulse), and you will 
 have the signs of the onset of the worst forms of diph- 
 theria. Some hours after you will observe false mem- 
 brane on the uvula and velum ; the dischargee from the 
 nose becomes fetid, and if you open the nares with an 
 ear speculum, false membranes are observed on the 
 septum and turbinated bones. The patient does not 
 sleep, and is in a state of extreme agitation ; the 
 breathing is stertorous and snoring 
 
 "After thirty-six or forty-eight hours, the features 
 assume a livid pallor, delirium follows, and the unfortu- 
 nate patient dies with all the appearance of amemia, and 
 in a state of somnolent tranquillity which strongly con- 
 trasts with the agitation that distinguishes the agony of 
 croup. It is impossible to describe the horrible prostra- 
 tion, the powerless exhaustion, the frequent faintings, 
 in one of which the thread of life is often severed." 
 
 Again, in the course of a report read before the 
 
NATURE. 33 
 
 Imperial Academy of Medicine, on the 2d ISTovember, 
 1851, M. Trousseau makes tlie followinor remarks: — • 
 
 " Those of us who for twenty -five years have followed 
 the epidemics of diphtheria which have stricken the 
 capital, may satisfy ourselves that the disease has not 
 only extended itself considerably, particularly during 
 the last twelve or thirteen years, but has assumed a 
 much graver form. Up to about 1846, diphtheria 
 scarcely appeared in the epidemic form, and the cases of 
 it which were observed in Paris presented all the 
 characters so well described by Bretonneau in his 
 treatise, and so clearly pointed out by Guersant in the 
 Dktionnaire de Mtidecine, where this excellent practitioner 
 confirms in every particular what the illustrious physi- 
 cian of Tours had seen 
 
 "The diphtherite described by Bretonneau generally 
 commenced in the pharynx, and there remained the 
 longer in proportion to the youth of the child, giving 
 rise usually to but little fever, scarcely in any way 
 affecting the rest of the economy, and was propagated 
 to the larynx, thus constituting croup. But within the 
 last ten years, in place of this affection, comparatively of 
 little severity, there has appeared another, in which 
 hitherto all the resources of art have been nearly un- 
 availing. 
 
 "The pharynx, it is true, is most commonly first 
 attacked, but in a little time the disease extends to the 
 nares, to the nasal duct, and sometimes to the internal 
 surface of the eyelids ; and at the same time ataxo- 
 
34 DIPHTHERIA. 
 
 adynamic symptoms become manifest, the pulse becomes 
 very frequent, the cervical glands greatly enlarge, and 
 frequently forty-eight hours after the attack, the patient 
 dies, iviihout the larynx having heen sufficiently affected to 
 suggest the idea of croiij). It seems as though a poison 
 had been introduced into the system, by which the 
 latter had been intimately and rapidly modified." 
 
 So also in the account given by M. Isambert' of the 
 epidemic in Paris in 1856, we find, under the head of 
 malignant diphtheritic angina, the following observa- 
 tions : — 
 
 "We retain the old name of malignant an2:ina to 
 designate that specific form in which the patient suc- 
 cumbs to a profound adynamia, to a general intoxica- 
 tion, and in nowise to the occlusion of the larynx. For 
 in cases of this description tracheotomy not only does 
 not save, but it does not even temporarily relieve the 
 patient. This form of angina seems to have escaped the 
 notice of M. Bretonneau, and as we cannot suppose that 
 a man of his powers of observation could overlook a 
 type of the disease so well marked, we must admit that 
 it did not present itself in those epidemics, in the midst 
 of which the eminent physician wrote his Traite de la 
 Di/phtherite. This form, then, appears to be a new one, 
 although without doubt it is to this that many of the 
 descriptions of the malignant or gangrenous anginas of 
 the early epidemics apply." 
 
 ' Ar.;li. Gen. de Meaecine, 1857. 
 
NATURE. 85 
 
 Having described the anatomical lesions, tlie enormous 
 tumefaction of the cervical glands, and the other local 
 changes, he goes on to say : — 
 
 "These local disorders, so grave in character, are 
 accompanied by a general state not less serious : burn- 
 ing fever, extreme restlessness, insupportable headache, 
 depriving the patient of all sleep, are present; shortly 
 tv^phoid symptoms, the most complete adynamia, declare 
 themselves; the fever appears to diminish towards the 
 end, the pulse becomes small, and the patient falls into 
 a condition of somnolent tranquillity, which announces 
 the termination." 
 
 Were it necessary, in order to prove that the constitu- 
 tional symptoms of diphtheria have not only been pre- 
 sent, but have often assumed a primary importance 
 during the epidemics of the last few years, we might 
 refer to many other papers published by French practi- 
 tioners. We shall have occasion to observe the import- 
 ance of these symptoms when we study the historj^ of 
 the English epidemics. 
 
 One of the points most particularly insisted upon by 
 M. Bretonneau is the absence of all relation between 
 diphtheria and gangrene of the fauces. He even con- 
 siders it characteristic of the affection that the mucous 
 membrane remains unaltered throughout. He says that 
 malignant angina is unaccompanied with any sloughing, 
 and a contrary opinion could only arise from deceptive 
 appearances, for in none of the cases at Tours, even 
 w^hen malignant angina had assumed the most repulsive 
 
36 DIPHTHERIA. 
 
 aspect, could anything be discovered which resembled a 
 gangrenous lesion. 
 
 In this opinion he certainly seems to be supported by 
 historical testimony, especially as regards some of the 
 epidemics of the last century. 
 
 "The results of the analysis of historical testimony do 
 not differ in any respect from those which my own 
 direct observations furnish me."* 
 
 But in others of the recent French epidemics, in 
 which researches were conducted with a special view to 
 a solution of this point, gangrene has occurred as the 
 expected termination of all the most malignant cases, 
 and not as a mere accident. In the epidemic at Paris in 
 1841, described by M. Becquerel, and to which we have 
 already referred, gangrenous sore throat prevailed at the 
 same time wdth cases which presented the true char- 
 acters of diphtheria. The two forms of disease were not 
 to be distinguished as respects their origin, the local 
 affection not being preceded by any constitutional 
 symptoms. The fauces, too, in all cases, at first pre- 
 sented appearances purely diphtheritic. In those which 
 in their progress took on the gangrenous aspect, the 
 exudation became friable, and soon separated from the 
 mucous surface. At first this was usually entire, but 
 exhibited the appearance of a limited eschar, and, on 
 being thrown off, left a deep excavation. The constitu- 
 tional symptoms preceding death were the same as those 
 
 ' Traite de la Diphlherite, p. 13. 
 
NATURE. 87 
 
 wliich usually accompany gangrene — diminution of tern" 
 perature, a rapid and almost imperceptible pulse, great 
 restlessness, frequent vomiting, involuntary stoolS; &;c. 
 These cases were generally fatal. 
 
 From the fact that many of these cases were examined 
 after death, there is no reason to suppose that there 
 could be any mistake as to the actual presence of gan- 
 grene. In 15 cases examined, there was gangrene affect- 
 ing the tonsils exclusively in 9, and in the remaining 6, 
 the pillars of the velum and pharynx. In the tonsil, the 
 gangrene was either in the centre or near the surface. 
 In either case, the resulting cavity was irregular in form, 
 filled with a thin fetid fluid, and was surrounded by 
 softening of the submucous tissue, which was to a 
 greater or less extent converted into greenish-gray 
 detritus. The disintegration evidently commenced be- 
 neath the mucous membrane, which, at first merely 
 swollen and rugose, gradually took on a gangrenous 
 appearance and color, and finally terminated in an 
 eschar. AYhen this separated, the cavity was left 
 exposed. 
 
 The history of this epidemic clearly shows that 
 although the gangrenous form of diphtheria differs from 
 the purely membranous in various ways, yet it occurs 
 under the same epidemic influence. 
 
 M. Isambert, in his account of the Paris epidemics of 
 1855 and '56, distinguishes both forms of diphtheria, the 
 one tending to a fatal result by extension to the larynx, 
 4 
 
38 DIPHTHERIA. 
 
 the other, wliicli lie calls angina maligna diphtheritica, 
 assuming a totally different character. 
 
 " It is particularly to this form," he says, " that are to 
 be referred those confluent exudations of a dirty gray or 
 black color, giving out a gangrenous odor. . . . Several 
 times we have observed undoubted loss of substance 
 beneath the exudation."^ 
 
 Again : — 
 
 "In this disease the membranous exudation, soon 
 after its appearance, softens, and assumes a dirty gray 
 or blackish color, the uncovered mucous surface is livid, 
 the adenetic swelling is enormous, and affects not only 
 the glands themselves, but the cellular tissue, the skin 
 often sloughing from extensive tension." 
 
 Death is preceded by gradually increasing prostra- 
 tion, but not accompanied by any nervous symptoms 
 more marked than those described by M. Becquerel in 
 the account of his epidemic. 
 
 M. Duche gives a description of the diphtherite which 
 has proved so fatal for the last few years in the depart- 
 ment of L'Yonne. 
 
 "The principal features of this epidemic (1858) are 
 cephalalgia, fever more or less intense, and pain in the 
 fauces. Upon examining the mouth, the tonsils are 
 found swollen and red, and on the surface of one — some- 
 times on both at the same time — there is a white patch 
 of variable dimensions. These patches quickly enlarge, 
 
 • Archives Generales, 1857. 
 
NATURE. 89 
 
 reacli tlie velum palati and uvula, wliicli latter, at times, 
 becomes enormously enlarged ; later, they invade the 
 posterior wall of the pharynx, and descend gradually 
 into the larynx and bronchia, and even into the oesopha- 
 gus and digestive organs. 
 
 "The first period, which may be called pharyngeal, is 
 characterized by a painful sensation, and the ejection 
 from the mouth of abundant sputa, mixed with blood 
 and false membrane. The invasion of the larynx is 
 marked by all the signs of croup, and asphyxia rapidly 
 terminates the scene of agony. On the contrary, when 
 the larynx escapes, there is an apparent calm, which de- 
 ceives the most experienced eyes. Then there is a little 
 vomiting of glairy matter, great thirst, absence of pain, 
 but, soon complete prostration ; pulse insensible ; absence 
 of urine during four or five days, and death by syncope. 
 
 "It is generally easy, by aid of curved forceps, to 
 seize and tear away the membranous exudations, when 
 they cover only the tonsils, uvula, or pharynx. The 
 mucous membrane, thus denuded, is livid and bloody ; 
 and in spite of the most energetic cauterizations, a few 
 hours suffice for the reappearance of new morbid forma- 
 tions like the first. Gangrene of the pharynx often 
 terminates the disease in a sudden manner, and we are 
 warned of this fatal issue by the fetor of the breath, and 
 of substances ejected from the mouth." 
 
 According to Bretonneau, diphtheria also includes 
 croup. He says : " Croup is but the extreme degree of 
 malignant angina." Now, it would certainly seem very 
 
40 DIPHTHERIA. 
 
 evident, to those of us who have derived our ideas of 
 the word croup from Dr. Francis Home's description of 
 this affection/ or from the graphic lecture on Cynanche 
 trachealis, by Dr. Watson, that Bretonneau uses the 
 word in a very different sense. 
 
 It is well known that Dr. Home first introduced the 
 term croup into medical literature in 1765, and to him 
 is due the honor of first defining the characters of a dis- 
 ease which had been in part described by the most an- 
 cient authors. He first drew attention to the fact, that 
 the formation of a false membrane in the trachea and 
 larynx is essential to the disease, and constitutes the 
 source of danger. 
 
 Dr. Home's description of croup was not only accepted 
 by most of the physicians of England, but also by many 
 in Europe. His views were especially supported by the 
 writings of Cheyne, Cullen, and others, but still more 
 particularly by the report of the commissioners of the 
 famous concours instituted by Napoleon. The ideas of 
 these writers were, in brief — 
 
 "That croup is an acute inflammation of the mucous 
 membrane of the air-passages, distinguished from others 
 by the rapidity of its progress ; by the existence of con- 
 crete exudation in the larynx, and by the fact that it 
 principally attacks children under ten years of age. 
 They regard cold and moisture as its main causes, and 
 support this inference by all that is known as to the 
 
 ' Inquiry into the Nature, Cause, and Cure of the Croup — Ediuboro', 
 1765. 
 
NATURE. 41 
 
 seasons during wliich the disease is most apt to occnr; 
 and the climates in which it is most prevalent ; and they 
 hold that it is its habit, to select for its invasion, single 
 individuals in large populations, without communicating 
 itself to the rest — in other words, that it is apt to be 
 sporadic, not epidemic." 
 
 Dr. Watson, in his lectures, says : — 
 
 " Some analogy with that disease (croup) it certainly 
 has, but the points of difference are stronger and more 
 essential. It resembles croup, inasmuch as it leads to 
 the production of an adventitious membrane upon a 
 mucous surface. It differs in the position of that mem- 
 brane, which is seldom formed in the trachea. The 
 affection of the windpipe, when it occurs at all, is second- 
 ary, so that the term ^cynanche trachealis' would be 
 quite inappropriate." 
 
 In an admirable lecture on Diphtheria, by Dr. 
 Eanking, and published in the Lancet,^ we find the 
 following remarks : — 
 
 "The great distinctive m.ark between diphtherite and 
 croup, properly so called, is to be found in the locality 
 chiefly affected. In both, it is true, a main feature is the 
 presence of an exudation ; bat in the one disease, it 
 commences in the fauces, and only reaches the windpipe 
 by extension, and in a certain number of cases ; in the 
 other, that of true croup : it commences in the larynx 
 and trachea, and does not necessarily affect the soft parts 
 above the glottis at all. As a consequence of this, a 
 
 1 The Lancet, Jau. 15, 1859. 
 
42 DIPHTHERIA. 
 
 marked difference is also found in the symptoms of the 
 two diseases. In diphtheria the uneasiness is first re- 
 ferred to the parts subservient to deglutition; in croup^ 
 on the contrary, the earliest symptom is that of stridu- 
 lous voice and breathing — a symptom which, in the 
 former, indicates the final development of diseased 
 action." 
 
 Dr. Hauner,^ director of the children's hospital at 
 Munich, concludes a paper upon this subject with the 
 following aphorisms : — 
 
 "1. True croup (laryngeal croup) is a disease proper 
 to childhood, and its cause is chiefly to be sought in the 
 organization (the period of development) of the hirynx 
 at this period of life. 2. The anatomy and physiology 
 of the larynx sufficiently explain the nature of croup. 
 3. It cannot be shown that croup is connected with any 
 peculiarity of the blood crasis. 4. True croup always 
 commences in the larynx, and often passes downwards 
 to the trachea, kc, but it never passes upwards. 5. 
 Laryngeal croup is characterized by a pseudo-membrane 
 of more or less extent. 6. Laryngeal croup is to be 
 carefully distinguished from diphtheritic croup, the 
 latter alwa3^s depending upon a peculiar blood crasis, as 
 seen in other organs of enfeebled individuals. 7. 
 Diphtheritic croup is almost always secondary, and is 
 not essentially different from croup in an after acute 
 exanthemata, 8. The diphtheritic form begins, as a 
 general rule, in the fauces, uvula, tonsils, &;c., and 
 
 ' Journal fur Kinderkrankheiten. 
 
NATURE. 43 
 
 extends hence downwards. It is very rare for it to 
 commence in the larynx or trachea, &c." 
 
 It is well known that Dr. West, in his work upon dis- 
 eases of children, has considered diphtheritis as a form 
 of croup. In the last edition of his work, however, he 
 has seen fit to modify his previous views. In speaking 
 of croup and diphtheria, he says : — 
 
 "Of 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 course, and usually proves amenable to 
 antiphlogistic treatment. The other attacks by prefer- 
 ence 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 attend 
 it. The one selects its victims almost exclusively from 
 among children ; is incapable of being diffused by 
 contagion ; is governed in its prevalence by influence of 
 season, temperature, and climate, but rarely becomes, in 
 the usual acceptation of the term, an epidemic. While 
 the other attacks adults as well as children, is propagated 
 by contagion, and, though it occasionally occurs in a 
 sporadic form, is susceptible of wide-spread epidemic 
 influence. 
 
 . . . . "Different, however, as are the two dis- 
 eases, there are yet between them points of similarity no 
 less strikino:, and the diasrnostic difficulties are still 
 further enhanced by the occasional simultaneous preva- 
 lence of both affections. 
 
44 DIPHTHERIA. 
 
 .... "It has, indeed, been suggested by M. Isam- 
 bert, in a recent valuable paper, that the condition of 
 the subjacent mucous membrane furnisbes a ground of 
 distinction between the affections; and that while in 
 diphtheria the surface beneath the exudation is often 
 ulcerated, no such erosion of the mucous membrane is 
 met with in true croup. This is not, however, accord- 
 ing to my observation, for ulceration of the mucous 
 membrane has come under my notice in primary croup, 
 though less frequently than in cases of the diphtheritic 
 kind. 
 
 "Whatever differences exist between croup and diph- 
 theria, must be sought elsewhere than in the patho- 
 logical changes observable in the respiratory organs ; 
 and the affinities of the latter disease are seen to be to 
 the class of blood diseases, rather than to that of purely 
 local inflammation to which croup belongs." 
 
 With Bretonneau, nearly all French writers regard 
 croup and diphtheria as identical. In justification of 
 this view, so little consonant with our own ideas, we 
 may remark that in France, true croup is commonly 
 introduced by a diphtheritic affection of the fauces, and 
 that sometimes it appears to be contagious, which is not 
 considered to be true of the sporadic disease as observed 
 in England and in our country. ^loreover, in France, 
 it differs by its asthenic character, and to some extent 
 by the nature of the exudation, which is less tenacious. 
 
 In fine, the laryngeal diphtheritis of Bretonneau, and 
 of other French authors, although closely resembling 
 
NATURE. 45 
 
 the disease described by Home, and known to us as 
 croup in its anatomical cliaracters, differs widely in its 
 dynamical ones. Moreover, it is contagious and epi- 
 demic. 
 
 Bretonneau lias also in a measure confounded scarla- 
 tina with diphtheria under the term " Scarlatina Angi- 
 nosa." 
 
 The exact relation which exists between these two 
 diseases has been a much debated question. By some 
 persons the two affections, notwithstanding certain 
 points of strong resemblance, are regarded as essentially 
 different. By others, diphtheria is looked upon as a 
 form of scarlet fever, in which the throat affection is 
 unaccompanied by the eruption w^hich usually charac- 
 terizes it. 
 
 We must admit that there are many circumstances 
 which favor this latter opinion. For instance, not only 
 do the two diseases prevail frequently at the same time 
 in the same region, but even in the same family ; some 
 members being attacked by all the symptoms of true 
 diphtheria, while others present the symptoms of 
 common scarlatina. Then, again, in some instances, 
 in those who have been attacked by diphtheria, a rash 
 very similar to that of scarlatina has been observed. 
 This rash may have been very partial, and may have 
 remained but a few hours, but its characters have been 
 thought sufficiently marked to leave no douhit as to its 
 nature. Moreover, since the albuminous condition of 
 the urine has been so frequently observed in cases of 
 
46 DIPHTHERIA. 
 
 diplitberia, it may be tLonght that the analogy between 
 the two diseases is drawn still closer. 
 
 These facts are certainly of great weight, but we shall 
 see that there are other considerations still stronger 
 which may be adduced in favor of the essential differ- 
 ence between the two diseases. For example, as regards 
 the existence of a rash. This has certainly been occa- 
 sionally noticed in some epidemics of diphtheria, but in 
 the great majority it has not been observed at all. 
 Whereas, in epidemics of scarlet fever its absence is a 
 rare exception, and occurs only in those cases of very 
 malignant character which are marked by great cerebral 
 disturbance, violent delirium, and by speedy death. 
 In diphtheria, on the other hand, the intellect remains 
 undisturbed until the very last. 
 
 Then, again, the rash is in many respects dissimilar 
 from that seen in scarlatina. It is described as being 
 for the most part, of a uniform erythematous redness, 
 without the peculiar punctated appearance of the scarlet 
 fever rash, appearing suddenly in patches, not deepening 
 in intensity gradually, and not followed by any change 
 in the other symptoms, nor by any increase in their 
 severity. 
 
 As to the presence of albumen in the urine, there are 
 certain points to be especially observed. When present 
 there is no diminution in the quantity of the secretion, 
 neither is frhere any other particular change in its charac- 
 ter. Moreover, the albumen seems often to disappear at 
 a very early period of the disease. 
 
NATURE. 47 
 
 "Its disappearance takes place suddenly, and thougli 
 its presence is usually observed in cases where this dis- 
 ease is severe, yet there does not seem to be any neces- 
 sary connection between the urine becoming non- 
 albuminous, and the disease assuming a milder type." 
 
 Again, the sequelae of the two diseases are widely 
 different. For while, on the one hand, we have none of 
 the formidable dropsical symptoms in the convalescence 
 of diphtheria, which so often succeed scarlatina, on the 
 other, we do have a peculiar loss of nervous power, and 
 temporary muscular paralysis which have no analogy 
 to anything in the sequelae of the latter disease. 
 
 Dr. GreenhoW; in his excellent monograph^ on this 
 disease, says : — 
 
 "Besides the absence after diphtheria of the well 
 known sequelae of scarlet fever, the former disease is 
 succeeded by sequelae of a character peculiar to itself, 
 and such as have not been found to follow scarlet fever. 
 These are partial paralysis of the muscles of deglutition 
 and voice, impairment or disorder of vision, paraplegia, 
 hemiplegia, partial paralysis of the upper extremities, 
 numbness of the hands or feet, tenderness, pricking or 
 tingling of the extremities, and gastrodjmia. Then, 
 lastly, the occurrence of diphtheria on other parts of the 
 body, as on abrasions of the skin or wounds, or on the 
 pudenda, has no parallel in scarlet fever. When to 
 these differences we add that the anaemia which soon 
 
 > On Diphtheria, by Edw. Headlam Greenhow, M. D., F. R. C. P. 
 N.Y.,1861. 
 
48 DIPHTHERIA. 
 
 occurs, and for a long time succeeds to diplitberia, is 
 more intense than in almost any other acute disease, 
 there can be little hesitation in accepting the conclusion 
 that diphtheria and scarlet fever are not the same disease." 
 
 Lastly, almost universal experience bears testimony to 
 this fact, viz., that diphtheria does not protect from 
 scarlet fever, nor, on the other hand, does scarlet fever 
 prove any defence against diphtheria. Of this the 
 following may serve as examples : — 
 
 "Three children in a family in my district (Islington) 
 were attacked with diphtheria in August, 1858. Two 
 of them died ; the third, aged three years, recovered. I 
 saw these children, and satisfied myself that there was 
 no error in the diagnosis. In January, 1859, the child 
 that recovered was attacked with scarlet fever, after 
 playing about upon a carpet brought from a house 
 where a fatal case of this disease had occurred. There 
 was both the rash, and the usual throat affection, but no 
 diphtheritic exudation ; and the child died."^ 
 
 Dr. West gives the following case : — 
 
 "In a school in the neighborhood of London, diph- 
 theria broke out ; many of the lads w^ere affected by it, 
 and one or two died. Several of those who were conva- 
 lescent from the disease were sent to the sea coast for 
 the more speedy recovery of their strength, and while 
 there some were attacked by scarlet fever, and this also, 
 in one or two cases, proved fLital."'^ 
 
 1 Dr. Eclw. Ballard, Med. Times and Gazette, July 23,1859. 
 
 2 Dr. West, Diseases of Childhood, 1S50. 
 
HISTORY. 49 
 
 Dr. Greenhow states that, at the outset of his in- 
 quiries, he was inclined to doubt that diphtheria was 
 entirely distinct from scarlatina. But careful observa- 
 tion aud more ample experience have satisfied him that 
 notwithstanding their frequent occurrence in the same 
 place, and their occasional coincidence in the same 
 individual, diphtheria and scarlatina are distinct dis- 
 eases. 
 
 Numerous cases similar to these might be cited. 
 And, although further and more accurate observations 
 may hereafter tend to a different conclusion, we are 
 decidedly of the opinion that the balance of evidence at 
 the present time is in favor of the non-identity of scarla- 
 tina and diphtheria. 
 
 As regards the history of the earlier epidemics of 
 "sore throat" in England, we have few reliable accounts, 
 and even of the origin and progress of the late epi- 
 demics of diphtheria, our knowledge is far from being 
 either accurate or satisfactory. We have already alluded 
 to the description of the epidemics of throat disease 
 by Fothergill and Huxham, about the middle of the last 
 century, as also to the admirable paper of Dr. Starr. 
 The first of these writers, as we have seen, speaks dis- 
 tinctly of sloughs in the fauces which leave ulcers. 
 Huxham and Starr speak of the exudation extending to 
 the air-passages. It is not a little remarkable, that the 
 same neighborhood in Cornwall (Liskeard and the other 
 towns in which the epidemic of ulcerous sore throat 
 described by Dr. Huxham prevailed), has been subject 
 5 
 
60 diphthp:ria. 
 
 during the last three years to a similar affection, and 
 which closely resembles the disease described by M. 
 Becquerel, inasmuch as the membranous exudation of 
 unusual thickness is associated with softening and 
 destruction of the submucous tissue. This epidemic 
 has been well described by Mr. Thompson, of Laun- 
 ceston.' 
 
 "About three years since, this neighborhood was 
 visited by an epidemic of this disease. The first cases 
 occurred in the town ; and no others then appeared for 
 several months, when it again broke out in the district 
 north of this place, where it prevailed for several 
 months ; whilst the south side was comparativel}^ free 
 from it. From the north it gradually spread until the 
 whole line of country had been visited by it. There 
 appeared to be no difference in the geological nature of 
 the country, the level, or the aspect, in increasing the 
 severity, or granting an immunity from the disease. 
 The premonitory symptoms varied somewhat. A few 
 retired to rest comparatively well, and awoke in the 
 morning with the throat sore, and covered with white 
 deposit. In the majority it was preceded by all the 
 ordinary symptoms of pyrexia, of which headache was 
 one of the most severe ; followed in the course of a day 
 or two by the usual throat symptoms. An extreme 
 feeling of depression, not to be accounted for by the 
 amount of mischief in the throat, was a characteristic 
 
 ' Brit. Med. Journal, June, 1858. 
 
HISTORY. 51 
 
 symptom in eacTi case. An external examination of the 
 throat showed the tonsil generally to be swollen, hard, 
 and tender to the touch ; whilst sometimes the parotid 
 gland participated in the swelling. Internally the tonsil 
 was swollen, and either covered with the diphtheritic 
 deposit which frequently extended over the pharynx, 
 and sometimes into the nares and palate; or else it 
 would be scooped out into an ulcer with raised violet- 
 colored edges; the floor exhibiting a dark ash-colored 
 slough. In some instances there would be no deposit or 
 ulceration at first, but simply the tonsil painful and en- 
 larged. These cases generally change for a state of 
 ulceration, which began in several distinct spots, and 
 gradually spread over the whole tonsil. In the most 
 severe examples, the tonsil sometimes sloughed en masse. 
 I saw one instance in which this occurred in an early 
 stage of the disease, and where now (two years since it 
 occurred) a cavity remains capable of containing a 
 pigeon's egg, across the surface of which extends a small 
 band of mucous membrane which did not slough at the 
 same time, and gives great inconvenience from retaining 
 the food impacted in the hollow during deglutition. I 
 have seen no case in which I could detect the extension 
 of the disease into the oesophagus ; but in many it has 
 entered into the air-passages, this being the most fre- 
 quent and most fatal complication." 
 
 "It can scarcely fail to strike the reader that the 
 affection under consideration would be just as correctly 
 
52 DIPHTHERIA. 
 
 designated by tlie term 'sore tliroat witli ulcers,' em- 
 ployed by nuxbam and Fothergill, as by that of diph- 
 theria, a fact which appears the more remarkable when 
 w^e consider that the very towns in which Iluxham's dis- 
 ease most prevailed in 1748-50, have been most severely 
 visited during the last few years. Are these two epi- 
 demics, separated by an interval of more than a century, 
 of the same nature? A careful comparison of their 
 symptoms assures us that they are, and that Bretonneau, 
 in disclaiming all relationship between his diphtheria 
 and the ' sore throat with ulcers,' was mistaken."^ 
 
 As we have before remarked, in the year 1765 Dr. 
 Home published a small treatise^ upon a disease of the 
 larynx which had long been known, but the characters 
 of which had never been clearly defined. To this he 
 gave the name of croup, and upon this essay the modern 
 doctrine of croup is based. Home's description is based 
 upon the careful observation of twelve cases, in ten of 
 which post-mortem examinations were made. He first 
 pointed out that the formation of a false membrane is 
 essential to the disease, and that its presence in the 
 larynx is the source of danger. Others also published 
 their observations upon this disease, among whom were 
 Cheyne and Cullen. The affection described by these 
 writers is essentially different from the croup of Breton- 
 neau. 
 
 ' Brit, and For. Med.-Cliir. Review, Jan. 18G0. 
 
 2 Inquiry into the Nature, Cause, and Cure of Croup, Edinb., 17G5. 
 
HISTORY. 53 
 
 From this time, until its recent outbreak, although we 
 may gather a few scattering allusions to diphtheria from 
 British medical literature, it was a disease practically 
 unknown to even the most experienced of English 
 practitioners, certainly, in the form in which it has of 
 late presented itself. 
 
 The advent of the present epidemics of the disease 
 attracted public attention in England, in the autumn of 
 1857, a few cases having occurred for twelve months 
 previously. It first appeared in the southeastern coun-^ 
 ties, especially in Kent, in the town of Canterbury. In 
 Essex, particularly in the marshy districts, it prevailed 
 extensively; thence it spread through all the eastern 
 counties. 
 
 "The local name was 'throat fever.' It appeared 
 after arriving at a certain stage to baffle medical skill, 
 and something of a fungus nature showed itself in the 
 throat. Croupal suffocation was one of its complica- 
 tions, which appears to eliminate 'putrid sore throat,' 
 and those, therefore, who classify this Cornish epidemic 
 with diphtheria are probably warranted in so doing.'" 
 
 During the next summer months the disease spread 
 northwards to Lincolnshire and Yorkshire. In the 
 winter months of 1858 the southeastern counties still 
 suffered. In parts of Essex the disease was almost 
 universal. 
 
 ' Ou Diphtlieria, hy Ernest Hart, London, 1859. 
 5^ 
 
54 DIPHTHERIA. 
 
 "At Teignmouth, Mr. Lake observed cases of that 
 severest form of diphtheric inflammation, in which the 
 local manifestation of the disease is from the first over- 
 shadowed in importance by the constitutional symptoms. 
 The blood-making powers were seriously compromised 
 after the annihilation of the throat affection, the patient 
 sinking then through general failure of the powers of 
 life, without anything like typhoid symptoms, a distinc- 
 tion which it is very important to maintain, or being left 
 in a state in which he is liable to be carried off* by any 
 prevalent disorder, or during convalescence continuing 
 unusually weak and anaemic." 
 
 In Suffolk, and in some of the eastern counties, 
 as also in Nottinghamshire, scarlatina prevailed in con- 
 junction with diphtheria. In the northwestern counties 
 we find hooping-cough and diphtheria prevailing. 
 
 In fact the disease spread to almost all parts of Eng- 
 land, appearing with much greater severity in some 
 localities than in others. Dr. Hart has given in his 
 report a very succinct account of its progress through 
 the country. 
 
 If now we examine some of the various accounts of 
 the recent epidemics in England, as they have appeared 
 in different parts of the country, there will be seen to be 
 a considerable amount of discrepance, and, moreover, 
 many of the accounts will be found to differ widely 
 from Bretonneau's model. We select a few as they have 
 appeared in the various journals of the day : — 
 
HISTORY. 55 
 
 At a meeting of the Harveian Society,^ Dr. B, Sander- 
 son said : — 
 
 "That the disease recently prevalent in England was 
 identical with the malignant sore throat described by 
 many authors, and that in a great number of instances 
 scarlatina precedes it. It was attended with much fever 
 and fetid breath, the fever sometimes of a typhoid char- 
 acter. The thickness and adhesiveness of the exudation 
 were less marked than that occurrino^ at Tours. In Encr- 
 land exhaustion and fever destroyed the patient rather 
 than asphyxia, which suddenly put an end to Breton- 
 neau's patients. In true diphtheria there was no fever 
 and no fetid breath ; both these were remarked in this 
 country. Finally, he believed croup and diphtheria 
 identical, and that the disease in England was not diph- 
 therite, but the pultaceous pharyngitis of the French." 
 
 Dr. Laycock, of Edinburgh, in a clinical lecture, 
 published in May, 1858, regards diphtheria as a disease 
 produced by a fungous growth — "oidium albicans" — ■ 
 similar to that found in thrush. He says: — 
 
 "If the fungus multiply in a population at the same 
 time that there is an epidemic of scarlatina or rubeola 
 prevalent, that epidemic may be expected to take the 
 diphtheritic form." 
 
 His remarks, however, appear to be based solely on 
 the following case, in which there was an aphthous 
 affection of the mouth and throat. 
 
 James D , aged 35, married — admitted into the 
 
 • Lancet, Oct. ]858. 
 
56 DIPHTHERIA. 
 
 Infirmary Marcli 19 — stated that, until two years ago, 
 his health was good. About that time he had diarrhoea 
 with frequent desire to go to stool, and much straining 
 at stool without result. A few weeks afterwards had 
 shiverings and sweatings, and a peculiar feeling of 
 numbness, with loss of sensibility in upper and lower ex- 
 tremities. The arms would become stiff. At present, 
 the attacks of stiffness come on only when his hands are 
 placed behind the back. Continued at work until eight 
 days ago. 
 
 On examination it was found that he slept well, 
 swallowed easily, had no pain after eating, but was flatu- 
 lent. Bowels regular, motions solid. Abdomen large 
 and tumid. Urine of spec. grav. 100.5, no albumen, no 
 sugar — amount seventy ounces per diem. Under the 
 microscope, the blood was seen to contain colorless cor- 
 puscles in slightly increased quantity. Lungs healthy, 
 no cough or expectoration. His skin under the clothing 
 was pale; the inner surface of the lips pallid, the face unu- 
 sually brown, but evidently from atmospheric pressure. 
 In three weeks after admission, the bowels became re- 
 laxed, and by April 13 an obstinate diarrhoea had set in, 
 which resisted all the usual remedies. On the 15th he 
 complained of sore throat, and on examination, the fauces 
 were seen to be deeply congested, and covered with 
 white spots. The tongue had also white patches upon it. 
 He still complained of the hypersesthetic sensations in 
 his arms, and was hopeless as to his recovery. On 
 April 23, pulse 120, deglutition difficult, with a constant 
 
HISTORY. 57 
 
 burniDg pain in the throat. On the 24th the pharynx 
 was seen to be covered with a thick yellowish pellicle, 
 and the surface beneath, when it was detached, was raw 
 and bleeding. The pellicle, when a fragment was placed 
 under the microscope, was found to consist of the 
 mycelium and sporules of the oidium albicans, with epi- 
 thelium and pus cells. He was ordered 'the aqua chlo- 
 rinata, and a solution to the fauces of nitrate of silver. 
 .... The patient gradually sank until the morning of 
 the 11th inst., when he died. - 
 Autopsy. — On removing the tongue, trachea and 
 oesophagus, it was found that a soft yellowish- white pul- 
 taceous matter was adherent to the mucous membrane of 
 the tongue, pharynx, and oesophagus. This occurred in 
 some places as a continuous layer, in other places as 
 patches. It could be readily scraped ofl^ when the 
 mucous membrane was found to present a somewhat raw 
 appearance. It was most abundant in the pharynx over 
 the back of the larynx. The matter extended down the 
 oesophagus to within two inches of the stomach. On 
 examining microscopically the matter found on the 
 mucous membrane, it was seen to consist of the 
 branching filaments and sporules of the oidium albicans, 
 mixed with large quantities of somewhat altered epi- 
 thelial scales. The larynx and trachea were quite natu- 
 ral The mesentery was found to be converted 
 
 into a large cancerous mass; the lumbar glands and 
 supra-renal capsules were also implicated in the same 
 disease. 
 
58 DIPHTHERIA. 
 
 Comment hy Dr. Lmjcoch. — The immediate cause of 
 death was the exhausting diarrhoea. Now this super- 
 vened coincidently with an attack of diphtheria. At 
 the onset of the disease, and just at the period before 
 death, we found in the pellicle formed on the tongue 
 and fauces, the sporules and mycelium of the o'idium 
 albicans, a parasitic fungus found also in muguet, the 
 epidemic aphtha or diphtheria of infants in France. 
 This is an interesting fact at the present moment, when 
 diphtherite is prevailing, more especially as the pellicle 
 was also found abundantly after death in the oesophagus. 
 I have little doubt that this pellicle was due to the action 
 of the parasite on the enfeebled mucous surface of the 
 mouth, fauces, &;c. It acts like all its tribe, as an irritant 
 inducing increased formation of epithelial scales, and 
 effusion of mucous exudation, corpuscles or plasma; 
 intermingled among these are the sporules, and the 
 mycelium of the microscopic fungus ; the whole consti- 
 tutes a pellicle or membrane, varying in thickness. 
 (Fig. 1.) The parasite seems to act upon the capillaries 
 of the subjacent tissue, as, when removed, blood is not 
 uncommonly effused, and the surface looks raw. Diph- 
 theria is not, however, limited to one form of disease. 
 
 .... If the fungus multiply in a population at the 
 same time that there is an epidemic of scarlatina or 
 rubeola prevalent therein, that epidemic may be ex- 
 pected to take the diphtheritic form in those cases which 
 are attacked by the o'idium. I must add, however, that 
 we have had reasons for thinking that the oidium, 
 
HISTORY, 
 
 59 
 
 acting alone, will fasten upon tlie mucous membrane of 
 the mouth and throat, and excite inflammation and 
 without the formation of a pellicle The diagnosis 
 
 Fig. 1. 
 
 The sporules and the mycelium of the o'idium. After Eobia, 
 
 of diphtheritic oidium from ordinary aphtha is founded, 
 first, on the character of the morbid appearance, for, in 
 ordinary aphtha, the disease is vesicular, and the white 
 specks or patches are ulcers, while in diphtheria, they 
 
60 DIPHTHERIA. 
 
 are pellicular, and not ulcerative, while the redness is 
 much deeper than in aphtha. Besides, the microscope 
 may reveal the spores and mycelium of the fungus. The 
 development of the mycelium is, however, by no means 
 a necessary result of the action of the fungus. This 
 seems to be peculiar to the more advanced stages; at 
 first there is not even a pellicle, only characteristic red- 
 ness of the affected surface Further, it is pro- 
 bable that besides the stage of development, the condition 
 of the hahiiat may make a considerable difference as to 
 
 the mordid products How great a share these 
 
 microscopic parasitic organisms have in the causation of 
 disease, remains yet to be ascertained. 
 
 In answer to remarks made by Dr. Kogers, that he not 
 only thinks diphtheria to be a blood disease, but that, as 
 such, it cannot be a parasitic disease. Dr. Laycock says 
 {Lancet, Jan. 22 and 29, 1859): "Comparative pathology 
 teaches, however, that this conclusion is at least doubt- 
 ful. The muscardine (an epizootic disease of the silk- 
 worm) is due to a species of fungus like that which 
 infects the potato, called, after its discoverer, the Botrytis 
 bassiana, and the sporules are described as being repro- 
 duced in the blood of the insect when it becomes acid ; 
 while the filaments and mycelium appear on the respi- 
 ratory surfaces, that is, at the outlets of the tracheal 
 tubes. 
 
 " Again, the fungus of the common house fly (Mj^co- 
 phyton Cohnii) is a mould or oidium found in the blood, 
 abdomen, and sometimes in the intestines of the insect at 
 
HISTORY. 61 
 
 beginning of autumn. Its first symptom o"bservecl, is a 
 milky appearance of the blood. It is found in tlie blood 
 in all stages of development, from tlie simple minute 
 spore or cell, to the full-grown mycelium. It is found 
 in like manner in the fluids of the intestines, and appears 
 externally as a mould. Flies thus affected may be often 
 seen sticking with outstretched wings to the window 
 panes at the end of the summer and beginning of autumn. 
 These are by no means solitary instances of parasitic 
 blood disease. Indeed, hamatophyta, as Lebert terms 
 these microscopic blood parasites, infest the blood of 
 several classes of insects. The same facts also hold good 
 
 as to the vegetable parasites These are facts 
 
 which ought to make us hesitate, at least in coming to 
 the conclusion, in the absence of all inquiry, that a 
 parasitic disease cannot be a blood disease in man. 
 
 .... "That these parasites are sometimes powerful 
 irritants of the lining tissues, is, I think, fully established 
 both from the history of muguet and other circum- 
 stances, and although French writers speak of X'^eudo- 
 diphtherite, the accuracy of the term may be ques- 
 tioned, for the exudation appears externally on ulce- 
 rated or exposed surfaces, as well as internally, in both 
 muguet and diphtheria alike. An interesting case of 
 vaginal blennorrhoea, due probably to oidium albicans 
 introduced from without, may be found in ArcMv fur 
 Fhysiologle, vol. ix. p. 466. The labia were swollen, the 
 vagina of a bright-red, studded with enlarged papillae, 
 and covered with star-like patches of membrane, like 
 6 
 
62 DIPHTHERIA. 
 
 those of the mouth in muguet^ which were found to 
 contain the 0. albicans. The patient in the next bed 
 had subsequently active fever, abdominal tenderness, O. 
 albicans of the mouth with muguet. 
 
 '' It is usual to speak of the characteristic pellicle as 
 if it were peculiar to diphtheria, but this is by no means 
 the case. It is not unfrequently seen in cases of typhus 
 and relapsing fever, sometimes in yellow fever, and I 
 believe in all fevers. A series of carefully conducted 
 experiments, made with a thorough knowledge of 
 crj^ptogamic botany on lower animals so as to show the 
 real pathological origin and the effects of these parasitic 
 
 fungi, would be very valuable I am inclined 
 
 to think that it would probably be shown that these 
 parasites may act either through the blood or locally 
 only. 
 
 "I may observe, in conclusion, that antiseptics and 
 parasiticides appear to be the most efficient remedies in 
 diphtheria. I can speak very favorably of the tinct. of 
 the sesquichloride of iron (an antiseptic and hydro- 
 chlorate of potass)." 
 
 Dr. Kingsford,' in a letter to the Lancet, thus speaks 
 of the disease as it has come under his observation : — 
 
 "Diphtheria may be divided into the mild and severe 
 forms. 
 
 ''The mild form, which, for the sake of distinction, 
 may be designated the diphtheritic sore throat, is ushered 
 
 Lancet, Nov. 1858. 
 
HISTORY. 63 
 
 in by a variable amount of feverishness, loss of appetite, 
 and at first only slight pain in swallowing ; the tongue 
 presents a thick, white, creamy coat, through which 
 some of the papillas are visible ; the velum palati, uvula, 
 and pharynx are of a bright red color ; the tonsils are 
 much swollen, and of the same livid hue, and upon the 
 inner side of one or both of them distinct white patches 
 are seen, which in some instances resemble an exudation 
 from the sulci of the tumid gland, but more frequently 
 are flat and filmy in appearance, not confined to the 
 tonsils alone, but spread over the uvula and posterior 
 wall of the pharynx ; both the exudation and the filmy 
 deposit adhere tenaciously to the submucous surface, 
 and cannot easily be scraped off. Ulcerative stomatitis 
 not rarely precedes and accompanies this mild form of 
 diphtheria — indeed, by some they are considered to be 
 identical ; the parotid and submaxillary glands- are not 
 much swollen, although one or two enlarged glandulas 
 concatenat^e may often be detected. 
 
 "The severe form, or genuine diphtheria, is always 
 characterized by a high state of fever, hot, pungent skin, 
 flushed countenance, congested lips, a rapid, feeble pulse, 
 great difficulty in swallowing, and hurried respiration ; 
 the tongue is covered by a thick, dirty, yellowish-brown 
 or sometimes slaty-colored coat ; the velum palati, uvula 
 and pharynx are of a deep, dark, erysipelatous redness ; 
 the tonsils usually enormously swollen, and of the same 
 dark red color, but instead of the white patches ob- 
 served in the mild form a large ash-colored membrane 
 
64: DIPnTITERIA. 
 
 is spread over the inner side of one or both tonsils, and 
 also upon the uvula and posterior wall of the pharynx. 
 As the disease advances, the above symptoms increase 
 in severity; the breathing becomes stertorous from 
 mechanical obstruction; deglutition so painful that 
 young children will refuse to swallow even liquids ; the 
 saliva dribbles from the mouth, and a foul acrid dis- 
 charge often flows from the nares; the pulse becomes 
 more rapid and feeble ; the glands of the neck are 
 now swollen and tender, and the voice is hoarse and 
 indistinct; the patient restless, tosses about upon the 
 bed, or else lies on his . back in a semi-comatose state. 
 These cases, Avhen fatal, terminate either by rapid pros- 
 tration of the vital powders, or by an affection simulating 
 croup, from extension of the diphtheritic membrane into 
 the air-passages ; in both instances death is usually pre- 
 ceded by obstinate vomiting, probably the result of 
 inflammation or irritation of the par vagum. . . . 
 
 " In fatal cases, the 2^ost-mortem examination reveals 
 the ash-colored membrane spread over the pharynx, 
 extending to the posterior nares and down the oeso- 
 phagus; but when death is preceded by symptoms of 
 cronp, it is found also in the larynx and trachea. Upon 
 detach in q: this membranous exudation, the submucous 
 surface presents an ecchymosed appearance, but no dis- 
 tinct signs of ulceration." 
 
 Dr. Ileslop, in a communication to the Medical Times 
 (Did Ga?:ctie,^ expresses his belief that, although so little 
 
 ' May 29, 1858. 
 
HISTORY. 65 
 
 known now, this disease was well understood and de- 
 scribed by former British authors, especially Fothergill. 
 It is a pestilence with well-marked features. It is con- 
 tagious, though not highly so, and its ataxic phenomena 
 are most striking — prostration, quite disproportionate to 
 the amount of disease in the throat, coming on early, 
 and remaining after all other indications of disease have 
 passed away. In the worst cases a foul, ulcerous condi- 
 tion of the fauces complicates the genuine membranous 
 angina. The mode of death, as in other pestilences, is 
 by asthenia, and frequently the event is sudden and un- 
 looked for. 
 
 Dr. Heslop points out in detail the differences between 
 this affection and croup. 
 
 Dr. Whitehead, in the same journal, describing the 
 disease, states that the symptoms are very similar to 
 those of croup, but that they come on suddenly, without 
 the peculiar crowing, after what seems a slight sore 
 throat. On examining the fauces then, they are found 
 red and dry, the tonsils dripping with a thick, opaque, 
 offensive matter. Sometimes there is also great external 
 swelling of the throat. 
 
 Dr. Camps' believes that three distinct varieties of the 
 disease, if not three distinct diseases, have prevailed. 
 1. Cases which have presented a precise resemblance to 
 those described by Bretonneau. 2. Other cases present- 
 ing many of the characters of the Fothergill sore throat. 
 
 ' Med. Times and Gazette, Marcli, 1853. 
 6^ 
 
66 DIPHTHERIA. 
 
 3. Cases consisting in the sore throat accompanj-ing 
 scarlatina, whether the eruption has been present or not. 
 The type of diphtheria, properly so called, is essentially 
 asthenic. 
 
 Dr Pollock^ conceives that Bretonneau had painted 
 the disease too strongly. True diphtheria, so described; 
 was not a prevalent disease, but many cases more or less 
 approached it. All such arose from poisonous influ- 
 ences, and however different, were yet identical. In the 
 same family these throat affections may approximate to 
 and diverge from the diphtheritic type, there being in 
 some exudations, in others ulceration and excoriation. 
 Mr. Bottomley,^ of Croydon, remarks as follows : — 
 '' It appears to me that at the commencement of the 
 attack there is but a slight congestion of the mucous 
 membrane of the pharynx, accompanied with slight 
 constitutional disturbance ; but in a few hours the 
 membrane puts on a livid appearance, and runs rapidly 
 into the gangrenous state ; and that the false membrane 
 is a deposit of layers of lymph in the early stage of the 
 disease, which soon loses its vitality, and acts as an 
 extraneous body, thereby preventing the parts from 
 performing their natural functions, and, accompanying 
 this change, great depression of the vital powers of the 
 system takes place." 
 
 Mr. Thomas Smith, of Kent County, writes : — 
 
 " There are three forms in which the disease presents 
 
 > British Medical Journal, July, 1859. ^ Hjja. 
 
HISTORY. 67 
 
 itself, viz : simple ash-colored diphtheritic membrane in 
 patches, with very slight congestion of the surrounding 
 parts, and without fetor; secondly, a deeper color, and 
 more widely spread membranous exudation, with fetid 
 breath, and intense engorgement of dark hue ; thirdly, 
 the membrane with much tonsillitis, in a few cases 
 resulting in quinsy. But there has been a fourth and 
 more formidable state of things to contend with, viz., 
 an extension of the membrane, in either of the above 
 forms, to the lar3'nx and trachea. . . . Lately there has 
 been more tonsillitis, and frequently superficial ulcera- 
 tion. There is a depression of the vital powers. 
 
 "In observing the progress of this epidemic, I have 
 been instinctively led to reflect on the altered type of 
 disease in general. I have myself no doubt of that 
 alteration in the type of disease observed since the year 
 1832 in England." 
 
 Mr. Cammach,^ of Bennington, remarks : — 
 " Diphtheria was epidemic in this district last year, in 
 November and December, and has been so again since 
 July. Diphtheria varies in extent from simple herpes 
 of the lips or nose, which are covered with vesicles 
 which burst, ulcerate, and heal in two or three days, 
 to the most extensive inflammation and sloughing and 
 ulceration of the cheek, the palate, and the pharynx ; and 
 more in children than in adults. It extends into the 
 larynx and trachea, and kills by asphyxia. In the 
 
 ' Lancet, Oct. 1858. 
 
68 DIPHTHERIA. 
 
 mildest form there is a tendency to ulceration beneath a 
 white, loosely attached membrane. ... In the worst 
 cases its vesicular nature can be distinctly traced, for a 
 few hours after its commencement, from the large patch 
 within the cheek or upon the gum, which will slough 
 like cancrum oris, to the more diffused bullae upon the 
 soft palate and pharynx." 
 
 Dr. Moncton, in a letter to the Medical Times and 
 Gazette, June, 1857, says : — 
 
 "Diphtheria is a distinct disease, easily recognized, and 
 not to be dreaded till such changes have occurred about 
 the fauces and tonsils as it is impossible to overlook. 
 A remote kinship there certainly is between it and scar- 
 let fever, but identical they are not. . . . Though, as the 
 diphtheritic membrane loosens and separates from the 
 surface of the throat and tonsil, sloughing ulceration 
 may ensue, I feel at present fully persuaded that diph- 
 theria and cynanche maligna are not the same thing. . . 
 The constitutional symptoms, at first altogether slight, 
 become very real as the disease advances. The main 
 feature is prostration, not typhoid at all — no coma, no 
 sensorial disturbance throughout, no sordes, no heavy 
 lurid look; and in many cases the practitioner, if not 
 warned by previous experience, or a careful observation 
 of the pulse, is surprised to learn that the patient he left 
 with clear countenance, cheerful manner, and little 
 suffering, a few hours ago, has just gone off, while casu- 
 ally sitting upright, in a fatal syncope. . . . The practi- 
 cal fact is, however, this, that after the fourth or fifth day 
 
HISTORY. 69 
 
 a diphtheritic patient becomes the subject of very real 
 asthenia, not so much perceived by the patient as dis- 
 covered by the lax pupil and feeble pulse, and that this 
 state is the one which, about the eighth day, is too apt to 
 terminate in death." 
 
 Dr. Copeman, in an essay on diphtheria, recently pub- 
 lished, remarks : — 
 
 " On turning our attention to the features presented 
 by the present epidemic, we shall find that, as a general 
 rule, the constitutional symptoms bear but little propor- 
 tion to the local mischief, and the danger chiefly to be 
 feared is the extension of the folse membrane into the 
 larynx and trachea, so as to produce suffocation in the 
 same way as in croup. . . . 
 
 " It is true that on the first appearance of the epidemic, 
 in several instances it knocked down its victims at once, 
 showing itself as a poison too powerful to give time for 
 the development of any decided symptoms, either con- 
 stitutional or local. But this is a character common to 
 almost all severe visitations of epidemic disease at their 
 first onset, and, as I have said before, many of the 
 patients who have since died from it have exhibited no 
 very marked constitutional disturbance." 
 
 Thus it will be seen from these various accounts of 
 the disease, as it manifested itself in Great Britian, that 
 not only was a distinct loss of substance in the fauces 
 frequently observed, but that the great prostration and 
 general constitutional disturbance did not fail to attract 
 the attention of almost every practitioner. 
 
70 DirnTHEEIA. 
 
 If the materials for a full and satisfactory account of 
 tlie epidemics of sore throat wliicli have prevailed in 
 Great Britian are scanty, tlicy are very much more so as 
 regards our own country. 
 
 Dr. Douglas, of Boston, in the year 1736, published 
 an account of the first appearance of a "sore throat dis- 
 temper" in this country. This account is alluded to by 
 Dr. Bard in his valuable paper.^ The epidemic which 
 he describes was very malignant, and was attended 
 with erysipelatous appearances and highly putrid symp- 
 toms. 
 
 In the first volume of Medical Ohservalions and 
 Inquiries, published in London in 1771, is an extract 
 from a letter from Mr. Cadwallader Golden to Dr. 
 Fothergill, concerning the throat distemper, dated — 
 Goldenham, New York, October 1, 1753. lie says : — 
 
 " The first appearance of the throat distemper was at 
 Kingston, an inland town of New England, about 1735. 
 It spread from thence, and spread gradually westward, 
 so that it did not reach Hudson's Kiver till nearly two 
 years afterwards. It continued on the east side of 
 Hudson's Eiver before it passed to the westward, and 
 appeared first in those places to which the people of New 
 England resorted for trade, and in the places through 
 which they travelled. It continued to move westwardly, 
 till, I believe, it has at last spread over all the British 
 
 ' Researches on the Nature, Causes, and Treatment of SufTocativo 
 Angina, kc. By Samuel Bard, M. D., New York. 
 
HISTORY. 71 
 
 Colonies on the Continent. Children and young people 
 were only subject to it, with a few exceptions of some 
 above twenty or thirty, and a very few old people who 
 died of it. The poorer sort of people were more liable 
 to have the disease than those who lived well with all 
 the conveniences of life, and it has been more fatal in the 
 country than in great towns. 
 
 ''In some families it passed like a plague through all 
 their children; in others, only one or two were seized 
 with it. Ever since it came into the part of the country 
 where I live (now about fourteen years), it frequently 
 breaks out in different families and places without any 
 previous observable cause, but does not spread as it did 
 at first. It seems as if some seeds, or leaven, or secret 
 cause remains wherever it goes. When the distemper 
 becomes obvious, it has the common symptoms attending 
 a fever, except that a nausea or vomiting is seldom ob- 
 served to accompany it. 
 
 "It is attended with a moist putrid heat, the skin 
 being seldom parched. The pulse is usually low, but 
 frequent and irregular. The countenance dejected, with 
 lowness of spirits; no considerable thirst; the tongue 
 much furred, and the furring sometimes extends all over 
 the tonsils as far as the eye can reach. At other times, 
 in the milder kind, the tonsils appear only swelled with 
 Avhite specks of about a quarter of an inch or half an 
 inch in diameter, which are thrown off from time to time 
 in tough, cream-colored sloughs. Sometimes all the 
 parts near the gullet or throat are much swelled both 
 
72 DIPHTHERIA. 
 
 inwardly and outwardty, so as to endanger suffocation, 
 and frequently mortify ; but most generally ttie swelling 
 internally is not so much as to make swallowing diffi- 
 cult. Sometimes these swellings impostliumate. The 
 last complaint is commonly of an oppression or strictness 
 in the upper part of the chest, with difficulty of 
 breathing, and a deep, hollow, hoarse cough, ending in a 
 livid, strangled-like countenance, which is soon followed 
 by death. This disease is not often attended with that 
 loss of strength that is usual in other fevers ; so that 
 many have not been confined to their beds, but have 
 walked about the room till within an hour or two of 
 their death ; and it has often appeared no way dangerous 
 to the attendants, till the sick were in their last agony. 
 Some died on the fourth or fifth day ; others on the 
 fourteenth or fifteenth day, or even later. When this 
 disease first appeared, it was treated with the usual 
 evacuations in a common angina, and few escaped. In 
 many families, who had a great many children, all died ; 
 no plague was more destructive." 
 
 As we have before remarked, Dr. Samuel Bard, in 
 1771, gave a very faithful description of an epidemic of 
 sore throat, Avhich prevailed in ISlew York. It will be 
 seen in the extracts which we give from his treatise, 
 that his opinions correspond with those of Bretonneau. 
 He recognizes the analogy between this disease and 
 croup, as well as the manner in Avhich it spreads from 
 the throat to the larynx. He observed it sometimes as 
 
HISTORY. 73 
 
 simple angina ; sometimes as angina complicated with 
 larjaigitis, and occasionally as laryngitis alone. 
 
 In general the disease was limited to children under 
 ten years of age, though some few grown persons, 
 particularly women, had symptoms very similar to it. 
 Most of the persons attacked were observed to droop 
 before they were confined. Usually, the first symptoms 
 were a slightly inflamed eye, a livid countenance, and 
 slight eruptions upon the face. At the same time, or 
 very soon after, those who could speak complained of an 
 uneasy sensation in the throat, but without much sore- 
 ness or pain. Upon examination, the tonsils appeared 
 swelled and highly inflamed, with a few white specks 
 upon them, which, in sonie cases, increased so as to 
 cover them all over with one general slough ; this, how- 
 ever, although a frequent symptom, did not invariably 
 attend the disease. The breath was not offensive, and 
 deglutition but very little impeded. 
 
 These symptoms continued in some cases for five or 
 six days without creating any alarm ; in others, a difli- 
 culty of breathing came on within tv/enty-four hours, 
 especially during sleep, and was often suddenly increased 
 to such an extent as to threaten immediate suflbcation. 
 Generally, it came on later, increased more graduall}^, 
 and was not constant. 
 
 This stage of the disease Avas attended with a very 
 
 great and sudden prostration of strength, a very 
 
 peculiar, hollow, dry cough, and a remarkable change 
 
 in the tone of the voice. In some the voice was almost 
 
 7 
 
71 DIPHTHERIA. 
 
 entirely lost, and would continue very weak and low for 
 several weeks after recovery. These symptoms con- 
 tinued for one, two, or three days, and greatlj^ increased 
 in those who died; purging in several cases came on, 
 the difficulty of breathing became more marked, and the 
 patient died apparently of suffocation. This commonly 
 happened before the end of the fourth or fifth day. One 
 child, however, lived under these circumstances to the 
 eighth day. Shortly before he died, his breath and 
 expectoration were somewhat offensive ; " but this was 
 the only instance in which I could discover anything 
 like a disagreeable smell, either from the breath or 
 expectoration." 
 
 In some cases, instead of the difficulty in respiration, 
 very troublesome ulcers appeared behind the ears. 
 
 '* These began with a few red pimples, which soon ran 
 together, itched violently, and discharged a great deal of 
 very sharp ichor, so as to erode the neighboring parts, 
 and in a few days spread all over the back part of the 
 ear, and down upon the neck." 
 
 In a few cases, swelling of the parotid and sublingual 
 glands was noticed. Dr. Bard says : — 
 
 "I met with but two instances of an3^thing like this 
 complaint in adult persons. Both of these were women, 
 and one of them had assisted in laying out two of the 
 children that died of it. At first her symptoms 
 resembled rather an inflammatory angina; but, about 
 the third day, the tonsils appeared covered in some 
 places with sloughs resembling those on the tonsils; her 
 
HISTORY. 75 
 
 pulse was low and feeble ; she had a moist skin, a dejec- 
 tion of spirits, and some degree of anxiety, though 
 nothing like the difficult breathing of the children. 
 
 " The other was a soldier's wife, who, for some time 
 before she perceived any complaint in her throat, 
 labored under a low fever. Her tonsils were swelled 
 and inflamed, and covered with sloughs resembling 
 those of the children ; but her breath was more offen- 
 sive, and she had no suffocation. 
 
 " I have had an opportunity of examining the nature 
 and seat of this disease from dissection, in three in- 
 stances. One was a child of three years okl. Her first 
 complaint was an uneasiness in her throat. Upon 
 examining it, the tonsils appeared swelled and in- 
 flamed, with large white sloughs upon them, the edges 
 of which were remarkably more red than the other 
 parts of the throat. She had no great soreness in her 
 throat, and could swallow with little or no difficulty. 
 She complained of a pain under left breast ; her pulse 
 was quick, soft, and fluttering. The heat of the body 
 was not very great, and her skin was moist; her face 
 was swelled ; she had a considerable prostration of 
 strength, with a very great difficulty of breathing; a 
 very remarkable hollow cough, and a peculiar change 
 in the tone of her voice. She was exceedingly restless ; 
 was sensible, and when asked a question, would give a 
 pertinent answer; but, otherways, she appeared dull 
 and comatose. All these symptoms continued, or rather 
 
76 DIPHTHERIA. 
 
 increased, until tlie third night, on which she had five 
 or six loose stools, and died early in the morning. 
 
 "Upon examining the body — which was done on the 
 afternoon of the day she died — I found the fauces, uvula, 
 tonsils, and root of the tongue interspersed with sloughs, 
 which still retained their whitish color. Upon remov- 
 ing them, the parts underneath appeared rather pale 
 than inflamed. I perceived no putrid smell from them, 
 nor was the corpse in the least offensive. The oeso- 
 phagus appeared as in a sound state. The epiglottis 
 was a little inflamed on its external surface ; and on the 
 inner side, together with the inside of the whole larynx, 
 was covered with the same tough white sloughs as the 
 glands of the fauces. The whole trachea, from the 
 larynx down to its division in the lungs, was lined with 
 an inspissated mucus, in form of a membrane, remark- 
 ably tough and firm ; which^ when it came to the first 
 subdivisions of the trachea, seemed to grow thin and 
 disappear. It was so tough as to require no inconsider- 
 able force to tear it, and came out whole from the 
 trachea, which it left with much ease; and resembled, 
 more than anything, both in thickness and appearance, 
 a sheath of thin chamois leather. The inner membrane 
 of the trachea was slightly inflamed ; the lungs, too, 
 appeared inflamed, as in peripneumouic cases, particu- 
 larly the right lobe, on which there were many large 
 livid spots, though neither rotten nor offensive; and the 
 left lobe had small black spots on it, resembling those 
 marks left under the skin by gunpowder. Upon cutting 
 
HISTORY. 77 
 
 into any of the larger spots which appeared on the right 
 lobe,. a bloody sanies issued from them without froth- 
 ing." 
 
 Dr. Bard attributes the prevalence of the epidemic 
 which he describes to a particular disposition of the air, 
 or miasmata sui generis — 
 
 " Which more or less, according to particular circum- 
 stances, generate an acrimony in the humors and dispose 
 them to putrefaction; and which have a singular ten- 
 dency to attack the throat and trachea, affecting the 
 mucous glands of these parts in such a way as to occa- 
 sion them to secrete their natural mucus in greater 
 quantities than is sufficient for the purposes of nature, 
 and which in this particular species, Avhen secreted, is 
 really either of a tougher or more viscid consistence 
 than natural, or is disposed to become so from rest and 
 stagnation." 
 
 The disease he considered of an infectious nature. In 
 the treatment bleeding was advocated, according to 
 circumstances, and the use of mercury, gargles, fomenta- 
 tions, &c., as local remedies. 
 
 AYe have devoted much space to the remarks of Dr. 
 Bard. But his little treatise has always been considered 
 as very accurate and truthful in its delineations, and as 
 a valuable contribution to medical science. His ob- 
 servations are quoted by almost all writers on this sub- 
 ject since his day, and particularly by Bretonneau. 
 
 Since the epidemic described by Dr. Bard, we do not 
 find any other of a similar character mentioned by 
 
 7* 
 
78 DIPHTHERIA. 
 
 writers, until, iu 1831, Dr. Bell speaks of Laving wit- 
 nessed this af!ection in an epidemic form in Pliiladel^Dliia. 
 For tlie last few years, however, as in England, diph- 
 theria has been much more frequently met with, and in 
 some portions of the United States, especially in Cali- 
 fornia, very fatal epidemics have prevailed. The 
 medical journals in the various parts of the Union con- 
 tain numerous descriptions of the disease as it has pre- 
 vailed in certain sections. From a few of these we 
 select extracts. 
 
 A terrible epidemic occurred at San Francisco, and iu 
 other towns of California, in the autumn of 1856. It 
 had all the characters of pharyngeal diphtheria. Dr. J. 
 V. Fougeaud^ has published a monograph on this epi- 
 demic, in which he speaks of the mortality amongst 
 children in several counties around the Bay of San 
 Francisco as having "assumed an appalling character." 
 
 "Few children attacked by it recovered. The disease 
 begins in a very insidious manner by a little engorge- 
 ment or inflammation of the soft palate, pharynx, and 
 one of the tonsils. (The attack seldom commences on 
 both at the same time, but soon extends to both if not 
 arrested.) At this period of the malady, the patient 
 complains but little, there is often no fever, or it is very 
 moderate. The pain in the throat is much slighter than 
 in the usual forms of common sore throat, so slight in- 
 
 • Diphtheria: a Concise Historical aiul Critical Essay, &c. Sacra- 
 
 nieiito, lb58. 
 
HISTORY. /y 
 
 deed, that tlie little patients go about playing as if 
 nothing was the matter. In some exceptional cases> 
 however, the fever and inflammation about the pharynx 
 are considerable from the beginning. The character- 
 istic signs of the affection soon follow this period of 
 invasion. They consist in small portions (plaques) of 
 white or yellowish lymph deposited on the soft palate, 
 the tonsils, and the posterior part of the pharynx. The 
 cervical and submaxillary gland becomes inflamed and 
 swollen, and the pain in swallowing and opening the 
 mouth is occasioned more by the engorged state of the 
 glands than by the internal secretion of lymph. These 
 deposits go on increasing in size more or less rapidly, 
 and, in violent cases, in a few hours the whole cavity of 
 the throat is covered by them. Generally one side is 
 more afi'ected than the other, and upon examination the 
 glands corresponding with the parts affected will be 
 found more swollen than those of the opposite side." 
 
 Dr. James Blake,' of Sacramento, in a memoir on 
 this subject, says : — 
 
 "The first effect produced by the poison is evidently 
 on the nervous system. Drowsiness, prostration, or 
 oppression, are manifested by infants, or complained of 
 by adults, and when the disease is prevailing, this desire 
 of children to sleep at other than their usual hours 
 should awaken our suspicions. The pulse is accelerated 
 from the first, but generally soft and typhoid, although 
 
 ' Pacific Med. and Surg. Journal, August, 1858. 
 
80 DIPHTHERIA. 
 
 in some cases it is for a few Lours rather hard. The 
 temperature of the skin is raised, although it is seldom 
 harsh or dry, but frequently moist, or even covered 
 with profuse perspiration. There is seldom any pain, 
 rarely headache or backache. The tongue is usually 
 coated, edges red, and papilla prominent. The appetite 
 may remain good, and the digestion unimpaired. If we 
 examine the throat, we may, even within twelve hours 
 after the occurrence of the first slight symptoms, find 
 the tonsil covered with a grayish, pultaceous exudation, 
 which rapidly extends upwards into the nostrils, and 
 downwards towards the larynx; and again we might 
 detect only a redness of the tonsil, and a small point of 
 exudation two or three days after the commencement of 
 the disease, and at a time when the symptoms of general 
 prostration had become alarming. 
 
 "Again, cases present themselves in which the 
 general symptoms and the anatomical lesions proceed 
 Ijari j)assu ; but in almost every case that I have seen, I 
 have considered that death was the result rather of the 
 action of the poison on the system, than from obstruction 
 of the larynx. In from twelve to twenty-four hours 
 after the formation of exudation on the tonsil, we shall 
 generally find the cervical glands enlarged, and in pro- 
 tracted cases this enlargement may become so great as 
 to afford a serious obstacle to deglutition and respira- 
 tion. I have seen cases in which I think death was 
 thus produced, when the patient might otherwise have 
 rallied from the eftect of the poison. 
 
HISTORY. 81 
 
 "The duration of the disease is very uncertain. I 
 have seen it terminate fatally in four days from the first 
 ascertainable departure from perfect health, and this in 
 a strong, healthy child, and I have witnessed it run 
 along for two or three weeks, and then terminate fatally. 
 The cases that arise from contagion, and remain exposed 
 to the original source of contagion, I believe, as a general 
 rule, run a more rapid course than the sporadic cases ; 
 thus we frequently find two or three children in the 
 same family dying within a day or two of each other, 
 although the sporadic case might have had the disease 
 some days before the others took it. This is probably 
 owing to the continued absorption of the poison in a 
 state of concentration." 
 
 In a communication to the Bostoii Medical and Surgi- 
 cal Journal, Dr. L. K. Beardsley, of Milford, Conn., 
 writes that — 
 
 "This disease [diphtheria] appeared in an epidemic 
 form and with great mortality in this vicinity during 
 the months of March and April last. It first made its 
 appearance in Orange, an adjoining town (which is in 
 an elevated situation, and is a remarkably healthy place, 
 with a sparse population), and for a while was confined 
 entirely to the scholars attending a select school in the 
 village. ..." 
 
 "Fourteen cases out of fifteen, of those who were first 
 attacked, proved fatal, in periods varying from six to 
 twenty-four days. 
 
 "Most persons residing in the district where the dis- 
 
82 DIPnTHERIA.. 
 
 ease first appeared sooner or later had some manifesta- 
 tion of the disease. The period of incubation varied 
 from five to twenty days. The lymphatic glands were 
 in many cases greatly enlarged. 
 
 ''The first symptom of this disease — and it is one 
 which we have never seen referred to by any writer on 
 the subject — was ijctin in the ear. It was not only patho- 
 gnomoniC; but prominent, and almost invariably present, 
 in every case that came under our observation, for a 
 day or two before the patient made the least complaint 
 in any other respect, and before the smallest point or 
 concretion of lymphatic exudation could be discovered 
 on the tonsils or elsewhere." 
 
 The tonsils were enlarged and inflamed, with small 
 points of lymphatic exudation upon them, which gradu- 
 ally spread upwards into the nasal fossa3, and down- 
 wards into the larynx and trachea. There was extreme 
 prostration, depression of the nervous system, feeble 
 pulse, &c., but in no case was there any mental disturb- 
 ance. There was nothing peculiar in the treatment. 
 
 Dr. Beardsley's account is concise, and well drawn up. 
 
 In Albany, N. Y., diphtheria assumed an epidemic 
 character in 1858, proving very destructive. Dr. 
 Willard, of that city, in a paper read before the New 
 York State Medical Society, states that it first appeared 
 in April, 1858, although its greatest severity was in 
 the autumn. In a population of about 60, 000 there 
 were 167 deaths. Of the whole number only three 
 were of adults, the remainder being of children, mostly 
 
HISTORY. 83 
 
 under twelve years of age. The deaths of females were 
 about one-third more than of males. One portion of 
 the city suffered more than another, but no satisfactory 
 connection was traced between the disease and any local 
 cause. 
 
 A few cases of diphtheria have also been observed in 
 Boston, Providence, New Bedford, Weymouth, and in 
 several other portions of ISTew England, but there has 
 been no serious epidemic of the disease in this section of 
 the country, besides those we have mentioned. 
 
 There is reason to believe that the disease may 
 become more firmly established with us, as has been the 
 case in both France and England. 
 
 We have thus given some account of the epidemics 
 of "sore throat" which have prevailed in various por- 
 tions of the world at different periods. On making a 
 comparison, it will be found that all these epidemics 
 possess certain characters in common, although pre- 
 senting occasional features of difference. If we study 
 them together, it will be also seen that they are closely 
 connected b}^ a bond of union which is to be found in 
 the pathological anatomy of the disease, and which con- 
 sists in a peculiar exudation. This was clearly recog- 
 nized by Bretonneau, and is in fact the dominant idea 
 in his memoir upon the subject. Bretonneau was in- 
 correct, however, as we have shown, in bringing together, 
 under the term diphtherite, affections which are se- 
 parated by wide intervals ; he was wrong in supposing 
 the absence of all constitutional sjnnptoms in the disease 
 
84 DIPHTHERIA. 
 
 as also in regard to the integrity of the subjacent 
 mucous membrane on the removal of the exudation. At 
 least, we can truly say that his views on these points do 
 not coincide with what experience has taught us within 
 the last few years. So that, while we give M. Breton- 
 neau the credit of having established these two leading 
 facts — viz., that all the various forms of epidemic sore 
 throat which have prevailed in difierent parts of the 
 world are identical, and that the characteristic of this 
 identity is the existence of the exudation — we must 
 confess that his description is wanting in many points 
 necessary to a faithful representation of the disease. 
 
 We subjoin portions of an article by MM. Barthez and 
 Eilliet, contained in their admirable Traite des Maladies 
 des Enfans, as also the brief definition by Dr. J. Copland 
 in his dictionary as being more comprehensive than the 
 description given by M. Bretonneau. 
 
 "The angina described by authors under the name of 
 gangrenous, pseudo-membranous, coiienneuse, and to 
 which M. Bretonneau has applied the term diphtherite, 
 is a disease which principally attacks children, and the 
 character of which has given ri^e to numerous discus- 
 sions. It may occur as a primary disease (the true diph- 
 therite of Bretonneau), and also as a secondarj^ disease, 
 supervening most commonly upon eruptive fevers. 
 
 " Paiholog leal Anatomy. — The uvula, tonsils, and pha- 
 rynx are covered by false membranes of greater or less 
 thickness, of a 3^ellow or yellowish-white color, and some- 
 times gray. They exhale no fetid smell after death, and 
 
NATUKE. 85 
 
 are generally very firmly adherent to tlie subjacent 
 mucous membrane, especially in tlie pharynx and arch 
 of the palate. The tonsils are rarely covered with a 
 continuous layer, but spotted here and there with patches 
 of various sizes, many of which penetrate into the lacunse 
 of these organs. In the pharynx, the false membrane 
 forms a large plate, a sort of yellow covering to the 
 mucous membrane, sometimes continuous, sometimes 
 disposed in broken or interrupted layers. The false 
 membranes have sometimes a gray color, which led for 
 some time to the belief that they were the result of gan- 
 grene ; but the gangrenous aspect of the pharynx is due 
 to the putrid degeneration of the pellicular concretions 
 themselves. 
 
 ''The exudation of blood, which is not unusual in 
 diphtheritic inflammation, completes the error. The 
 false membrane, colored by this fluid, successively as- 
 sumes different tints, marks of its decomposition. 
 
 '' M. Bretonneau maintains that the mucous membrane 
 subjacent to the exudation for the most part preserves 
 its usual consistence and appearance. ' Slight ecchymo- 
 sis, and a trifling amount of erosion upon the surface, in 
 cases where the disease has been of long standing, con- 
 stitute the chief alterations in the tissues.' In some cases 
 which have come under our observation we have wit- 
 nessed much more serious lesions; but, on the other 
 hand, we have not met with those lines of ecchymosis 
 which are described as being always present in the 
 8 
 
bb DIPHTHERIA. 
 
 pharynx and upon the velum palati. In two cases under 
 our care the pharynx was deeply ulcerated. 
 
 "The tumefaction of the submaxillary glands is a 
 lesion which M. Bretonneau considers as being almost 
 constant. They attain a considerable size, but rarely 
 suppurate. 
 
 " SymiUoms, &c. — Diphtheria commonly sets in with 
 slight febrile symptoms, the strength and appetite not 
 being sensibly affected. The patient complains of a 
 slight pain in the throat: no change in deglutition. 
 Very shortly after the first attack, a slight swelling of 
 the tonsils is observed, and frequently a little exudation 
 of false membrane. Soon whitish or yellowish-white 
 spots are seen on the tonsils, which extend to the larynx, 
 velum palati, and pharynx. Sometimes these are limited 
 to the tonsils and velum palati, when they often lose the 
 white color, and become of a dirty gray, giving out an 
 extremely fetid odor ; an abundance of saliva is at the 
 same time running from the corners of the mouth. The 
 glands of the neck gradually become enlarged. 
 
 "At the end of a certain time, according as the mem- 
 brane is more or less adherent, it commences to separate, 
 and is thrown off. Or, remaining adherent to the 
 mucous surface, it gradually grows thinner, and thus 
 disappears. 
 
 "During the course of the disease, the appetite not 
 unfrequently remains unimpaired. There is neither 
 diarrhcea nor vomiting. If the disease terminates favor- 
 ably, there remains only a slight redness about the 
 
NATURE. 87 
 
 throat. In tlie fatal cases, tlie inflammation extends 
 from tlie fauces to the air-passages, thus giving rise to 
 croup. Occasionally the disease assumes a typhoid 
 character, a condition which has not been observed by 
 M. Bretonneau. When diphtheria runs through its 
 course without complications, it generally lasts from six 
 to nine days ; if croup intervenes, it may prove fatal in 
 one or two days." 
 
 Dr. Copland, in his dictionary, defines diphtheria 
 as follows : — 
 
 " Soreness, pain, and heat in the throat, often increased 
 on deglutition ; redness, with an exudation of a buff or 
 gray-colored lymph in spots at an early stage, com- 
 mencing either in the fauces, on the tonsils, or pharynx, 
 and quickly extending to these, and often also to the 
 larynx and oesophagus; the exudation becoming more 
 continuous and firm, accompanied with fever, and ap- 
 pearing generally either epidemically or endemically." 
 
 If we carefully examine the various epidemics of diph- 
 theria, we shall be able to bring them together under two 
 principal forms of the disease — the mild and the severe. 
 
 The mild form is usually preceded by more or less 
 fever, by some loss of appetite, a slight difficulty in 
 deglutition, with, perhaps, some discomfort about the 
 fauces. The tongue presents a thick whitish coat. On 
 examination, at the very outset of the disease, the velum 
 palati, uvula, and pharynx are of a bright red color. 
 The tonsils are slightly swollen, and are of the same red 
 liue. In a short time, gcnerallj'' from twelve to thirty- 
 
88 DIPHTHERIA. 
 
 six hours after the attack, upon one tonsil, and some- 
 times upon both, are seen distinct white patches of ex- 
 udation of false membrane. These soon extend over 
 the uvula and posterior wall of the pharynx. The ex- 
 udation adheres more or less firmly to the adjacent 
 mucous surface, and cannot be easily removed. In a 
 few cases the exudation remains confined to the tonsils, 
 and neither grows black nor putrefies. The surrounding 
 mucous membrane is swollen and projecting. The 
 parotid and submaxillary glands are not much swollen. 
 
 The duration of the mild form of the disease is from 
 six to nine or ten days. 
 
 In the severe form, the disease is ushered in by intense 
 headache, hot pungent skin, rapid feeble pulse ; there is 
 great difficulty in deglutition, and the respiration is 
 much hurried. The tongue is covered with a thick, 
 dirty brownish coat. On examination of the throat, the 
 tonsils are found enormously swollen and covered with 
 a thick ash-colored membrane, which has also extended 
 to the uvula and to the posterior walls of the pharynx, 
 and not unfrequently gives out a fetid odor. Unless 
 arrested by treatment, all the symptoms increase in 
 severity, the respiration becomes much oppressed, there 
 is a barking cough, and a change in the voice, which 
 becomes hoarse and indistinct ; the deglutition becomes 
 so painful that children refuse to swallow even liquids ; 
 the saliva dribbles from the corners of the mouth, and 
 an acrid discharge flows from the nares. The glands of 
 the neck are greatly swollen and tender. The patient i^ 
 
NATURE. 89 
 
 restless to an extreme degree, tossing about and then 
 sinking into a semi-comatose condition. These cases, 
 when they prove fatal, as is the general rule, terminate 
 either by rapid prostration of the vital powers or by an 
 extension of the diphtheritic membrane into the air- 
 passages. 
 
 M. Trousseau makes two divisions of the disease — ■ 
 simple and malignant diphtheria. In both, the essentials 
 of the disease are the same. The one may generate the 
 other, and the most simple case may give rise to another 
 of the most malignant type. 
 
 Such, then, are the principal features of diphtheria. 
 There are some points, however, as regards its nature, 
 which require to be considered more in detail. First, the 
 characteristics of the false membrane itself claim our 
 special attention. 
 
 As regards the physical appearances of the false mem- 
 brane, if closely examined by the unaided sight, it has 
 the character of a fibro-plastic membrane. In the larynx 
 it presents a whiter color than when it is situated in the 
 fauces, and very much resembles the membrane thrown 
 out in true croup, although it is softer and often 
 soddened by the sanious matter wliich exudes from 
 beneath and around it. 
 
 Dr. Jenner distinguishes two varieties of diphtheritic 
 exudation, one of which is very tough and elastic, and 
 as much as one-eighth of an inch in thickness, resembling 
 washleather; the other, gray, pulpy, or creamy. The 
 former consisting of such fibres as we see in the buffy coat 
 
 8* 
 
90 DIPHTHERIA. 
 
 of the blood coagula — the latter, pus pjoid corpuscles of 
 Lebert and other smaller and larger granular corpuscles, 
 epithelium and oleo-protein granules. Dr. J. teaches that 
 these two forms of concretion are severally related, the 
 latter with the asthenic, the former with the so-called 
 inflammatory types of the general disease.^ 
 
 After very long and careful examination, it has been 
 observed that the exudation is preceded by a sero- 
 mucous transparent liquid which in some cases is very 
 abundant. This liquid once exuded, soon takes on more 
 density and a closer adherence to the surface which 
 secretes it, and at certain points becomes a little less 
 transparent, assuming a yellowish tinge. These points 
 soon run together, coalesce, and thus form a very thin 
 pellicle, which may be regarded as the commencement 
 of the false membrane. In fact, this commencement of 
 the false membrane is an act of coagulation, according to 
 M. Empis, which takes place by a precipitation of fibrin 
 independently of any agency of the living tissue. This 
 is to be seen most distinctly in the air-passages, particu- 
 larly in the larynx and trachea, in which the tubular 
 cast is seldom ever adherent, and is commonly much 
 smaller than the cavity it occupies ; its external surface, 
 therefore, being separated by a considerable interval 
 from the mucous membrane. 
 
 That coagulation is not determined by the mucous 
 membrane is, in fact, shown by the experience of M. 
 
 ' Britislt and Forei'ni Med.-CLir. Review, 1802. 
 
NATURE. 91 
 
 Empis' in cases where tracheotomy has been performed 
 upon children. He says : — 
 
 ''At the end of a few hours after the operation of 
 tracheotomy, whatever care might be taken to clear the 
 canula, the instrument was seen to be lined with a layer 
 of whitish concretions, the thickness of which continually 
 increased. These concretions were evidently only the 
 result of the coagulation of the liquid by which the sides 
 of the canula were constantly covered." 
 
 The pellicle thus formed, which we said may be con- 
 sidered as the first des^ree of the false membrane, is 
 thicker at the centre than at the circumference, and 
 generally may be easily lifted up, although in very 
 small pieces, owing to its friability. Beneath this super- 
 ficial pellicle, according to M. Empis, there is still an 
 exudation of sero-mucous matter which gradually 
 coalesces with the pellicle already formed, thus pro- 
 ducing a false membrane several lines in thickness, and 
 adhering very closely to the subjacent surface. 
 
 In many cases the membrane thus formed appears to 
 remain for some time stationary, and then sooner or later 
 it takes on an increase in thickness as well as in extent 
 of surface. The secretion of sanious fluid which embues 
 and softens the concretions is also augmented, becomes 
 yerj dark colored, and exhales a fetid odor similar to 
 that of gangrene. This especially applies to the deeper 
 j)ortions of the fauces, to the vulva, and to the anterior 
 parts of the vagina. 
 
 ' Arch. Gen. de Med., Fevrier, 1850. 
 
92 DIFHTHEKIA. 
 
 With regard to the cicatrization of the subjacent sur- 
 face^ and to the disappearance of the false membrane, M. 
 Empis^ says : — 
 
 "We never see the membrane disappear all at once, 
 leaving in its place a cicatrized surface, as is the case 
 with an ordinary eschar, but it is by a gradual process 
 that the pellicle diminishes in thickness, in proportion as 
 the edges of the abraded surface cicatrize. If, however, 
 we modify the secreting surface by an energetic local 
 treatment, we can cause the complete disappearance of 
 the membrane, leaving nothing beneath but a granulat- 
 ing surface of a healthy character." 
 
 The exudation is sometimes situated upon the cuta- 
 neous surface, at other times upon the mucous, and not 
 ■unfrequently upon both at once. Any portion of the 
 external surface of the body may become the seat of a 
 diphtheritic false membrane, the onlj^ condition essen- 
 tial being the absence of the epidermis, the skin thereby 
 approximating to the condition of a mucous membrane. 
 This cutaneous diphtheria has been much more 
 prevalent in certain epidemics than in others, especially 
 in France. In some the cutaneous affection has been so 
 frequent as to become the prominent characteristic of the 
 disease. Leech-bites, blistered surfaces, excoriations of 
 any part, various wounds, in the progress of an epidemic, 
 might become the seat of diphtheritic inflammation. 
 Whatever may be the situation of the exudation, it has 
 been incontestably proved that the diphtheritic affections 
 
 ' Arch. Gen. de Med., 1850. 
 
' NATURE. 93 
 
 of the skin are identical in their nature with those which 
 are seated in the mucous membrane of the fauces and 
 larynx. Nor is the external manifestation of the diph- 
 theritic poison in any way less formidable than the 
 faucial. In many cases reported by M. Trousseau, the 
 symptoms of low typhoid were present ; they often ter- 
 minated fatally, or were followed by a long tedious con- 
 valescence. 
 
 When a wound is attacked by diphtheritic inflamma- 
 tion, it becomes painful, fetid, and discolored serosity 
 pours from it in abundance, and a gray soft coating soon 
 covers it with a layer of increasing thickness ; the edges 
 swell and become violet. The wound remains often 
 obstinately stationary for months ; sometimes it spreads ; 
 then an erysipelatous blush is seen around it ; pustules 
 form, become confluent, burst, and leave apparent a diph- 
 theritic patch, which spreads ^ven from the head to the 
 loins. 
 
 A curious fact which has been observed as regards 
 the seat of the diphtheritic exudation, is, that although it 
 is found equally in the mouth, on the soft palate, the ton- 
 sils, the pharynx, the nasal foss^, the larynx, trachea, 
 and even in the bronchial tubes, on the conjunctiva, the 
 vulva and anus, and upon the skin, it is not found upon 
 those portions which are removed from the contact of 
 the air; these seem refractory to the extension of the 
 disease. M. Empis^ remarks, that he never saw true 
 diphtheria extend into the oesophagus, while, on the con- 
 
 * Arcli. Geu. de Med. 
 
91 DIPHTnERTA. 
 
 trary, the exudation of certain aphthous affections show 
 a great tendency to spread into the oesophagus, but never 
 into the respiratory organs. The atmosphere would thus 
 certainly seem to exert an influence in promoting diph- 
 theritic inflammation. The same observations have been 
 made by M. Isambert/ as well as by others. 
 
 Mr. Smith directs the attention of the profession to an 
 affection which in many respects resembles diphtheria, 
 but which differs from it essentially both in its nature 
 and its results. He gives the following as the charac- 
 teristics of spurious diphtheria: The patient usually com- 
 plains, first of a curious feeling in the throat, as if a pin 
 were pricking it ; there is languor with pains in the back 
 and legs ; and sometimes considerable tenderness on pres- 
 sure on the outside of the throat, just under the angle of 
 the jaw. 
 
 The tonsils and uvula are more or less tumefied, and of 
 an angry red color, while on their surface there are 
 small, irregularly shaped yellowish white spots. These, 
 however, are evidently of an aphthous nature — there 
 may be only one or two on the tonsil or on the uvula, or 
 they may be very numerous. However great their 
 number may be, their edges do not coalesce; each spot is 
 isolated. They never look excavated, but seem as if 
 they just floated on the mucus which moistens the 
 throat. 
 
 The appearance of the tongue usually indicates 
 
 • Ai-cliiv. Gen. de Me.l., 1S57. 
 
NATURE. 95 
 
 derangement of tlie digestive organs, and the pulse 
 is smaller and more frequent tlian in health. 
 
 The treatment of spurious diphtheria is exceedingly 
 simple ; a mild aperient — 10 or 15 drops of the tincture 
 of the muriate of iron, three times a day, with a simple 
 gargle of chlorine water, will be sufficient. The use of 
 stimulants and a liberal diet will remove the prostration 
 and muscular debility which may follow after an attack 
 of this disease. Spurious diphtheria never proves fatal. 
 Though accompanied with debility, it is not followed by 
 paralysis or albuminuria ; a patient who has suS'ered from 
 this afiection may afterwards have true diphtheria. The 
 affection seems to be most common among young 
 females.^ 
 
 In order to determine the value of the exudation as a 
 characteristic of diphtheria, it is well known that M. 
 Bretonneau made numerous experiments relating to the 
 effects produced by the application of irritant substances 
 to the mucous membrane. As the result of these experi- 
 ments, he found that no substance was capable of 
 producing similar effects excepting cantharides. He 
 says:— 
 
 '•' The action of the oil of cantharides when applied to 
 the surface of the tongue and lips is almost instantaneous. 
 In less than thirty minutes the epidermis shrivels and 
 becomes raised and detached. It is soon replaced by a 
 concrete pellicle, at first thin and semi-transparent, which 
 speedily becomes more opaque and thicker. Like the 
 
 • Edinburgh Med. Journal, Nov. 1863. 
 
96 DIPHTHERIA. 
 
 diphtheritic exudation, this membrane, which is at first 
 slightly adherent, is detached and reproduced with great 
 readiness. Within a period of six or seven days it may 
 be several times renewed." 
 
 M. Bretonneau concludes, from these experiments, 
 that the membrane of cantharides is anatomically iden- 
 tical with that of diphtheria, and is, therefore, forced to 
 admit that diseases cannot be distinguished merely by 
 their anatomical characters.^ 
 
 ''The facts relating to the cantharidic inflammation do 
 not in the slightest degree weaken the specificity of diph- 
 theria; on the contrary, if we consider them in their 
 true light and in their complete development, they prove 
 it experimentally and demonstratively. However close 
 may be the resemblance between the two forms of inflam- 
 mation, they are distinguished by well-marked charac- 
 ters. The cantharidic inflammation is limited to the 
 surfaces which have been subject to the inflaming action 
 of the vesicant, and soon become extinct ; while it is in 
 the nature of the diphtheritic inflammation to extend 
 and to persist." 
 
 " With the view of determining how far the act of 
 fibrinous concretion may be considered a consequence 
 of the anatomical or physiological peculiarities of the 
 structure affected, independently of the constitutional 
 state, or of the morbid condition of the blood arising 
 from the disease, I made the following experiments : I 
 
 ' Traits de la Diplitherite, p. 367. 
 
NATURE. 97 
 
 injected into the air-passages of several dogs small 
 quantities of a solution of cantharides in olive oil, and 
 examined tlie consequent alterations of tlie mucous 
 membrane after various periods. Two liours after the 
 introduction of the solution, it was found that the 
 mucous surface of the larynx was scattered over with 
 patches scarcely perceptibly redder than the surround- 
 ing membrane, and that that structure was covered 
 co-extensively with those patches, with a gelatinous 
 covering of tolerably firm concretion, differing from 
 that of diphtheria only in its greater transparency — a 
 character, probably, mainly attributable to the absence 
 of lamination — arising from its simultaneous formation. 
 This concretion possesses a structure which is identical 
 with that of the early condition of diphtheria, consisting 
 of a fibrinous matrix or substratum, in some parts of 
 which cells are imbedded. The substratum appears on 
 microscopic examination to be transparent and faintly 
 granular, but sometimes exhibits indistinctly the cha- 
 racters of fibrillation The cell wall is of 
 
 extreme delicacy, and incloses a spheroidal nucleus, 
 distinguishable without the addition of acetic acid. 
 (Fig. 2.) On the addition of that re-agent, the former 
 becomes distended but does not disappear, while the 
 latter either assumes the form of a spheroidal highly 
 refractive body or is resolved into . the double, triple, 
 or horse-shoe shaped forms often described as char- 
 acteristic of the pus-corpuscle. On examining the 
 mucous membrane subjacent to the concretion, it was 
 9 
 
98 DIPHTHERIA. 
 
 found to have lost its columnar or ciliated epithelium, 
 but the cells of the subjacent epithelial layer existed in 
 an unaltered condition. They differed so completely in 
 appearance, size, and structure, from the exudation cells. 
 
 Fig. 2. 
 
 After Sauderson. 
 
 that there was no difficulty whatever in distinguishing 
 them. In two daj^s the process of transformation of the 
 substance of the concretion into fibrous tissue had com- 
 menced. The pellicle possessed great firmness and 
 ehxsticity, and could be stripped ofi" the affected patches 
 with ease to any extent. 
 
 " Of these facts, I will not further comment than to 
 observe that the only important difference between the 
 cantharidic and the diphtheritic concretion, consists in 
 the absence of any tendency in the latter to transforma- 
 tion into permanent tissue, as contrasted with the early 
 period, at which that process commences in the former. 
 So far as concerns this mere fact of fibrinous concretion, 
 we are perhaps entitled to infer that it indicates nothing 
 more than the intensity of the process of exudation ; 
 
NATURE. 99 
 
 and that in diphtheria, the subsequent changes are pre- 
 vented or retarded either by a morbid modification of 
 the fibrin itself, or bj an abnormal condition of the 
 adjacent living structures." (Sanderson on Diphtheritic 
 Sore Throat. Brit, and For. Med.- Chir. Review, Jan. 1860, 
 pp. 181-9.) 
 
 Under the microscope the false membrane of diph- 
 theria exhibits the ordinary elements of such structures, 
 although its characters appear to vary somewhat. The 
 elements usually detected are, chiefly, molecular par- 
 ticles, matted epithelium-cells of all kinds and shapes, 
 pus, and blood- cells. These are arranged in layers, and 
 united so as to form a membranous deposit. 
 
 Dr. J. Darrack states that he had examined a num- 
 ber of the patches of the membrane, which were care- 
 fully removed during life, and some after death. The 
 elements found in all these examinations, were cells — 
 young epithelial nuclear bodies, not affected by acetic 
 acid, and m.ost likely aborted epithelial cells, w^ith pus 
 corpuscles and granular matter — the granules occasion- 
 ally assuming a disposition to form themselves into 
 parallel lines. In no one case could be perceived a 
 distinct fibrillation as is easily recognized in the transu- 
 dations, upon the pericardium and other serous mem- 
 branes. It is true that a granular form of fibrin has 
 been described, but this has not been established.' 
 
 M. Empis has particularly investigated the pathologi- 
 cal anatomy of the disease by the aid of the microscope. 
 
 ' American Jouraal of Med. Sciences, 1861. 
 
100 DIPHTHERIA. 
 
 Now, it is well known that some observers, among whom 
 we may mention Yogel and Dr. Lajcock, have associated 
 with the disease the presence of a parasitic fungus which 
 fixes itself on the mucous membrane of the fauces, and 
 is thought to be the starting-point of the vascular con- 
 dition of which we have spoken, which afterwards gives 
 rise to the exudation. This parasitic fungus is the 
 oidium albicans. 
 
 M. Empis, after noticing the statement of Yogel, that 
 the oidium albicans is to be found in the pellicle of diph- 
 theria, says : — 
 
 "This author has evidently confounded under the 
 term diphtherite all the pseudo-membranous exudations, 
 without examining into their nature or characters, for 
 this parasite is not found in the true diphtheritic or 
 fibrinous exudations, but only in those of muguet." 
 
 He then goes on to compare the diphtheritic exuda- 
 tion with other similar products, such as the buffy coat 
 of the blood, the false membrane of pleurisy, the exuda- 
 tion of blistered surfaces, and that which occurs in the 
 scarlatinal sore throat, and arrives at these conclusions : 
 That it is easy to determine, by means of the micro- 
 scope — 1st, the pseudo-membranous exudations of 
 muguet, which have nothing in common with other 
 false membranes ; 2d, the buffy coat of the blood ; 3d, 
 the false membrane of pleurisy ; but that it is impossible 
 to draw any distinction, founded on microscopic investi- 
 gation, between the exudation of diphtheria and that of 
 
NATURE. 101 
 
 the blistered surface, or tliat which occurs in the angina 
 of scarlatina. 
 
 As the development, then, of this parasitic growth 
 takes place in a variety of other diseases, we must regard 
 it as purely accidental, or at least secondary, and by no 
 means as characteristic, or an exciting cause of the 
 disease under consideration. 
 
 The communication of Dr. Lay cock also fails to in- 
 spire us with that confidence in his theory which it 
 would perhaps have done, had the case been one of 
 uncomplicated diphtheria. Moreover, he himself also 
 admits that this parasite is discoverable in the patches 
 of aphthae as w^ell as in the secretions of the mouth in 
 other diseases. 
 
 In an excellent communication to the Medical Times 
 and Gazette,'^ Dr. Wilks says : — 
 
 "Opinions still vary as to the true nature of diph- 
 theria, and therefore as to its connection with a parasite 
 fungus (o'idium albicans). As on several occasions the 
 white film on the throat has been found to consist of 
 this fungus, it has been conjectured w^hether the malady 
 is not one having a parasitic origin, and the belief has 
 been rendered more probable from the fact that several 
 new diseases have of late prevailed throughout the 
 organic kingdom, both animal and vegetable, which are 
 clearly traceable to parasites— for example, the oidium 
 of the vine. ... 
 
 ' October 2, 1858. 
 
 9* 
 
102 DIPHTHERIA. 
 
 "My attention being directed to tliis matter, I took 
 tlie opportunity to examine the films which occasionally 
 form on the mouths of those sick with various diseases ; 
 and on submitting them to the test of the microscope, 
 felt some surprise in witnessing, in all, fungous growths, 
 which I have not been able to distins^uish from that of 
 diphtheria." 
 
 After giving a brief history of several cases of differ- 
 ent diseases, in all of which either a distinct pellicle or a 
 thick secretion was present. Dr. Wilks says : — 
 
 "These facts are sufficient to show that a vegetable 
 fungus may spring .up on the buccal mucous membrane 
 in various cases of disease, but requiring probably some 
 previously morbid condition for a nidus. Is it not so in 
 diphtherite? Is the disease, strictly speaking, a malig- 
 nant sore throat, and the formation of a pellicle an acci- 
 dent, or is the latter an essential part of the affection ? 
 
 "In speaking of the parasitic growth found in the 
 above-mentioned instances, we are aware of the objection 
 which can be made — that the fungus of diphtheria is 
 peculiar (supposing it always to be present), and that 
 found in the mouth of other sick persons is in connec- 
 tion with aphthoe, and is another variety. In answer, I 
 can only say that I failed to discover in the above cases 
 any difference, and, moreover, the chai^acter of the pelli- 
 cle, and its rapid extension over the whole mouth, throat, 
 and tongue, was totally unlike ordinary aphtha3." 
 
 Dr. Wade, of Birmingham, considers that there is 
 present in some cases, \ipoy near the exudation of diph- 
 
CONTAGION. 103 
 
 theria, a fungous growth — not, however, the oidium 
 albicans, but the leptothrix buccalis, such as is so com- 
 monly met with in the mouth and phar3^nx. Further 
 investigations, however, have shown that the presence 
 of either of these parasitical growths is to be considered 
 as a mere accident, and not an essential part of the affec- 
 tion. In conclusion, we may say that the distinguishing 
 character of the diphtheritic exudations, and that which 
 separates them from other forms of exudation, is, " that 
 they have the power of organization, and never become 
 vascular. Hence they never concur in the reparation of 
 tissue, but putrefy on the su.rface if they be not removed, 
 existing always as a foreign body." 
 
 Is Diphtheria Infectious ? — Upon this point, as we 
 might naturally suppose, there is a wide difference of 
 opinion. M. Bretonneau maintained that the exudation 
 of diphtheria possessed a special virulence, and that the 
 disease may be not only propagated by the application 
 of the secretion from an affected surface to sound parts, 
 after the manner of smallpox, but that, like syphilis, 
 diphtheria cannot be communicated from a diseased 
 to a healthy person in any other way. He says : — 
 
 " Innumerable facts have proved that those who attend 
 patients cannot contract diphtheria unless the diphthe- 
 ritic secretion in the liquid or pulverulent state is placed 
 in contact with the mucous membrane, or with the skin 
 on a point denuded of epidermis, and this application 
 must be immediate. 
 
104 DIPHTHERIA. 
 
 ''The 'Egyptian disease" is not communicated by 
 volatile invisible emanations, susceptible of being dis- 
 solved in tlie air, and of acting at a great distance from 
 their point of origin. It no more possesses this quality 
 than the syphilitic disease. If the liquid which issues 
 from an Egyptian chancre, as visibly as that which pro- 
 ceeds from a venereal chancre, has seemed under certain 
 circumstances to act like some volatile forms of virus, 
 the mistake has arisen from its not having been studied 
 with sufficient attention. The appearance has been 
 taken for the reality."^ 
 
 In support of his opinion, M. Bretonneau has collected 
 a few cases. One is that of M. Herpin, who was surgeon 
 to the hospital at Tours. A child attacked with diph- 
 theria, who had also transmitted the affection to its 
 nurse, was placed under his care. Upon visiting it one 
 day, and during the process of sponging the pharynx, in 
 a paroxysm of cough, a portion of the diphtheritic 
 matter was ejected from the mouth, and lodged in the 
 aperture of the nostril of M. Herpin. This he neglected 
 to remove, and the consequence was a severe diphtheri- 
 tic inflammation which spread over the whole nares and 
 pharynx. The constitutional symptoms were extremely 
 severe, and the prostration so great, that conva- 
 lescence occupied more than six months.^ Dr. Gendron, 
 of Chateau de Loire, received on his lips portions of 
 
 ' Considered by Bretonneau as identical with diphtheria. 
 
 2 Traite de la Diphtherite. 
 
 * Arch. Grt-nerales de Med., Jan. 1804. 
 
CONTAGION". 105 
 
 diphtheritic exudation, expelled by a patient during a 
 fit of coughing. Laryngeal inflammation came on with 
 much violence, but his life was saved by prompt and 
 decided measures. 
 
 In 1826, M. Bretonneau was summoned to the Ecole 
 Militaire, in which diphtheria was prevailing; although 
 many cases of the disease occurred, none proved fatal 
 after his arrival. He states, however, that a boy affected 
 with frost-bite of his foot, happening to use a bath that 
 had been employed for a diphtheritic patient, became 
 the subject of painful diphtheritic exudation on the great 
 toe. 
 
 M. Lespiea' also gives an account of a soldier who, 
 during the epidemic of the disease at Avignon, used the 
 teaspoon of a diphtheritic patient, and in consequence 
 contracted the disease in his mouth ; and of another, who 
 was attacked with diphtheria the night after sleeping 
 with a patient. 
 
 Similar cases have been cited by authors in favor of 
 the theory of contagion by inoculation. On the other 
 hand, Prof. Trousseau failed in experiments which had 
 in view the inoculation of himself and two of his pupils 
 with diphtheritic matter, and Dr. Harley, of London, was 
 not more successful in similar experiments on various 
 animals. 
 
 M. Bretonneau goes so far as to maintain that the 
 facts which he relates, and other details in his possession, 
 
 ' Memoires de Med. et Chirurgie Militaire, Paris, 1854. 
 
106 DIPHTHERIA. 
 
 corroborate the assertion that the atmosphere cannot 
 convey the contagion of diphtheria, Avhich is only trans- 
 missible by inoculation. This opinion, however, is not 
 supported by the experience of other writers, neither 
 does it accord with the facts deduced from recent epi- 
 demics. In fact, it may be very clearly shown from the 
 evidence already collected, that contagion plays the 
 principal part in the propagation of diphtheria. 
 
 M. Isambert,^ in his paper upon the epidemic of malig- 
 nant sore throat, which occurred in Paris in 1855, gives 
 the following as his experience : — 
 
 "Diphtheritic affections sometimes appear sporadi- 
 cally ; they also often seem to be endemic, as wxll as 
 epidemic and contagious. As predisposing causes, we 
 may consider that the lymphatic temperament, a feeble 
 constitution, privation, &c., all exert a decided influence. 
 Youth is much more exposed to the .disease than any 
 subsequent age. Locality and overcrowding have 
 a positive effect ; so also do cold and changeable seasons. 
 
 "Epidemic influences are much the most powerful. 
 As to the contagious nature of the disease there can be 
 no doubt, since many physicians have contracted the dis- 
 ease. The opinion of M. Bretonneau that diphtheria is 
 not transmitted by the atmosphere, but is always the 
 result of inoculation, is altogether too exclusive. With 
 M. Trousseau, we cannot reject infection at a distance as 
 one of the means of propagation possessed by diphthe- 
 ria." 
 
 ' Archives GC-uerales de MOd., 1850. 
 
CONTAGION. 107 
 
 With regard to tlie influence exercised by the moist- 
 ure of the air, by the temperature, and by the particukr 
 locality, M. Trousseau thus expresses himself: — 
 
 "In the villages of the Loire, remarkable for their 
 salubrity and for their excellent position, I have seen 
 diphtheria prevail to a terrible extent, while the villages 
 of Sologne, situated in the midst of marshes, remained 
 exempt ; and, again, hamlets bordering upon ponds 
 depopulated , by the epidemic, while others enjoyed a 
 complete immunity." 
 
 The observations of M. Empis lead him to favor the 
 idea of contagion. AYhile at the same time he recog- 
 nizes, as a character of diphtheria, " the property which 
 it has of being generalized in the economy, like the dis- 
 eases totius suhstantise ;" a property which, as he observes, 
 may be best appreciated when the disease is studied epi- 
 demically. 
 
 Carnevale and M. Aurelius Severinus, as well as Fran- 
 ciscus Kola, admit the contagious properties of diph- 
 theria, as well as almost all the writers upon the subject 
 of the sevententh century. 
 
 Dr. Samuel Bard, as we have before remarked, con- 
 sidered the "suffocative angina" which he describes, as 
 infectious. 
 
 " The disease I have described, appeared to me to be 
 of an infectious nature, and as all infection must be 
 owing to something received into the body, this, there- 
 fore, whatever it is, being drawn in by the breath of a 
 healthy child, irritates the glands of the fauces and 
 
1U8 DIPHTHERIA. 
 
 trachea as it passes by them, and brings about a change 
 in their secretions. The infection, however, did not 
 seem, in the present case, to depend so much on any 
 generally prevailing disposition of the air as upon 
 effluvia received from the breath of infected persons. 
 This will account why the disorder should go through a 
 whole family and not affect the next-door neighbor." 
 
 To come now to the observations of more recent 
 writers upon this point, we may cite the reniarks of Dr. 
 Banking in his admirable lectures on diphtheria,^ to 
 which we have already alluded : — 
 
 " My own conviction is, that it is infectious to a limit- 
 ed degree; by which I mean that when patients are 
 accumulated in small, ill- ventilated rooms, the disease 
 is likely to be communicated ; but I do not fear that, 
 like scarlatina or erysipelas, it may be propagated in 
 spite of all sanitary precautions, still less that the infection 
 can be conveyed by the clothes or persons of those who 
 visit or superintend the patients. That it commonly 
 spreads through the family once invaded is to be 
 attributed, in some degree, to the persistence of the same 
 cause as originated the first case. What that cause is, it 
 is difficult to determine. 
 
 . . . . '^ Stench and poverty and crowded rooms 
 have ever been the sad heritage of the agricultural 
 laborer, but diphtherite is only of recent origin. 
 Doubtless these insanitary adjuncts to a laborer's life 
 predispose him and his children to the assaults of any 
 
 ' Lancet, Jan. 15, 1857. 
 
CONTAGION. 109 
 
 epidemic malady, but the true and specific cause of diph- 
 theria is a something superadded, and which our senses 
 cannot appreciate." 
 
 In an article by Dr. Edward Ballard, of Islington 
 {Med. Times and Gaz., July 23, 1859), the following facts 
 are given in support of the infectious character of diph- 
 theria as it came under his own observation : — 
 
 "1. Infectious diseases habitually spread in families 
 they invade. Out of 47 families there were only 15 in 
 Avhich the other members all remained healthy. Of 
 course it may be argued, in opposition, that all the mem- 
 bers of a family are equally exposed to the operation of 
 local causes of disease. 
 
 " 2. As a rule, it spread in the houses it invaded chief- 
 ly among those members of the several families who 
 were most closely in communication. 
 
 "3. In no case where separation from the sick person 
 has been effected early in the disease, have I noticed 
 that it has spread to the separated individuals. In one 
 case where communication had been allowed for three 
 days before separation, a child was seized with diphthe- 
 ria on the sixth day of removal from home. 
 
 '' 4. The following special instances (of which we give 
 one) may be adduced of communication of the disease 
 from one house to another : — 
 
 "Jane J., set. 10 years, resided at Islington, with her 
 
 mother, an aunt, and three sisters. On May 1st and 2d 
 
 she was on a visit at the house of an uncle, whose 
 
 daughter, Jane's cousin, was kept at home because she 
 
 10 
 
110 DIPHTHERIA. 
 
 was believed to have a cold. On the 2d; this child ex- 
 hibited decided symptoms of diphtheria ; the attack was 
 slight and she recovered. 
 
 "On May 6th, a servant in this house was taken ill 
 with a severe attack of diphtheria, and was removed to 
 St. Bartholomew's Hospital, where she died. On the 2d; 
 Jane returned home, was taken ill on the third with 
 diphtheria in a severe form, and died on May 9th. Iler 
 mother and a sister, aged fourteen years, were both taken 
 ill on May 11th. She had not been so much with her 
 daughter as other members of the family up to the Sth, 
 when she sat up with her all night. The tonsil sloughed, 
 and there was a complete cast of the trachea expectora- 
 ted. She died on the 18th. The sister, who was also 
 attacked on the 11th, slept v/ith her mother, and, when 
 not at school, was continually in and out of Jane's room, 
 sitting there sometimes for hours together. She died on 
 May 14th, asphyxiated. Another elder sister, who slept 
 with Jane and the aunt, suffered from nothing but a 
 slight sore throat." 
 
 The results of inquiries instituted at fifty-seven houses 
 where fatal cases occurred, with respect to local causes of 
 disease, were as follows : — 
 
 " In more than half the houses, then, which were ex- ■ 
 amined there was some defect or other in the sanitary 
 arranocements or in the surroundino; conditions of the 
 patients. In the greater number of the houses thus defi- 
 cient, the fault was discovered in the state of the drain- 
 age." 
 
CONTAGION. Ill 
 
 Some writers of experience maintain that diphtheria 
 possesses no contagious properties whatever, and others 
 accord to it but comparatively feeble influence in this 
 respect. 
 
 M. Daviot,' in a memoir on diphtheria^ says: — 
 
 " Pharyngeal diphtheria is purely and simply an epi- 
 demic disease. Like other diseases which assume this 
 character, it only manifests itself in those localities and 
 individuals which have the most affinity for it. Spring- 
 ing from an alteration in the constituent elements of the 
 atmosphere, an alteration unknown in its essence but 
 appreciable in its effects, it is propagated through the 
 medium of that fluid. ... A great number of 
 persons were struck by the epidemic a few days after 
 arriving in the infected places, and without having 
 communicated with any patient." 
 
 M. Daviot denies, as regards an epidemic which he 
 describes, that it generally happened that all or the 
 greater number of the members of a family were attacked 
 at once, and states that it was quite as common that only 
 a certain number of persons living under one roof were 
 affected, while the successive attacks took place at 
 considerable intervals. M. Daviot thinks such results 
 can only be accounted for by — 
 
 "Similarity of organization and predisposition in 
 individuals placed under the same hygienic circum- 
 stances, and, therefore, subject to the same morbific influ- 
 ences. . . . Will any one contend that the conta- 
 
 ' Memoirs on Diplitheria (New Sydenham Soc), London, 1857. 
 
112 DIPHTHERIA. 
 
 gious principle could have six months, a year, or even 
 more of incubation before its development? Such an 
 explanation is contrary to all probability, and does not 
 require to be refuted." 
 
 M. Daviot did not meet with an instance where diph- 
 theria was communicated by personal intercourse. He 
 remarks that neither the attendants nor those who cauter- 
 ized the throats of affected children contracted the dis- 
 ease. He concludes that pharyngeal diphtheria is not 
 in itself contagious, and that it only appears to be so 
 when associated with eruptive fever. 
 
 Dr. Crighton/ of Edinburgh, records the results of 45 
 cases of diphtheria occurring in his practice. Of these, 
 25 were males and 20 females ; out of this number 9 
 proved fatal, or 1 in 5. Of these, 6 died of asphyxia 
 with membranous exudation in the air-passages, and 3 
 by pure asthenia. They were instances of faucial diph- 
 theria. In one case, aged 21 months, vulval diphtheria 
 occurred. The mean age of the fatal cases was within a 
 fraction of seven years. 
 
 " In only two cases was there anything like proof of 
 contagion, and, from all that I have seen of diphtheria, 
 I believe that, although it would be incorrect to separate 
 it from the list of communicable diseases, yet it is very 
 feebly so compared with many others. I may mention 
 one instance which struck me particularly, where, in a 
 large family of six or seven children, and chiefly under 
 the age of twelve, a child had the disease in a very 
 
 ' Notes on an Epidemic of Diphtheria. By R. W. Crighton. 
 
CONTAGION". 113 
 
 severe form, and although he was never isolated during 
 the day from the others, but lay on a sofa in a room 
 where I generally found several of them at my visit, 
 they all escaped." 
 
 Dr. Moncton {Med. Times and Gaz., Feb. 26, 1857), 
 after much experience in the disease during epidemics 
 which prevailed in the county of Kent, says : — 
 
 "No decisive instance of its communicability has come 
 before me ; on the contrary, I have seen it attack indi- 
 viduals only, in a family of liable persons, much more 
 frequently than I think scarlet fever would have done. 
 My own conviction is, that diphtheria is epidemic, 
 endemic (?'. e., largely affected by locality), and non-con- 
 tagious, or, if contagious at all, vastly less so than 
 scarlet fever, from which last it is very distinct." 
 
 Dr. Jenner, in his lectures upon the origin of diphthe- 
 ria, draws the following conclusions : — 
 
 " First, that the disease is infectious ; second, that the in- 
 fected element does not require for its development any 
 of the ordinarily considered antihygienic conditions; 
 third, that the family constitution is one of the most im- 
 portant elements favoring the development of the dis- 
 ease and -determining its progress; fourth^ that it is very 
 doubtful even if any of these hygienic conditions favor its 
 development or give it a more untoward course when it 
 occurs."' 
 
 ' Diphtheria, its Symptoms and Treatment, by William Jenner, M. D. 
 London, 1861, page 51. 
 
 10- 
 
114 DIPHTHERIA. 
 
 Space would fail us, if we attempted to bring forward 
 more than a very small portion of the argument and evi- 
 dence wliich have been offered in favor of the contagious 
 or non-contagious properties of diphtheria. There 
 are, however, one or two points which we may consider 
 further. 
 
 In connection with certian epidemics, especially in 
 France, there were frequently observed cases of cuta- 
 neous diphtheria, which, from their persistence and 
 superficial site, seemed peculiarly to favor transmission 
 by contagion. As a general rule, this was never devel- 
 oped unless when the epidermis was raised or removed; 
 and the observations of M. Trousseau, and others, have 
 incontestably proved that the diphtheritic affections of 
 the skin are of a nature identical with those which have 
 their seat in the mucous membrane of the larynx and 
 fauces. 
 
 Now, although those who favor the idea of contagion 
 find in the phenomena of cutaneous diphtheria strong 
 ground for the support of the theory of inoculation, there 
 are facts which would seem equally to oppose it. For 
 example, it has been observed in these epidemics, that 
 the false membrane upon the skin not only presents 
 itself in those not previously affected with faucial diph- 
 theria, but it not unfrequently attacks remote parts, such 
 as we sljould suppose were inaccessible to inoculation, 
 as, for example, the folds of the groins in children, and 
 the spaces between the toes. ^' A jingle well observed 
 
CONTAGION. 115 
 
 fact of this kind is sufficient to cast a doubt on the theory 
 of inoculation." 
 
 Again, it sometimes happens, according to M. Trous- 
 seau, that diphtheria, especially when it occurs as a 
 sequel to measles and scarlatina, is complicated with an 
 eruption of bullai of rupia simplex. These often become 
 the seat of cutaneous exudation. As the bulla becomes 
 flaccid from the absorption of its contents, instead of the 
 formation of a thick brownish crust, it is observed that 
 a firm concretion can be felt beneath the still entire epi- 
 dermis. 
 
 The influence which meteorolosfical and cosmic condi- 
 
 o 
 
 tions exert in the production of diphtheria, is no better 
 understood than is the relation existing between these 
 same conditions and the production of other epidemic 
 diseases. 
 
 Bretonneau, for example, had the idea that his diph- 
 theria needed a damp atmosphere for its development. 
 In the recent epidemics, both in France and in England, 
 many instances are recorded where the disease prevailed 
 in very dry and high situations. And in our own 
 country, similar observations have been made. Dr. 
 Wooster, in a monograph on diphtheria as it prevailed in 
 California, explains how far the views of Bretonneau are 
 applicable to the disease as it presented itself to his 
 notice. He says : — 
 
 " In our climate the air in summer becomes so dry, 
 that if an ordinary soft wooden pail or bucket, be half 
 filled with water, and set in the sun in the open air for 
 
116 DIPHTHERIA. 
 
 six hours, and then two quarts of water be added, it will 
 leak through the joints of the shrunken staves, above the 
 surface of the first portion of water. A miner uses a 
 bucket to bail water from a hole all the forenoon, and, 
 although it is perfectly saturated with water, yet if he 
 leaves it in the sun while he goes to his dinner, when he 
 returns it will often fall to pieces as he attempts to take 
 it up. 
 
 "This is the kind of air in which the disease has 
 occurred with unequalled fatality in this State. In this 
 city I cannot ascertain that a case has occurred in that 
 part of the town built over, or near the waters of the bay, 
 or on the salt marshes near it. But I have seen cases in 
 the high part of the city, and on bluff headlands extend- 
 ing into the bay, points that, from their elevation and 
 constant exposure to a strong breeze, would be thought 
 inaccessible by any morbid effluvia." 
 
 In this connection, Ave cannot refrain from citing the 
 somewhat poetical, but at the same time very truthful 
 remarks of Mr. Ernest Ilart.^ 
 
 " It was observed of diphtheria in France, and it is 
 equally characteristic of its course in England, that it did 
 not obey any known climatic or meteorological laws. 
 It descended upon Tours, in the rear of the Legion of La 
 Yendee ; it broke out in crowded and ill- ventilated bar- 
 racks, and it spread throughout the town. It visited 
 alternately the open hamlets of the rural departments 
 and the crowded courts of the great cities. It raged in 
 
 ' On Diplitlieria, its Ilistoiy, ^"^c, by Ernest Hart, London, 1S59. 
 
CONTAGION. 117 
 
 Orleans and in Paris, througli the Sologne and in the 
 Loiret. It reached the sea-side, and fell with violence 
 upon the infant population of the city of Boulogne. It 
 appeared to be equally independent of all atmospheric 
 conditions. Was a theory formed that its intensity de- 
 pended upon the solar influence, and that the heat of the 
 summer months lent fresh force to its destructive attacks 
 — soon it raged with greater violence in the winter 
 months, and during the cold season. "Was a connection 
 traced between the localities of its invasions, and the 
 marshy ill-drained character of the land — the next sea- 
 son it was found to ravage dry and elevated stations with 
 equal rage. It has been no less careless of the limita- 
 tions of heat, cold, dryness, and moisture, since it has 
 established a camp in this country. -5^ ^ -^^ It has swept 
 across the marshy lowlands of Essex, and the bleak 
 moors of Yorkshire. It has traversed the flowery lanes 
 of Devon, and the wild flats of Cromwell that are swept 
 by the sea-breeze. It has seated itself on the banks of 
 the Thames, scaled the romantic heights of North Wales, 
 and has descended into the Cornish Mines. Commencing 
 in the spring months, it has continued through the 
 summer, and if extremes of temperature have appeared 
 to lend it fresh vigor, and the heat of the dog-days, or 
 the severe frosts and sleet of winter have fostered its 
 strength, yet moderate temperature has not greatly abated 
 its influence, and it has struck a blow here and there 
 through all the seasons." 
 
 Without doubt, diphtheria, as well as other diseases of 
 
113 DIPHTHERIA. 
 
 a similar character, follow general laws, and in many 
 cases we are obli^'-ed to confess our entire it<norance as 
 
 o o 
 
 to the exact nature of those laws. 
 
 But if we cannot ascertain the influences which govern 
 these epidemics, perhaps on closer investigation we may 
 discover certain individual or hygienic circumstances 
 which may affect them either as^irect or as predisposing 
 causes. Thus, as a general rule, we shall find that diph- 
 theria is more frequently associated with the ill-ventila- 
 ted, contracted hovels of the poor, seizing by preference 
 upon the unhappy subjects depressed by poverty and 
 its attendant evils. Yet these are not the exclusive con- 
 ditions for the development of diphtheria. We find in 
 the various reports of these later epidemics that the dis- 
 ease has made its appearance, and carried off" its victims, 
 in the abodes of refinement and wealth. 
 
 "Zymotic in its nature, it tends to fasten upon 
 whomsoever is debilitated by previous disease, or by a 
 constitution naturally feeble and artificially effeminized, 
 or whose vitality is lowered by the depressing influences 
 of luxury, indolence, and inactivity ; and the habitual 
 defiance of physical and hygienic laws, which is so fre- 
 quent an element in fashionable life. Hence individual 
 causes come into play, and introduce this associate of the 
 poor into the palaces and mansions of the great, which 
 they so often fringe. Diphtheria finds there its victims 
 pale and anaemic, or grossly sanguineous, and unhealthily 
 excited."' 
 
 ' On Dii-litli.jiia. By Ernest H.-irt, Lonrlon, 1S50. 
 
ALBUMINURIA. 119 
 
 Finallj, all we can affirm is^, that, as a general rule, 
 anti-hjgiemc conditions of anj kind favor the invasion 
 of dipMheriaj as \Yell as of other similar epidomio dis* 
 eases. 
 
 One element in the nature of diphtheria is of reeent 
 discovery. We refer to the presence of albuminous 
 urine in the dise^ise. The first observation upon the 
 relation of albuminuria to diphtheria appears to have 
 been made in connection with a case reported bj Mr, 
 Wade, of Birmingham, to the Queen's College Medico- 
 Chirurgical Society in December, 1857, and afterwards 
 published in his Oh-sermii'ms mi DkjMhma} Shortly 
 after this, during researches on this disease at Paris, 
 MM. Bouchut and Empis made a similar discovery. 
 Albuminuria did not e:xist in every case examined, but 
 ii was present in twelve out of fifteen cases. Both of 
 these observers attach great importance to this renal 
 complication, as affording an anatomical explanation of 
 the cause of death, when this cannot be attributed to 
 either of the other modes, viz., death by asphyxia or 
 general poisoning. In fact, it was considered by them 
 to indicate the infectious nature of the disease, in this 
 respect resembling purulent infection, which is accom- 
 panied by a similar alteration of the urine. On this 
 point M. Bouchut arrives at these conclusions. ** Albu- 
 minuria in the absence of scai^latina or asphyxia (de- 
 pendent on laryngeal obstruction) is a sign in diph- 
 theritic diseases of a eommen cement of purulent infec- 
 
120 DIPHTHERIA. 
 
 tion, and coincides with a very great gravity of the 
 disease." These conclusions he founds on the observa- 
 tions, that both in diphtheria and purulent infection 
 there are, 1st, alteration of the color of the blood, which 
 assumes a bistre tint; 2d, masses of pulmonary apo- 
 plexy, more or less numerous, similar to those which 
 precede the development of metastatic abscesses; 3d, 
 ecchymoses of purpura on the skin, or the serous mem- 
 branes and the viscera. MM. Bouchut and Empis are 
 of opinion that in addition to the preceding alterations, 
 there is nothing farther necessarj^ to establish the connec- 
 tion between these diseases but the presence of visceral 
 abscesses, or purident collections in the serous mem- 
 branes. 
 
 In all the children under their care for diphtheria, the 
 urine was analyzed both by heat and nitric acid. When 
 albuminuria was present, the urine contained a very 
 large proportion of salts, which rendered it cloud}^ and 
 of a milky appearance at the moment of emission. At 
 first, the heat caused the salts to be held in solution, 
 when carried to a higher degree of heat, the albumen 
 was precipitated. In three cases, the precipitate was 
 very large, in the remainder, it was moderate in amount. 
 
 Together with albumen, Mr. Wade usually found in 
 the urine tube casts and renal epithelium, the former 
 being either ''small waxy casts," or '^ epithelial casts." 
 He is of opinion that albuminuria produces a diminu- 
 tion ill the total amount of solid excreta, that is, that the 
 special functions of the kidney are suspended, whereby 
 
ALBUMINURIA. 121 
 
 symptoms arise which are indicative "of the retention 
 within the sj^steni of those matters which should be ex- 
 creted." 
 
 Our author has not informed us at what period of the 
 disease he has first detected albuminuria^ neither does 
 he give any observations tending to show how far the 
 progress of the disease is affected by the condition of 
 the kidneys, which would seem to be indicated by the 
 presence of "casts," kc, in the urine. 
 
 More recently, Mr. Wade, in speaking of this subject, 
 remarked that the changes are more commonly micro- 
 scopical, consisting of crowding and opacity of the epi- 
 thelium, which is most readily detached and rapidly 
 disintegrates. Casts of various kinds are to be found in 
 some specimens of the albuminous urine of diphtheria. 
 Apart from its early occurrence, there seems to be a 
 special tendency to albuminuria, about the seventh or 
 eighth day, at which time the disorder has a natural 
 tendency to terminate. Under such circumstances it is 
 to be looked upon as a critical phenomenon. It may 
 occur at any period. 
 
 Diphtheritic albuminuria is often preceded by urine 
 of high specific gravity. The supervention of albu- 
 minuria may fail to reduce this. Mr. Wade therefore 
 recommends the ingestion of bland fluids in as great 
 quantity as the patient will take— half a pint every hour 
 or two, if possible, in the case of adults.^ 
 
 In a paper, communicated to the British and 'Foreign 
 
 ' Lancet, Aug. 23, 18G2. 
 11 
 
122 DIPnTHERIA. 
 
 Med.-Chirurrjical Review, Jan. 1860, Mr. Sanderson, 
 upon the basis of eight cases, is not inclined to admit 
 either of the doctrines advanced by Mr. Wade. He 
 says : — 
 
 "In eight cases in which I have had the opportunity 
 of making repeated observations as to the condition of 
 the urine, the only ones which occurred to me since my 
 attention has been directed to the subject, it has been 
 albuminous in all." 
 
 Dr. Sanderson, having given a brief report of each of 
 these cases, goes on to remark : — 
 
 "Although in several of the cases above related the 
 cessation of albuminuria was clearly coincident with the 
 amelioration of the patient, and the disappearance of the 
 most alarming symptoms, it is not less certain that in 
 one or two others albumen existed in large quantities in 
 the urine, although the cases maintained a mild character 
 throuo-hout. From this it mav be inferred that albu- 
 minuria is not in itself so alarming a symptom as ^I. 
 Bouchut is inclined to imagine." 
 
 As it appeared of importance to Dr. Sanderson to 
 ascertain whether the existence of albuminuria coincided 
 with the solid excreta of the urine, he directed his ex- 
 periments to that end. lie offers, however, only one 
 satisfactory observation, the following : — 
 
 Case YI. W. D., male, aged 30. Albuminuria first 
 observed about the eighth day ; disappeared three days 
 after; abundant. 
 
 General eltaraeter of symiUnns. — Extreuicly grave ; 
 
ALBUMINUKIA. 123 
 
 excessive prostration; intense adynamia, with nervous 
 agitation and busy delirium. Concretion not examined. 
 
 Result — recovery, — Slow convalescence, with extreme 
 muscular weakness. 
 
 During a period of about nine days the albuminuria 
 continued. During this time observations were made as 
 to this condition of the urine. "Without giving the two 
 tables of analysis, we come directly to the result. 
 
 "At the acme of the disease, when the urine was 
 intensely albuminous, when there was complete ano- 
 rexia, and the ingesta were reduced to a minimum, the 
 quantity of urea excreted in a period of twenty-four 
 hours was about twice as great as that excreted during a 
 similar period when convalescence was established, and 
 he was eating with an appetite the ordinary diet of the 
 hospital, with extras. 
 
 "The above, facts show that diphtheria agrees with 
 the other pyrexia in being attended with a marked in- 
 crease in the excretion of nrea, and that the existence in 
 the kidney of the condition which is implied by albumen 
 and fibrinous casts in the urine, does not necessarily 
 interfere with that increase in the elimination of nitro- 
 genous material. There is, therefore, no reason to ap- 
 prehend the occurrence of urasmia as a consequence of 
 the renal complication in diphtheria ; this complication 
 not being the cause of the dyscrasia, but merely the 
 index of its existence." 
 
 With reference to the presence of albuminuria in 
 diphtheria, there have been but few accurate observa- 
 
12i DIPHTHERIA. 
 
 tious made, and, in fact, until comparatively recently, it 
 Avas tliongbt that one distinctive mark of diphtheria, 
 over other kindred diseases, was, that there were no 
 albumen and no dropsy present. Certain it is that albu- 
 minuria has manifested itself throughout almost the 
 entire course of grave cases of diphtheria, and which, 
 have 3^et terminated favorably. On the other hand, 
 cases have occurred which have proved fatal when it 
 has been absent. 
 
 There can be no doubt of the serious character of this 
 renal complication, but further research and observation 
 are necessary before we can ascribe to it any settled 
 prognostic value. 
 
 In this connection we may also speak of the remark- 
 able after symptoms of diphtheria, whicli have been 
 observed by almost every practitioner who has had even 
 a limited experience during the epidemics of the last few 
 years, and which have been particularly referred to by 
 MM. Trousseau and Bretonneau, and also by M. Faure. 
 
 After apparent recovery from the immediate effects of 
 the disease, in many cases there still seems to be lurking 
 in the system a morbid poison, whose special affinity is 
 for the nervous system. Thus, prominent among the 
 sequelae of diphtheria, is paralysis in its various forms, 
 more frequently local than general, also otalgia, amau- 
 rosis, headache, ophthalmia, &g. Epidemics of this last 
 have been observed in Germany, and were described by 
 Graefe in 1854:,^ and, in France, by ^[. Jobert in 1857."^ 
 
 ' Gazette Ilebilomaflaire, 185G. ^ Archives Geuerales, 1S57. 
 
SEQUELS. 125 
 
 The most frequent form of paralysis lias been that of 
 the soft palate. The symptoms are a nasal twang in the 
 speech^ incapacity for suction, and the regurgitation of 
 fluids by the nostrils. This form was thought both by 
 M. Trousseau and others to be local in its origin. But 
 further observation has led them to change their views. 
 M. Trousseau makes the following clinical remarks : — ■ 
 " The pathology of the paralytic afl'ection was, for a 
 long time, altogether misunderstood both by himself and 
 others. In consequence of its being more frequently 
 local than general, in other words, the palate and 
 pharynx being more "usually affected with paralysis 
 than the system generally, he was for a long time under 
 the impression that the loss of power was dependent 
 upon the inflammation of the coats of the nerves supply- 
 ing these parts, and on infiltration producing pressure on 
 their motor muscles. A more extensive experience, 
 however, of the general character of the paralysis which 
 accompanies and follows diphtheritic affections, caused 
 him to change his views, and he now believes that loss of 
 power and sensibility is the direct consequence of the 
 peculiar diphtheritic poison acting generally on the sys- 
 tem, and strangely modifying the blood. He further 
 stated a fact which has often come under his observation, 
 that many children who have been subjected to the 
 operation of tracheotomy fall victims to paralysis of the 
 epiglottis and larynx."^ 
 
 ' Med. Times and Gazette, Jan. 27, 1859. 
 11- 
 
126 DIPHTHERIA. 
 
 Again, in a communication to the Gazelle des 
 II6]jilaux, I860, M. Trousseau remarks that this affec- 
 tion may be analogous to what is observed in certain 
 cachexias. One curious circumstance in diphtheritic 
 paralysis is the temporary extinction of venereal desire, 
 Avhich occurs at a very early period, even in those 
 possessed of considerable genital ardor. 
 
 In a paper read before the Royal Med. and Chir. 
 Society, March 24, 1863, Dr. Greenhow remarked that 
 he had observed nervous affections were more frequent 
 after the worst cases of diphtheria, and to bear some pro- 
 portion even to the local severity of the attack ; he had 
 noticed that the paral^^sis and anassthesia w^ere sometimes 
 more complete on that side of the fauces which had been 
 most severely affected by the primary disease ; he had 
 found that a brief period of convalescence had almost 
 always intervened between the disappearance of the sore 
 throat and the accession of the nerve symptoms. This 
 seemed important, as it went far to show that paralysis 
 could not be entirely attributable either to the albuminu- 
 ria, which often accompanied the acute stage, or to the 
 anaemia, Avhich closely follows it, as patients had often 
 got rid of the former symptoms, and had begun to get 
 strength and flesh before the accession of paralytic symp- 
 toms. These nerve affections are progressive in the 
 same set of muscles, but do not attain their maximum of 
 intensity even in the same set of muscles. The muscles 
 of the fauces are the earliest and the most frequently 
 attacked, and sometimes the only ones; next, impairment 
 
SEQUELS. 127 
 
 of vision, probably due to paralysis of the ciliary mus- 
 cles, appeared to be the most frequent of tbe nervous 
 disorders consequent on diphtheria : a great majority of 
 sufferers from these nerve affections recover. As to 
 treatment, Dr. Greenhow advised generous diet, rest in 
 bed, &c. He considered nux vomica and strychnine as 
 very valuable remedies after the complete development 
 of the paralytic symptoms. 
 
 In the Med, Times and Gazette, January 4th, 1860, M. 
 Rover makes the followinsr statement : — 
 
 During the year 1860, there were 200 cases of diph- 
 theria at the Hopital des Enfans, in Paris; paralytic symp- 
 toms followed in thirty-one of these cases. The propor- 
 tion was really greater, several children having been re- 
 moved from the hospital prior to the period at which 
 consecutive symptoms are usually developed. M. Royer 
 believes that these cases of secondary paralysis are as 
 rare in the other acute diseases of children, as they are 
 common in diphtheria. Of forty cases of diphtheritic 
 paralysis, which have come under his notice, the most 
 frequent age was from four to six years, there being 21 
 female to 17 male infants. In almost all cases, the para- 
 lysis has commenced by the pharynx and velum palati, 
 as shown by the nasal twang and dysphagia. Its occur- 
 rence would seem to be a proof of a greater amount of 
 blood poisoning. The usual appearance is from the 
 fourth to the eighth day; its mean duration is about a 
 month. As a general rule, the prognosis is not unfavora- 
 
128 DIPHTHERIA. 
 
 ble. Tonics, iron, sulphurous preparations, and tlie 
 application of electricity constitute tlie chief treatment. 
 
 A paper was read before the Prussian Association for 
 Scientific Medicine, in May, 1861, by Dr. Ebert, upon the 
 subject of diphtheritic paralysis, which gave rise to an 
 interesting discussion. Dr. Ebert referred to cases 
 recently published by Bouillon La Grange, in which not 
 only the soft palate, but also vision, smell, taste, and 
 touch, the throat, oesophagus and the limbs had been 
 paralyzed ; and then related a case which had fallen 
 under his own observation. Dr. E. believed that such 
 palsies originated in the same way as rheumatic paralysis, 
 and that a cold would be sufficient to produce paralysis 
 in a patient who had suffered from diphtheria. Prof. A. 
 Yon Graefe denied that there Avas any connection between 
 common paralysis and the diphtheritic disease; cases of 
 paralysis occurred after every grave disease of the nerv- 
 ous system, as typhoid fever, erysipelas, &c. It was not 
 difficult to trace the origin of the paralj^sis in diphtheria, 
 as the nervous system was greatly affected. Every dis- 
 ease which was accompanied by fever, was also accompa- 
 nied by paralysis of accommodation, and a semi-paralytic 
 state of most of the muscles of the eye. If the large num- 
 ber of epidemics which had been observed in France was 
 considered, the number of cases of paralysis was very 
 small when compared with the frequent occurrence of 
 palsy after other grave diseases.^ 
 
 M. Maingault finds that the impairment of vision 
 
 > Med. Times aud Gazette, Maj, ISGl. 
 
SEQUELAE. 129 
 
 comes next in order of frequency after tlie affection of 
 the soft palate. It varies in duration from a few days to 
 six months, and in degree from the mere inability to read 
 small print to perfect blindness. The ophthalmoscope 
 3'ields no information; its sudden accession and rapid 
 disappearance lead us to regard it as purely neurotic.^ 
 
 Dr. Wade remarks {Lancet, Aug. 23, 1862) that paraly- 
 sis, may follow as a kidney complication, and may attend 
 slight, as well as severe cases of diphtheria. 
 
 In one case under his observation the paralysis 
 has lasted two years, and may be considered as perma- 
 nent. 
 
 Dr. Jenner, in his work on diphtheria, observes that the 
 heart is the organ next in order of frequency to manifest 
 disordered innervation ; the patient dies from a literal 
 asphyxia. In some cases, the paralysis is more widely 
 extended : in these recovery is rare, death ensuing as from 
 general paralysis. 
 
 But it is to Dr. Faure that we are more particularly 
 indebted for the most complete account of these remote 
 consequences of diphtheria. He describes this peculiar 
 condition of the system 
 
 "As a state characterized by a gradually increasing 
 loss of power, showing itself especially in all those func- 
 tions connected with muscular movement. In some 
 instances, several sets of organs are affected, in others 
 only one, while again in others, the whole system is 
 involved in the general debility. But whatever are the 
 
 1 Brit, and For. Med.-Cliir. Review, 18G2. 
 
130 DIPHTnERIA. 
 
 variations in this respect, there is no definite relation 
 between the severity of the primary symptoms of diph- 
 theria and that of the sequela3. The primary symptoms, 
 though very formidable, do yet by no means of necessity 
 prove fatal ; while, on the other hand, the comparative 
 mildness of the attack will not justify an absolutely 
 favorable prognosis, since death sometimes follows where 
 everything had seemed to warrant the most confident 
 expectation of recovery." 
 
 Several cases are given by M. Faure, in illustration of 
 the various phases of this condition, and he sums up as 
 follows : — 
 
 "Some time after an attack of diphtheria, from which 
 the patient has so completely recovered that no trace of 
 false membrane is left behind, the skin grows more and 
 more colorless without apparent cause, so that at length 
 it assumes almost a livid pallor. Severe pains begin at 
 the same time to be felt in the joints, the patient loses 
 power over his limbs, and soon sinks into a state of 
 indescribable weakness. At the same time, the disorders 
 that appear in different functions show that the various 
 organs which should minister to them are involved so 
 far as they are dependent upon muscular power. In this 
 respect, however, the phenomena are not constant, for 
 sometimes it is one set of organs, and sometimes another 
 which suffers most from this weakness. Yery generally, 
 in consequence of the want of muscular power, the 
 patient becomes unable to sit upright, or does so with 
 great difiiculty, while the legs cannot bear the weight of 
 
SEQUELS. 131 
 
 the body ; all the movements grow uncertain, tottering, 
 hesitating and apparently purposeless. Yery remarka- 
 ble disorders show themselves also within the throat, for 
 the velum is completely paralyzed, and hangs down like 
 a flaccid lifeless curtain, which interferes with speech and 
 deglutition. All the muscles of the jaw, neck, and chest 
 are partially paralyzed in consequence of which masti- 
 cation is rendered difficult, and the food can be neither 
 easily moved about in the mouth nor readily swallowed. 
 Vision is impaired, squinting is not unusual. The sensi- 
 bility of the skin is much diminished, in the limbs it is 
 sometimes completely lost, though morbid sensations, 
 such, for instance, as formication, are sometimes experi- 
 enced. CEdema of the various parts often occurs, and 
 occasionally parts, here and there, lose their vitality, and 
 become gangrenous. No general reaction occurs ; fever 
 is rare. The features grow duller and more and more 
 expressionless, though a foolish smile sometimes crosses 
 them, or now and then a ray of intelligence appears. 
 Some patients have frequent fainting fits. As the condi- 
 tion goes on from bad to worse, the weakness becomes 
 extreme, and death at length follows some fainting fit, or 
 takes place when exhaustion has reached its uttermost ; 
 life, as it were, quietly, almost imperceptibly, passing 
 away." 
 
 Such are some of the most common sequels of diph- 
 theria. It is not to be understood, that in these cases a 
 fatal termination is necessary, nor that the symptoms are 
 
132 DIPHTHERIA. 
 
 necessarily so severe as have been depicted by Dr. 
 Fail re. 
 
 Further observations will undoubtedly clear away 
 much that is obscure upon these singular after-efFects of 
 the disease. Even in our present state of knowledge of 
 them, they certainly furnish materials towards the solu- 
 tion of the question — the identity or non-identity of diph- 
 theria and scarlatina. 
 
 These cases are to be treated on tonic principles. The 
 nervine tonics are especially indicated. In cases of local 
 paralysis, astringents, feeble cauterization, and electricity 
 may be employed. 
 
 Eecent observations have shown, that clots in the heart 
 may undoubtedly occasion the sudden deaths which are 
 sometimes witnessed in diphtheria. Dr. Thompson calls 
 the attention of the profession to this fact, in a communi- 
 cation to the London Med. Times and Gazette, Jan. 1860, 
 and in the American Journal of the Med. Sciences for 
 April, 1864, Dr. J. F. Meigs, of Philadelphia, reports 
 three cases of death from this cause. 
 
 Our knowledge of the nature of diphtheria may be 
 summed up in the following words : — 
 
 Diphtheria is a specific disease. This fact is shown by 
 its origin, its progress, its manner of termination, and its 
 sequelae. 
 
 Its diagnostic sign is the formation of an aplastic mem- 
 branous exudation upon any portion of the cutaneous or 
 mucous surface which is exposed to the contact of the 
 atniospbcre. 
 
TREATMENT. 133 
 
 It is propagated by infection and contagion, and is 
 both epidemic and sporadic in its invasion. 
 
 Its characters plainly indicate that it belongs to the 
 category of hlood diseases. 
 
 It is not allied either to cynanche trachealis, or to 
 scarlatina. 
 
 The treatment is to be directed to the control of the 
 exudation, and to the support of the constitution by 
 means of tonics, stimulants, and by a nutritious diet. Of 
 this we shall speak next. 
 
 Treatvient. — Like all diseases which have prevailed 
 epidemically, and which have appalled by their severity 
 and fatality, or perplexed by their novelty, diphtheria 
 has been subjected to a great variety of treatment. It is 
 only within the last few years that anything like iman- 
 imity has existed in the profession in regard to this 
 important point. ISTot to go back further than the period 
 of Bretonneau's memoir on this subject, we shall find 
 that an activity of treatment prevailed which would 
 scarcely coincide with the ideas of the present day. 
 Bleeding, both local and general, blisters, certain local 
 applications to the pharynx, rapid mercurialization, 
 formed the treatment in all cases. Mercury, in fact, 
 was considered as the sheet anchor by a great majority 
 of medical men. To quote the words of Dr. Bard : " But 
 although I consider mercury as the basis of the cure, 
 especially in the beginning of this disease, I do not by 
 an}^ means intend to condemn or omit the use of proper 
 alexlpharmics and antiseptics." Although a few practi- 
 12 
 
134 DIPHTHERIA. 
 
 tioners may still make use of this therapeutic agent, it is 
 now generally agreed that such is the asthenic nature of 
 the disease at the present day, that depletion is not borne 
 well in any form, neither is the action of mercury defen- 
 sible either in theory or practice. 
 
 As we are still unacquainted with any specific capable 
 of arresting the course of diphtheria, our treatment must 
 be directed simply to the conducting our patient in his 
 progress through the disease. In the first place strict 
 attention to certain hygienic rules is necessary. The 
 most scrupulous cleanliness of person and surroundings, 
 free and uninterrupted ventilation should be insisted on. 
 If there are children in the family where the disease 
 breaks out, the well ones should be sent away, or at 
 least should be kept out of the room where the infected 
 individual lies. 
 
 Mr. Wade recommends that the patient in all cases 
 should be clothed in a flannel gown and kept in bed. I 
 believe that the adoption of this plan would have saved 
 almost innumerable lives.' 
 
 In the very early stages of the disease, if there is much 
 heat and engorgement about the throat, cold wet com- 
 presses may for a time give relief. As the disease pro- 
 gresses, warm fomentations, and emollient applications 
 generally, may be substituted. Blisters are to be avoid- 
 ed, both on account of their adding, by their irritation, 
 to the eno:orQ:ement and to the cellular infiltration, and 
 
 DO ' 
 
 » Lancet, Aug. 23, 1852. 
 
TREATMENT. 135 
 
 on account of their liability to take on a diplitlieritic or 
 sloughy appearance. As everything in the aspect of the 
 disease, from the first, indicates that the powers of life 
 must not be lowered, but on the contrary that the tend- 
 ency to prostration must be averted in every way, neither 
 leeches nor local bleeding are admissible, except perhaps 
 in very rare exceptional cases. In certain epidemics, 
 there is also danger that the punctures might take on a 
 sloughy character. 
 
 Many practitioners commence the treatment of diph- 
 theria with the administration of an emetic or a purga- 
 tive. Under certain circumstances an emetic may be 
 advisable, particularly when there is an early tendency 
 to croupal symptoms. For the purpose, fall doses of 
 ipecac are preferable. Anything like purging, however, 
 is to be sedulously avoided on account of the asthenic 
 nature of the disease. The bowels may be moved by 
 simple enemata, or by some mild laxative. 
 
 There are occasional cases of diphtheria so mild in 
 character that local applications to the fauces may be 
 sufScient, but as a general rule it is conceded that the 
 disease requires a tonic and sustaining treatment, par- 
 ticularly is this the case at a late period of the disorder. 
 In cases at all severe, the tendency is to depression and 
 to death by asthenia, unless earlier terminated by 
 asphyxia. 
 
 Stimulants and nourishment should be commenced 
 with early, and persisted in systematically. The amount, 
 of course, must depend upon circumstances, but in order 
 
136 DIPHTHERIA. 
 
 to insure efficiency; they should be varied, and given in 
 small doses at regular and frequent intervals ; if rejected 
 by the stomach, they should be given in the form of 
 enemata. So also with respect to children, when they 
 are frightened and distressed by painful attempts at 
 swallowing, and absolutely refuse everything, we have 
 the same resource. 
 
 Injections of beef-tea, with braedy and quinine, may 
 be employed, and thus life be not unfrequently sustained, 
 when otherwise it would inevitably have been ex- 
 tinguished. 
 
 With regard to the particular form of internal tonics, 
 there is a variety of opinion. There are some which, 
 perhaps, promise a greater chance of success than others, 
 among which we may mention quinine, tinct. ferri 
 chloridi, and chlorate of potash. But as each of these 
 has powerful advocates in its favor, we imagine that, 
 provided the strength of the patient be sustained, it is of 
 little importance by which of these tonics it is accom- 
 plished. 
 
 The tincture of chloride of iron seems now to be pre- 
 ferred by the great majority of practitioners, on account 
 of its unquestionable usefulness in the more asthenic 
 forms of disease. The dose is from 10 to 15 drops, in 
 water, every three or four hours. 
 
 " Of the many internal remedies which have been ad- 
 vised, we do not know of any on which so much reliance 
 can be placed as on the tincture of sesquichloride of iron, 
 with chlorate of potass, chloric ether and hydrochloric 
 
TREATMENT. 137 
 
 acid in the form of mixture, sweetened with syrup, full 
 doses being employed according to the age of the patient, 
 and frequently repeated. A free use should be made of 
 generous wine, beef-tea, coffee, eggs, in combination with 
 brandy and wine, milk, and whatever other form of nu- 
 triment the ingenuity of the surgeon or the fancy of the 
 patient can suggest."^ 
 
 Quinine may be administered in mixture, with or 
 without the dilute hydrochloric acid, or in the form of 
 pill; the dose and frequency of repetition must be 
 governed by circumstances. If the chlorate of potash 
 be preferred, it should be given in doses of from four to 
 eight grains, according to age, in a bitter infusion with 
 two to five drops of the dilute hydrochloric acid. 
 
 We come now to speak of the auxiliary measures to 
 be adopted in the treatment of this disease, and first, of 
 the local applications to the fauces. The propriety of 
 these has been called in question by some writers, on 
 the ground that the disease is a constitutional one, and, 
 therefore, that they can be of no service. But there can 
 be no more reason why the local remedies are not as 
 applicable to this affection as in other constitutional dis- 
 eases, for example, as in syphilis, scrofula, carbuncle, 
 &c. In an excellent paper by Dr. Bristowe,^ on the 
 treatment of diphtheria, the following reasons are given 
 for discarding heroic applications to the fauces : — 
 
 • Lancet, Sauitarj Commission. 
 
 2 Med. Times and Gazette, Sept. 1859. 
 
 12* 
 
138 DIPHTHERIA. 
 
 " 1. That the throat affection is merely a local evidence 
 of a constitutional disease, which is "unlikely to be ar- 
 rested in its progress by any treatment directed to the 
 secondary manifestations only. 2. That the throat affec- 
 tion rarely kills, except by involving organs, such as the 
 trachea and deeper tissues of the neck, which are beyond 
 the region of the possible influence of such agents. 3. 
 That if the theoretical correctness even of such treatment 
 be admitted, the application of remedies to the surface 
 of a thick false membrane, with the hope that they may 
 affect the subjacent mucous tissue, is not only clumsy, 
 but, as regards the object intended, practically useless; 
 and that the prior forcible removal of the membrane 
 from the entire surface, in order to their efficient em- 
 ployment, is unjustifiable in the early stage, even if 
 possible, and is likely only to be followed by increased 
 inflammation, and reproduction of false membrane. . . . 
 Of course, if a gangrenous state of the tonsils, or any 
 other local complication, supervenes, such topical appli- 
 cations as are commonly had recourse to in like condi- 
 tions of the throat should be employed." 
 
 While we concur in the remarks of Dr. Bristowe so 
 far as regards the forcible removal of the false mem- 
 brane, particularly in the early stages, the experienae of 
 almost all medical men of the present day bears witness 
 to the eflicacy of the application of caustics or escharotics 
 to the throat. 
 
 M. Trousseau remarks that topical medication is, //«?• 
 
TREATMENT. 139 
 
 excellence, the treatment, notwithstanding the opposition 
 to it.' 
 
 Mr. Wade maintains that interference with the false 
 membrane will not prevent its reprodaction, nor will it 
 prevent laryngeal complication. We are justified in 
 interfering with the throat exudation when there is 
 excessive fetor, or when it is so copious as to interfere 
 with respirations or deglutition, not otherwise.^ 
 
 "Local treatment," says Dr. Greenhow, "applied to 
 the throat internally, has been almost universally 
 adopted in the treatment of diphtheria ; and though I 
 by no means deny its value when judiciously employed, 
 I am sure much mischief has been produced by its indis- 
 criminate use, especially by the tearing away of the exu- 
 dation by probing or similar contrivances for the applica- 
 tion of nitrate of silver or of strong caustic solutions. 
 Observing that removal of the exudation, and the applica- 
 tion of remedies to the adjacent surface, neither shortened 
 the duration nor sensibly modified the progress of the 
 complaint, but that the false membrane rarely failed to 
 be renewed in a few hours, I very soon discontinued 
 this rough local medication to the tender and already 
 enfeebled mucous membrane. The propriety of this 
 course became evident at the very first post-mortem 
 examination I had the opportunity of witnessing, and 
 has been confirmed by all my subsequent experience. In 
 the fi/rst place, the application can but rarely extend to 
 the entire diseased surface, and, in the next, the subjacent 
 
 » Brit. Med. Journal. 2 Lancet, Aug. 23, 18G2. 
 
14:0 DIPHTHERIA. 
 
 tissues are so deeply involved in cases of really malig- 
 nant diphtheria, that any application to the surface of 
 the mucous membrane could apparently exercise no 
 
 beneficial influence upon the disease The 
 
 only instance in which much benefit can be expected 
 to arise from the local application of escharotics, is 
 when the patient is seen at a very early stage of the 
 illness while the throat is simply inflamed or the exuda- 
 tion, if it be already present, is circumscribed fully in 
 view and surrounded by healthy tissue."* 
 
 On the other hand, some writers maintain that the 
 disease at the outset is a local one, which rapidly brings 
 on a general intoxication. This would be a still stronger 
 argument — if we granted this to be true — for these very 
 local remedies, if applied in season, might prevent a 
 further extension of the disease. 
 
 There are a multitude of substances which have been 
 employed as local applications to the fauces, each of 
 which has its special advocates. During the last four 
 years the nitrate of silver, either solid or in solution, has 
 been perhaps more extensively used than any other sub- 
 stance. This, when used early in the disease, seems in 
 many cases to check the progress of the exudation ; yet 
 it does not answer the purpose altogether, and further 
 experience has somewhat diminished confidence in it. 
 Indeed, in some instances it is a question whether the 
 free application of this caustic does not rather add to the 
 evil. 
 
 ' On Diphtheria, by Dr. E. Headlam Greenliow. 
 
TREATMENT. 1-il 
 
 "I have mentioned that I tliought that tlie indiscrimi- 
 nate mopping of the fauces, as it is called, with solutions 
 of nitrate of silver, was frequently attended with in- 
 jurious results in this disease, principally, I believe, for 
 this reason, that, owing to the struggles of the little 
 patient, it is impossible to apply the caustic solution 
 with that precision which the case absolutely requires. 
 Thus, it is applied to parts which are entirely free from 
 disease. I have been told of cases where the inside of 
 the cheeks has been covered with it; in coughing, a por- 
 tion of it has been expelled upwards through the nose, 
 corroding the susceptible surface of its mucous mem- 
 brane ; and, again, other portions of it have seemed to 
 pass downwards into the pharynx and oesophagus ; and 
 I am not sure that, during the convulsive struggling of 
 the patient in resistance, some of it may not also enter 
 the larynx, wdiere it may possibly initiate those inflam- 
 matory changes in the mucous membrane of the air- 
 passages wdiich are too frequently the harbinger of death 
 in this disease.'' ' 
 
 Still, if carefully and properly used, nitrate of silver, 
 in many cases, is undoubtedly of benefit. If in solution, 
 it is to be applied by means of a probaug or brush, 
 swabbing over the diseased surface quickly, at the same 
 time thoroughly. The strength of the solution should 
 be from 30 to 60 grains, and perhaps higher, to the 
 ounce of water, according to circumstances. For chil- 
 
 • Observations, &c., by F. A. Bulley, F. R. C. S., Med. Times and 
 Gaz., April, 1859. 
 
112 DIPHTHERIA. 
 
 clren, a full-sized camel's-liair brush is best. The clnld 
 should be placed on the lap of an attendant, and the 
 head firmly fixed. If he will not open the mouth, the 
 nostrils should be closed for a few moments, and as he 
 opens the mouth for breath, the jaw should be at once 
 depressed, and then, the tongue being kept down by the 
 finger, the fauces are brought well into view, and the 
 solution thus thoroughly applied. The utmost gentle- 
 ness and patience should be exercised ; but at the same 
 time, it should be done with firmness, for upon the 
 effectual accomplishment of this proceeding the success 
 of the treatment will greatly depend. This should be 
 repeated every three or four hours, so long as it is 
 necessary. 
 
 The nitrate of silver may also be employed in the 
 solid form, but this we should not advise, particularly 
 in the case of children. During the struggles of the 
 little patient the crayon might become broken, an acci- 
 dent which has happened, and fragments fall into tlie 
 oesophagus or larynx, giving rise to serious lesions. 
 Moreover, the nitrate of silver in this form has the dis- 
 advantage of creating a more decided eschar than the 
 solution, simulating the diphtheritic exudation, and thus 
 hindering the perception of the progress of the disease. 
 
 The tinct. fcrri chloridi is an excellent substitute for 
 the nitrate of silver, and is now generally preferred by a 
 great majority of practitioners both in this country and 
 in Europe. This may be applied by means of a brush 
 
TREATMENT. 143 
 
 or sponge, or in a gargle of the strength of two drachms 
 to eight ounces of water. 
 
 The hydrochloric acid may be useful in some cases, 
 and has also been extensively advocated. It is to be 
 applied in a similar manner to the other substances of 
 which we have spoken. In the case of children, the 
 addition of honey to the acid is desirable. This is a 
 favorite topical remedy of M. Bretonneau. He says: — ^ 
 
 "At the commencement of the epidemic at Tours, 
 topical remedies suggested themselves. The beneficial 
 effects of hydrochloric acid soon gained for it an exclu- 
 sive preference. In the use of this acid, it is preferable 
 to employ it in full strength, at long intervals, than to 
 return to less energetic applications more frequently." 
 
 Another gargle, which is very ef&cacious, and which 
 has also the advantage of correcting the fetor of the 
 breath and the secretions of the throat, is a solution of 
 the chloride of soda, in the proportion of one drachm to 
 six ounces. This may either be employed by itself, or 
 combined with other applications. The same may be 
 said of the chlorate of potash. The combination of chlo- 
 rate of potash and hydrochloric acid with the tincture of 
 the sesquichloride of iron is strongly to be recom- 
 mended, especially in the croupal cases, the chlorate of 
 potash having an undoubtedly anti-diphtheritic influence, 
 where time permits it to be brought into play. 
 
 Numerous other applications to the fauces have been 
 advocated and successfully employed. Among these 
 
 ' Traite de la Diphtherite. 
 
14i DIPHTHERIA. 
 
 may be mentioned, strong solutions of sulpliate of 
 copper ; the chloride of sodium, either by itself or com- 
 bined with vinegar ; gargles of tannin, capsicum, &c. ; 
 Monsell's salt in powder. Of this last substance. Dr. 
 Beardsley, in his paper upon the epidemic at Milford, 
 Connecticut, to which we have previously referred, 
 writes : — 
 
 '' Monsell's salt was found to be the, most efficacious 
 and valuable of all topical remedies, affording in some 
 instances decided relief. Its active astringent property 
 rendered it peculiarly appropriate, and well adapted to 
 obviate that relaxed and enfeebled condition of the 
 throat Avhich attends the advanced stas^e of the disease." 
 
 In cases where there is much tonsillitis, we may em- 
 ploy the inhalation of steam, mucilaginous gargles, 
 warm fomentations, &;c. These often afford marked 
 relief, and are useful adjuncts to the other treatment. 
 
 M. Grand Boulogne states that, in the Havannah, 
 during two violent epidemics, he met with great success 
 in the use of ice as a remedy. He caused the patients 
 to keep it constantly in their mouths even into convales- 
 cence. 
 
 M. Bouchut^ advises the ablation of the tonsils early 
 in the disease, not only for the purpose of removing the 
 exudation which appears on them, and which he con- 
 siders the localization of the disease, but also of facili- 
 tating respiration. Such a proceeding we should not 
 consider advisable, to say the least, for the following rea- 
 
 ' Gazette des Hopitaux, 1858. 
 
TREATMENT. 145 
 
 sons : In tlie first place, the exudation is almost sure to 
 re-forra upon the cut surface ; next, there is a great risk 
 of severe hemorrhage ; and finally, any cutting opera- 
 tion, however simple, had better be avoided, if possible, 
 especially upon young children, and in a disease so 
 asthenic in its character. 
 
 The removal of the tonsils in this disease might pos- 
 sibly be practised upon an adult, when there is great 
 tumefaction, and for the purpose of facilitating respira- 
 tion, and for this purpose only. 
 
 When the nasal fossae have become implicated, various 
 solutions should be injected through the nostrils. MM. 
 Bretonneau and Trousseau recommend a solution of 
 alum, or the insufflation of the same substance in powder. 
 We should advise, however, a solution of the chloride 
 of soda, in the strength of two drachms to eight ounces 
 of water, to which two ounces of glycerine may be added. 
 Frequent injections of warm water and soap may also be 
 thrown up, in order to cleanse the parts and remove the 
 offensive odor. 
 
 Kitrate of silver, sulphate of zinc, and, in fact, any 
 solution which is applicable for the fauces, will answer 
 a good purpose for injecting the nasal foss^. 
 
 But when in spite of all means of treatment, energeti- 
 cally and judiciously employed, the disease progresses 
 steadily onwards, and the larynx and trachea are invaded 
 by the exudation, giving rise to sj^mptoms of imminent 
 danger, then the important question of tracheotomy must 
 be entertained. 
 13 
 
146 DIPHTHERIA. 
 
 Without going into a history of tracheotomy, or a 
 recapitulation of the arguments on the one side or the 
 other, we most unhesitatingly say that, under the cir- 
 cumstances above mentioned, this operation is a resource 
 which we are in duty bound to afford our patient, and in 
 view of what experience teaches us is otherwise certain 
 death. It is not that, by so doing, we increase his 
 chances for life solely, but in the case of an unfavorable 
 termination, we render his last moments less distressing. 
 
 It has been urged that the operation of tracheotomy is 
 not warrantable in those cases of croup which are the 
 result of the extension of the diphtheritic exudation to 
 the larynx, as the patient not merely dies from asphyxia, 
 but sinks likewise from a constitutional infection ; on the 
 other hand, it has been urged that there is even a better 
 chance of success with the operation than in true croup, 
 the membrane being less apt to spread to the bronchi. 
 
 For ourselves, we can see no validity in any argu- 
 ments which have been adduced either in favor of or 
 against tracheotomy in diphtheria, which would not be 
 equally applicable to the same operation in cases of 
 croup, and in this opinion we are supported by statistics. 
 
 "With a view to a correct appreciation of the subject, 
 we would refer to the remarks made by Dr. Fuller, in 
 the course of a paper read to the Eoyal Med.-Chirurgical 
 Society, in 1857. Dr. Fuller began by referring to the 
 difference existing physiologically and pathologically 
 between idiopathic inflammatory croup, and the diph- 
 thcj'itic form of the disease which commonly prevails in 
 
TBEATMENT. 147 
 
 France, and he pointed out that the objection usually 
 ■urged against French statistics of tracheotomy in croup, 
 viz., that diphtheritic cases are much more favorable for 
 the performance of the operation than the croup cases 
 usually met with in Great Britain, has no foundation in 
 fact. By reference to 483 cases in which tracheotomy 
 had been performed for the relief of croup in France, 
 he showed that the operation had been eminently suc- 
 cessful in the hands of French surgeons, and he reminded 
 the society that inasmuch as the condition of the throat 
 externally and the nature of the accompanying fever in 
 diphtheritis are by no means favorable to the operation, 
 the success which has attended it can be explained away 
 only on the supposition often put forward by English 
 writers, that in France the disease seldom extends into 
 the trachea and bronchi, and is rarely accompanied by 
 bronchitis or pneumonia. The fallacy of this supposi- 
 tion was, however, shown by reference to the recorded 
 results of the post-mortem investigations of 311 cases of 
 croup in France, and he also showed that in regard to its 
 pathological effects, diphtheritis, when accompanied by 
 croupal symptoms, does not, as compared with inflamma- 
 tory croup, present any greater prospect of success for 
 the operation than it does in the character of its 
 accompanying fever, or the condition of the throat 
 externally. 
 
 Granting then that the two diseases, inflammatory 
 croup and diphtheria, stand on an equal footing as 
 regards the applicability of the operation, let us briefly 
 
148 PIPnTHERIA. 
 
 consider a few of tlie oLjectioiis wliicli have been brought 
 against tracheotomy. 
 
 It is urged that the small amount of success which has 
 hitherto attended the actual performance of this opera- 
 tion in croup renders it an expedient to which it is 
 scarcely justifiable to have recourse. If we refer to the 
 statistical inquiries of different countries^ we shall find 
 that this objection has no foundation. Thus, in France, 
 where in cases of croup tracheotomy has been resorted to 
 on an extended scale, although the rate of mortality has, 
 on the whole, averaged about seventy-six per cent, of 
 the cases operated upon, yet in about 680 cases in which 
 the operation was performed, the mortality only 
 amounted to sixty-eight per cent. 
 
 According to M. Andre, during the year 1856, there 
 were 54 operations of tracheotomy for croup at the 
 Children's Hospital in Paris. Out of these there were 
 39 deaths and 15 recoveries, or over 27 per cent. 
 
 The proportion of recoveries obtained by M. Guersant 
 in a very considerable number of operations performed 
 during the last three or four years Avas about one-third. 
 
 In a summary drawn up by M. Bouchut, he says : — 
 
 "Although the success of traclieotomy is not very strik- 
 ing, yet the results are such as ought to encourage its 
 adoption. Thus M. Bretonneau performed the operation 
 in 20 cases, and out of these 6 were successful. In my 
 own practice, 160 operated upon, 5 saved. M. Velpeau 
 saved 2 in 10. M. Petit, 6 operated upon, of which 3 
 
TREATMENT. 149 
 
 were successful. Thus, out of 176 cases, we have 16 
 which terminated favorably." 
 
 M. Chaillou, in the Journal of Practical Medicine and 
 Surgery, gives the following statistics as regards the 
 operation in cases of confirmed croup. In eight years, 
 880 operations of tracheotomy were performed, of which 
 86 were successful, an encouraging result, when by far 
 the greatest number of patients were operated upon in 
 the last stages. 
 
 The statistics of tracheotomy at the Hopital des Enfans 
 in 1855 showed ten cures and thirty-eight deaths, out of 
 forty-eight cases, or one patient saved in five. Since this 
 period the ratio has very much improved, owing to a 
 more extended experience in the mode of performing the 
 operation, and in the necessary after-treatment. 
 
 In Great Britain the recorded results of the operation 
 exhibit a fair amount of success. In 22 recorded cases 
 in 1857, no less than eight terminated satisfactorily. 
 
 Dr. Fuller, above cited, reports five cases of croup for 
 which tracheotomy was performed, in two of which life 
 was saved. The* results of the operation in England are, 
 however, for some undetermined cause, far less favorable 
 than those which have been obtained in France or in 
 this country. 
 
 The most recent statement of the results of trache- 
 otomy in France, is that of MM. Eoger and See ;' this 
 
 ' Gazette HeLiloin., Nov. 1858. 
 13" 
 
150 DIPHTHERIA. 
 
 gives 126 recoveries in 416 operations, or 27 per cent, 
 during the last seven years. 
 
 A mucli lamer amount of statistics mi^-ht be added to 
 those which we have brought forward, but sufficient has 
 been offered to prove the propriety under certain circum- 
 stances, of performing tracheotomy in this disease. 
 
 It has been objected that the operation was a very 
 difficult one, and that in itself it was very dangerous. 
 In answer to the first of these objections, we will say 
 that, in the case of young children, it is often a difficult 
 proceeding, and requires a greater amount of operative 
 skill and care than is commonly supposed. These 
 circumstances, however, should scarcely be held to 
 militate against our having recourse to the operation 
 wlien the necessity of the case demands it. 
 
 But that tracheotomy is in itself a very dangerous 
 operation, the tendency of the evidence on this point 
 goes to disprove. Thus, M. Trousseau^ has collected the 
 records of ninety-six cases, in which tracheotomy was 
 performed for the removal of foreign bodies in the wind- 
 pipe, and in seventy-three of these a complete cure was 
 effected, the rate of mortality after the operation amount- 
 ing to about twenty-four per cent, of the cases operated 
 upon. This gentleman has himself performed tracheot- 
 omy in more than 200 cases, with success in. more than 
 a quarter of the whole number of cases.* 
 
 Dr. Gross, in his Treatise on Foreign Bodies in the Air- 
 
 ' " Discussion at French Academy," hy M. Trousseau. 
 * Brit. Med. Journal, Jan. 18G2. 
 
TREATMENT. 151 
 
 Passages, lias collected the particulars of 176 cases in 
 which foreign bodies had accidentally gained entrance 
 into the air-passages. Id 68 of these, tracheotomy was 
 performed; and the mortality reached only 11 per cent. 
 
 We must take into consideration, when making a 
 comparison between the results of tracheotomy performed 
 for the removal of foreign bodies, and those of this oper- 
 ation for the relief of croup, that, in the former case, the 
 tissues operated upon are generally healthy, whereas, in 
 the latter case, they are the seat of certain morbid 
 chano-es. Yet not with standinsr this, there is not suffi- 
 cient danger in the operation itself, under any circum- 
 stances, to deter us from performing it. 
 
 Dr. West, after speaking of the more favorable results 
 of the operation obtained in France than in England, 
 owing, as he thinks, to its frequent performance in the 
 former country when other means might have been tried 
 which would prooably have controlled the disease, 
 says : — 
 
 " Still, if these facts detract something from the appa- 
 rent value of the operation, they at least show that in 
 itself it is not attended by serious danger ; and recent 
 statistics prove that, in as far at least as the diphtheritic 
 form of croup is concerned, there is no sort of connection 
 between an increased frequency in the performance of 
 tracheotomy and a higher mortality from the disease."^ 
 
 The gravest objection which is brought against the 
 operation, is, that it is apt to induce severe bronchitis, or 
 
 ' Lectures on Diseases of Cliildhood, &c., 1859. 
 
152 DIPHTHERIA. 
 
 at least to greatly aggravate any previously existing 
 inflammation of the lungs or bronchial tubes. In answer, 
 we say, that, although there is some ground for this 
 accusation, on the other hand, it must be remembered 
 that these very inflammatory conditions are the almost 
 invariable complications of croup, however treated, and 
 that they do not ordinarily follow tracheotomy when 
 resorted to in other circumstances, as for the removal of 
 foreign bodies, for acute laryngitis, or for oedema of 
 the glottis. 
 
 Other objections have been brought against the pro- 
 priety of tracheotomy in cases of croup and diphtheria, 
 which we could satisfactorily answer did space permit. 
 AYe can only add, in conclusion, that there do not appear 
 to be any evils attendant upon the operation which 
 counterpoise the indisputable benefits to be derived 
 from it. 
 
 A few words upon the proper period for performing 
 the operation. Tracheotomy has been, and is still con- 
 sidered by a great portion of the profession, especially 
 in this country and in Great Britain, as the very last 
 resort. Within the last few years, however, the opinion 
 of those best able to form a judgment has materially 
 changed. A middle period should be selected for the 
 operation. We should not wait until the case is des- 
 perate, the patient in a complete state of prostration, in 
 fact moribund ; nor, on the other hand, should we attempt 
 the operation too early, before other remedies have been 
 fairly and completely tested. But we are to resort to 
 
TREATMENT. 153 
 
 the operation " so soon as ever we feel that our remedies 
 are too tardy to overtake the disease." 
 
 There are some circumstances relating to the proper 
 management of the operation and to the after-treatment, 
 which greatly influence the results of tracheotomy, at 
 which we must hastily glance. The first of these con- 
 cerns the size of the tracheal tube, the importance of 
 which was first insisted upon by M. Trousseau. This 
 gentleman explains the occasional sudden and appa- 
 rently causeless disappearance of the amendment which 
 at first follows the operation, by the inadequate size of 
 the canula, which is frequently emploj^ed, and which 
 does not provide for the constant and permanent ad- 
 mission of a sufficient quantity of air. In illustration of 
 this fact, M. Trousseau says : — 
 
 " Take a quill, and, closing your nostrils, endeavor to 
 breathe entirely through it ; at first you breathe easily 
 enough, but soon your respiration becomes laborious, 
 and at length you are fain to throw away the quill, and 
 with open mouth once more to fill your lungs com- 
 pletely. Now precisely this is what happens when an 
 opening of inadequate size is made into the trachea, air 
 enters readily, and without the interruption which the 
 spasm of the glottis occasioned ; but it does not enter in 
 sufficient quantity, and hence the return of the symptoms 
 and the patient's death." 
 
 Acting on this principle, M. Trousseau makes a larger 
 opening into the trachea, and introduces a larger canula 
 
15i DTPIITIIEPvIA. 
 
 than was formerly used ; and this practice is now gaining 
 ground, especially in the United States. 
 
 Dr. Hillier says, in a clinical lecture on Diphtheria, 
 that in order to give the child an opportunity of cough- 
 ing and clearing the tubes of mucus and other matters, 
 the tube may be closed for two or three seconds by the 
 finger. AYhen the finger is removed a deep inspiration 
 is taken, then the tube is closed again until an effort to 
 cough is made, then the finger is suddenly taken away 
 and the offending materials are expelled. Use a good 
 sized double tracheal tube.' 
 
 Another necessary precaution has reference to the ne- 
 cessit}^ of insuring to the patient, after the operation, a 
 warm moist atmosphere, which may be easily effected by 
 filling the room with steam from some simple apparatus ; 
 and to keeping the room at a fixed temperature, and, 
 though well ventilated, free from all draughts. The neck 
 also should be surrounded with several folds of muslin, so 
 as to cover the orifice of the tube. Great care should also 
 be taken to keep the canula free, and as upon this one thing 
 the whole result of the operation may depend, it should 
 not be intrusted to unskilful hands, but to a medical 
 student, or to some competent person, upon whom full 
 reliance can be placed. This is a point which has not 
 attracted the attention which it deserves, for not unfre- 
 quently cases occur where death suddenly takes place 
 from the stoppage of the tube, the persons in charge 
 fearinnf to do what the occasion of the moment demands. 
 
 o 
 
 1 Med. Times and Gazette, April, 18G2. 
 
TREATMENT. 155 
 
 Medical treatment must not be suspended after t"he 
 operation. The same measures wMcli were considered 
 useful before the operation must be steadily persevered 
 in. Great stress has been laid by a few writers in our 
 country upon the importance of throwing nitrate of silver 
 injections into the trachea. These we certainly advocate, 
 as cases have come under our observation where very 
 beneficial results have followed their employment. 
 
 The period at which the canula ought to be removed 
 is also an important point, on account of the irritation of 
 the edges of the wound which its long continued 
 presence is apt to produce. M. Andre, in his statistics 
 before alluded to, has endeavored to ascertain the proper 
 period for this purpose. His observations were made in 
 17 cases. In 1 it Avas taken out on the fourth day ; in 5 
 on the sixth day; in 2 on the seventh; in 3 on the eighth; 
 in 1 on the eleventh ; 1 on the thirteenth ; 1 on the four- 
 teenth, and 1 after the fourteenth. From the fourth to 
 the fifth day is the time recommended by M. Andre. 
 After the removal of the canula the wound is to be 
 covered with a bit of gauze, the edges touched daily 
 with the nitrate of silver, and dressed with a little sper- 
 maceti or other ointment. The tube is to be replaced if 
 dyspnoea recur. 
 
 In addition to what has been already said on the treat- 
 ment of diphtheria, it may not be inappropriate to give 
 a summary of the treatment recommended by some of 
 the principal practitioners of Europe. 
 
 Mr. Ranking, in his lectures on diphtheria {Lancet, 
 
156 DIPHTHERIA. 
 
 January, 1859), recommends the tinct. ferri chloridi, 10 
 to 15 drops every three or four hours, and the same to 
 be applied locally ; the diet to be nourishing. 
 
 Mr. Hart, of the '^Lancet Sanitary Committee," advises 
 a tonic treatment, tinct. ferri chloridi, chlorate of potasli, 
 (fee. ; and as local treatment, the nitrate of silver, 30 to 60 
 grs. to the ounce, or the muriatic acid. 
 
 Dr. Kingsford {Lancet, Nov. 1858), in simple diphthe- 
 ria, uses a calomel purge in the commencement. Then 
 chlorate of potash, with dilute hydrochloric acid in a 
 decoction of bark, and mopping the throat two or three, 
 times a day with the compound solution of alum. In the 
 severe forms he uses wine and nutritious diet freely, and 
 gives tinct. ferri chloridi, with chlorate of potash, 10 to 
 30 drops of the former with 10 to 30 grs. of the latter, 
 every two or three hours, according to circumstances. 
 Nitrate of silver to the throat — wine and nutritious diet 
 freely. If much difficulty of deglutition, enemata of 
 strong beef-tea, and port-wine every two hours, the 
 quantity to be injected not to exceed two or three ounces 
 at a time. Mercury he thinks contraindicated, except as 
 a cachectic at the beginning. 
 
 Dr. Perry, of Kent {Med. Times and Gaz., March, 1859), 
 gives oil of turpentine, ten drops every second hour, to a 
 child of from two to six years of age, and alternates this 
 with five grains of carbonate of ammonia every two 
 hours. Besides this, port-wine, porter, and beef-tea, or 
 wine with the velk of an ei2-<r, ad llhltum. He thinks 
 tliut mercury hastens tlie fatal result. 
 
TREATMENT. 157 
 
 Dr. Cammack {Lancet, Oct. 1858) gives a calomel pur- 
 gative where symptoms of laryngitis appear, and a decoc- 
 tion of cinchona with hydrochloric acid. A gargle of 
 salt and vinegar for the mouth and throat, which he also 
 injects up the nostrils when they become affected. He 
 applies the solid nitrate of silver to the exudation. He 
 is convinced that the malady is herpetic. 
 
 The editor of the Lancet (October, 1858) thinks the 
 disease is not a new one, but believes it to be a form of 
 scarlet fever. He gives ammonia and beef-tea early, and 
 keeps the skin softened by the steamed blanket. A 
 warm blanket wrung from hot water is to be put around 
 the patient, this to be enveloped in dry blankets, and the 
 patient to be sweated for an hour and rubbed rapidly 
 dry, and again covered with dry blankets. '' Keep him 
 up with ammonia and good nutritious broths." 
 
 Mr. Thompson {Brit. Med. Journal, June, 1858) advises 
 thorough applications of nitrate of silver to the throat, 
 a stimulating gargle of nitrate of potash, and capsicum, 
 or solution of chlorinated soda. Mild but continued 
 counter-irritation over the upper part of the chest ap- 
 peared of great service. General treatment he thinks of 
 little use. Stimulants are often required in the early 
 stage. 
 
 M. Roche {L Union Medicate, July 26, 1^59) places 
 great reliance on the following treatment. Having first 
 freely cauterized the false membrane with lunar caustic, 
 he injects every hour against the fauces a solution of 
 common salt, not of sufficient strength to create nausea. 
 14 
 
158 DIPHTHERIA. 
 
 The tincture of iodine he also employs as a topical appli- 
 cation. 
 
 Mr. Ramskill {Lancet, February, 1859) makes use of an 
 infusion of chamomile to wash and syringe out\ the 
 throat and nares of children, to which he adds a few 
 drops of creasote, or of the liquor calcis chlorinate. 
 Internally he gives chamomile with muriatic acid and 
 ether and quinine^ at the same time good nourishment 
 and stimulants. 
 
 Dr. West, in his Treatise on Diseases of Childhood, 
 adopts the following mode of treatment. A drachm of 
 the nitrate of silver to the ounce of water is applied to 
 the throat either by means of brush or probang; if 
 necessary, afterwards the strong hydrochloric acid, di- 
 luted with from four to ten parts of honey. One, or at 
 the most, two applications of the stronger caustics in the 
 twenty-four hours suffice. These are preferable to the 
 weaker ones, as these latter must be applied frequently, 
 which distresses the child. For this reason he does not 
 make use of the tincture of iron, nor does he employ 
 insufflations of powdered alum or calomel. The mouth 
 may be kept free from the secretions which are apt to 
 accumulate in it by syringing it every three or four 
 hours, with a lotion of the chloride of soda, half au ounce 
 to six ounces of vratcr. As constitutional treatment, he 
 advises quinine with the tincture of bark and hydro- 
 chloric acid, at short intervals. The best of nourishment 
 and stimulants. 
 
 Dr. Semple (Lancet, October, 1858") says that the best 
 
TREATMENT. 159 
 
 treatment is the application of strong caustics, of which 
 the concentrated hydrochloric is the best, at the very 
 earliest possible period. Nourishing diet, &c. 
 
 M. Enipis {Arch. Gtn. de Medecine) advocates the use 
 of local remedies, such as the hydrochloric acid and the 
 nitrate of silver, and for constitutional treatment, tonics 
 and nutritious food. In these views M. Isambert also 
 concurs. 
 
 In our own country, during the epidemic which pre- 
 vailed at Albany in 1858, gargles containing chlorates of 
 potash and soda, or vinegar with the mineral acids and 
 tonics internally, constituted the principal treatment. 
 During the epidemics at San Francisco, very much the 
 same treatment was pursued. So also in Connecticut. 
 
 Prof. Chapman, of New York, in a series of excellent 
 papers upon this disease, advocates the adoption of a 
 stimulating treatment. He gives the history of thirty- 
 eight cases in which the disease is presented in almost 
 every varied phase. He says: ''Of the remedies that 
 have been employed in diphtheria, two only have proved 
 themselves in our hands worthy of confidence, wdth the 
 exception, in the chronic stage, in favor of the salts of 
 iron. These two remedies — alcohol or cinchona in one 
 of its forms — are administered in such doses and at such 
 intervals as to secure one effect — the fullest stimulation 
 of the nervous and vascular systems. Either singly may 
 suffice when the vital force needs but slight aid to main- 
 tain the integrity of the blood ; but the two united have 
 more than a double power, and call out the greatest 
 
160 DIPHTHERIA. 
 
 possible amount of resistance, since the nerve centres 
 and bloodvessels^ the great life-factors, are exalted to the 
 highest point; although liquors, when given in such 
 quantities and intervals as to occasion and keep^ up a 
 steady, but not excessive excitation, not only quicken the 
 functional offices of each organ, but act more especially 
 on the nervous and vascular systems. 
 
 "It is a noteworthy fact that, in my experi- 
 ence, the diphtheria never attacks those habituated to the 
 use of spirits. This, if confirmed, may be more than a 
 
 remarkable coincidence Both the cinchona and 
 
 the alcoholic stimulant, whether used singly or united, 
 should be given with regularity and in sufficient doses to 
 obtain their full effects ; and then the latter, in a lessened 
 quantity, continued for two or more weeks after the 
 disappearance of the disease and its sequelas. From the 
 outset to a permanent restoration to health, one or 
 perhaps both of these remedies are to be continuously 
 administered.'" 
 
 Although there is some diversity in the treatment of 
 diphtheria, as laid down by different authorities, still, it 
 will be seen that the affection is considered by all as one 
 decidedly adynamic in its character, and tliat conse- 
 quently a supporting treatment is necessary, and all 
 depletory measures are to be strictly avoided. Authori- 
 ties are also united upon the necessity of a more or less 
 
 ' Practical Observations on and the Treatment of Diphtlieria. By 
 E. N. Chapman. Boston Med.. and Surg. Journah Feb. 18113. 
 
TREATMENT. 161 
 
 enei'getic local treatment, particularly in the early stages 
 of the disease. 
 
 Before closing our remarks upon the treatment of 
 diphtheria; we must say a few words upon tubing of the 
 glottis. 
 
 The unquestionable efficacy of tracheotomy under 
 certain circumstances suggested the idea of inserting into 
 the larynx through the mouth an instrument which 
 might replace the canula of tracheotomy and render 
 unnecessary the use of the knife. Although others had 
 tried the experiment, M. Bouchut was the first who put 
 it to practical use. 
 
 The operation consists in inserting into the larynx a 
 metallic tube, which is to be retained for a longer or 
 shorter time according to circumstances. 
 
 The instruments used are: 1. Curved male catheters 
 of different sizes, open at both ends, and intended to 
 penetrate into the larynx (C, C). 2. Straight cylindrical 
 silver rings {A) of from J to | of an inch long, provided 
 at their extremities with two ridges at the distance of a 
 quarter of an inch and pierced with a hole for the pas- 
 sage of a silk thread {B), the function of which is to pre- 
 serve a hold upon the ring from without. 8. A ring 
 {D) to protect the forefinger. 
 
 The process is quite a recent one, and has not as yet 
 been attended with any very great success. Bouchut re- 
 ports seven cases, five of which terminated fatally, and 
 the other two underwent tracheotomy. At a meeting of 
 the French Academy of Medicine, a committee was ap- 
 
 14* 
 
162 
 
 DIPHTHERIA. 
 
 pointed to examine M. Boucliut's communication on the 
 subject; of this committee M. Trousseau was appointed 
 
 Fig. 3. 
 
 chairman. The report, which is of some length, con- 
 cludes with the following resolutions : — 
 
 "1. Tubing the larynx, in certain forms of acute 
 laryngitis, may, by delaying asphyxia, become a remedial 
 agent. 
 
 "2. In certain chronic affections of the same organ, 
 
KESUME. 163 
 
 tu"5ing may permit traclieotomy to be postponed, and 
 may occasionally give time to treat and cure the disease. 
 
 "3. In the treatment of croup, tubing retards asphyxia, 
 and affords a more easy mode of introduction into the air- 
 passages of remedies calculated to modify diphtheritic 
 inflammation. 
 
 "4:. It cannot, however, supply the place of trache- 
 otomy, which to this day remains the only expedient in 
 croup, when the resources of medicine seem to have been 
 exhausted." 
 
 RESUME. 
 
 In the preceding pages, we first gave Bretonneau's 
 description of diphtheria. We then remarked that it 
 was only by a comparison of the various epidemics of 
 "sore throat" Avhich had prevailed at intervals in various 
 parts of the world, that w^e could ascertain how far his 
 description was to be taken as a model of the disease. 
 Accordingly we took up the history of the epidemics 
 from remote ages to the present day. 
 
 Having given an account of those which had prevailed 
 in various parts of Europe, and having compared the 
 descriptions of various writers upon these epidemics, 
 with that of Bretonneau, we showed that he was incorrect 
 in denying the presence of all constitutional disturbance, 
 as also in insisting upon the absence of all relation be- 
 tween diphtheria and gangrene of the fauces — both of 
 these conditions having been frequently observed, par- 
 ticularly during the epidemics of late years. 
 
16i DIPHTHEEIA. 
 
 We next observed that Bretouneau's idea of croup, 
 which he associates with diphtheria, does not conform to 
 our ideas of that disease, founded, as they are, upon the 
 description given by Dr. Home. The distinctions be- 
 tween diphtheria and croup were dwelt upon, as also the 
 non-identity of diphtheria and scarlatina. 
 
 In order, we took up the history of the disease in 
 England. A comparison of the descriptions of the dis- 
 ease by various writers, as it appeared in the several 
 counties, gave no marked uniformity, and but little cor- 
 respondence with Bretouneau's model. 
 
 Diphtheria in America was then considered, and we 
 gave at some length a description of an epidemic of "sore 
 throat," by Dr. Bard, also an account of the epidemics in 
 California and other parts of the Union. 
 
 We next remarked that all these epidemics of '^sore 
 throat" were connected by a bond of union, to be found in 
 the pathological anatomy of the disease, which consists in 
 the peculiar exudation. That although Bretonneau fully 
 recognized this fact, his description was deficient, hence 
 we subjoined that of MM. Barthez and Rilliet, as being 
 more comprehensive. We also considered the disease 
 as existing under two forms, the mild and severe. 
 
 Certain points as respects the nature of the disease 
 were taken up in order. First, the characteristics of the 
 false membrane, its physical appearances, its seat, the ex- 
 periments of Bretonneau in order to ascertain the specific 
 nature of the diphtheritic membrane, its microscopic ap- 
 
RESUME. 165 
 
 pearances, and its dependence upon certain parasites 
 were discussed. 
 
 Next, in answer to the question, Is diphtheria infec- 
 tious ? Having^ o-iven the aro^uments of various authors, 
 we replied, that although we were ignorant of the exact 
 laws which governed these epidemics, we are able to de- 
 tect certain hygienic or individual circumstances which 
 undoubtedly had their effect, either as direct or as pre- 
 disposing causes. 
 
 The presence of albumen in the urine and its significa- 
 tion were commented upon. We remarked that further 
 observation was necessary before we could ascribe to it 
 any settled prognostic value. We spoke of the singular 
 after-effects of the disease, as shown especially upon the 
 nervous system. We gave the observations of MM. 
 Trousseau, Faure, and others upon this point. 
 
 In our account of the treatment of diphtheria, we said 
 that it was only within the last few years that anything 
 lik# unanimity had prevailed. That it was now univer- 
 sally regarded as an asthenic disease, and consequently 
 would bear no depletory measures, but, on the contrary, 
 required tonics, stimulants, and a nourishing diet, even 
 in the early stages. Blisters, leeches, and local bleeding 
 of any sort should be prohibited. 
 
 The tonics best suited we enumerated. Of the auxil- 
 iary measures, we first spoke of the local applications to 
 the fauces, their utility and propriety, the various agents 
 which had been employed and the mode of use. The 
 ablation of the tonsils recommended by Bouchut, we con- 
 
166 DIPHTHERIA. 
 
 ceived to be inadmissible; excepting under rare circum- 
 stances. 
 
 Tracheotomy we discussed at considerable length. 
 Eemarking that the two diseases, inflammatory croup 
 and diphtheria, were on an equal footing as regards the 
 applicability of the operation, we answered the various 
 objections which had been brought against it; the small 
 amount of success ; the difficulties of performing it ; the 
 tendency to the production of bronchitis, &c. 
 
 We considered that the proper time for performing 
 the operation was an intermediate period. We gave some 
 necessary rules as to the size of the canula, the state of 
 the surrounding atmosphere, the importance of having 
 some competent person at hand in the case of emergency, 
 the propriety of keeping up the medical treatment, and 
 the time for removing the canula. 
 
 Having given a summary of the treatment recom- 
 mended by some of the leading men in Europe, we 
 concluded by a brief consideration of the operation for 
 "tubing the larynx." 
 
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