■ DIPHTHERIA, AS IT PRSVAIt.BO IN THE UNITED STATES FROM 1860 TO 1866, PRBCBDCD Bj aa nislflrical Accoiiat of its Pliittoiiieiia, ITS N^VTURE, AXD HOMCEOPATHIC TREATMENT. BY ^ , ^ C. IS"EIDHAEi);M.D., LATE PBUFE3S0R OP CLISICAI. MEDlriXE IN THE HOMCF.OPATHIC MEDICAL COLLEOE OP PBK.NSYLVANIA, ETC., ETC., ETC. NEW YORK: WILLIAM RADDE, No. 550 PEARL STREET. PHiLADBLPniA: F. E. Bff.iiicKE, 6.35 A EC H Street. BoaTOw: Otw Clapp. St. Loria: H. C. G. LcTTiE.-*. Cisci.s.vATi: Smith & Worth i.xotow. Detroit: E. A. Lodok, M. D. Chicaiio: C. S. Halret. Clevelasd: Beckwith & Co. PirrsnrKu, Pa : J. G. Backofes & Son. Lo.-ido.v, E.vo. : H. TfR.tSR A Co.. 77 Fleet Street; Jamhs Epph, No. 112 Orbat Kc«bll Strbkt. 1867. ■IOL06Y Entered according to Act of Congress, in the year 1867, BT WILLIAM RADDE, In the Clerk's OfBco of the District Court of the United States for the Southern District of New York. 79-^ ^f Kma it Baibd, PRinraiu, 607 Saoioin Street, I'Uilodolpbla. TABLE OF CONTENTS. CHAPTER FIRST. Page Historical Account 9 CHAPTER SECOND. Special Description of the Phenomena of the Dis- ease BY THE MOST PROMINENT AUTHORS, FROM THE EARLIEST KNOWN PERIOD OF ITS EXISTENCE TO OUR OWN TIMES 11 Section I. Diphtheria in the Sixteenth and Seventeenth Centuries. Spain 12 Italian Epidemic 1-1 Section XL Diphtheria in the Eighteenth Century. England 15 Italy -. 22 France 2o Sweden 24 United States of America 25 4 CONTENTS. Section* III. Diphtheria in the Nineteenth Century. France 27 Eni^land. Epidemic of 1857-60 3-1 Mild form 3-i A more severe form o5 Dangerous cases of Dii)btlieria 39 Dijilitlieria in the Nares 41 Dijilitlicritic Ophthalmia 41 Diphtheritic Croup 43 Dii^itheria of the Oesophagus and Stomach 45 Dij)htheria of the Mouth 46 Diphtheria of the Pudenda 47 Diphtheria on Wounds 48 Dii)htheria on Blistered Surfaces and Abrasions of the Skin 48 CHAPTEIl THIRD. Diphtheria in the United States, 1856-1864. California 50 ^[ilford, Conn 52 Stoubenvillc, Ohio 53 Albany, New York 53 CHAPTER FOURTH. The different forms under \yhicii Diphtheria manifested itself in philadelphia. Maliijnant Canes. A. Witli predominance of Throat symptoms 56 B. Combined with Croup 59 C. Extension of the Throat Disease to the Stomach and Alimentary Canal 60 CONTENTS. 5 II. Sliffht Cases. A. A diglit deposit of the membrane is visible on the Schneideriau membrane of the nose, on the tongue, pharynx, tonsils, etc. The glands of the neck are only slightly swollen 61 B. Diphtheritic Cough, with or without Croup 61 C. Characterized by a mucous diarrhoea and dysen- tery 62 I). Diphtheria complicated with other diseases 63 CHAPTER FIFTH. Nature of Diphtheria. A. Cause miasmatic 67 B. Its appearance in animals 69 C. Locality, cold air, damp air 70 D. Age, strumous constitution, etc 72 E. Chemical examination of the membrane 73 F. Examination by the microscope 76 G. Diagnosis between Diphtheria and Scarlatina 83 //. Diagnosis between Diphtheria and Cruup 87 /. Diagnosis between Laryngitis Stridulous and Diphtheritic Croup 88 TT. Diagnosis between Diphtheria and Aphthie 89 L. Pathological Anatomy 90 J/. Prognosis 92 X. Sequeke 96 0. Contagion 97 tStalistics of JJeaths from Viphtlieria, Croup and Scarlet Fever in Fhiladephia, from 1860 io 1864 99 CHAPTER SIXTH. Treatment of Du'iitiieria. Allopathic Treatment lUl " CONTENTS. CHAPTER SEVENTH. HoMCEOPATiiic Treatment of Diphtheria. Section I. British Physicians. iqq Section II. French Physicians n-j Section III. German Physicians 120 Section IY. American Physicians 227 CHAPTER EIGHTH. My own experience in Diphtheria. General Bemarks ^^^ Dose of the Remedy 247 Remedies i ,- i-il Proto-iodide of mercury 248 Kali bichroraicuni ^^^^ Cantharides ' y^^. Argentum nitric -,'X Crotalus horrid ir.. _^ . i O D Bromine ^^^. Chlorate of potash ^^^1 Liquor potass, caustic 2dl Borax in Diphtheritic Fever I(j2 Chlorinated lime iu acute cases 1(^7 Chlorinated lime in Chronic Diphtheria 169 ^"^'-quelije -^gp Summary ; -. ^ - PREFACE In January, 1861, I saw my first case of malignant Diph- theria, a malady then hardly known in Philadelphia. Never having met with the disease before, I had recourse to the treatment recommended by the British and French physicians, and was unsuccessful. I then determined to make myself, as far as possible, familiar with the nature of Diphtheria, by examining its records from the most ancient times. For this purpose I procured from the Library of the Pennsylvania Hospital all the works relating to the subject. Since that time, now over six years, I have attended about one hundred and eighty malignant or severe cases of Diph- theria and diphtheritic croup, and at least four hundred and twenty slighter cases of the disease ; including in this latter class all where the membrane, or a few patches of it, could be distinctly seen in the throat. This treatise is the result of my researches and subsequent experience. The more I contemplate this disease in all its details, the more I am convinced of its identity with malignant scarlatina 8 PREFACE. and membranous croup, and that tliese diseases are different manifestations of the same or a similar poison in the blood. I have contributed my share towards the solution of this important question, and furnished practical information for a successful treatment. My labors, I hope, will not have been in vain. _ C. NEIDHARD, M.D. Philadelphia, March, 1867. [KoTE, — In order to obtain a clear and easy supervision of the remedies employed, it was my wish to have them printed in the margin of the text. By a misunderstanding they were printed as headings. Throughout the chapter relating my own experience this plan has been followed.] ox DIPHTPIERTA. CHAPTER I. HISTORICAL ACCOUNT. The historical researches of Ozanan, Fuchs, Ehenmann, Ilecker, and Bretonneau, show that the malignant inflamma- tion of the pharynx, now recognized under the descriptive term Diphtheria,^ was known m its chief features to Aretseus, Cselius Aiirelianus, and Actins, under the name of Ulcera JEgyptica Syriaca. In the beginning of the latter half of the sixteenth century, the disease appeared epidemically in Holland, and was de- scribed by P. Forest. Towards the end of that century it swept a similar march through Spain, terminating with such general fatality in suffocation, that it received the name of (jurrotillo. From that period to the present, the disease has showed itself, at different times, and with greater or less in- tensity, in most European countries, and in North America, and has been described by a great number of writers of all nations, under different names. The kingdom of Naples and Sicily seems to have been sadly scourged. In 1641, it is described by Si^verinus as car- rying ofi" many thousands of children. With such opportuni- ties for post-mortem examinations, J/oryar/ni blames Severinvs for the remark that he was not willing to take upon him the tedious labor of delineating the seat of the disorder itself. ' ^tipSeplrns and Ai^Stpiaj signify, that which is covered with a skin. 2 (9) 10 HISTORICAL ACCOUNT. From 1745 to 1748, it spread throughout Europe, and about the same time showed itself in England, when it was ably described by Dr. Fothergill. As seen by him, the dis- ease was attendant iipon scarlatina ; but the account published nearly at the same time (Philosophical Transactions, 1750) by Starr, refers evidently to a primary diphtheria, and the cases related by Ghisi as occurring at Cremona during 1747 and 1748, are independent of scarlet fever. A very able description of the disease was given by Bard, New York, (1771.) He was the first to point out its resem- hlance to croup, denying its gangrenous nature. In modern times, the disease has been most minutely described by Bre- t07ineau, who himself observed a violent epidemic in Tours, (1818 to 1820.) From 1818, the date of M. Bretonnea'ah work, to 1829, diphtheria has annually appeared as an epidemic in France, and sometimes in Switzerland ; generally in the form described by Bretonneau, but semetimes showing a low type with ulceration and gangrene. In 1856 and 1857 it prevailed in Boulogne in a very fatal form. From Boulogne it crossed to England, and in the autumn of 1856 attacked various places, especially towns on the Channel coast. Since this date it has continued in England, appearing to diminish during the winter, and to increase in summer and autumn.^ Like most epidemics, the first cases in a locality are the most se- vere ; as lueeJcs pass, the disease gradually diminishes in severity. Dr. Brown, of Haverford West, describes an epidemic which prevailed there in 1849 and 1850. He treated two hundred cases, forty of which proved fatal. The pharynx, tonsils, larynx, trachea and bronchial tubes were found to be more or less, coated with false membranes, and the stomach showed signs of irritation.^ About the year 1858, the disease appeared in the United States. It was particularly fatal in Albany and its neighbor- ' In the United States the disease seemed to improve, and even entirely cease, during the summer months. * Remarks on Dijjhllieria, by Francis Black, M. D. Br. Jour. Ilora., vol. xvi., page G37. HISTORICAL ACCOUNT. 11 hood, from which circumstance it became known as the Al- bany sore throat. It afterwards appeared in other parts of the United States, even as far as San Francisco. The tirst se- vere cases that fell under my own observation were in the be- ginning of the year 1860. According to the Rock Island Argus, diphtheria has been raging throughout Western Illinois to an alarming extent. The writer says that it is almost exclusively confined to chil- dren, and, when once under headway, death is almost certain to be the result. It will pass through whole towns, missing scarcely a household, and in some instances lohole families of chiklren have been sivept aiuay by it. CHAPTER II. SPECIAL DESCRIPTION OF THE PHENOMENA OF THE DISEASE BY THE MOST PROMINENT AUTHORS, FROM THE EARLIEbT KNOWN PERIOD OF ITS EXISTENCE TO OUR OWN TIMES. Section I. — Diphtheria in the Sixteenth and Seven- teenth Centuries. Aretsens} "Ulcers occur on the tonsils, some indeed of an ordinary nature, mild and innocuous, but others of an unu- sual kind, pestilential and fatal. Such as are clean, small, superficial, without inflammation and without pain, are mild ; but such as are broad, hollow, foul, and covered with a white, livid, or black ooncretion, are pestilential. If the concretion has depth, it is an eschar, and is so called ; .but around the eschar there is formed a great redness, inflammation and pain of the veins, as in carbuncle, and small pustules form, at first few in number, but others coming out, they coalesce, and a broad ulcer is produced." ' The extant works of Aretceus, the Cappadocian. Book i., chap, ix., pp. 253-255. London, 1856. Published by the Orst Sydenham Society. 12 DIPHTHERIA IN THE SIXTEENTH CENTURY. SPAIN. Villa Real} The disease appeared in Andalusia and other parts of Spain in 1590-1591. The Spanish physicians stu- died the complaint very carefully, and described what they saw with great fidelity. "The apex of the mouth is at one time altogether white, at another a certain membranous crust, of a bluish color, covers the fauces, throat and gullet. The tongue, from the root upwards, is also either wholly or par- tially white. It indicates the existence of the white crust in the unseen adjacent parts, and also that it will presently ap pear in the oesophagus and throat. Tumefaction in the neck, behind and below the ears, such swelling being always pres- ent in tliis disease, but especially in cases where the crust tends to a livid hue, and resembles a membrane. The swelling of the diseased parts is not effused into the pores, but external to the parts, as if it flowed over the surface, which it covered like a solid membrane." Hemorrhage from the nose and mouth, which, according to the experience of Vill'j Real, is invariably a fatal symptom, is so only in the more malignant cases. In the slighter cases it is often beneficial. I)e Fontecha? The disease described by this writer pre- vailed in an epidemic form in Spain, 1599-1600. "Garrotillo sometimes began with little, sometimes with much pain. There was always more or less swelling of the throat, both external and internal. At one time large, whitish, scabby ulcers appeared ; at other times only a white color. ' Joannisde F/7/ai?eaZ, deSignis, Caiisis, Essentia, Prognostico, et Cu- nitione, morbi siiffocatis. Compluti, 1611. Not having access to these authors, I quote from the work of Dr. CJreenhow. * Dispiitationes mcdica; super ea quai Hippocrates, Galenus, avienas, nccnoii et alii Grajci, Arabes et Latini, do aginarum naturis, speciebus, causis et curationibus, Scripserc diversis in locis, et circa aflectioncm hisce temporibus vocatam garrotillo. Opus Doctoris Johauuis Alphonsi de Fontecha, etc., Compluti, IGll. SPAIN. 13 Tliere was also at the beginning a blackish crust, inclining to a bluish or greenish hue. Fever often accompanied the dis- ease, but was also frequently absent, particularly in certain epidemics. The disease was unquestionably present when, although there was little pain, a color like flour appeared in the throat and fauces/ accompanied by some difficulty of swallowing, by fever, and by a small, weak and irregular pulse. These signs denoted not only the presence of this throat affection, but likewise its intensity." llerrera? Herrera describes eight varieties or stages of this destructive disease. The first two varieties closely resembled common sore throat, and were characterized by inflammation of the throat and surrounding parts, unaccompanied either by exudation or ulceration. Herrera places them in the same category, seeing that they may pass into it. The third variety had ad- vanced a stage farther; there was excoriation attended by slight soreness. For the fourth, there was ulceration with purulent secretion and severe pain. In the fifth, a spreading, sanious ulcer, with still intenser pain and an offensive smell, but without the crust. In the sixth variety, the characteristic crust, from which the disease derives its modern name, diph- tlteria, was plainly observable upon the ulcer. In this variety, which was more dangerous than any of the preceding, the crust was of a white color. In the seventh variety, the crust was livid ; and in the eighth, which is the worst variety of all, the crust was black. Lastly, he mentions the occurrence of a diarrhoBa, as an unfavorable sign, at whatever stage of the illness it appeared. ' This symptom, so louc^ ago observed by Fontecha, is with me at \.\\\» day one of the most certain and characteristic diagnostic symptoms of the disease. * De Essentia, Causis. Notis, Pra'sagio, Curatione et Precautione Fau- cium et tiutturis Anginosorum ulcerum morbi siiffocatis, ijdrroltllo His- pano appellato de aulhorc Doctore Cristophero Perez de Herrera, etc. Matrili, 1G15. 14 DIPHTHERIA IN THE SEVENTEENTH CENTURY. ' ITALIAN EPIDEMIC. Cortesius} "Redness and inflammation of the surface of the palate and mouth, the tonsils remaining unaffected ; more frequently, these glands were swollen, and sometimes so much so that they touched each other, thereby interfering with deglutition and respiration. In the beginning, there was usually swelling, heat and redness ; afterwards, pain, and diffi- culty of swallowing. When there was only inflammation of the parts about the throat, the sick easily recovered ; but sometimes a certain pituitous substance, (exudation,) descend- ing from the head, so speedily and unexpectedly followed the inflammation, that the patient was suddenly suffocated. Very often a white substance, which soon became liquid and after- wards black, unaccompanied by pain, appeared on the inflamed surface. This material could be readily torn away from the subjacent parts, either by the finger or an instrument; but, although the operation caused no pain, the patient invariably died a short time afterwards, as happened, among others, to the son-in-law and the grandchild of Cortesius. Sometimes mortification, accompanied by fetor, quickly invaded some part of the throat; and when this occurred, whether fetor were present or not, remedies proved unavailing, and the patient died about the fourth day, or even earlier, rarely so late as the seventh day." Cortesius notices the frequent occurrence of several fatal attacks in the same family. There was reason for supposing the disease to be contagious, and a case reported by Cortesius strengthens the opinion. A monk being attacked by the dis- ease, constantly complained that he observed a foul odor pro- ceeding, as he supposed, from his mouth ; so to assure himself of the truth, requested a friend to verify the fact by smelling. Not many hours after doing so, in the presence of Cortesius and others, the friend was laid up with inflammation of the fauces and tonsils, and, remedies proving useless, died on the fourth day of his illness. ' .(uiinnis Hiiptistic Cortcsii, Misccllanconiiu mcdiciiialium. Decades J)l-ii;l' .Mussauaj, 1G25. ENGLAND. 15 Section II. — Diphtheria in the Eiguteentu Century. ENGLAND. Dr. Father gill} "Children and young people were more liable to the disease than adults, girls more than boys, women more than men, the delicate more than the robust. The illness usually began with giddiness, chilliness or shivering, followed by fever, acute pain in the head, stiffness of the neck, soreness of the throat, and sometimes vomiting and diarrhoea. The pain, heat and restlessness increased towards night, and were often mitigated by the breaking out of a sweat towards morning. " If the mouth and throat be examined soon after the first attack, the uvula and tonsils appear swelled, and these parts, together with the velum pendulum palati, the cheeks on each side near the entrance into the fauces, and as much of them and the pharynx behind as can be seen, appear of a florid red color. This color is commonly most observable on the poste- rior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this redness, a broad spot or patch of an irregular figure, and of a pale ichite color, is sometimes to be seen, surrounded with a florid red ; the whiteness commonly appears like that of the gums immedi- ately after having been pressed with the finger, or as if matter ready to be discharged was contained underneath. " Generally on the second day of the disease, the face, neck breast, and hands to the fingers, are become of a deep, erysipel- atous color, with a sensible tumefaction; the fingers are fre- quently tinged in so remarkable a manner, that from seeing them only it has not been difficult to guess at the disease. A great number of small pimples, of a color distinguishably more intense than that which surrounds them, appear on the arms and other parts. They are larger and more prominent ' An Account of the Putrid Sore Throat, by John Fulhergill, M. D. 5th edition, Luiulon, 17G9. 16 DIPHTHERIA IN THE EIGHTEENTH CENTUKY. in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and lower extremities. " These white places presently became more of an ash color, when it was discernible that what at first might have been taken for the superficial covering of a suppurated tumor, was really a slough, concealing an ulcer of the same dimensions. All parts of the fauces were liable to be affected, but the disease generally first appeared in the angles above the ton- sils, or on the tonsils themselves, on one of the arches formed by the uvula and tonsils, on the posterior wall of the pharnyx, on the inside of the cheeks, or on the base of the tongue. " In the milder forms of the disease, an irregular, superficial ulcer, scarcely to be distinguished from the sound parts but by the roughness of the surface it occasioned, appeared on one or more of the above-mentioned parts. A thin, pale, white slough seems to accompany the next degree ;' a thick, opaque, or ash-colored one is a further advance ; and if the parts have a livid dk- black aspect, the case is still worse. The sloughs are not formed of any foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the substance ; since, whenever they come oft' or are separated from the parts they cover, they leave an ulcer of a greater or less depth, as the sloughs were superficial or penetrating. " In one case these sloughs were separated by a surgeon's probe without much difficulty, but the same parts were cov- ered the following day with thick, dark, ash-colored sloughs, penetrating deep into the substance. The eruption was not always present, and especially in the winter of 1754, it either did not appear at all, or its appearance was retarded. There was commonly much swelling of the parotid glands and neighboring parts, and the tonsils and uvula were sometimes ' During the winter of I8G2-63, diphtheria in Philadelphia was charac- terized by this appearance. The same white membrane was observed in the ulcers, sores, and even whitlows of dii)litheritic patients. It seemed to mingle with all kinds of diseases and modify them. ENGLAND. 17 80 much swelled as to leave but a narrow entrance to the gullet, which was also frequently surrounded with ulcers and sloughs. Yet, although food was sometimes forced back through the nose, patients often swallowed with little diffi- culty or pain. An olYeusive putrid discharge, and a corrosive, sanious discharge from the nostrils often accompanied the complaint; it was also sometimes attended by an excessive faintness, the greater or less urgency of which seemed to in- dicate the degree of danger. There was less thirst than usual in other acute diseases, and the tongue was moist and seldom furred. Hemorrhage from the nose and mouth sometimes suddenly carried oft" the patient." Dr. Fothergill distinguished the disease from scarlet fever, for which one of his cases was mistaken by the persons about the patient, but several of the symptoms he describes, partic- ularly the appearance of a red rash on the second day, are rather those of scarlet fever than of diphtheria. It seems probable, as has happened in more recent epidemics, that scarlet fever and diphtheria were intermingled ; that the cases of scarlet fever had a diphtheritic character, and that, while in all probability Dr. Fothergill saw some cases of uncomplicated diphtheria, especially of that kind in which the exudation re- mains until the subjacent surface sloughs, he nevertheless confounded the two diseases. Indeed, we have other evidence, both that scarlet fever sometimes presented unusual features, and that diphtheria, complicated with scarlet fever, prevailed in England about the time when Dr. Fothergill observed the particular form of sore throat described in his book.' Dr. Nathaniel Cotton, St. Albans, 1748," describes the same peculiar form of scarlet^ fever. " Upon looking into the ' During the recent epiJemic in Fiiiladelphia. I have observed this in- termingling of scarlet fever and diphtheria in twenty cases. In fact I am more convinced every day, that the two diseases are the product of the same miasma in the blood. * Observations on a particular kind of scarlet fever, that lately pre- vailed in or about St. Albans, in a letter to Dr. Mead, by Xathan.Cullun, M.D. 18 DIPHTHERIA IX THE EIGHTEENTH CENTURY. mouth, there were frequently seen, especially after the disease was a little advanced, ulcers scattered up and down the fauces, pretty broad upon and about the tonsils, superficial, and covered with a whitish slough. The scarlet efflorescence dif- fered as to extent and time of appearance ; there was high fever, intense thirst, a moist and but slightly-furred tongue, frequent cough, sudden loss of strength, and great dejection of spirits, especially towards evening, which continued for some time after the patient was convalescent." Dr. Starr, Cornwall, 1748 or 1749.^ "Swelling of the ton- sils, parotid and submaxillary glands ; gangrenous sloughs (which were evidently false membranes) often formed in the mouth at an early stage of the illness. Others again com- plained of a slight pain on swallowing, succeeded by fever ; a short, low) barking, hoarse cough, which sooner or later was productive of a difficult, noisy, and strangulated respiration (croupy form). After an illness of a day or two, the voice usually became so hoarse that it was difficult to understand. The expectoration was never a well-digested or concocted phlegm, or mucus; on the contrary, the greater part of it was of a jelly-like nature, glairy and somewhat transparent, mixed with a white, opaque, thready matter, sometimes more and sometimes less resembling a rotten membranous body or slough. " Such a slough I have seen generated on the neck and arm, where blisters had been applied. The blister had been dressed with colewort leaves, and ran but little ; but con- tiguous to its place, small red pustules, not exceedingly fiery, arose, and, sweating plentifully, in a few hours became quite white. These, hourly enlarging their bases, united and covered a large surface, — fresh pustules arising in the adja- cent parts. This white surface had the aspect of an over- soaked membrane that had become absolutely rotten." " I scratched the slough," says Br. Starr, "with my nail; it sepa- rated with ease, and without being felt by the child."' ' Philosophical Transactions, vol. xlvi. * This is a must accurate accoiiut of the origin and progress of the ENGLAND. 19 Dr. Huxham, of Plymouth, 1751 to 1753.^ "The disease began in various ways, but commonly with chills and heats, pressure and pain in the head, soreness of throat and hoarse- ness, some cough, sickness of the stomach, frequent vomiting and purging. These symptoms occurred more frequently in children, and were then very severe ; in adults they were less emphatically expressed. From the beginning, there were in all a great dejection of spirits, very sudden weakness, great heaviness on the breast, and faintness. The pulse was gene- rally quick, small and fluttering, though sometimes heavy and undose. The urine, commonly pale, thin, and crude, was, however, in many grown persons, scanty and high-colored, or like turbid whey. The eyes were heavy, reddish, and weep- ing; the countenance very often full, flushed and bloated, though sometimes pale and sunk. " How slight soever the disorder might appear in daytime, at night the symptoms became greatly aggravated, and the feverish habit very much increased ; sometimes even delirium appeared on the very first night, — and this exacerbation con- stantly returned in the evening, through the whole course of the disease. Indeed, when it was considerably on the decline, I have been often surprised to find a patient had passed the whole night in a frenzy, whom I had left tolerably cool and sedate in the day. Some few hours after the seizure, and sometimes cotemporaneously with it, a swelling and sore- ness of the throat were perceived, and the tonsils became tumid and inflamed ; and many times, even at the beginning of the attack, the parotid and maxillary glands swelled so greatly and suddenly as to threaten strangulation. The fauces also very soon appeared of a high florid red, or rather of a bright crimson color, wery shining and glossy ; and com- monly on the uvula, tonsils, velum palatinum, and back part of the pharynx, several whitish or ash-colored spots appeared diphtheritic deposit, such as we have witnessed very frequently in Phil- adelphia. • Dijjsortation on the >faglignant Ulcerous Sore Throat, by John Hux- ham, M.D. Loiidun, ITJ'J. 20 DIPHTHERIA IN THE EIGHTEENTH CENTURY. scattered up and down, which oftentimes increased very fast, soon covering one or both the tonsils, uvula, etc. These eventually proved to be the sloughs of superficial ulcers, (which sometimes, however, ate very deep into the parts.) The tongue at this time, though only white and moist at the top, was very foul at the root, and covered with a thick yel- lowish or brown coat. The breath also now began to be very nauseous ; the ofl'ensive smell increased hourly, and in some instances became quite intolerable, even to the patients them- selves. " By the second or third day, the sloughs were much en- larged, and of a darker color, and the surrounding parts tended much more to a livid hue. The breathing became more difficult, with a kind of rattling stertor, as if the patient was actually strangling, — the voice being exceedingly hoarse and hollow, exactly resembling that from venereal ulcers in the fauces. This noise in speaking and breathing was so pecu- liar that any person in the least conversant with the disease might easily know it by this symptom alone ; whence, indeed, the Spanish physicians named the disease r/arrotillo, expressing the noise made by those who are being strangled with a rope. I never observed in one of them the shrill*, barking noise that we frequently hear in inflammatory quinsies. The breath of the diseased was very nauseous, of some insuffer- ably fetid, especially in the advance of the distemper to a crisis ; and many, about the fourth or fifth day, spit up a vast quantity of stinking, purulent mucus, tinged sometimes with blood, and sometimes quite livid. The nostrils likewise in many were greatly inflamed and excoriated, continually dripping down a most sharp ichor, or sanious matter, so ex- cessively acrid that it not only corroded the lips, cheeks and hands of the children that labored under the disease, but even the fingers and arms of the very nurses that attended them. Not only the nostrils, fauces, etc., were greatly aft'ected by this extremely acrid matter, but the windpipe itself was some- times much corroded by it, and pieces of its internal mem- brane were spit up, with much blood and corruption. At ENGLAND. 21 length the patient died tabid ; though there were more fre- quent instances of the disease falling suddenly and violently on the lungs and killing in a peripneumonic manner." Dr. Wall^ of Worcester, 1751.* "Aphthous ulcers and sloughs on the tonsils and parts about the pharynx. Very few pa- tients had the scarlet efflorescence on the skin, which was rather an accidental than an essential symptom; but in some persons the skin was covered with petechia3 and purple spots ; and in one or two, when the disease was far advanced, large black spots appeared on the tonsils." (Our malignant cases.) "The complaint was evidently infectious and very liable to return. If they who had it were at any time afterwards seized with a fever of a putrid kind, they seldom failed to have this complaint likewise. I have frequently known the parts very much swelled and covered with thick sloughs, though the sick person made little complaint of the soreness, and swallowed nearly as well as in perfect health." Mr. Rumsey^ Chisham, 1793 and 1794.^ Diphtheritic Croup. " It was not confined to the town, which lies in a valley, but appeared with equal violence upon the neighboring hills, at a distance of five, or six miles. The subjects were children from the first to the fourteenth year of their age, and it attacked many fine, healthy, robust children, as well as the pale, phleg- matic and delicate. The illness crept on imperceptibly at first, the patient appearing to be in good health, the counte- nance not altered, and, excepting at intervals, the appetite and spirits unimpaired ; but it sometimes happened, that symp- toms which had appeared trifling for two or three days, sud- denly increased, and the disease then advanced so rapidly as to prove fatal before many hours had elapsed." Mr. Rumseij met with about forty cases of this croup. The disease rarely proved fatal earlier than the fourth or fifth day; ' Gentleman's Magazine, November, 1751. * Transactious of a Society for the Improvement of Meilical ami Chi- rurgical Knowledge, vol. ii. London, IbUO. 22 DIPHTHERIA IN THE EIGHTEENTH CENTURY. often later. Two or more children in a family were some- times seized with it, whilst on other occasions, when it proved fatal to one or two children, several others escaped without any particuhar pains being taken to keep the healthy apart from the sick. Many children suffered from erysipelatous inflammation behind the ears, in the groins, in the labia of girls, or wherever the skin folded, attended with very acrid discharge. "At first the cough was dry, but in the course of the dis- ease, by the third day or sooner, the passage of air was ob- structed by viscid matter in the trachea, some of which was occasionally thrown up by cough or retching ; and according to the quantity thrown up, respiration was more or less re- lieved. Several children brought up portions of a film or membrane of a whitish color, resembling the coagulated mat- ter which was found in the trachea of those children whose bodies were opened. This was thrown off by violent cough- ing or retching, and the efforts made to dislodge it were often so distressing, that the child appeared almost in a state of strangulation. This was succeeded by an abatement of all the symptoms, until a fresh quantity of the same substance was formed, when the distress recurred as before. " Most of the cases which occurred in November and after- wards, were attended with inflammation and swelling of the tonsils, uvula, and velum pendulum palati, and frequently large films of a white substance were formed on the tonsils. The swallowing was usually less impeded than might have been expected from the degree of disease which was observed in the throat." ITALY. Ghisi, Cremona, 1747 and 1748.' " Deglutition was fre- quently free and unimpaired ; there was great thirst ; the countenance was pale, and there was a dry, harsh cough. Ees- piration was difficult, and the larynx almost always affected • Joornal G6n6ral de Medicine, torn, xxxvii., p. 227. 1810. FRANCE. 28 by pain or a sense of pricking. The voice was slirill, pulse feeble and generally irregular, and the external fever scarcely observable. By and by these symptoms were followed by others of a more alarming nature ; the pulse became ex- tremely irregular and intermittent, the skin dry, and the ex- tremities cold. There was excessive restlessness, so that even his bed became insupportable to the patient, and the respira- tion was most difficult and attended by agonizing eft'orts. The sufferers generally died on the third, fourth, or fifth day ; sometimes, but rarely, as early as the second or as late as the seventh day. Although the cough was generally dry, the patient often, in the act of coughing, detached from the air- passages a substance very like the buffy coat of the blood or the pseudo-polypous substance met with in the heart or larger vessels after death. Many patients who had this tracheal form of angina continued to speak with a nasal voice, and to reject food through the nostrils for some time after re- covery." FRANCE. CJiomel, 1748.^ "At first the uvula was elongated; there was slight heat in the throat, accompanied by some pain ; the tongue was more or less swelled, and there was generally a little fever. Insensibly and within the first twenty-four hours, one or other of the tonsils became covered with a white, aphthous spot, which, extending in every direction, reached the uvula, descended towards the pharynx, and ascended to the pituitary membrane. These symptoms were fully de- veloped within two or three days. "About the third day, an aggravation of the illness was manifested by an increase of fever, a faint unpleasant odor, observable on approaching the sick, and by a whitish eschar, which, without extending much farther, grew thicker, became a crust, and seemed disposed to loosen, but was either still ' Dissertation Ilistoriquc sur I'Esp^ce dc Mul de Gorge gangr^neux, qui a regn6 parmi les Enfants I'ann^e dernifere. Paris, 1749. 24 DTI'IITIIERIA IN THE EIGHTERNTH CENTURY. held by numerous pedicles, or, if it fell, left a second crust, hidden under the first. There was ichorous discharge, and often bleeding from the nostrils, dnd the smell became putrid and insupportable. The trachea was eroded by ulceration, the respiration became laborious and sibilous, and the lung ulcerated. Death took place sometimes on the fifth, more fre- quently on the seventh or ninth day. The sick emaciated from day to day, had a difficulty in articulating, and spoke with a nasal tone. Sometimes there were large swellings of the glands of the neck, which did not suppurate. Convales- cence was much retarded ; patients remaining long feeble and delicate. " The illness was neither preceded by shiverings like acute and inflammatory diseases, nor was there headache, delirium, nor the other symptoms of malignant fever. The digestion was unimpaired. The patients were free from heat and thirst, and when pressed to drink were able to do so, and even to eat without pain. The disease especially attacked children, whom, when they lived together, it seized either all at once or one after the other, and but rarely affected persons above the age of fifteen or sixteen years." SWEDEN, FROM 1755-1762. Wikke, Upsala, 1764.^ " In many houses it carried off the children, proving fatal sometimes as early as the second, but more commonly on the fourth or fifth day of the illness. It appeared to be contagious; children from other houses, who visited the sick, being frequently seized by the disease shortly afterwards. The disease, aiB has so frequently occurred in other places, appeared under two for 7ns. In one, the tonsils, uvula, and the piiarynx were found, on inspection, to be the seat of the characteristic membranous exudation. In the other, the symptoms were almost exclusively referable to the larynx and trachea, which were found after death to be covered with fiilse ' Dissertatio Medica de Angina Infantum in patria recentioribus. UNITED STATES OP AMERICA. 25 membrane." On account of their difference of situation and character, the two varieties were regarded as distinct diseases by some of the Swedish physicians, the former variety being classed as malignant sore throat, the latter as croup. The de- scription of the first form of the disease, given by Wilcke, does not differ materially from that of the physicians of other I countries about the same time. UNITED STATES OF AMERICA. Dr. Samuel Bard, 1789.^ " In general, this disease was con- fined to children under ten years of age, though some few grown persons, particularly women, (while it prevailed,) had symptoms very similar to it. Most of those who had it, were observed to droop for several days before they were confined. The first symptoms, in almost every case, were a slightly in- flamed and watery eye, a bloated and livid countenance, with a few red eruptions here and there upon the face, and in one case a small ulcer in the nose, whence issued an ichor so sharp as to inflame and erode the upper lip. At the same time, or very soon after, such as could speak, complained of an uneasy sensation in the throat, but without any great soreness and pain. Upon examination, the tonsils appeared swelled and slightly inflamed, with a few white specks upon them, which in some increased so as to cover them all over with one gen- eral slough ; but this, although a frequent symptom, did not invariably attend the disease, and some had all the other symp- toms without it. The breath was either noways offensive, or had only that kind of smell which is occasioned by worms, and the swallowing was very little, if at all, impeded. " These symptoms, with a slight fever at night, continued in some for five or six days without alarming their friends in others, a difficulty of breathing came on in twenty-four hours, especially in the time of sleep, and was often suddenly iu- ' Researches on the Nature, Causes, and Treatment of Suffocative Angina, etc. By Samuel Bard, 31. D. New York, 1771. 26 DIPHTHERIA IN THE EIGHTEENTH CENTURT creased to so great a degree as to threaten immediate suffoca- tion. In general, however, it came on later, increased more gradually, and was not constant ; but the patient would now and then enjoy an interval of an hour or two in which he breathed with ease, and then again a laborious breathing would ensue, during which he seemed incapable of filling his lungs, as if the air was drawn through too narrow a passage. " This stage of the disease was attended with a very great and sudden prostration of strength; a very remarkable, hollow, dry cough, and a peculiar change in the tone of the voice, not easily described, but so singular, that a person who had once heard it could almost certainly know the disease again by hearing the patient cough or speak. In some, the voice was almost entirely lost, and would continue very weak and low for several weeks after recovery. A constant fever at- tended this disease, but it was much more remarkable in the niglit than in the daytime, and in some there was a decided remission towards morning. The pulse at the wrist was in general quick, soft and fluttering, though not very low, and it was remarkable, that at the same time the pulsations of the heart were rather strong and smart, than feeble. The heat was not very great, and the skin was commonly moist. " These symptoms continued for one, two or three days. By that time it was usual for them to be greatly increased in such as died, and the patients, though commonly somewhat comatose from the beginning, now became much more so ; yet even when the disorder was at the worst, they retained their senses, and would give distinct answers when spoken to, al- though, on being left to themselves, they lay, for the most part* in a lethargic condition, only raising up now and then to re. ccive their drink. Great restlessness and jactation came on towards the end of the disease,, the sick perpetually tossing from one side of the bed to the other ; but they were still so far comatose as to appear to be asleep immediately upon changing their situation or posture. A universal languor and dejection were observed in their countenances; the swell- ing of the face subsided ; a profuse sweat broke out about the FRANCE. 27 head, neck and breast, particularly when asleep ; purging in several came on ; the difficulty in breathing increased so as to be frequently almost entirely obstructed, and the patient died apparently from the sulYocation. This commonly hap{)oned before the end of the fourth or fifth day; in several, within thirty-six hours from the time the difficulty of breathing came on first. One child, however, lived under these circumstances to the eighth day, and the day before he died his breath, and what he expectorated, were somewhat ofl'ensive ; but this was the only instance in which I could discover any thing like a disagreeable smell, either from the breath or expectoration. " Out of sixteen cases attended with this remarkable sulYo- cation in breathing, seven died; five of them before the fifth day, the other two about the eighth. Of those who recovered, the disease was carried off in one by a plentiful salivation, which began on the sixth day, in most of the others by an ex- pectoration of a viscid mucus. "Some cases during the epidemic began with a few red pimples behind the ears, itching violently and discharging pro- fusely. These ulcers would sometimes continue for several •weeks, and appeared in some cases to be covered with sloughs, resembling those on the tonsils." Section III. — DipnTHERiA in the Nineteenth Century. FRANCE. M. Bretonneau, 1821-1826.^ "At the beginning of the dis- ease a circumscribed redness is perceived, covered with a co- agulated semi-transparent mucus. The first layer, which is slight, supple and porous, may be still further raised up by • • Des Inflammations Sp^ciales da Tissu Muqueux et en particulier, de la Diphth6ritc, ou Inflammation Pelliculaire, connue sous Ic Nom de Croup, D'Aii<,Muc malignc, D'Angine gaiiur^neuse, etc. Par P. Breton- neau, M<«(lecin en Chef de I'Hopital de Tours. Paris, 1826. Also, in Memoirs on Diphtheria, selected and translated by Dr. Semple for tlio New Sydenham Society, pp. lTG-7. 28 DIPHTHERIA IN THE NINETEENTH CENTURY, some portions of unaltered mucus, in such a manner as to form vesicles. Often in a few hours the red spots extend percepti- bly from one to another, by continuity or by contact, like a liquid which is eftused on a flat surface, or which flows by streaks in a tube. The concretion becomes opaque, white and thick, and assumes a membranous consistence. At this period it is easily detached, and does not adhere to the mucous mem- brane, except by some very slender prolongations of concrete matter, which penetrate into the muciparous follicles. The surface which it covers is generally of a slight red tint, with points of a deeper red, this tint being more vivid at the pe- riphery of the spots. If the false membrane, in detaching itself, leaves the surface of the mucous membrane uncovered, the redness which was obscured by the exudation returns, and the points of a deeper red allow blood to transude. The concrete coating is renewed, and becomes more and more adherent upon the points which have been first attacked ; it often acquires a thickness of sev- eral lines, and passes from a yellowish-white color to brown, gray or black. At the same time, the transudation of blood becomes still more free, and is the source of those stillicidia which have been so generally remarked by authors. At this time the alteration of the organic surface is more apparent than at the beginning ; portions of concrete matter are often effused into the substance itself of the mucous tissue ; a slight erosion and a few ecchymoses are observed in the spots, which, by their situation, are exposed to some friction, or from which the avulsion of the false eschars has been at- tempted. It is, above all, towards this period that the pellicles, which are being decomposed, exhale a foul odor. If they are circumscribed, the oedematous swelling of the surrounding cellular tissue makes them appear depressed, and by this ap- pearance alone we might be tempted to believe that we have under our eyes a foul ulcer, with a considerable loss of sub- stance. If, on the contrary, they are extended over large sur- faces, they are partly detached, they hang in more or less FRANCE. 29 putrefied shreds, and they put on the appearance of the last stage of sphacelus." M. Louis, 1824. " The commencement of the disease was marked by more or less severe pain in the throat, which, nevertheless, was sometimes preceded by the formation of false membrane in the nasal cavities, and by coryza. This pain was accompanied by a more or less vivid redness of the pharynx, tonsils, and soft palate, by slight swelling, tightness, pricking, and especially by difficulty in swallowing. The diffi- culty in swallowing, commonly inconsiderable at first, some- times became so great that the patients returned a portion of their drink by the nose ; or deglutition even became impos- sible, and the separation of the jaws impracticable. Sooner or later after the commencement of the pain in the throat, a false membrane was observed, which successively or simul- taneously covered the pharynx, soft palate, uvula and tonsils. Once only, throughout the whole course of the disease, were any of these parts left uncovered by the membrane. The neck became more or less swollen. A slight pain in the larynx and trachea was observed sometimes before, sometimes simul- taneously with the appearance of the false membrane, but always after the commencement of pain in the throat. This pain, the character of which was, in general, difficult to de- scribe, manifested itself in certain subjects under the form of a burning heat, which they endeavored to mitigate by the ap- plication of cold. Soon after its appearance, the voice, which until then had exhibited only a change similar to that which occurs in simple sore throat, assumed a character more or less perfectly analogous to what is called croupal voice. Respira- tion became more or less difficult, but was rarely sibilous ; and out of the five patients, whose cases have been related, it was only observed to be so in one, a few hours before death. Throwing back the head appeared in certain cases to lessen the dyspnoea. The cough was sometimes distressing, but generally so slight that it only inconvenienced the patient by exasperating the pain in the throat. Paroxysms of sufloca- tion were very rare. Some of the patients exhibited great 30 DIPHTHERIA IN THE NIXETEEXTH CENTURY. uneasiness and anxiety ; others, though very uneasy about their condition, did not lose the kind of quietness in which we saw them, till a few hours before death." Dr. Mackenzie, 1825.^ His views of the pathology of the disease coincide very exactly with those of Bretonneau, a circumstance, he says, in a subsequent paper, which, as it arose without any knowledge of each other's labors, tends to con- firm the observations of both. In 1821, two cases of the dis- ease proved fatal under Dr. Mackenzie's care. In both, the fetor of the breath and the sloughy appearance of the effused lymph were remarkable. " In the first case," he adds, " I was surprised, on dissection, to find the tonsils and uvula entire and coated over only with an effusion, for I had laid my account to find a gangrenous loss of substance in these parts." He now announced to several of his medical brethren, that what had been considered as ulcers and sloughs in this disease, were nothing else than effused lymph, the progress of which over the velum and uvula, and towards the alimentary and respi- ratory passages, he had distinctly observed. The following description of the disease by Dariot very much corresponds to our Philadelphia epidemic : Dr. Dariot, 1845.^ I. " In the first stage, the pathological conditions were sometimes limited to a slight sense of uneasi- ness in the throat, accompanied by scarcely any difficulty in deglutition. There was, most commonly, in addition to these symptoms, a more acute pain in the pharynx, while the move- ments of the neck were constrained, and there was in some degree torticollis. The cervical and submaxillary glands soon became engorged, the face was congested and puffy, with injec- tion and lachrymation of the eyes. On examining the lower part of the buccal cavity, all or nearly all the parts constituting the guttural fossae were seen to present a deep rose-red color ' Edinburgh Medical and Surgical Journal, vol. xxiii., p. 296. 2 Relation Historiquc d'une Epid6iiiie de Diphtli6ropatliie obscrv^e dans le D6parteinont de Saone et Loire, et dc la NiJjvre. pendant les au- nfees 1841, 1842, 1843 et 184.4. Par D. J. Dariot. Autun, 1845. FRANCE. 31 in children, and a more deep brown one in adults. There was also swelling of one of the tonsils, more rarely of both ; the uvula was almost always tumefied and relaxed ; there was almost habitually coryza. At these periods the disease, when suitably treated, lasted, in certain cases, for several days, but I was terminated in other cases at the end of a few hours. II. "When the disease passed to a more advanced stage, commencing often on the very day of invasion, and sometimes ! a few hours afterwards, this transition Avas inaugurated by a , very remarkable state. The parts which were about to be- j come the seat of a pseudo-membranous exudation, presented ! an cedematous appearance, similar in tint to a piece of meat bleached by the action of boiling water. Soon afterwards, I thpre were observed upon the tonsils, the uvula, the velum palati, the posterior surface of the pharynx, etc., etc., either solitarily, simultaneously, or progressively, small vesicular points, formed by partial elevation of the epithelium, of a shining and whitish appearance, and which, though at first separated, in general soon became united and confused toge- ther, and then were transformed into patches of lardaceous, smooth, whitish, yellowish, or brownish appearance, irregu- larly circumscribed, more prominent in the centre, and be- coming thin at their edges. Sometimes the primitive patches remained isolated, and appeared to rest on a depressed sur- face." (This latter I have seen very often in the Philadelphia epidemic.) " "With the appearance of false membranes, the glandular engorgements increased considerably, especially on the side where the tonsil was more swollen, and the pellicles were more numerous and thicker. Deglutition was more difficult. It was never painful in proportion to the inconvenience which must have existed, a character which establishes a well- marked line of demarcation between pharyngeal diphtherite and simple angina. The voice was altered and became nasal; cough was infrequent ; there was stoppage of the nose, and a flux of a serous liquid by the nostrils ; the patient was abun- dantly salivated, and voided a semi-transparent fluid, inter- 62 DIPHTHERIA IN THE XIXETEEXTH CENTURY. spersed with large bubbles, pouring out like white of egg and manifestly albuminous. Liquids were often thrown up and ejected by the nasal fossas ; the mouth exhaled an odor sm generis, compared to that of carious teeth. With the local pathognomonic symptoms were united some general symptoms, such as more considerable swelling, but less deep coloration of the face ; more or less intense febrile reaction ; the pulse was generally frequent, nearly always small and compressed ; cephalalgia more or less marked ; tongue swollen, covered with a thick and yellowish mucous coat ; rather frequently nausea and vomiting. We often also remarked, on different parts of the body, diphtheritic patches, especially on the lips, around the ala3 nasee, behind the ears, around the circumfer- ence of the anus, of the vulva, of the nipples, on the penis and the hands, and on the blisters which had been applied to the patients. " When the disease was about to terminate favorably, the extension of the false membranes ceased ; the latter were then circumscribed by a red areola, were swelled up, and began to separate, and being detached in strips, allowed the oozing of a few drops of blood, and were then thrown up by the pa-' tients, together with a frothy saliva. These pellicles would, be frequently reproduced in a short space of time, and we; were often astonished at the prodigious quantity of decom- posed matter which was expelled in certain cases. Those of the second and third formation were more white, thinner, and more transparent than those of the first; at least they ceased' to be reproduced after their detachment. "In proportion as the resolution of the disease took place' in the pharynx, the lymphatic glands diminished in volume and ceased to be painful ; there was a diminution, and then a complete cessation of all the general phenomena. Convales- cence was established, but slowly and with difficulty, and was remarkable for a state of languor, luhich remained for a long time, and a peculiar paleness of face, etc. III. " Lastly, the disease was aggravated — the tonsils be- came enormously enlarged, so as to touch one another, and to FRANCE. 88 form with the uvula, wliicli was very large itself, a mechanical obstacle to the introduction of liquids, as well as to the pas- sage of air. The membranous patches began to thicken, were very adherent, of a dull yellow-grayish or brownish color, and invaded the whole guttural cavity, the nasal fossa;, and very often the palatine arch ; there was considerable enlarge- ment of the cervical and submaxillary glands, extending sometimes as far as the clavicular regions, more marked es- pecially at the base of the lower jaw, a circumstance which gave to the patients a peculiar expression ; laborious respira- tion, accompanied by more or less noisy guttural rattle ; not much cough ; voice generally feeble ; discharge by the nostrils of a sanious and fetid fluid ; frequent epistaxis, sometimes so abundant as to require haemostatic measures ; mouth always open, and exhaling a gangrenous odor ; spitting of a viscid purulent matter, mixed with membranous flakes, often black- ish, and then presenting altogether the color and aspect of gangrene ; lips bleeding and covered with brownish crusts ; greater puffiness of the face ; remarkable lividity of the com- plexion ; continued cephalalgia ; an expression of weakness and languor, but never great alteration of features ; constipa- tion, either persistent or replaced by a fetid diarrhoea, and fever, with irregular paroxysms. The pulse soon became thready, and lost regularity, the extremities were cold and co- vered with a viscid sweat, there was drowsiness in children, and agitation in subjects of more advanced age. Lastly, the patients, after having presented the paleness of the face which Laennec calls a sciiii-cadaverous phenomenon, expired, having exhibited all the symptoms of true asphyxia. If combined with pneumonia, it was uniformly fatal."' ' Several cases combined with pneumouia, iu my practice, have beeu cured. 3-i epidemic of 1857-60 — mild form. The Epidemic of 1857-60. IN ENGLAND. MILD FORM. Dr. Greenhow, i860.' " Diphtheria generally begins with very slight and almost imperceptible premonitory indisposi- tion. Sometimes there is a slight malaise for a few days before the throat becomes sore; sometimes drowsiness or chilliness, occasionally amounting even to shivering, followed by febrile reaction. Sometimes aching of the limbs and loins, or headache, and less frequently nausea and vomiting are fore- runners of the local affection. More commonly the earliest complaint is of slight stiffness of the neck or of soreness, or a sense of pricking in the fauces. On examination, the glands at the angles of the lower jaw are almost always found to be slightly swollen and tender. Internally, one or both tonsils are for the most part swollen, and usually reddened and in- flamed, but occasionally much enlarged without much red- ness. The redness, when present, is of a rose color in young children, and of a crimson or deep claret color in older chil- dren and adults, the hue varying with the intensity of the disease. The arches of the palate, the velum, uvula, and sometimes the posterior wall of the pharynx, generally par- ticipate more or less in the inflammatory action. The tonsils are sometimes so much swollen that they touch one another and impede deglutition and speech, especially when, as is common in severe cases, the uvula is also much enlarged. Deglutition is sometimes painful, but is often easy, even to the termination of the worst cases ; and is rarely, if ever, so difficult as in the angina of scarlet fever, or in ordinary ton- sillitis. Indeed, the pain and difficulty of swallowing afford no index of the intensity of the disease, being sometimes very ' Dr. Greenhow on Diphtheria, 1860. ENGLAND. 35 slight in the most serious cases, and severe in the slightest. Some of my patients have spol-ixin of the uneasiness in the throat as being rather a sensation of fulness or of a " lump " in the throat, than of pain. "The pulse is usually accelerated, but not very high at this period of the disease, and the temperature of the skin slightly, but not much, above the standard of health. There is never, so far as I have observed, the pungent heat or dry- ness of skin which accompanies scarlet fever and most other acute febrile diseases. " The general malaise, drowsiness, discomfort and soreness of the throat bear no direct proportion to the severity of the suc- ceeding attack, being frequently more marked in cases which do not present symptoms of a severe character than in others of the worst description. Indeed, in the severest forms of diphtheria, these premonitory symptoms are sometimes so slight as to escape observation altogether, and the illness is not noticed until it has assumed a serious aspect. It has fre- quently happened, especially with children, that patients have continued to go about without complaining until the disease has reached an almost hopeless stage. Thus far, there is little, if any, difference between true diphtheria and the cases of mild sore throat, that so often prevail simultaneously with it, and which, as I have already said, probably differ from it only in degree. The essential character of both is inflammation of the throat and fauces, but little prone to terminate in suppu- ration or ulceration ; and, although the milder kind differs greatly from fully developed diphtheria, the two forms pass insensibly into each other, so that cases of intermediate degree of severity may often be observed in the same epidemic. A MORE SEVERE FORM. Dr. Greenh.mo. "If it be conceded that the kind of mild sore throat unattended by diphtheritic exudation, which pre- vails so commonly during epidemics of diphtheria, differs only in degree from the latter, then does the early stage above described sometimes comprise the whole of the disease In 36 EPIDEMIC OF 1857-60 — more severe form. other cases it is but the prelude to the exudation of fibrinous material upon the inflamed mucous surface, the tendency to which conslitutes the essential local character of diphtheria. In such cases the inflammation, instead of terminating in sup- puration of the tonsils, or in ulceration of the inflamed mem- brane, as in the commoner inflammatory affections of these parts, is followed by an effusion of plastic fibrinous material upon the free surface of the mucous membrane, when it coag- ulates, forming a false membrane, or more rarely a pasty or friable deposit.^ This exudation, which has frequently been mistaken for sloughs, takes place when the preliminary symp- toms have lasted with more or less intensity for a time which in some cases extends to a few days, and in others terminates in the course of a few hours. It usually appears first on one of the tonsils or the soft palate ; sometimes simultaneously upon both, or upon the posterior wall of the pharynx, more rarely — at least, during the recent epidemic — upon the buccal mucous membrane of the gums. " The exudation generally shows itself at first in the form of detached specks, which, enlarging at their edges, coalesce, forming plates of deposit, investing the inflamed surface, and bordered by a margin of inflamed membrane, the more or less deep hue of which presents a striking contrast to the white, gray or ash-colored concretion. In some cases both tonsils, the soft palate, and the posterior fauces are coated with exuda- tion, which, if it coagulates firmly, forms an exact cast of the parts it envelopes. The disease often likewise creeps upwards into the nares, or begins there simultaneously with its appear- ance in the throat, or it extends downwards into the oesopha- gus, or through the glottis, into the larynx and trachea. Be- sides growing in extent with the wider spread or increased intensity of the inflammation, the deposit increases in depth by successive additions from below, until it occasionally at- tains a thickness of more than a line. In other cases the dis- ' This appearance the membrane assumes, according to my experi- ence, in the latter stages of the disease. ENGLAND. 37 eased action is more limited, the deposit manifesting but little tendency to extend either in depth or breadth, and appearing only upon the tonsils or posterior wall of the pharynx, when it may consist of a rough patch, or of several distinct patches, or of a mere film, covering the parts at first affected. The intensity and danger of a case, though mostly, are by no means always in exact proportion to the extent of the exuda- tion. Sometimes cases attended by excessive exudation make a favorable recovery; at others, the exudation is of small extent, when the case is in other respects of severe character. " The exudation is sometimes firmly attached to the subja- cent mucous membrane, from which it is with difficulty re- moved ; at others, it is so loosely adherent as to be easily rubbed off or removed with a forceps. In either case the subjacent membrane is generally more or less deeply reddened, and if there should have been difficulty in removing the false mem- brane, it exhibits spots of blood. With this exception, the mucous surface is in general free from abrasion or ulceration. In some cases, the inflamed membrane surrounding the exuda- tion is much congested, very tender, and so lacerable that the slightest touch with any instrument used for depressing the tongue, or removing the false membrane, causes hemorrhage. " When the exudation has been artificially removed, it commonly reappears within a few hours, and several succes- sive false membranes may thus be formed on the surface of the throat. Sometimes, even when the exudation has come away spontaneously, it is followed by a second, or by several others in succession, but when this happens, the later mem- branes are, for the most part, less and less dense, more and more filmy, and whiter than the preceding, until the diseased part recovers its normal condition. Frequently, when the false membrane has exfoliated naturally, it leaves the subja- cent surface unbroken, paler than in health, and either ragged, or sensibly diminished in size. The uvula, for example, if it has been affected, appears shrunken, the tonsils more or less excavated, the flat mucous surface depressed ; the depression being often abruptly bounded, as if its margin corresponded 88 EPIDEMIC OF 1857-60. with that of the space lately covered by the false membrane. This depression of the surface, which has been covered by false membrane, is sometimes very marked after death ; and is perhaps, in some measure, attributable to the loss of fluids by the part, consequent upon the exudation ; but probably still more to the pressure of the false membrane, which, in co- agulating, contracts,' and will thus, when only moderately adherent, exert considerable pressura upon the subjacent surface. In other cases, the false membrane, instead of exfo- liating entire, or in large slips, wastes insensibly, day by day, until it disappears ; lessening from the circumference towards the centre, but probably, also,, at the same time becoming attenuated.^ " The exudation varies much in texture in different cases, being sometimes dense, firm, coherent, and elastic ; at others, soft, gelatinous, almost liquid, or dry and friable. In color it varies from white to gray or ash-colored, brown, and black- ish. Although these varieties do not proceed from any es- sential difference in the nature of the disease, they indicate different degrees of its intensity, and their careful observation afibrds valuable aid to prognosis. "In the several epidemics which I have had the opportu- nity of studying in different places, but more particularly in this metropolis, (London,) many cases of diphtheritic sore throat, the course and symptoms of which, save for the pre- sence of exudation, have scarcely differed from those of sim- ple tonsillitis, have been intermingled with the severest form of the disease. The most common, and, as regards danger or suffering to the patient, the least important of these, have been cases of inflamed sore throat, attended by a thin exudation, glazing the posterior wall of the pharynx or the tonsils, and manifesting little or no tendency to increase in breadth or thickness. Sometimes the exudation is almost ' This description is remarkably accurate, and I have seen the same lessening of the membrane from the circumference to the centre, in nu mcrous instances. ENGLAND. 39 transparent, and gives to the surface it covers the aspect of being painted over with varnish or thin glue ; at others, it is opaque and white, but filmy, the mucous surface being cov- ered with an extremely line pellicle. The transparent glazing is most frequently seen on the posterior wall of the pharynx, where it is very apparent from its refractive property. The filmy pellicle is seen both on the tonsils, the posterior fauces, the inside of the cheeks, and the gums. The swelling of the tonsils is generally either absent or slight in these cases, and the redness of the inflamed mucous membrane is not intense. There is usually slight depression of strength, and more or less general malaise, but the constitutional symptoms are mild, and such cases rarely or never terminate seriously, or are fol- lowed by troublesome results. " This form of diphtheritic sore throat, for the most part, yields readily to treatment, but it is very liable to relapse, and sometimes becomes chronic, causing uneasiness of the throat of many weeks' duration.^ DANGEROUS CASES OF DIPHTHERIA. Dr. GreenJioiv. " The class of cases to which attention must be directed, is of a much more serious kind than any of those hitherto described. The exudation may, as in the former va- rieties, commence in the form of a thin, translucent pellicle, or in detached patches, but it rapidly becomes thicker, and, the separate patches coalescing, soon cover the inflamed sur- ■ This form of diphtheria was very prevalent in Philadelphia during the last eighteen months. It is still prevalent (May, 18GG) to some ex- tent. I may truly say, that I have attended several hundreds of such cases during this time. The disease particularly attacked the tonsils, pharynx, and also roof of the mouth and tongue. If there was any ten- dency to bronchitis, pneumonia, or chronic catarrh, it was sure to com- plicate itself with these diseases, as well as with affections of the stomach and intestines. The throat affection was frequently accompanied with enlargement of the tonsils, a thin veil-like pellicle covering them, as well as the surrounding mucous membrane. It was frequently accompanied by a very hard, obstinate cough, aggravated by the reclining position at night in bed. 40 EPIDEMIC OF 1857»-60. face, which often continues to widen in extent, until the dis- ease has crept into the nose, the ossophagus, or the larynx. This variety of diphtheria is, in truth, one of the most for- midable of diseases, and very often, indeed, baffles the best- directed efforts of the practitioner. The exudation may ap- pear as a granular deposit, possessing little cohesion, and of various degrees of dryness or humidity, or as a more or less dense, elastic, and coherent false membrane. Doubtless, the two forms pass by insensible gradations into each other, and coexist on different mucous surfaces of the same subject. " The most usual appearance of diphtheritic exudation is that of a false membrane, possessing more or less cohesion, and frequently very firm and elastic. Doubtless liquid, when first effused, it speedily coagulates, and, as it grows in thickness, becomes, denser, firmer, and tougher. It usually makes its appearance in the form of detached spots, very fre- quently upon one or both tonsils; these spots becoming thicker by successive additions from below, at the same time extend in circumference, and coalesce, so as to form a single plate of deposit. When first seen, they are usually white or ash-colored, and when these have united so as to form a uni- form layer, they very closely resemble wet parchment, thus agreeing very accurately with the description given by Villa Eeal of the false membrane observed by him in the Spanish epidemics of the sixteenth and seventeenth centuries. By and by they become discolored from the effects of decompo- sition or exposure, or stained of a blackish hue, probably in consequence of a slight hemorrhage. In other cases, the membrane assumes a buff" or brownish color, very much re- sembliug damp wash-leather, and then usually adheres very firmly to the subjacent surface. In either case, the breath is apt to smell offensively, partly, no doubt, from the decomposi- tion of the exudation ; but likewise, and especially as the smell sometimes exists at a very early stage of the disease, from the depraved secretion of the tonsils. Whichever of these appearances the exudation may present, the disease is very apt, as has already been said, to spread along continuous ENGLAND. 41 mucous surfaces. It will thus invade the nares, and some- times, but rarely, the eye. It extends to the lower part of the pharynx, larynx, trachea, more rarely to the oesophagus, and sometimes on to the cheeks and gums.^ " The invasion of the nares by diphtheritic inflammation is generally manifested by redness of the margin of the nostrils, and a discharge of sanious ichor, resembling that common in scarlet fever and also like it, sometimes excoriating the upper lip. Epistaxis is not an uufrequent consequence of nasal diphtheria. " Hemorrhage from the throat also occurs in pharyngeal diphtheria, but, unless in connection with purpura, less fre- quently, I think, than that from the nose. In either case, the loss of blood, by exhausting the already enfeebled powers of life, has sometimes appeared to determine a fatal result, and must always be regarded as an unfavorable symptom." DIPHTHERITIC OPHTHALMIA. Dr. Greenhovj. " This variety of diphtheria is so rare that, according to Mr. Dixon, of the Royal Ophthalmic Hospital of London, there was only one genuine case out of thousands of cases of ophthalmia in that institution. The membrane was situated on every part of the conjunctiva of one eye, pal- pebral as well as ocular, and was concealed from sight by a thick layer of coherent lymph." Professor Von Grsefe, the celebrated oculist, has published an excellent monograph on Diphtheritic Conjunclivitis. We avail ourselves of the labors of Dr. Liehold, contained in the North American Journal of Homoeopathy, November, 1866. Quoting Von Graefe, he says : "While in blennorrhoeic inflam- mation the tissue of the mucous membrane is loose, succulent and saturated with infiltrated fluid exudation, in diphtheritis we find it resistant, stiff -^iih. consistent exudation all through it. ' The spreading of the disease into the nares, larynx, and trachea, was most common in our epidemic, and generally in the most dangerous cases. In the eye, 1 have never seen it. 4 42 EPIDEMIC OF 18.')7-60. A lid attacked with blennorrhoea is consequently, in general, soft, puffy, easily to be turned ; a diphtheritic one, hard, and without elasticity and mobility. "/w hlennorrJioea, the mucous membrane presents a dark-red, puckered appearance, as if covered with small red grains, which look, in the higher grades, like so many papillary ex- crescences or intensely inflamed little warts. The histolog- ical examination shows the net-work of vessels under the epithelium very much enlarged in every direction ; they ex- pand most when the least resistance is offered, and therefore preserve externally those erectile loops, filled to overflowing with fluid blood. An incision, therefore, induces profuse bleeding, showing that in blennorrhoea the circulation is so far free, tJtat at least the majority of vessels contain coagulated blood. A partial collapse follows the incision. " Quite a different picture the mucous membrane presents in diphtheritis ; instead of the dark-red color of blennorrhoea, the appearance is pale, of a yellowish-red, or white, or whitish- red ; the surface is perfectly even and smooth. The small red spots of ecchymosis never unite in large suffusions ; they give a speckled appearance to the pale-yellowish conjunctiva, but are visible on the conjunctiva bulbi, when the layer is thin- ner and the underlying white sclerotica heightens the contrast. An incision into the diphtheritic mucous membrane neither evacuates blood nor exudation; there is no collapse and the cut gapes. The swelling of the mucous membrane is much greater in diphtheritis than in blennorrhoea. The production of heat and 79am is very much greater in diphtheritic than in blennorrhoeic and catarrhal inflammation. Many an eye is destroyed by gouorrho^al ophthalmia with re. nuirkably little pain ; but in diphtheritis Von Graafe had often to give chloroform when simply inspecting the lids, so excru- ciating is the suffering. The secretion also presents essential differences ; in blennor- rhoea the discharge is of thick yellow pus, which gradually, as the disease subsides, becomes of a lighter color and more mu- ENGLAND. 43 cous like ; in diphtheritis it is a thin, serous, dirty-graTjislt fluid, in which shreds of pseudo-membrane of a yellow color are floating; it is very corroding, making the adjacent parts very sore." Eegarding the nature and causes of this diphtheritic inflam- mation, Professor Von Grsefe observes: " Blennorrhoea has no necessary connection with any other disease; the perfectly healthy is just as liable to contract it as one suffering from other causes. Very difi'erent in diphtherial' Among forty children so affected he observed three times death by croup ; several times by pneumonia and hydrocephalus acutus ; fre- quently, too, affections of the skin, diphtheritic patches on the genital organs, angles of mouth, blister sores and other wounds. During dentition he saw frequently the occurrence of diphther- itis, even relapses or returns of the disease, simultaneous with the cutting of single teeth. Altogether diphtheritis is more com- mon in diseased and weak individuals than in healthy ones. Diphtheritis appears mostly as an epidemic. The first cases, as in other epidemics, were always found to be the most acute and serious. Affections of the cornea were then often produced in a few hours, leading to rapid destruction of the eye, while later in the epidemic the cornea was affected in latter stages of the disease, or escaped entirely, a circumstance of the great- est importance with regard to prognosis. Other diphtheritic afi'ections were at those times also prevalent, and almost every other acute inflammation of the conjunctiva showed a certain tendency to diphtheritic infiltration ; tumefaction was harder, the exudation contained more solid ingredients, and the elimi- nation of artificially produced eschars took more time. DIPHTHERITIC CROUP. Dr. Greenhow. " The extension of diphtheria to the larynx and trachea is a common occurrence in some epidemics, and in particular localities, but rare in others. It was very com- mon in at least the earlier epidemics seen by Bretonneau, and in some of the older epidemics, which, on this account, ob- tained for the disease the name of morbus sirunjulatorius, or 44 EPIDEMIC OF 1S57-60. garrotillo. Of fifty-two post-mortem examinations made by Bretonneau in two years, the larynx or trachea was only free from exudation in one instance, that of a child, who appeared to die from exhaustion, on the fifteenth day of the disease. The recent epidemics in the north of France, and the English epidemics of the last four years, have less uniformly mani- fested that character. In a few places the disease is said to have manifested no disposition to attack the larynx or trachea ; in others, most of the cases ending fatally have terminated in croup, consequent upon the extension of the disease through the glottis. But in a large proportion of the districts where the disease has prevailed, its character has, in this respect, been mixed, many cases ending in recovery or death without affection of the larynx ; others being complicated with the symptoms of croup. Dr. Heslop, of Birmingham, informs me that he does not think the disease has reached the larynx in more than five per cent, of the cases he has seen in that neigh- borhood. Of thirteen fatal cases in the practice of Mr. Scho- field, of Highgate, near Birmingham, with the particulars of which he favored me, only three were accompanied by symp- toms of croup. Diphtheria had been the sequel of scarlet fever in all three. Of nine fatal cases seen by Dr. Capron, of Guilford, only three died with laryngeal symptoms. Of twenty-six fatal cases reported by correspondents of the Brit- ish Medical Journal, only nine, including one from bronchitis, appear to have proved fatal from laryngeal complication. Mr. Thompson, in an account of the disease in the neighbor- hood of Launceston, says, that of four hundred and eighty- five cases that came under his observation, the air-passages were involved in fifteen, eleven of which died, generally within a few hours after the commencement of croupy breath- ' Diphtheritic croup has been observed by me as only fatal when the diphtheritic poison in the blood has been in such quantities as to over- power the vitality of the system. The mere symptom of a croupy cough did not constitute a symptom of danger. Numerous cases of this kind were cured without any dilTiculty. ENGLAND. 45 DIPHTHERIA OP THE (ESOPHAGUS AND STOMACH. Dr. Greenhoio. ^^ Mr. Stiles, of Pinchbeck, informs me that he has met with cases in which there was difficulty of swal- lowing, without any evident throat affection. He attributed this to the existence of diphtheritic exudation in the lower part of the pharynx, or in the oesophagus, beyond the reach of vision. In one instance, a patient thought, from a sensa- tion of choking, that some substance was sticking in his throat, and, on passing a probang, shreds of false membrane were brought up on the sponge. Diphtheria existed in the patient's house at the time. Probably oesophageal diphtheria is most frequently caused by the extension of the disease from its usual seat in the fauces, and thus sometimes occurs after the disease would seem to have disappeared. It is attended by extreme difficulty of deglutition, often followed within a day or two by pain, either during the passage of food through the oesophagus, or after it has arrived in the stomach. In- deed, severe gastrodynia is not of infrequent occurrence dur- ing convalescence from diphtheria; but has not, under my observation, led to any worse result than delaying recovery by preventing the patient from eating. In one instance, in the practice of Mr. Balls, of Spaulding, diphtheria was fol- lowed, after apparent recovery, by intense pain at the epigas- trium, vomiting, and collapse, which proved fatal in thirty hours. The patient had been imprudent in diet the day pre- vious to the attack of pain, but this would scarcely have de- termined so serious an affection. Unfortunately, as no post- mortem examination was made, it is impossible to decide whether the cause of death was, as supposed, perforation of the stomach, or not. Mr. Coleman, of Wolverhampton, also had a case of diphtheria, that of a female, aged twenty-two years, in which severe pain of the cardiac extremity of the stomach, much aggravated by taking food or wine, came on alter the exudation had disappeared from the throat, aud the 46 EPIDEMIC OF 1857-60. patient was supposed to be going on favorably. The case proved fatal.^ Monsieur Espngne, of Montpellier, relates a case of oesopha- geal diphtheria in a patient, aged ten and a half years, suffer- ing from typhoid fever. The diphtheria came on about the twenty-third day of the illness, and, after death, the arch of the palate, the uvula, and tonsils were covered with shreds of firm, gray-colored false membrane. The entire posterior wall of the pharynx was coated with a thick false membrane, which extended, without breach of continuity, down to the cardiac orifice of the stomach. This false membrane was ex- actly moulded upon the oesophagus, and about the thickness of a line almost throughout its entire length. It became notably thinner towards the stomach, ceasing abruptly at the lesser curvature, but ending by some very thin portions, pro- longed in the direction of the greater curvature. The diph- theritic concretion formed a complete tube, flattened from be- fore backwards, and plaited longitudinally. It was easily de- tached from the oesophagus, the mucous membrane below it being injected and of a violet color, without any trace of ul- ceration. The larynx and trachea presented no appearance of false membrane. DIPHTHERIA OF THE MOUTH. Dr. Greenhow. "The extension of diphtheria forwards into the mouth has been less common in this country (England) than it would appear from the French writers to have been in France. The exudation has occasionally appeared on the gums, has sometimes extended on to the buccal mucous mem- brane, and has more rarely formed a complete covering to the ' A similar case observed by me will be detailed in its proper place. The post-mortem examination showed the membrane not only in the stomach, but along the whole course of the alimentary canal. In one case, which recovered, the membrane was seen in the rectum and verge of the anus. Dr. GuernsanO also mentions a case where the membrane was discovered in the stomach ; he showed it to Dr. Alters, of Bremen. ' Dr. Ouernsant, on Croup, Dictionnairo do M6decine, 1833. New Sydenham Society, lSu9, pago 221. ENGLAND. 47 palate and inside of the cheeks, and from the fauces to tlio teeth. One such case proved fatal in the practice of Mr. Rush, of Southminster, and in a second, the patient nearly- died of starvation, from inability to swallow after the mem- brane had come away. The first case seen by me was one of pellicular diphtheria of the inside of the cheeks and gums ; and I have observed exudation in the same locality in several other instances, but the danger in such cases has always arisen from the condition of the fauces, and not from that of the mouth. . DIPHTHERIA OF THE PUDENDA. Dr. Greenliow. " The pudenda and vaginal mucous mem- brane are perhaps, after the throat, the most common situation of diphtheritic deposit." According to Dr. Greenhow, puden- dal diphtheria is generally an accompaniment of diphtheritic disease of the throat, but sometimes it occurs without the latter. "The late Mr. Edwards, of Wolverhampton, saw two cases of vaginal diphtheria, both of which proved fatal from exhaustion. The disease accompanied diphtheria of the fauces, and both children were inmates of the same cottage, where there had already been two fatal cases. Mr. Cooper, of Cromer, had in one instance seen the pudenda of a little girl covered- with exudation, unattended by diphtheria of the throat. Dr. Nicholson, of Eedditch, also writes me word that he has met with one case of pudendal diphtheria in a patient, whose throat remained unaffected, and several practitioners in the fenny parts of Lincolnshire, Cambridgeshire and Norfolk, inform me that they have, from time to time, met with cases of pudendal diphtheria, unaccompanied by throat affections, anterior to the present outbreak. In Dr. Nicholson's patients, the parts were abraded by an acrid discharge ; there was great depression, requiring the free use of stimulants, and recovery was very tardy." ^ ' In one or two cases I have met with this pudendal diphtheria, but the mothers of the children thus afflicted would with difficulty be persuaded of the existence of such a disease. 4§ EPIDEMIC OF 1857-60 — ABRASIONS OF THE SKIN. k DIPHTHERIA ON WOUNDS. Dr. Greenhoiv. " Wounds and abrasions of the skin often become covered with diphtheritic deposit, analogous to that on the throat. Dr. Nicholson mentions the occurrence of diphtheria on wounds without throat affections. One of these, a man aged thirty-two years, had been operated upon for fistula in ano. On the fifth day, diphtheritic exudation appeared on the wound, which eventually sloughed under the use of caustics. The patient died. The other case was that of a female, aged fifty-three years, who was suffering from caries of the metacarpal bones of the second and third fingers. On the third day after an abscess connected with the diseased bones had been opened, the wound became covered with diphtheritic exudation. The parts were subsequentjy ampu- tated, but diphtheria reappeared on the new wound, hemor- rhage from the bowels supervened, and the patient sank fourteen days after the operation. More frequently diphtheritic exudation has appeared on wounds simultaneously with the occurrence of diphtheria in the fauces."^ DIPHTHERIA ON BLISTERED SURFACES AND ON ABRASIONS OF THE SKIN. Dr. Greenhotu. " M. Becquerel mentions the occurrence of eighteen cases of gangrene of blistered surfaces, during an epidemic diphtheria, at a hospital for sick children at Paris, in 1841. The gangrene was always preceded by the develop- ment of membrane upon the raw surface. This false mem- brane did not separate, but became confounded with the slough, which frequently spread so as to occupy a gradually widening surface. The affection sometimes occurred simulta- ' I have in numerous instances observed a deposit of diphtheritic mem- brane, in the ulcers of children, as well as in some grown persons ; also, iu panaritio and iu the Schueiderian membrane of persons subject to the annual cold. ENGLAND. 49 neouslj with diphtheria of the throat, but in several cases independently of any other diphtheritic disease.^ Accordiug to Bretonneaii these membranes are detached and reproduced with great readiness, within a period of six or seven days."" Troupeaxi^ also mentions numerous well-authenticated cases of cutaneous diphtheritis. The following quotations give his own view: "Where malignant angina exists in any person, the application of blisters is often followed by the most disas- trous consequences, so that the skin becomes inflamed, covered with peculiar exudations, and gangrenous. Besides, in the same communes, and in the same houses, where the irritation produced on the skin by cantharides is at present so dan- gerous, blisters had previously been employed without the slightest inconvenience, and we could always easily calculate the local effects of this treatment."^ In another place he says : " Only in the locality where some one is dying of malignant diphtheria do wounds assume suddenly a character of severity which they did not before present, etc." He also believes that cutaneous diphtheritis is sometimes fatal, and equally capable of propagating the disease as malignant angina. Dr. Greenhow also quotes Drs. Starr and Sanderson, as mentioning cases where diphtheria made its appearance in connection with cutaneous eruptions. ' Gazette M6dicale de Paris, 1843, p. 692. « Traits de Diphth6rite, p. 356. ' Memoirs on Diphtheria, New Sydenham Society, London, 1859, p. 254. * The cause of this violent action of cantharides is certainly owing to its being one of the principal remedies in the disease. 50 DIPHTHERIA IX THE UNITED STATES, 1856-64. CHAPTER III. DIPHTHERIA IN THE UNITED STATES, 1856-1864. Dr. T. V. Tougeaud} A terrible epidemic occurred at San Francisco and in other towns of California, In his mon- ograph on this epidemic Dr. Tourjeaud says : "Few children attacked by it recovered. The disease be- gins in a very insidious manner, by a little engorgement or inflammation of the soft palate, pharynx and one of the ton- sils. (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, indeed, that the little patients go about play- ing, as if nothing was the matter. "In some exceptional cases, however, the fever and inflam- mation 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 glands become 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. Then 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 affected than the other, and upon examination, the glands corresponding with the parts affected will be found more swollen than those of the opposite side." ' Diplitheria, a concise Historical and Critical Essay, etc. Sacra- mento, ibjti. ^UNITED STATES. 51 Dr. James Blal'e, of Sacramento.^ " The first effect pro- duced by the poison is evidently on the nervous system. Drowsiness, prostration and oppression are manifested by in- fants, 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 in some cases it is, for a few hours, rather hard. The temperature of the skin is raised, although it is seldom harsh or dry, but frequently moist or even covered with pro- fuse perspiration. There is seldom any pain, rarely headache or backache. The tongue is usually coated, edges red, papillae prominent. The appetite may remain good and digestion unimpaired. If we examine the throat, we may, even within twelve hours after the occurrence of the first slight symp- toms, find the tonsil covered with a grayish, pultaceous exu- dation, 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 be- come alarming. " 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 the exuda- tion on the tonsil, we generally find the cervical glands en- larged, and in protracted cases this enlargement may become so large as to afford a serious obstacle to deglutition and res- piration. I have seen cases in which I think death was thus produced, when the patient might otherwise have rallied from the effect of the poison. " 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 ' racific Medical and Surgical Journal, August, 1858. 52 DIPHTHERIA IN" THE UNITED STATES, 1856-64. 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 con- tagion, 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 proba- bly owing to the continued absorption of the poison in a state of concentration." Dr. L. N. Beardsley, of Milford, Connecticut, writes to the Boston Mi'dical and Surgical Journal: "This disease (diphthe- ria) 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 vil- lage. "Fourteen cases out of fifteen of those who were first at- tacked proved fatal, in periods varying from six to twenty- four days. "Most persons residing in the district where the disease first appeared, sooner or later, had some manifestation of the dis- ease. The period of incubation varied from five to twenty days. The lymphatic glands were in many cases greatly en- larged. " The first symptom of this disease — and it is one which we have never seen referred to by any writer on the subject — was pain in the ear} It was not only pathognomonic, but promi- nent, 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. ' lu many cases 1 have observed this paiu in the ear. UNITED STATES. 58 " The tonsils were enlarged and inflamed, with small points of lymphatic exudation upon them, which gradually spread upwards into the nasal fossa3, and downwards into the larynx and trachea. "There was extreme prostration, depression of the nervous system, feeble pulse, etc., but in no case was there any mental disturbance." Steuben ville, Ohio, and vicinity, suifered terribly from the ravages of diphtheria. The disease attacked both old and young, but most generally children, among whom it was most fatal. The number of deaths from diphtheria in Steubenville was not far short of two hundred, during 1860. The deaths among adults were probably one-fourth of that number. Many families were made desolate from the virulence of the disease. Dr. H. D. Paine, of Albany, New York, gives the follow- ing account of an epidemic of diphtheria which he witnessed during five months, from September, 1858, to February, 1859 : " Some idea of the grave nature of this sickness may be gathered from the fact that, since the breaking out of the dis- ease, few, if any, less than two hundred and fifty deaths there- from have occurred in the city (Albany) and its immediate neighborhood. The victims have been almost exclusively children and young persons. In fifteen families, there had been in each two deaths ; in four families, there were in each three deaths, and one hundred and four children had been swept away by the pestilence. "If the experience of other practitioners has been similar to ours, the total number of cases, of every kind and degree, must have been immense, not less, perhaps, than a fourth part of the entire population. " The cases that have come under our notice, although ex- hibiting great variety in the manner of attack, symptoms, course, and termination, may be conveniently arranged, for description, in two or three groups. " In the most severe and strongly-marked cases, there is violent inflammation of the fauces, tonsils, and uvula, extend- 54 DIPHTHERIA IN THE UNITED STATES, 1856-64. ing as far back as can be observed, accompanied by a more or less extensive formation of false membrane, of a dull-white or ashy color, sometimes deposited in small, irregular patches, and at others covering a large part of the mucous lining of the throat on one, and occasionally on both sides. There is also in these cases, very frequently, a viscid discharge from the nostrils, and a most fetid breath. "The appearance of the throat, before the occurrence of membranous deposit, is generally indicative of intense in- flammation, not always equally diffused, but in spots of ery- sipelatous redness, or with streaks of a deeper redness, irregu- larly scattered over the inflamed surface. Deglutition is gene- rally very painful and difficult from the first, indeed often more so at the beginning than in the latter stages ; but in- stances have not been rare in which, notwithstanding a highly inflamed appearance of the throat, the patient manifested no difficulty at all in swallowing. "The fever runs high, but is generally brief, seldom ex- hibiting much activity, except in the early stage of the dis- ease, and is followed by a stage of depression and debility, apparently disproportionate to the amount of the preceding excitement. In many, even serious, cases, the febrile symp- toms have scarcely been observed at all, but a tendency to an asthenic state of the system is evident from the first. * * " Sometimes the membranous stratum is a mere film, and quite transparent at first, which may, perhaps, cause it to be overlooked ; but it soon becomes thicker and opaque, and the color is usually of a dark-white or grayish hue. " It appears to be of a fibrous structure, quite tough and firm. Specimens of it have been detached and thrown oft", as thick as kid-leather, and I have seen some that were as thick as thin calfskin. When loosened and separated from the surface to which it is attached the underlying membrane very rarely exhibits any evidence of ulceration or other disorganization, but the plastic exudation is liable to form again, if the pro- cess of detachment be prematurely hastened. " The space covered by the false membrane is subject to the UNITED STATES. 65 greatest variation. In slight cases there may be, perhaps, a i.\v dots of it here and there, or one or two spots a line or two in diameter, while, in the more aggravated examples, the [lalate, tonsils, and fauces present to the eye an unbroken coating of this substance, at the same time that the other un- mistakable indications prove its extension into the pharynx and trachea. "As the disease progresses, and sometimes at an early stage of the attack, the breath becomes exceediogly ofieusive, so much so as to affect the atmosphere of the room where the patient lies with an almost intolerable fetor; at the same time the inflammation may extend to the nostrils, accompanied by a more or less abundant discharge of an acrid, foul-smelling secretion from the nose, not uufrequently mixed with the shreds of membrane. " In addition to these symptoms, there is more or less swell- ing of the' parotid glands, upon one or both sides. These swellings are sometimes very considerable, but seem not to 1)0 very painful, nor do they manifest any disposition to sup- })uration. " The most frequent cause of death appears to have been the extension of the false membrane into the air-passages, producing the same mechanical obstruction to respiration, and terminating precisely in the same manner as in ordinary croup. "In a portion of the cases, however, the fatal result seems tr) depend less upon the obstruction of respiration than upon tl.c L'^cneral prostration and exhaustion of the vital forces. T\ic process of throwing out this plastic exudation appears to law so heavily upon the system as, with the low typhoid character of the constitutional symptoms, to imperil the life of the sufferer from sheer exhaustion. "In one or two cases that have come under our observa- tion, the inflammation has so affected the organs concerned in deglutition, as to make the act of swallowing very jiainful, and wellnigh impossible ; the half-lethargic patient preferring i«) die of starvation rather than undergo the distressing effort of taking the simplest nourishment into the stomach." 56 DIPHTHERIA IN PHILADELPHIA. CHAPTER IV. THE DIFFERENT FORMS UNDER WHICH DIPHTHERIA MANI- FESTED ITSELF IN PHILADELPHIA. From the year 1860, to January, 1866, I have treated at least six hundred cases of diphtheria, including in this num- ber all cases where a membrane could distinctly be seen by me in the throat on examination, no matter whether these cases ivere malifjnant or slight. They may be divided as follows : I. — Malignant Cases. A. — With Predominance of Throat Symptoms. Characteristic Phenomena. — Malignant cases are almost ex- clusively confined to children, or at least to young persons not over sixteen or seventeen years of age. From the very commencement of the attack, the whole face and neck are very much swelled. The tonsils are swelled, and a large patch of the membrane is visible on both tonsils at an early date, spreading in an incredibly short time over the whole pharynx, palate, and also tongue, and often the gums. If re- moved by remedial agents or caustics, it returns again, and this process is often repeated several times in the course of the disease. Drowsiness and complete loss of appetite are the forerunners of serious trouble. Immense prostration of strength. SymiAoms. — The elimination of the diphtheritic membrane was preceded for several days by chills, followed by fever, with great lassitude of body. The tonsils and the palate are swelled and inflamed. In children this inflammation is of a rose color, but in adults it is of a crimson or deep scarlet color. The deposit becomes visible on both tonsils about the third day. PITILADELPHIA. 57 Emph^ observed that the exudation of a sero-mucous, transparent, slightly viscous and ropy liquid preceded tlie appearance of the pellicle on the affected part. " The serous liquid is sometimes very abundant, and in some cases there would even be, in the vicinity of a part already covered with pellicular exudation, a kind of sub-epidermic exudation, suffi- ciently considerable to raise the epidermis under the form of phlyctenas, by the rupture of which the dermis, being ex- posed, soon becomes covered with the false membrane." I have never seen this liquid in the form here described, but the membrane seemed to me always, in the first instance, of a more fluid form, becoming gradually more compact. Like Empis, I have observed that the pellicle never disap- pears at once, leaving a cicatrized surface in its place, and consequently detaching itself like a crust or an eschar ; on the contrary, it is a continuous pathological process ; the pellicle diminishes in thickness in proportion as the edges of the wound are cicatrized. The color of the red border, limiting the exudation, grad- ually loses its intensity in proportion as the edges of the false membrane are raised by cicatrization. In all severe cases, the whole countenance is pale and somewhat swelled, even at the beginning. On the Schnei- derian membrane of the nose, the same false membrane is visible. Bretonneau avers that the membrane produced by diph- theria and that produced by cantharides are so alike, that one cannot be distinguished from the other. This is true with regard to the commencement of the disease ; but with the progress of the disease toward a fatal termination, the membrane becomes thicker and harder, in some cases like a piece of leather. If the remedies act favorably, the mem- brane softens and becomes pulpy, being easily detached from 'Researches on Diphth6rite, founded upon an Epidemic of tliis Dis- ease, observed at the Hospital Necker, 1«48. By (J. ,V. Emi>is. (Archives G6n6rales de Medicine, 1850.) 5 58 DIPHTnERIA IN PHILADELPHIA. the surface of the fauces and tonsils. The membrane seems to be perfectly distinct from the mucous membrane, which latter, after the detachment of the former, appears red and inflamed, with the blood oozing out. In all severe cases the membrane, even if removed partially by specific remedies, would often return three or four times in succession. There is also abundant testimony by various writers on diphtheria, that the disease may return in the same house or same child three to four times consecutively. This has so often hap- pened to me in my [)raetice that I consider it an established fact. Dr. Lee Williamson, of Mississippi, corroborates this fact, affirming that the membrane, after being removed, renews itself several times, each time becoming thinner and whiter, and finally disappearing. In one malignant case, that of an adult, I discovered the membrane even in the anus, and iu six cases it assumed the form of panaritium. If the slighter symptoms were disregarded by the family, and no medical aid sought, the membrane, which at first ap- peared only as a small speck on the tonsils, would, in an in- credibly short time fill up the whole throat, palate, roof of mouth, and also the tongue and the whole pharynx as far as could be seen. I made it a point to examine the throat of even the smallest children at each visit. The glands of the neck, which were only slightly swelled at first, would grad- ually involve the whole circumference of the throat; the pa- rotid glands soon became very large and indurated. The cel- lular membrane of tiie external neck, together with the whole face, cheeks and eyelids became swelled. In the beginning, the natural color of the face was still retained ; but the disease advancing, a deadly pallor sjyread over the central ^iortions of the face from the forehead to the nose,mouth^ li23s and chin. In the most severe and dangerous cases, there was a very fetid odor from the mouth ; in all of them, the smell of au acid or mouldy character was perceptible. Occasionally, after appropriate treatment, the fetor would diminish or disap- MALIGNANT CASES. 59 pear, but, whenever the disease advanced to a more malignant stage, this smell would return. This would occur several times in the course of the treatment. In many malignant cases the membrane in the throat at first looked white, afterwards became yellow, and finally turned entirely black, together with the tongue, which was swelled. The appetite now began to fail, and the food had almost to be forced down the throat, but the thirst for water and ice was ver}^ great in all cases. The patients would drink to the last. The urine was high colored and fetid. The discharge from the bowels had, generally, a natural appearance. A constant drowsiness and sleep, with difficulty of breathing, is among the early symptoms of the malignant type. There is also considerable heat in the forehead. The skin remains dry. The pulse is moderately frequent, and often, even in unfavorable cases, quite strong to the last. Finally, if the hands and feet get cold and the pulse sinks, all hope is over. Of this malignant type, as above described, I have attended about one hundred cases during the last six years, of which I lost five by death, — all during the first year. B. — Combined with Croup. The disease always commenced with the ordinary diph- theritic symptoms of the malignant type. As the disease advanced, symptoms of croup would gradually manifest them- selves. This form was very dangerous. I lost, however, only one of the twenty cases which I attended. The details ■will be given under the head of treatment. I was called in consultation in four cases of this kind, all of which terminated fatally. Two of these I saw only two hours before death. The breathing, in such cases, is short and accompanied by wheezing, with frequent attacks of ft croupy cough and suffo- cation. It is sufficient to say that the symptoms of croup would not in themselves constitute an element of danger if the system was not overpowered by the diphtheritic poison iu the blood. 60 DIPHTHERIA IN PHILADELPHIA. C. — Extension of the Throat Disease to the Stomach and Alimentary Canal. These were cases where the disease, after being apparently cnred*in the throat, reappeared, with symptoms of vomiting and pain in the stomach, and great tenderness on touching the abdomen. There was generally great prostration of strength, deadly paleness of countenance, and sinking of the vital power. Fortunately, I had to attend a few only of these dangerous cases. Iii one case, of which a post-mortem exam- ination was made, the true nature of the disease was discov- ered. The stomach and whole alimentary canal were lined by a membrane of an albuminous nature. The symptoms will be detailed in another place. Dr. Greenhow also mentions a similar case. The following symptoms detailed by him clearly indicate the nature of the disease : " Complained that swallowing gave him pain in the ears and head, and of being sick. Beef-tea and wine have re- turned several times ; brandy was therefore substituted for wine. Sixteenth day : passed an uncomfortable night ; there was difliculty in getting him to take any thing ; was thirsty and craved for water, which very generally returned imme- diately after it was taken, as did food, brandy and the medi- cines, prescribed with the hope of allaying the irritable (?) stomach ; pulse sixty, no fever, no pain. Seventeenth day : every thing is rejected by the stomach immediately, and alarm- ing attacks of vertigo or swimming of the head were com- plained of, accompanied by temporary loss of consciousness; pulse, forty. By the eighteenth day, the action of the heart had declined to thirty-two beats in the minute; on the morn- ing of the nineteenth day, it had fallen to twenty-four, but, on being disturbed to taste food, would suddenly rise to sev- enty or eighty per minute. lie would lose consciousness in a minute. In the afternoon he died." In the Philadelphia Medical Examiner, a similar case, that of a lady, is mentioned. She also died. The post-mortem revealed the nature of the case. SLIGHT CASES. 61 II. — Slight Cases, under the followixg forms: A. — A slight Deposit of the Membrane is visible on the Schnei- derian Membrans of the Nose, on the Tongue, Pharyiix, Ton- sils, etc. The Glands of the Neck are only slightly swollen. These cases occur in adults as well as children. Numbers of these merely called at the office to be prescribed for, and recovered in a few days. I counted over three hundred of such cases. The glands of the neck were in many cases swolleu only on one side ; and on the same side a speck of the mem- brane was always visible on examining the throat. The appearance of the membrane was generally preceded by a violent chill and followed by very great prostration of strength, but no further evil consequences. B. — Diphtlieritic Cough, ivith or without Croup. This variety occurred in adults as well as children. One case occurred in a man eighty-eight years of age. Patches of the membrane could be distinctly seen in all cases on the ton- sils, extending down the throat. The disease was also char- acterized by a hard, dry cough, causing choking and often of a croupy nature. On auscultating the chest, there was discovered more or less wheezing and whistling, with oppres- sion of breathing at night. Doubting at first the diphtheritic origin of these cases, the usual remedies for obstinate and croupy cough. Belladonna^ Phosphorus, Laurocerasus, Hepar sul. and Spongia mar. tost., were exhibited, but without the slightest benefit. There was no difficulty, however, in curing this cough with what I may call the diphtheritic remedies, as meeting not merely the'symptoms, but also the pathologi- cal condition of the throat and ramifications of the bronchia. Such remedies were Liquor Calc. chlorin.. Kali bichrom.. La- chesis, and Grotalus. During the autumns and winters of the years 1861 and '62, as well as '63 and '64, a great number of persons suftered with a sore throat, characterized by dryness, soreness, and 62 DIPHTHERIA IN PHILADELPHIA. slight swelling of the tonsils. More than a Mindred of such cases came under my observation. On examining these very carefully, the tonsils, palate, and pharynx, as far as could be seen, were covered by a veil-like membrane lining the throat, sometimes, also, hanging loosely in detached pieces. It was not mucus, but a skin. The disease was not at all danger- ous, and was generally cured by a few doses of Caustic. 1 and 2, or Calc. chlor. |. Where, however, the patients were liable to bronchitis or chronic lung disease., the diphtheria always complicated itself with these diseases, and was on this account more difficult to eradicate. The cough was particularly severe at night in the reclining position. In addition to the specific remedies for diphtheria, Kali hydriodicum, Calc. phosphor.^ Antim. sulph. aur., etc., had to be administered. The typhoid fevers so extensively prevailing during the winters of 1862, '63, were more or less complicated with this disease. Although often determined not to see it, the evi- dence of its presence in many chronic and acute diseases was too convincing to be cast aside. Where the attack commenced with croup, without any violent symptoms of the throat or severe general derange- ment, the cases invariably recovered, often, however, with great difficulty. Their number was about thirty. In this variety may be included a kind of diphtheritic fever, exacer- bating in the evening and remitting in the morning, with want of appetite, great thirst and many other symptoms, according to the individuality of the case. That this fever was of diphtheritic origin, was evident from the mouth and pharynx being covered by a slight membrane. G. — Characterized by a Mucous Diarrhoea and Dysentery. When the disease was on the decline, many persons were affected by a peculiar diarrhoea, preceded by a pain in the stomach, particularly at night. The discharges consisted of large flakes of mucus, and were accompanied by a soreness in tiie hypogastric region. Ordinary remedies remained pow- DTPnTIIEKTA COMPLTCATEP WITH OTHER DISEASES. 63 erless against this diarrhoea. The best remedies against the diphtheria were also the best against this diarrhcca. Toward the close of 1864 and the beginning of 1865, the diphtheritic miasma again showed itself in the form of mu- cous dysentery, with straining of the bowels, white mem- branous and mucous discharges, thickly white-coated tongue, and sometimes, also, slight cough, with thin pellicular deposit on the pharynx, as far as could be seen. There was some- times considerable fever, nausea and vomiting, and complete loss of appetite. That the disease was of the same origin was manifest, for the same remedies as were given in diphtheria were the best, with the addition of Guinmi Gutta. I must have attended, on a close calculation, something like fifty or sixty of such cases. They were generally very obstinate, lasting from two and three days to two weeks ; and two cases con- nected with scrofulous constitutions were even of longer duration. Although children from two to seven years of age were the most frequent objects of these attacks, they were not confined to them. A considerable number of adults also came to consult me. These were mostly but slightly affected. Latterly, some of the most obstinate cases of this mucous diarrhcea were cured by Ac. rmiriat. dil.^ 1st and 2d dil. D. — Diphtheria Coraplicated luith other Diseases. Although some of these forms are dangerous, T still have classed them among the slight cases, because I have not lost any of them. The English writers mention such combinations as taking place with scarlet fever, pneumonia, hectic fever loith tuberculo- sis, small-pox, rheumatism, and pericarditis. Excepting small- pox, I have seen all these combinations. Of the complica- tion with scarlet fever, there came twelve cases under my treatment, generally slight, and all terminating in recovery. The most dangerous combination is that with cerebral affections, and is very apt to occur in children liable to brain disease. 1 observed the disease also in one case of parturi- tion and one of erysipelas. 6-4 DIPHTHERIA IX PHILADELPHIA. Diseases of the lungs are particularly apt to be complicated with diphtheria, as already mentioned under slight cases, B. Hectic fever was a common symptom in tubercular patients, some of whom recovered with difficulty. Dr. Greenhow men- tions that cases of ulcerated sore throat have sometimes been intermixed in the same epidemic. Cases from Drs. Sander- son, Becquerel, etc., are adduced to illustrate this statement. Br. GallV- mentions having seen in a child suppuration of the inguinal glands simultaneously with slight diphtheria of the fauces. Albuminuria is a frequent but not a constant attendant upon diphtheria. Its occurrence was first observed by Br. Wade,- of Birmingham, who, when examining the body of a person who had died of diphtheria, found such changes in the kidney as induced him to examine the state of the urine during life more carefully than he had previously done. He thus discovered that albumen is frequently present in the urine of patients suffering from diphtheria, a fact which has been confirmed by subsequent observers both abroad and at home. When albuminuria occurs in diphtheria it usually does so at an early period of the illness, generally within a few hours after its commencement. In this respect diphthe- ria differs essentially from scarlet fever, in which albuminuria is rarely found in the urine till a much later period of the illness. 1 myself have discovered the presence of albuminuria, par- ticularly in those cases connected with pneumonia. Br. R. Ludlam mentions a case of a friend of his, Br. Lord, where two sets of symptoms succeeded each other with such distinctness as to attract the attention of the nurse and friends of the patient. The urine in each interval becoming clear, non-albuminous, and deficient in the chlorides, while a little of the sputa in the field of the microscope afforded a beau- tiful specimen of the crystals of chloride of sodium. lie gives ' Second Report of tlie Medical Officer of the Privy Council, pusfc 301. 2 Midhiiid Quarlorly Jouriiiil of the Medical .Sciences, vol. ii., p. 318. Pli'IITIIERIA COMPLICATED WITH OTUER DISEASES. G5 .two drawings of the experiments, and concludes as follows : "It is an interesting query for pathologists, to determine whether the presence of the chloride of sodium in the sputa and its absence in the urine — hitlierto, thought to be pathog- nomonic of hepatization of the lung — may frequently occur in case of functional disorder of the kidneys, as iu diphthe- ritic albuminuria. "From the foregoing observations, the following conclu- sions are plainly deducible : "1st. That albuminuria may be produced by causes acting exclusively through the nerve-centres. "2d. That disordered innervation of the kidneys may re- sult in such a congestion or stasis of the blood, in their capil- lary vessels, as interferes with the function of excretion, thus permitting the escape of albumen along with the urine. " 3d. That albuminuria, from this cause, is usually transient. When, however, the cause is persistently applied, the symp- tom continues, and a structural lesion may finally result. "4th. That the diphtheritic virus has a specific determina- tion to the nerve-centres, but more commonly affects the renal nervous system, and may produce albuminuria as a concomitant of diphtheria, without structural changes in the kidneys themselves. "5th. That the time when albumen generally appears, the freedom of the urine from epithelial casts in many well marked examples of diphtheritic albuminuria, the possible alternation of this symptom with another, which involves a remote organ, as well as the fact that it may disappear at the end of a few hours or days, — a reason why it is frequently unnoticed, — and the complete absence of renal sequelaB in a majority of cases, all serve to establish the position we have assumed. " 6th. That this view of the origin of the diphtheritic albu- minuria has a therapeutical bearing of which the intelligent physician may avail himself." Besides hemorrhage from the nose and throat, there is also frequently purpura on the gums, mouth, etc. Claret-colored blotches of purpurous nature are not uncommon. Other 66 DIPHTnERIA IN PHILADELPHIA. eruptions besides picrpnra sometimes accompany or follow diphtheria. An irregular, measly mottling of the skin is not infrequent at an early stage of the disease. Dr. Greenhow has, in several instances, seen an eruption very closely resembling the rose-rash of typhoid fever. Sim- ilar eruptions were observed by other physicians. I have seen, in six cases, an eruption resembling varicella, either preceding or following the disease. Dr. Nicholson, of Reddish, observes that erysipelas of severe and unmanageable character commenced, increased, and de- clined simultaneously with diphtheria. An unusual preva- lence of erysipelas has also been observed by practitioners of Birmingham, Brentwood, Maldon, Wirksworth, Derby, Dudley, Wolverhampton, and Leek. Puerperal and typhoid fevers were unusually frequent, as was also roseola. In October, 1863, I was attending two children of the ages of five and three years respectively, who had diphtheritic angina, with erysipelas of the face. At first there were symptoms of swelling of the submaxillary glands and face, with diphtheritic membrane visible in the throat. Three days afterwards, the erysipelas appeared on both cheeks, ac- companied by delirium at night. In one child, the erysipelas made its appearance, with convulsions lasting ten minutes. In November, 186+, I attended a child which had at first diphtheria, and afterwards very severe erysipelas of the face. Two cases of chancre I saw complicated with diphtheria. The diphtheritic membrane was clearly visible, surrounding the chancre, on the penis. In one case of secondary syphilis, where there were syphi- litic ulcers in the throat, diphtheritic deposits could be seen mingled with them. In another case, there appeared a white membrane over four very malignant chancres on the glans penis. Both chancre and diphtheria were cured by the alternate use of Merc, pre- dpi. ruhr., one-tenth, and the solution of Ghlor. of Lime. The Mercury, whicli was at first used alone, did not cure the diph- theria. CAUSE MIASMATIC. 67 According to Bouchnt, diphtheria has been observed in combination with hooping-cough, phthisis, and eruptive fever. In the case of an elderly lady, occurring in my own practice, the phthisical symptoms were excited to such a degree that she was brought to the brink of the grave. Her life was saved with great difficulty. In many cases of malignant typhoid fevers, which have been very common of late years, false membranes have been ob- served on the tongue and throat. CHAPTER V. NATURE OF' DIPHTHERIA. "When it is asked what is the interior nature of the disease which makes its appearance with such formidable symptoms, devastating a whole continent, and gathering its victims in every part of the world, we can only answer that we have made approaches towards unfolding the secret source of this scourge, but have not, as yet, succeeded in unravelling its com- plete mystery. "VVe shall state here all the facts which have been discovered, and the speculations which have been enter- tained concerning its nature. A. — Cause Jfiasmatic. All authorities and lur iters on the suhject agree that the main essence of diphtheria C07isists of a poison in the blood derived from miasmatic causes. Like all poisons of an epidemic nature, as that of cholera, small-pox, etc., it is most violent in its mani- festations at the beginning of the epidemic, but is gradually diminished in power as it becomes more diffused, although occasionally it will show its ancient violence. Professor A. E. Small, in a letter to the author, observes " that the disease arises from a poisonous miasma, that first prostrates the vital bo NATL^RE OF DIPnTHERIA. forces and predisposes to chilliness and fever ; that particu- larly affects the mucous surfaces of the air-passages, causing an exudation upon them of a plastic substance, which soon assumes a pseudo-membranous character;" and subsequently he again avers, " that there is a specific poison or miasma that causes the disease. I firmly believe." The cause of diphther- itic false membranes consists, according to Empis, in a special morbid property, manifested by an inflammation on which it im{)rcsses its special characters. JEmjns also confirms the fact, indicated by Roberts, that wounds, before being invested with the diphtheritic pellicle, change their aspect, become more painful, and furnish a less abundant and thinner suppuration, Dariot truly says, that pharyngeal diphtheria must derive its origin from some agent which is occult in its nature, but which always determines pellicular inflammation^ and is similar in its effects to certain chemical substances, as Mercurius, Chlorine, Ammonium, the Caustic Alkalies, the Ethereal 2Ync- ture of Cantharides, etc., etc.,^ which induce the same patho- logical state. Might not reagents, which demonstrate the presence of these different bodies, assist in discovering in the atmosphere the nature of the epidemic agent ? Dariot agrees with Bretonneau, that epidemic pharyngeal diphtheritis is a specific inflammation. The existence of the false membrane which constitutes its essential symptom, is due rather to the special character of the disease than to its intensity. Afterwards, Dariot comes on rational Homoeopathic ground in saying : " The pellicular exudation is not the only distinguishing feature which exists between simple angina ' Must not the true specific be found among these similar agents ? Of all these we have found the Liquor Calcis Chlorinatce as the most pow- erful and trustworthy. It was not, however, selected owing to the above remark, but from the similarity of the symptoms both of Chlor. and Calc. curb, to this diseaoC. More than the Iodide of Mercury, Amman, caus- iicum, and Caustic Potash, it seemed to arrest the progress of the disease in the blood. Next to it, and in some cases of decided benefit, were Argcntum Nitricum, Nitric Acid, Bichromate of Potash, and also Lachtsis and Crutalus. ITS APPEARANCE IN ANIMALS. 09 and pharyngeal diphthcrite. The latter is not a jnirehj local affection like the former, hut it is found inanifestly connected with a morbid state of the whole economy.''^ This opinion has already been offered by the illustrious Pinel. As a proof of this, Dariot truly remarks that he can dis- cover it in the miasmatic or epidemic nature of the disease ; in the rapidity of its course ; in its severity, which is gene- rally but little proportionate to the apparent mildness of the local inflammatory phenomena by which it is accompanied ; in the very remarkable disposition of the cutaneous ulcera- tions to assume the diphtheritic and even gangrenous charac- ter in their course, as in typhoid aft'ection ; and, finally, Dariot discovers this proof in the length and difficulty of the con- valescence, a general indication of a deep-seated affection of the whole organism. Others have supposed it to consist of an effluvium arising from the decomposition of animal or organic matter. Again, others have thought that it is due to a parasite, which enters the blood through the air-passages, and multi- plies like fungus or muguet, (oidium albicans,) or as in mil- dew. This last idea has a great deal of truth in it. We shall furnish below the microscopical examinations. B. — Its AjJpearance in Animals. The diphtheria in man was preceded, in the eighteenth cen- tury, by a similar epidemic in animals, a pulmonary murrain and sore throat, as mentioned by Drs. Brookleshy, Hurd, and Layard. Also, Ghisi, Wall, Severinus, and Maloni, mention the same fjict. M. Maloni observes, in his account of the epidemic at Paris, in 1746,' that the disease among cows had already appeared in France, when children were attacked by epidemic sore throat. The same reporter, in his remarks of the disease of < )ctober, 1748, when this form of epidemic sore throat was again prevalent, says it had been noticed that oysters dis- ■ Mdmoirea de I'Acad^mie Royale des Sciences, page 562. 1748. 70 NATURE OF DIPHTHERIA. agreed with every one who ate them during the month, espe- cially before the weather became cold. I have also seen the most violent symptoms produced by eating a plate of oysters during the height of our epidemic. Both eruptive and pulmonary murrain have, in many dis- tricts, prevailed contemporaneously with diphtheria, as ob- served by Greenhoiu^ of London. The fact was gathered from some respectable butchers, in extensive business. Pulmonary murrain and mouth and hoof disease have been very com- mon among cattle during the year 1858, and the early part of 1859. In 1857, there prevailed a kind of influenza among horses in England, which was very fatal. Dr. Morris, of Spalding, informed Dr. Greenhow that he had seen a horse with swelling of the glands about the jaw, in which the mouth and throat presented an appearance similar to diphtheria. G. — Locality, Cold Air, Dam/p Air, etc. Diphtheria has not existed exclusively in any particular kind of locality. It prevailed, according to Dr. Greenhow, in Birmingham, Wolverhampton, and Leek, places situate on high ground, forming, as it were, the backbone of England; in Hanley, said to be the most elevated town of its size in England; in villages on the ridges near Launceston, among which some of the smaller tributaries of the Tamar take their rise; in the flat parts of Sussex, Norfolk, Kent, and Essex, and in the fens of Lincolnshire. It prevailed both at Trim- ingham, the highest point of Norfolk, and in the neighboring parish of Southrex, a very low and marshy district. Greenhow is of opinion that it has not prevailed to an equal extent in each of the above districts, having been, upon the whole, most common in places either marshy or otherwise damp, as from the retention of moisture by an impermeable subsoil or the proximity of water. It is also noteworthy, that the sporadic cases of diphtheria were always observed in marshy districts. On the other hand, whilst drier places have Bull'ered very severely, damp districts in the vicinity have es- LOCALITY, COLD AIR, DAMP AIR. 71 caped. Dampness, therefore, cannot be the only cause. It may be regarded more as an auxiliary than the principal cause This is the opinion of the English physicians. Still, the com bined testimony is in favor of the noxious influence of moist ure or dampness. With regard to the epidemic in Philadel phia, whilst during the summer or dry season the city i: comparatively free from the disease, diphtheria always re turns icith the appearance of the rainy season and cold weather I have observed people, sitting near the window when the damp atmosphere entered, attacked by diphtheria. Several patients afflicted with diphtheritic fever from exposure to the damp atmosphere on board of vessels at Kensington wharves, were attacked by the disease for several consecutive years on the first appearance of cold and damp weather, whilst during the summer they remained entirely free. Enrpis also states that all the parts of the body which are completely removed from the contact of the air are preserved from the invasion of the disease. He calls this a remarkable fact. It corresponds with my view given above. In addition, it must be mentioned that the disease was very fatal in the neighborhood of Cape May, where there are nu- merous marshes and swamps. Nearly every family lost one or two children. In this connection, we must also allude to what Dr. Lea J. Williamson,^ of Lardis, Mississippi, says of the influence of locality on the high-water shed between the Tallahatchie and Mississippi rivers. "On each side are broad uncultivated valleys of matchless fertility, where grows vegetation of the richest and rankest character. Superadded to this are nu- merous lakes, marshes, and sloughs. The first cases of diph- theria occurred on August 5th, 1859. Remittent bilious fever, the only disease from ivhich the inhabitants usually suffer dunng the summer season, and toJiich had been prevailing to its usual extent, seemed now merged in the prevailing epidemic ; after the appearance of diphlheritis, n/}t one case of fever was seen in the ' American .Juurinil of Meilical .Sciences, page 100. 1859. 72 NATl'RE OF DIPnTHEKTA. epid'^mic reqion, ichere scores are icont in occur.''^ Dr. Williamson further remarks that the patients were always worse during wet weather. D. — Age, Simmons Consiitniion. Age. — The greatest mortality of diphtheria is among chil- dren from the age of two to five years. From the tenth to the fiteenth year the mortality diminishes, and is trifling after the fifteenth year. The same remark is also applicable to scarlet fever and croup. After the fifteenth year, still fewer die of these diseases than of diphtheria. Of the five hundred and fifty cases which I attended from January, 1860, until January 1st, 1804, there were only about twenty adults, of whom only two were severe cases. None of these died of the disease. Dr. Greenhow remarks that sometimes all the smaller children of a family die, and then, again, sometimes all the female children. I observed the latter in one family.^ Strumous Constitution. — There is no doubt in my mind, that children inheriting a strumous and tuberculous constitution are most liable to the disease, and are most severely affected by it. The same remark holds good with scarlatina. All the deaths occurring in my practice were of such children ; and although they seemed previously to enjoy good health, a closer examination generally determined me to pronounce them of scrofulous habit. Dr. J. P. Dake, in a letter to the author, October 30th, 1802, makes the following observation : '' The scrofulous diathesis affords the most favorable field for the operation of this poison." Prof. A. E. Small, of Chicago, writes to the author, that in subjects of a scrofulous nature he has had but little success, — nearly all such cases having proved fatal. ' Of the fifty-cipht cases attended by Dr. Williamson, of Mississippi, sixteen were over fourteen years of ap:e, (one was over forty, five over thirty, and nine past twenty;) the other forty-two had not reached the age of ptiburty. Twenty of these were between the ages of four and six. CHEMICAL EXAMINATION OF THE MEMBRANE. E. — Chemical Examination of the Membrane. My friend Dr. Koch drew my attention to a most ex- haustive analysis of the diphtheritic membrane contained in the " Monatsblatt," of the sixty-sixth volume of the "All- gemeine Homoeopathische Zeituug," by W. Kucheumeister, in Dresden. I herewith copy the whole table, as furnished by Kuchen- meister. 1. Aqua Calcis. (Pharmac. Sax- onic. Containing as much lime as the water will dissolve, i. e., one part of lime to thirty parts of rain- water.) 2. Acetura concentratum. 3. Acetum concentratum, part with three parts of water. 4. Acetum concentratum, one Ditto. part with six parts of water. 5. Acetum concentratum, one Ditto. part with twenty parts of water. 6. Acetum concentratum, one part with three parts of honey. In the shortest time (from ten minutes to a quarter of an hour) entirely dissolved ; much sooner al- ready loosened, and falling to pieces with moderate shaking. Soon strong swelling up and trans- parency, in which state the mem- brane remains for days. Ditto. 7. Concentrated solution of Bo- rax. 8. Liquor Calc. carb. 9. Natrum aceticum, concentra- ted solution. 10. Kali chloricum, (Chlorate of Potash. ) 11. Artificial herring's brine, (prophylamin with common salt.) 12. Real herring's pickle, (re- medy against croup.) 13. Acid. Muriatic, concentratum, one part to three parts of honey. 14. Acid. Muriatic, concentratum, one part to three parts of water. Soon strong swelling up and trans- parency, in which state the mem- brane remains for days. A slight swelling up. Ditto. Ditto. Ditto. Hardly swelling at all. No effect whatever. No effect except a greater con- densation of the membrane. Ditto. 74 NATURE OF DIPHTHERIA. 15. Acid. Muriatic, concentratum, one part to nine parts of water. 16. Acid. Muriatic, concentratum, one part to ten parts of honey. 17. Acid. Muriatic, concentratum, one part to thirty parts of water. 18. Acid. Muriatic, concentratum, one part to sixty parts of honey. 19. Liquor Kali caustic, (Caustic Potash.) 20. Liquor Kali caustic, one part to thirty parts of water. 21 Liquor Kali caustic, one part to sixty parts of water. 22. Acid, dilut. Nitr., (officinal.) 23. The Acid of Copaiba, dis- solved in 6ther. 24. Argent, nitr., one part to six parts of water. 25. 01. Terebinth., purum. Ditto. Ditto. Ditto. Ditto. No efifect whatever. A slight swelling. Hardly any swelling. No effect. No effect. 26. 01. Terebinth., five parts of spirits. 27. Kreosote-watcr. Only greater condensation of the membrane. Preserves the membrane beauti- fully, one part to Ditto. Ditto. From the above table, it would appear that Lime-water is tlie best solvent of the membrane. Dr. Richard Foerster, of Dresden, has also furnished an in- teresting article on the solvents of the diphtheritic membrane, particuharly with regard to the Carbonate of Lithia. Previous to this time I had made experiments with sub- stances recommended by other parties, but with almost no effect. Such were Glycerine^ recommended by Bouchut, a so- lution of Ammoniated Copper, solutions of Iodine and Bromine, a strong solution of Nitrate of Potash, Borax. The best effect was from the Lime-water and Carbonate of Lithia. The Lime-water occupies the first rank. Br. Foerster truly remarks that there must bo, of course, a great difference between the effect of these remedies in the test tube, and that produced by inhalation, lie, himself, has had no cases of late for trial, but mentions Br. Biermer as having used CHEMICAL EXAMINATION OF TUE MEMBRANE. 75 the inhalations of Lime-ivater with success in a case of diph- theria. Dr. Ozanam, of England, has made many experiments. According to him, "the Chloride of Potassium dissolves the false membranes completely in twenty-four hours ; Chloride of Sodium in thirty-six ; a solution of one-hundredth part of Bromide of Potassium in water, in twelve hours ; a mixture of Bromine and Bromide of Potassium is more powerful still. One part of Chromate of Potassium in ten of water will harden the membranes in the course of two days. The Sub and Bicarbonate of Potash, in concentrated solutions, will dissolve the membranes in twelve hours. Phosphate of Soda is less active ; the Cyanide of Potassium^ in a concen- trated state, will dissolve the membranes in fifteen hours ;. pure glycerine will soften them in twenty-four hours ; but the mother water of urane soda will effect a complete solution in four or five hours." Dr. Ozanam concludes, from his experiments, that, if it be in- tended to attack the membranes by dissolvents, alkalies should be preferred ; and from what we have quoted above, it will appear that the Subcarbonate and Chlorate of Potash and the Phosphate of Soda, so long advocated, are the lowest on the the list in point of efficacy. If, on the contrary, segregation or separation be aimed at, the Chloride of Bromine^ Bromine itself, and Chlorine, or else Iodine^ Perchloride of Iron, and Chromium, should be resorted to, since they harden the mem- brane and make it detach itself. Very naturally, no chemical test is sufficient to define the value of a remedy, although the hints received will be of great value to the practitioner of medicine. Bouclmt^ says: "The false membranes are insoluble in cold water, and even hot water. Stilphuric, Nitric and Hydrochlo- ric acid harden these productions, and they also shrivel and ' Memoirs on Diphtheria from the writings of Brelonneau, Gucnisaiif, Trousseau, Bouchul, Emjn's, and Dariut, selected and translated by Robert Hunter Semple, M. D. The New Sydeuhain Society. London, 1859. Page 273. 76 NATURE OF DIPHTHERIA. detach them. Liquid Ammonia and alkaline solutions dissolve and convert them into a transparent and diffluent mucus." From experiments made by myself, I have ascertained the following: Concentrated Nitric and Sulphuric aeid will not dissolve the membrane, but only harden it, as mentioned by BouchuL A solution of A^ali bichromic, one-tenth of a grain in half a tumblerful of water, dissolved a pretty large piece almost entirely; a solution of Chloride of Lime, two drachms to twelve ounces of water, dissolved the membrane partially. Per contra, Dr. W. Tod Ilelmuth, of St. Louis, found Hydro- chloric acid one of the best solvents. Dr. Starr, of England, in a published account of this dis- ease, states, that, on a chemical analysis, the deposit was found to be albuminous and not fibrinous, which latter statement, according to Dr. Madden, is of importance, as distinguishing diphtheria from croupy exudation. F. — Examination by the Microscope. At my request, Dr. Keller, the eminent anatomist, made a microscopical examination of the diphtheritic membrane. He said he could find nothing definite. This is also the opinion of Empis, who says, tiiat microscopic examinations do not afford much information. He gives the following data with regard to the distinctive characteristics of the difierent mem- branes : 1st. T)ie pleuritic false membrane is characterized by the absence of epithelial cells, wliich we shall find to exist in the other kinds of false membrane. 2d. Membrane of a blistered surface. This may be distin- guished from the pleuritic false membrane, by the presence of epithelial cellules, which are wanting in the pleuritic exuda- tion. 3d. False membrane of Diphtherite. Microscopical exami- nation ceases to afford much information. The diphtheritic exudations present, in a microscopical point of view, the greatest analogy with the membrane of a blistered surface. •llh. False membiane of Scarlatina Angina. According to EXAMINATION BY THE MICROSCOPE. 77 Empls, we cannot distinguish by means of the microscope the scarLatinal membrane from the diphtheritic membrane. By a more perfected micrography we may, perhaps, in the future, obtain more definite information. With regard to the simiLarity of aphthas and diphtheria, Empis remarks, that, when studied by the microscope, aphthae present peculiar characters, not met luith in any other kind of pseudo-membranoxis exudation. It is an organized product, the position of which, in the vegetable kingdom, cannot now be contested after the researches of Messrs. Berg and Grnby. More recently, a detailed and minute description has been given of it by J/. Charles Robin, in his work on the Vegetable Forms groioing on Living Animals, (1847.) Mr. Gruby regards the vegetable form of aphthae, as the analogue of sporotry- chitnn. Vogel, who has described the vegetable forms of aphthae, states that it is found in children and adults, in the false membrane lining the mouth in diphtheria. Empis gives generic characteristics, common to pseudo- membranes, namely: 1st. Pleuritic, serous, fibrous exudations. 2d. Membrane of a blister. 3d. Membrane of diphtherite. 4th. Membrane of scarlatinal angina. A. They present on the field of the microscope, a quantity of small filaments of fibrine, interlaced with one another in different directions, and crossing one another at acute angles, so as to form a kind of more or less regular net-work. B. A second characteristic, also met with in each of these exudations, is the presence of a great number of small, ir- regularly rounded corpuscles, forming a series of granular dottings around the filamentous net-work. These small cor- puscles, are formed in all pseudu-membranes. It is to them that M. Seyfert has given the name of molecular granules, and which resist, for rather a long period, the action of acetic acid. C. A third characteristic belonging to all fibrinous exuda- tions is, that when treated with a drop of the tincture of Iodine they immediately assume a very deep brown color. br. /Slade (Prize Essay) remarks : " Under the microscope 78 NATURE OF DIPHTHERIA. the false membrane of diphtheria exhibits the ordinary ele- ments of such structures, although its characters would appear to vary somewhat. The elements usually detected are, chiefly, molecular particles, 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." Empis, Laycock, and Wade, who made microscopic examinations, agree that the diphtheritic membranes are not a fungous growth. " They have not the power of organization, and never become vascular. Hence, they never concur in reparation of the tissue, but putrefy on the surface, if they be not removed, existing always as a foreign body." Dr. Laycock, Professor of Practice of Medicine in the Uni- versity of Edinburgh, in a clinical lecture, in the Medical Times and Gazette, 1858, points out an analogy between diph- theria and muguet, and endeavors to show, that both these diseases are due to the presence of a parasitic fungus on the surface of the mouth, fauces and other mucous structures. "The case before us has varied points of practical interest. The immediate cause of death was the exhausting, intractable diarrhoea. Now, this supervened coincidently with an attack of diphtheria or diphthdrite. At the onset of the disease, and just before death, we found in the pellicle, formed on the tongue and fauces, the sporules and mycelium of the oidiura albicans, a parasitic fungus, found also in muguet, — the epi- demic aphtha) or diphtheria of infants in France. This is an interesting fact, at the present moment, when diphtherite is prevalent, more especially as the pellicle was also abundantly present after death in the oesophagus. I have little doubt that this pellicle was due to the action of the parasite on the enfeebled mucous surfaces 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 corpus- cles, or plasma. Intermingled amongst these, are the sporules and the myc(!lium of the microscopic fungus. The whole constitutes a pellicle or membrane, as it has been termed, varying in thickness and tenacity, according to the surface EXAMINATION BY THE MICROSCOPE. 79 attacked, and according to the condition of the patient. 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. Diphtheria is not, however, neces- sarily limited to one form of disease. We have, in fact, bad a case of syphilitic disease of the fauces and pharynx, in which the pellicle containing the oidium was noticed, and which seems to have introduced it into the clinical wards. Again, if the fungus multiply in a population, at the same time that there is an epidemic of scarlatina or rubeola preva- lent therein, that epidemic may be expected to take the diph- theritic form in those cases which are attacked by the oidium, I must add, however, that we have reasons for thinking that the oidium, acting alone, will fasten upon the mucous mem- brane of the mouth and throat, and excite inflammation, and without the formation of a pellicle. Or, if it lead to the for- mation of a pellicle, this may be constituted of spores only, with exudation of corpuscles, constituting a tougher mem- brane than that usually found on the tongue and tonsils, and resembling the pellicle of croup. *' The diagnosis of diphtheritic oidium from ordinary aphthae is founded, first, on the character of the morbid appearance ; for, in ordinary aphthae, the disease is vascular, and the white specks or patches are ulcers, while in diphtheria they are pellicular, and not ulcerative, while the redness is much deeper than in aphthae. Besides, the microscope may reveal the spores and mycelium of the fungus. The development of mycelium is, however, by no means a necessary result of the action of the fungus. This seems to be a feature peculiar to the more advanced stages ; at first, there is not even a pellicle, only characteristic redness of the affected surface. Dr. Young, our resident physician, got an attack of sore throat, shortly after one of the patients affected with oidium coughed in his face, while he was applying a remedy to the patient's fauces. Dr. Younrj had this characteristic deep-red congestion of the fauces, with but very limited production of pellicle on tiie pharynx, in which no mycelium was to be discovered. Further, it is 80 NATURE OF DIPHTHERIA. probable that, besides the stage of development, the condition of the habitat may make a considerable dificrence as to the morbid products. Thus, since warmth greatly promotes the spread of the disease in the form of muguet, the absence of mycelium in diphtheritic croup may be due either to the fact, that the weather is cooler when it prevails, or that the mucous membrane of the larynx and trachea, being cooler generally, from the transit of air, is less favorable to the development of the mycelium, than that of the mouth, fauces and oesophagus. "Again, the condition of the intestinal mucous membrane seems less favorable to the formation of the mycelium, or of a pellicle upon it. Still, inflammation and even ulceration of the surfaces will occur, as the result of the irritative action of the parasite, in the same way as ulcerative inflammation super- vened in the oesophagus of the patient in question. This remark applies, also, to the bronchial mucous membrane, in which, I am inclined to think, the oidium may develop an inflammation of the same low type as that seen elsewhere, an asthenic bronchitis with a purulent secretion." In connection with this subject, I cannot help extracting the important observations of Dr. Wilkes, assistant physician to Guy's Hospital.' Dr. Wilkes took the 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 fungus growth which he had not been able to distinguish from that of diphtheria. Thus he lately had a woman die under his care, in Guy's Hospital, with acute cerebral and spinal meningitis, plouritis, &c., of a supposed phlebitic origin, and on exami- uution of the pharynx, after death, a pellicle was found com- posed of the parasite. Again, a child four years old presented itself among his out-patients, apparently dying with croup, but on examination was found to be suffering from an exten- sion of diphtheritic disease into the trachea. The throat and Modical Times and Gazette, October, 1858. EXAMINATION BY THE MICROSCOPE. 81 tongue were covered with pellicle, a portion of which being placed under the microscope displayed very readily the oidium, the only difficulty about the case being the statement of the mother, that the child had suffered with a throat afflic- tion tor several weeks. Mr. Hardy made a post-mortem ex- amination. The throat, trachea, &c., were covered with a pellicle, as before said ; and on removing this, to find a cause for the chronic symptoms, a polypus of a capillary character was seen growing from one of the vocal cords, with thickened tissue around. Here was an explanation of the chronic symptoms ; and upon this had arisen an acute inflammation, accompanied by the fungus. Another case was that of a man who died under Dr. Wilkes^ care, in the hospital, with soften- ing of the spinal cord. A few days before his death his mouth and tongue became covered with a white secretion, which very rapidly formed a complete layer over the whole buccal sur- face. An examination of this by the microscope showed a remarkably fine specimen of the fungus, the mycelium and sporules exhibiting themselves to perfection. On mentioning these circumstances to Dr. Barlow, he stated that he had under his care a child with a white film on his mouth, (the case not being one of diphtherite,) and he sent some of the secretion for examination, when it was found to resemble the specimens already named ; the same occurred in one or two other cases. These facts are sufficient to show that a vegetable fungus may spring up on the buccal mucous surface in various cases of disease, but requiring, probably, some previously morbid con- dition for a nidus. Is it not so in diphtherite ? Is the disease, strictly speaking, a malignant sore throat, and the formation of the pellicle an accident? Or is the latter an essential part of the alfection? In the case of the child last mentioned, if no post-mortem examination had been made to discover the chronic disease, the case would have been called diphtheria ; and in the man with spinal paraplegia, the condition of the mouth would have been sufficient to have marked it a case of the same kind, had there been no other affection present. Such cases may throw some light upon the opinions of those 82 NATURE OF DIPHTHERIA. practitioners who, not residing in diphtheritic districts, and who, seeing only isolated cases, regard the disease as a mere modification or peculiar form of some ordinary maladies, as cynanche and scarlatina, and this may, in some instances, be correct. 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 and throat of other sick persons is in connection with aphthae, and is another variety. In answer, Dr, Wilkes says that he failed to discover in the above cases any difference; and, more- over, the character of the pellicle, and its rapid extension over the whole mouth, throat and tongue, was totally unlike ordinary aphthae. Dr. Slack, in his essay, gives a picture of the diphtheritic pellicle, as examined under the microscope, and the sporules and the mycelium of the oidium, (after Bobiyi,) and the two are in appearance almost identical. Dr. Francis Black says : " I examined only one specimen of mem- brane, assisted by a friend who is daily engaged in the micro- scopic study of plants; but we were unable to discover the least ajipearance of verjetahle structure. The same microscopist also informed me that the same results were met with by a friend who examined upwards of a dozen different specimens." My friend, Coleman Sellers, took great pains to examine, by his powerful microscope, some specimens of diphtheritic mem- brane; but we could arrive at no definite conclusions about their nature. There certainl}^ appeared to be no vegetable structure. DIAGNOSIS. Diphtheria is considered by some physicians to be analo- gous to dy.sentery, by others, to malignant scarlatina and croup. That there are great affinities between it and these di.scases is undeniable; but it is difficult to establish the identity of their ultimate essence. DIAGNOSIS. 88 O. — Diagnosis heticeen Diphtheria and Scarlatina. Those who have carefully read my classification of the dif- erent forms of diphtheria, must have come to the conclusion with me that the disease has manifested itself in various forms since its first appearance in Philadelphia. At first, being very virulent, it attacked principally the fauces and larynx, and finally the brain, and was often suddenly fatal. At a later period, when it diffused itself throughout the system in a milder form, it was more manageable, although deaths would still occur from the more violent cases of this kind. During the year 1861 the greatest number of deaths from scarlatina occurred, as well as from diphtheria, namel}', one thousand one hundred and ninety of the former, and five hundred and two of the latter. The same or similar causes must, therefore, have been productive in originating these two diseases. The fact is, the more I consider the matter the more the opinion gains ground that these two diseases, and perhaps, also, croup, are only modifications of the same poison, as we know the com- mon bilious fevers of a country are only modifications of the violent yellow fever, and the same remedies will often be able to subdue them ; scarlet fever being the most violent form of the disease, and scarlatina and croup manifestations of the same poison in different forms. In the diagnosis of the two diseases by different writers, the main stress is laid upon scarlatina seldom or never attack- ing the larynx and bronchia. We have seen, by one classi- fication, that some forms of diphtheria attack the stomach, the intestines, and even the anus, but still the nature of the poison may be the same. Dr. 'Slade, of Boston, in his prize essay, says : " By some persons, the two affections scarlet fever and diphtheria, notwithstanding certain points of strong resemblance, are regarded as essentially different. By others, diphtheria is regarded as a form of scarlet fever, in which the throat affection is unaccompanied by the eruption which usually characterizes it. We must admit that there are many circumstances which favor this latter opinion. For in- 84 NATURE OF DIPHTHERIA. stance, 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. Tlien, 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 doubt as to its nature." W. II. Eddis, Esq., (Brit. Med. Jl., January 25th, 1861,) in giving an account of an epidemic occurring at Barton-upon- Ilumber, describes " diphtheria as so intimately connected with scarlatina, that it seemed almost impossible to separate them. I was indeed led to believe that they were identical, and only two forms of the same disease, modified by circumstances. It was only after having carefully observed the numerous cases that came under my notice, that I became convinced that they were two distinct diseases." He does this chiefly for the reason that the diphtheria appeared in some who had had scarlatina and were perfectly recovered, and in others who were grown up and remembered having had scarlatina in their childhood. But a modified form of scarlatina as well as diphtheria may occur in the same individual. In the following tables I shall compare in detail the differ- ent points of scarlatina and diphtheria from our own expe- rience, as well as what we could glean from the different writers on the subject, such as Emjns, David, Greenhow, the prize es.say of Slade, the treatise of Ludlow, and others. These statements show that there is strong probability of the dis- eases being of the same nature ; the absolute certainty of their positive identity remains as yet, however, undecided. SPAKI-ATINA. DIPHTHERIA. iHt. In the first pliioo, the rash Ist. In diphtheria the rash is only in scnrlutiua forms a main feature, present in exceptional cases. II is nearly always present. DIAGNOSIS. 86 SCARLATINA. 2d. The pulse in scarlet fever runs higher than in any other fever. 3(1. According to Emp/'s, the membrane in the throat in scarla- tina is similar to aphtha?. (In many cases I have seen it in diphtheria the same.) (a) The white particle constitut- ing it is detached with great fa- cility. {b) The pseudo-membrane of scar- latina does not possess the invading property of diphthcritis. It remains localized at the point of its devel- opment. (Laboidkue, F., Recherches Cli- niques et Anatomiijues sur les Af- fections pseudo-membraneuses, etc. Paris, 1861, referred to by Dr. Lud- low, says : " In certain cases of scar- latinal angina, especially when it is epidemic, the false membranes bear a close resemblance to those of diph- theria; they are thin, tenacious, con- sistent, and adherent; they may be- come reddish, brownish, or black in hue, and may assume a gangrenous appearance. Is this a complication with diphtheria, or a more aggra- vated form of anginal scarlatina ?") 4th. Suppuration of the glands of the neck is common after scarla- tina. 5th. Anasarca is a common se- quel of scarlet fever. 6th. Arthritic affections are com- mon after scarlet fever. 7th. Pericarditis is common after scarlet fever. yth. Paralysis occurs very seldom after scarlatina. DIPHTIIKRIA. 2d. In diphtheria it is only mod- erately frequent. 3d. Diphtheritic mcmbrajieis con- tinuous and consistent. {Empis.) (a) In diphthcritis the membrane adheres closely to the epidermis. {b) Diphthcritis e.xtends frequent- ly to the air-passages, where it be- comes so suddenly formidable. It very often is seen in the Schneide- rian membrane, the nose, the gums, intestinal canal, and anus, and also in wounds of the skin. 4th. It is very rare in diphtheria. It occurred only in one out of five hundred cases in my practice. 5th. Anasarca is hardly ever met with after diphtheria. I never saw a case. Br. Grecnhow met with one only. Cth. They are never met with af- ter diphtheria. 7th. Pericarditis is never met with after diphtheria. 8th. Paralysis is very common after diphtheria. 86 NATURE OF DIPHTHERIA. In the differential diagnosis between diphtheria and scarla- tinal angina, in the treatise of Dr. F. 0. Snelling^ it is said that in diphtheria the tonsils are covered with unmistakable false membranes, whereas, in scarlatinal angina, the tonsils are more bathed than covered with particles of membra- nous pellicles. In all slighter cases of diphtheria, as I ob- served in hundreds of instances, the tonsils look as if they had been brushed over by some white paint. Another charac- teristic is, according to Snelling, that the patches in diphtheria commence on the tonsils, and spread thence to contiguous parts, whereas, in scarlatina angina, the exudation, instead of commencing on the tonsils, simultaneously invades the whole cavity of the fauces, and even the posterior nares. This precise circumstance I have observed in numerous cases of diphtheria. According to the same author, there is in diphtheria great tendency to attack the respiratory organs, whereas scarlatina has a tendency to attack the oesophagus. My experience in this respect has been above adverted to. Dr. Snelling, in summing up, however, asserts that there are many cases which, without losing their character of scarlatinal origin, so assume the appearance of diphtheria, that it is impossible to distinguish them. The intimate relationship which exists between diphtheria and scarlatina is shown in many ways; the two diseases fre- quently coexist in the same house. In both, the throat symptoms are severe, and the constitutional irritation violent. Albuminuria also occasionally follows diphtheria as well as scarlatina. Dr. Alhin, of Hull, was the first to observe this. {Dr. Jos. Kidd, on Diphtheria, Brit. Jour, of Ilom., vol. xvii., page 218.) These characteristics of the two diseases are distinctive enough, but they may all be ascribed to the greater severity of the poison in scarlatina, where, when it attacks the brain, the patient may succumb in a few hours, or from one to two day.s, whereas, if it attacks the throat and fauces, it is of slower growili. In diphtheria, where the disease first pervades DIAGNOSIS. 87 the whole system and then finally manifests itself on the fauces, all phenomena are of slower growth. Both scarlatina and diphtheria, I have often observed, possess the power of propagation, if the least vestige remains in the system. There- fore the most active treatment can alone save the patient. If you have partially removed the throat disease by medicine, and you omit yoiir remedies only a few hours, it will be after that time as formidable as ever. H. — Diagnosis between Diphtheria and Group. DIPHTHERIA. CROCP. The great distinctive feature of True croup is apparently not con- diphtheritic croup is that it depends nected with any blood crasis. upon a peculiar blood crasis. Diphtheria commences in the fau- True croup commences in the la- ces, and only reaches the windpipe rynx and trachea, and does not ne- by extension. cessarily affect the soft parts of the glottis, (although in many cases the croup membrane can be seen in the back part of the throat.) In the first period of croupydiph- In membranous croup, in many theria, the cough is dry and sharp, cases the voice is almost extin- the voice is low. guished. In diphtheritic croup, during the In true croup the cough has a dry second period, the respiration is dif- and metallic sound, and is accom- ficult,but the cough becomes moist, panied by fits of suffocation. Bretonneau and nearly all the French writers consider diph- theritic croup and membranous croup as identical, particu- larly as croup, in France, is, like diphtheria, considered a con- tagious disease. In the report of the proceedings of the Societe Medical Homoeopathique dc France, held January, 1860, Dr. Curie, with Dr. Cretin, identifies croup and diphtheria, ascribing the difference in the respective membranes to their situation in each case, and the difference of the asphyxia to its suddenness in laryngeal affection. He asked whether, in contagious, the two supposed diseases did not equally transmit each other, the aflBrraation of which he considered as decisive of the 88 NATL'RE OF DIPHTHERIA. question. M. Cretin, without denying the distinct forms in- sisted on by M. Rayviond, considered them, with Dr. Curie, as forms of the same disease, depending on the constitution and condition of the subjects, and calling for variations in the treatment. He pressed the fact that when, in " croup," the suffocation is prevented by tracheotomy, the patients very often sink slowly in an adynamic state, just as in "diphth^- rite." M. de la Pommerais had often seen, in the hospital for children, a robust child ivith croup enter a ward where no di2:)h- thtrile existed^ and next day pharyngeal or nasal diphtherites broke out amongst the sickly ones. Again, in a family, he saw a child die of " diphthcrite" without "croup," and the latter form at once broke out in the two other children. The great distinctive mark between diphtheria and croup, which is given in an admirable paper by Dr. Ranldng, being in the locality of the two diseases, cannot be applied to this country ; for I have seen over twenty-five cases of diphthe- ritic croup commence in the larynx. As these occurred dur- ing the prevailing epidemic, and were sometimes complicated with throat diphtheria, it is but rational to suppose they be- longed to the same species of disease. Bouchut already re- marks, that if we were to examine the throat of individuals afflicted with croup, we should probably, in every case, find the disease commencing at the throat in the first instance. The question with regard to the different nature of croup and diphtheria is, therefore, still an open one. T. — Diagnosis between Striduhus Laryngitis and Diphtheritic Croup. It is important to establish a precise distinction between these two affections, which require entirely different thera- peutical appliances. Stridnlous laryngitis is accompanied, like croup, by a dry, hoarse, sibilous, and more or less sonorous cough. The diffi- culty of breathing is extreme; the child appears as if about to perish by suffocation ; still the larynx is free, and there cannot be any expectoration of false membranes. The phe- DIAGNOSIS. 89 nomena observed are purely nervous, they soon subside, and their progress is altogether peculiar. They appear suddenly, and in a very high degree of intensity, in subjects who are otherwise in good health or slightly affected with cold. They manifest themselves in the middle of the night. The par- oxysm lasts about two hours, and is reproduced on the fol- lowing two or three nights in succession, but it becomes gradually more feeble, and at last it disappears. Diphtheritic croup presents nothing like this, for the symptoms increase ^ gradually, and suffocation presents itself only at the end of several days. The fits appear by day as well as by night, and they are reproduced as long as the false membranes in the larynx are not thrown up. Far from diminishing gradually, they become, on the contrary, more alarming every moment, and they terminate by carrying off the patient. K. — Diagnosis between Diphtheria and Aphthse. [By Empis) DIPHTHERIA. APHTH.E. In diphtheria there is great force Aphth.-c present themselves in of cohesion in the membrane. True the form of a multitude of small membranes are formed. The adhe- white points, at first distinctly sepa- sion of the tissues is such that we rate from each other, but which, in are rarely able to detach them with- proportion as they become more nu- out causing the raw part covered merous, touch one another, and are by them to bleed in some measure, accumulated together so as to form a continuous whitish layer, which invests all the inflamed mucous meml)rane, and thus constitutes a pseudo-membrane. If we endeavor to detach this false membrane with a pair of forceps, we lind it diflicult . to obtain strips of it, because each of the points adheres too slightly to the others ; l)ut if, with a fine compress, we lightly wipe the part, we easily remove all the whitish layer,' and we uncover the mucous 'I have often observed this in patients dying of consumption, when the aphthae were thus easily detached, although they reappeared next morning. 7 90 NATURE OF DIPHTHERIA. The diphfhcritir product has the greatest tciideiicy to propag-ate it- self over the mucous mumbrane of the air-passages, where its presence constitutes croup. The appearance of diphthcritis is preceded by a very circumscribed irritation of the parts of the mu- cous membrane, which are com- pletely covered by tlie pellicle. Diphtherias is preceded by a se- rous exudation, is never developed above the ei)id(rmis, and ah^ays ad- heres to raw parts. membrane, which is red and in- flamed, but by no means raw. As the adhesion to the mucous mem- brane is inconsiderable, there is no bleeding, Aphthce especially affect the buc- cal mucous membrane, and never extend to the larynx and trachea: there has been hitherto no example of aphtha; extending to the respira- tory organs and producing croup, but they often extend to the pha- rynx and digestive canals. Aphthce are always preceded by a general inflammation of the mu- cous membrane of the mouth, char- acterized by a general redness and a very acute sensibility, which, in young children at the breast, pre- sents an obstacle to sucking. Aphthce are never preceded by a serous exudation, but it appears in the mucous membrane when still covered with its epithelium. L. — Palhohgical Anatomy. I have made only two post-mortem examinations of tlie disease. I. A professional friend called me in consultation in a case of a cliild, ait. 2, afilicted with the croupoid form of diphtheria. On examining the throat, the tonsils were found to be par- tially free from the exudation, but it had extended farther down the throat. His respiration was short and hurried, accompanied, every now and then, with a strangling croupy cough. His face was pale and swollen, as were also the sub- maxillary glands; and there was sopor. The case was evi- dently hopeless, and terminated fatally three or four hours after I saw it. This case was not very severe at the begin ning; tlie violent symptoms appeared only during the last two days. PATHOLOGICAL ANATOMY. 91 A post-mortem examination showed the membrane as having penetrated the larynx, trachea, and the smallest rami- fications of the bronchia, for in all of tliem it could easily be detached in the softened state in which it was found. A specimen, a small piece of this lung, is still in my possession. One lobe of the lung was also hepatized, and there was a high state of inflammation visible along the whole course of the bronchia. All the other organs of the body were perfectly healthy. II. In a case where the disease was apparently cured in the throat, it reappeared by sickness of the stomach, and complete poisoning of the whole system. The patient, a boy, ast. 12, died. A post-mortem examination showed the corrugae of the stomach in a highly congested state, and covered with a softened diphtheritic membrane, extending, as far as I could perceive, through the whole alimentary canal. The liver was very much enlarged and also highly congested ; the kidneys in the same state ; the peritonaeum not inflamed ; the anterior part of the cerebrum softer than natural after death ; the larger venous trunks engorged with blood, diffused through the parenchyma of the brain. Back part of the cerebrum more natural ; cerebellum in a normal condition. A resumd of the post-mortem examinations of Bard, M. Louis, Ramsey, Greenhuio, and Keller, gives the following data: The epiglottis and larynx generally were thickened ; the respiratory mucous membrane reddened, the larynx, trachea and bronchia were lined with a tube of false membrane, which began in the pharynx and extended into the smallest trace- able ramificatio-ns of the air-tubes. The exudation varies in consistency, from an almost liquid form to a more or less elastic membrane. It varies from a quarter of a line to a line in thickness {Oreenhoiv). In one instance, Greenhow saw it two lines in thickness. In some cases it is so tough that it is difficult to tear it {Bard). There is generally more or less inflammatory effusion into the structures of the tonsils. The lungs were oedematous, not very crepitiint, but floated in 92 NATURE OF DIPHTHERIA. water. The left pleura presented v.ery extensive adhesions at its lower part; the right, only a few. The right lung was more congested than the left. Professor IlehmUh, of St. Louis, to whom we are indebted for three or four autopsies, speaks of a fluid gushing out from the trachea as soon as the knife penetrated the cartilaginous rings. "This transudation was sanioas and frothy in charac- ter, and floating in it small particles of membrane were notice- able." The quantity was over a pint. M. — Prognos is . All writers on the subject agree that diphtheria is a very serious disease, and will often prove fatal in spite of all the remedies applied. The croupoid form, where the disease attacks the trachea and bronchia, is considered particularly dangerous. Bonchut remarks that when the false membrane, developed in the mouth, exists only on the epiglottis and at the superior opening of the larynx, the disease may be cured by suitable treatment. But if the products are extended to the trachea and bronchia, it is almost inevitably fatal. Dr. Lea Williamson, of Mississippi, even maintains that all died when the disease invaded the larynx and trachea. JJrs. Greenhoiv and Kmpis agree with the above statements about the danger of the disease attacking the trachea and bronchia. Ernpis relates a case of a child Avhere the diphtheritis began on the point of the tongue, ran through its stages on that part, and disappeared on the thirteenth day, after a complete cica- trization of the aflected part; then, on the fourteenth day, and when, by the disappearance of this local lesion, it might have been supposed that the child was henceforward out of danger, the mucous membrane of the larynx became the seat of a reappearance of the membranous exudation, and the pa- tient was carried ofl' by croup. in a similar case occurring in my own practice, mentioned PROGNOSIS. 93 under the head of Post-mortem Examinations, the disease was entirely cured in the throat, but a week Liter it returned, this time attacking the stomach and whole alimentary canal, and terminating fatally. Many such cases might be detailed in this place from various authors, both Allopathic and Homoeo- pathic, showing the absurdity and uselessness, if not positive injury, of a mere local treatment in this disease of the blood. Nevertheless, I have cured about fourteen cases of the crou- poid form of diphtheria, where the symptoms were not too severe. As unfavorable symptoms, Grcenhow also mentions, "com- plications with pneumonia, a brown or blackish appearance of the false membrane, hemorrhage from the nose, throat, and bronchial tubes or intestines, purpura, copious discharge from the nostrils, intense albuminuria, great swelling of the cer- vical glands, sickness of stomach or diarrhoea, especially at an advanced period of illness." All these symptoms denote, no doubt, the great severity of the disease, but if there is suffi- cient power of reaction they are not necessarily fatal. With Erapis, the paleness of the face, the feebleness of the pulse, and, particularly, the great prostration of strength, were signs of danger. He also remarks, that diphtheria is always serious when persons are already victims of an in- veterate disease, and it may be followed by a fatal termination. Thus he has seen a child, affected with constitutional syphilis, sink rapidly under the influence of diphtheria. The most fatal signs with me, during the Philadelphia epidemic, were complete want of appetite, or even aversion to food, with disposition to constant drowsiness and stupor. When these symptoms appear, the patient is not absohitely lost, but the physician who neglects to use the most active measures to restore the patient, e. (j., exhibiting the proper specific every ten minutes, with milk-punch, wine whey, and other stimulants, will surely lose his case. SiLdden death in patients, whose symptoms apparently pre- sent nothing alarming, is one of the most remarkable features of this disease, and will caution us not to be over-sauguiue 94 NATURE OF THE DISEASE. in our prognosis. I have met with several instances of this kind. In one case, where I was consulted, that of a little boy living in West Philadelphia, all the dangerous symptoms, the swelling of the cervical and submaxillary glands, and cel- lular membrane, the stupor, etc., had disappeared, and the patient was apparently getting better, when he suddenly died, as it were, from mere exhaustion. In another case, the disease had disappeared from the throat, and the patient was walking about, when he fell down suddenly and died. Quite lately, (May, I860,) in another case of a little boy, aged four, in West Philadelphia, where I was called into consultation towards the close of the disease, the patient died very sud- denly, with symptoms of anoBmia and congestion in the spine and left lung. An hour before his death his symptoms were by no means alarming ; he appeared much better. In three or four cases of the croupoid form in which I was consulted, the patients died very unexpectedly, without any apparent cause. A post-mortem was not permitted in most of these cases. One has been detailed under another head. Dr. Greenhow remarks: "Sudden death in patients, the aspect of whose case is not alarming, or who appear out of danger, is a peculiar characteristic of diphtheria ; and this circumstance has added greatly to the fear with which this disease has been regarded by the relatives of the sick and the public at large. "Mr. Wesl has sent me the history of a young woman, aged twenty, who presented herself as an out-patient of the Queen's Hospital at Birmingham, suffering from diphtheria. She declined to enter the hospital, but continued to attend, among the outpatients, for three successive days, on each of which slie walked a distance of a mile from her home for this purpose. The throat improved in appearance daily ; but, notwithstanding this amendment, she became . weaker, and, returning home tired on the third day, she took some food and went to bed. She a])peare(l very drowsy during the remainder of the day, was disinclined to exertion, refused nourishment, and continued in a dozini>: condition till the PROGNOSIS. 95 following morning-, Avlien she asked for breakfast. Whilst being lifted to receive it, she fell back fainting, and died before assistance could be obtained." Mr. Carr, of Blackheath, also mentions extreme suddenness of death as one of the most-marked characteristics of true diphtheria, and adds, that it occurs in an instant, when the patient has the power of sitting up in bed, of speaking and of swallowing. Mr. Ritchie^ of Leek, had such a case, in which he had discontinued his attendance; the throat being well and the sick person apparently convalescent. The patient suddenly became worse ; there was vomiting, the surface of the body was cold, and there was depression with- out hemorrhage or other ostensible cause. "When visited, the patient sat up in bed and answered questions ; but then^ having laid himself back and stretched out his arms, he died before the medical attendant left the room. Sometimes sudden death has occurred after patients were able to resume active habits, and may, perhaps, have been induced by over- exertion whilst in the very depressed, auaemiated condition produced by the disease. A boy, aged ten years, who had been suffering from diph- theria for five days, although well enough on the previous evening to hold the surgeon's horn, died on the sixth day of his illness. A carpenter's apprentice, convalescent from diphtheria, went home to visit his parents, who lived at a distance of three miles from his master's house. On his arrival he took a basin of bread and milk, went to bed, and died suddenly three hours afterwards. A man-servant, aged sixteen years, who had been ten or twelve days under treat- ment for diphtheria, seeming to be convalescent, obtained leave to go home and see his friends before returning to his occupation, and there died suddenly. Dr. Bellyn mentions a case of this kind, that of a boy aged ten years, who, having been ill nearly three weeks, had so far recovered as to be able to go out, and on the day of his death walked to a farm-house at a considerable distance from his home. About ten o'clock the same evening, Dr. Bellyn, on 96 NATURE OF DIPHTHERIA. being summoned to see his patient, who had suddenly been seized with violent pain in the bowels, about an hour before, found him sinking from exhaustion. Although relieved by fomentations and other remedies, he died very soon after the visit. A post mortem examination was refused. Convales- cents from diphtheria cannot be considered out of danger until some time after the throat is well, and the very marked aniemia produced by the disease has disappeared. It is true that death, whether sudden or otherwise, usually occurs witliin a few days; but, according to Greenhoiv, sometimes as late as the sixteenth and seventeenth day of the illness. Such was also the case with the little boy from West Phila- delphia, mentioned above. N. — Seqxielse. In the first place, it must be mentioned that, under a true Homuiopathic treatment, there are no sequelae of any conse- quence. In the great majority of the most malignant cases that I attended, the recovery was often slow, but no serious disease supervened. In a few of the more violent cases which recovered, a long-continued very fetid running from the nose and ear was observed. Patients liable to lung di.sease were afflicted with a cough which was difficult to cure. Chronic laryngitis and bronchitis were aggravated by the poison of diphtheria. Among the other sequelae are mentioned anaemia, impaired voice or power of deglutition, though rarely is there com- plete aphonia. I have observed several cases of ancemia, but none of aphonia, e.xeeptfor a short period of time. A husky, na.sal voice is also very striking, according to Greenhow. I observed it only in one case. Paraplegia, hemiplegia, im- paired vi.-ion and deafness are also mentioned among the sequela) of diphtheria. One little boy, who was treated by a very good Homtuopathic physician in the country, with strong doses of the BinioiUtk of Mcrmiry, returned to the city with complete paralysis of the lower extremities, accompanied SEQUELS. 97 with violent pain. A few doses of Bhii^. tax. 3 restored bim in two days. Di'. J. B. BeynoUs published in the ^fay number of the American Journal of Medical Sciences, 1S59, seventy-seven cases of diphtheritic paralysis. Four children, who got very well over a violent attack of diphtheria, could not read hlach letters for a whole month, Tiiere was a complete obscuration of sight. These symptoms gradually disappeared without any remedies. The most striking phenomenon after diphtheria is, accord- ing to my experience, an excessive prostration of strength. The convalescence is always lingering. The poison of the diphtheria has affected the whole nervous system. 0. — Contagion. The special character of diphtherite according to Breton- neau, is the exudation, whence the name he has applied to the disease. No inflammation unattended by exudation is diphtherite. The virus of the membranous exudations, ac- cording to him, forms the distinctive pathological feature of the disease. Bretonneau further asserts it to have been proved by numerous facts, that persons who attend cannot contract diphtheria unless the diphtheritic secretion, in the liquid and pulverulent state, be placed in contact with a soft or softened mucous membrane, or with the skin on a point denuded of epidermis, and this application must be immediate. In a word, a true inoculation is the only mode of transmission of the disease. On the other hand, he states that facts supplied by the epidemics of diphtheria which have broken out in the de})artment of Indre et Loire, or which have extended to the surrounding departments, prove in the most evident man- ner, that the atmosphere cannot transmit the contagion of diphtheria. Iroiisseau steeped a lancet in a false membrane which he had just extracted from a diphtheritic wound, and made a puncture on his left arm, and five or six on the tonsils and 98 NATURE OF DIPHTHERIA. velum palati. ITc found on his arm, on the seat of the punc- ture, that a vesicle was developed very similar to that of vaccination, but there was no result upon the mucous mem- brane. Some physicians in England have experimentally inocu- lated dogs with the poison, without any very decided effect. Tiie oi)inion of the able Bretonntau, that the disease can only be propagated by actual contact, has received no sup- port from subsequent observers. In no one instance have I seen the disease transmitted in this way. During the five years that the disease has been prevalent in Philadelphia, it seemed almost to disappear during the summer months, but reappeared during the first damp, cold and rainy days of the autumn, attacking, according to con- stitutional idosyncrasies, more or less severely the younger members of families. It is of an epidemic miasmatic origin, but becomes, in time, endemic in certain localities favoring its growth. It becomes less violent and fatal in the course of time, but still occasionally will assert its ancient virulence. Like all contagious diseases, it is most easily communicated when concentrated in a family. P.— Statistics. From the accomjianying table it will be seen that the wards on the outskirts of the city, with low grounds and marshes of stagnant water, near the Delaware as well as the Schuylkill, have the greatest mortality from diphtheria. Highest on the list stands the First Ward, with 137 deaths in a population of 30,886 ; next to that, the Twentieth Ward, with 132 deaths in a population of 29,963 ; and third, the Fifteenth Ward, with 119 deaths in a population of 32,091 ; all these during tlic last five years. On the other hand, the Second Ward, with a jiopulation of 29,123, has only 85 deaths; and the Seventh, with a population of 31,276, 92 deaths; the Eighth Ward, with a population of 27,770, 52 deaths during the lu.sl live years. The superior cleanliness of the Eighth Ward, STATISTICS OF DEATHS. ? i Diphthoria.... Croup 1860 1861 1862 1863 1864 1860 1801 1862 1S03 1804 1800 1801 1802 1803 1864 Yoarg. 1 « %mi s fitiii i s^gii Deaths, total. i 1 Sfeiiii § 3t0s^ i muf^ Mivles. i sBiii S iiSsi i £sS§g Females. 1 i isnli "i issii i §aiii Ages from un- der 1 to 15. £ w 1 oo-jot! 5 ^-^«tol {ll SgJSg^l Ages from 15 upwards. 1 s! §S2g§fe o jsiassiol S! §g=fej2 - i Slsoo^ass S §5s»ol sslsssss ts i si ssgs§ 3 S---^! g| -s;^5S w s SIkssss 2 SSoSm 1 SI SooSSoo jt 2 gi :::«r^S S5 bSIObSO>-'l SI «>4-Cd^C> i .Il§s^§t§ I « j _S5o5*.l gl§i3S5S ococ^l S! 5'^=icc OS 00 sl nisssr 2 oao.t^i^.iti.1 uil ocotsoos to 5 > 5 si ~,4.^fea S S«SooK,l g| -,««S« s s 1 si 0>.ggS s»o.4.=.l 5i!.o:=rs^ »*1 s -.S-o»tol si SoSiio, • s il 2 cs»s«lsl sss^s ^ 2lsgJ:2c. CO S3!iS5S-l SI 8fe{2g5 ^ g o »-.SS^ §SSSo.l feUSc.5a s 1^ »»:j§» s 5S3SS| $1 SS»i:c, ^ f- SUc«52=: S ---„ 5llU = 8§S CD ~8 t s! !£J3flSi g i2:;i3 1 Sisssis 1 I Efc5r»l U\ Ej5r:ss § 3L»«SS- k O»00»S*.| si OMOCM (S n S 1 MG9loSo 1 a Sm*.mmI al 5S5c« S=--=Ssl si ::r;8-,=. e g lsl»::gg» 1 2 :e:5 Horn. Vierteljahrschrift, toI. ii., page 382. 164 HOMCEOPATniC TREATMENT OF DIPHTHERIA. mucas from the nose, with obstruction of the same. Pale thin face. Painful swelling of the cheeks. Swelling of the face without heat. "White spots on the face, with itching. Chaj^ped lijys. Swelling of the upper lip early in the morning. Ulcerated angles of the mouth for a fortnight. Scurfy pimple on the margin of the vermilion border of the lower lip. On the left side of the lower jaw, considerable swelling with draw- ing pain. Hard swelling of a submaxillary gland, as big as a hen's egg, with painful tension when chewing, and stinging pain when touching it. Swelling of a submaxillary gland, with a sense of pressure in it. White, yellowish little ulcer on the right tonsil. Thiclc ivhite coating on the tongue, with sensation as if it were without any skin, and sore. Blisters on the tongue, which prevent eating. Little blisters on the tongue, with burning pain and heat in the mouth. Sore throat luith siuelling of the submaxillary glands. Sore throat like an inter- nal swelling, extending into the ears. Sore throat as from a plug in the throat, when swallowing. Sense as*if a foreign body were lodged in the pharynx, which constantly obliges one to swallow. Sensation as if the throat and the mouth were sore and raw. Swelling of the tonsils, with elongation of the uvula and sense of constriction of the oesophagus. Swelling and inflammation of the palate ; the uvula is dark-red and covered with little blisters. Great dryness of the mouth and tongue. Dryness in the throat. Phlegm in the throat. Loss of appetite. Painless hoarseness. Titillating irritation in the larynx, which becomes loose by clearing the throat. Painless glandular swelling in the nape of the neck. Swelling of a cervical gland on the left side, of the size of a hen's egg, with a stinging sore throat when swallowing. Swelling of the neck on the left side, with pain when touching and turning the head, and with sore throat. The cervical glands are painful. Hard swelling of the cervical glands. Droivsiness in daytime and weariness, laired and sleepy the whole day. Attack of general exhaustion, etc., etc." There is also an important fact, which cannot be over- looked. It is the universal use of the Chlorides and their CHLORIDE OF LIME. 1C5 combinations by the old school, such as the Chhridei of Irw, Soda, Potash, etc., and also Muriatic Acid. The almo.st uni- versal popular use of salt, also, comes into this category. There is always some truth at the foundation of such common popular practices. The people would not use these remedies did they not find benefit from them. Regarding my own experience with this remedy, I have made almost exclusive use of it in diphtheria, during the last five years, in at least three hundred cases. In many cases I have employed it in the form of Liquor Calcis Chlor- inatse, from five to fifteen drops, in half tumbler of water, of which a teaspoonful was taken according to the urgency of the symptoms, at intervals of from a quarter of an hour to six hours. For other slighter cases, a trituration of the remedy was prepared, of which I have seen also good effects. In the majority of these cases it was prescribed alone ; in others it was alternated with different remedies, according to constitutional idiosyncrasies. During these five years I have lost only two cases by death from this disease, although many of the three hundred cases appeared to me equally severe as those previously treated by other remedies, when I was not so successful. One of the above-mentioned cases was a young man, who had been ad- dicted to drinking, which he suddenly relinquished, when he was attacked with diphtheria. Notwithstanding my advice of not omitting his accustomed stimulants during the attack of this sickness, he would not resume it, and died a victim of his otherwise* praiseworthy resolution. The second fatal case was that of a child two years of age. The diphtheritic bron- chial croup had already progressed three days before I was called in. A large thick greenish membrane was visible all the way down the throat. The action of the Chloride of Lime in diphtheria is not like that of the caustics and acids, which remove the membrane at once as if by a charm. As long as the blood is infected with the diphtheritic poison, this external manifestation of the disease will return immediately, or devclope itself lower 166 HOMCEOPATEIC TREATMENT OF DIPnTHERIA. down in the oesophagus, stomach or bronchia, and thus prove fatal. Very difierent is the action of the Chloride of Lime. By examining the membrane in the throat of a patient under the effects of this agent we perceive that the progress of the disease has been impeded from within. The patches of the membrane have ceased to spread, they look shrivelled and dead, the inflammation around their edges diminishes grad- ually and the healthy mucous membrane reappears. It should also be mentioned, that in all severe cases stimu- lants, such as wine whey, milk punch, etc., were of incalculable benefit. "Without entering into the details of the cases, which would be neither instructive nor interesting, I will quote from the records of my practice the principal symptoms of about thirty cases, and the treatment pursued. In one most malignant case of throat diphtheria, where Iodide of MercurTj 1 and the Liquor Calcis clilorin. had been given in alternation, I omitted the Calc. chlor. for twenty- four hours and gave only Iodide of Mercury 1. All the symptoms were aggravated. I then returned to the Chloride of Lime alone, when the whole case perceptibly improved, the drowsiness and sopor diminished, the membrane became shrivelled, and the whole disease assumed a more favorable aspect. In five very severe cases of diphtheria in children, of from two to eight years of age, when the whole throat was covered with the membrane, and the swelling of the submaxillary glands was very great, Calc. chlor. soluL, alone,* (eight drops dissolved in a half tumblerful of water, of which a teaspoouful was given every half hour to two hours,) cured them in a short time. In some of the cases there was scarlet eruption on stomach, chest and head, which soon disappeared. In these cases Bella- donna was alternated with the Chloride of Lime. In others Kali hichrom., 1st or 2d trituration, was alternated with the Lime. Here there were more discharges of vitiated CHLORIDE OF LIME. 1G7 bile, a yellow complexion, want of api)etite, little taste in mouth, nausea, etc. In two of these cases there was also severe fever every night, with pain on the top of the head. In other instances there were frightful dreams and aching in the eyes. No change of the medicine took place owing to these symptoms. Many cases of this kind of greater or less severity have occurred in my practice, in all of which the Chloruk of Lime was the principal remedy. My main object ahcaTjs icas to save kfe. 1 have given the remedy alone, when this was possible, but when there were complications of the disease with chronic miasmas I never hesitated to alternate it with others. IS the symptoms in many of our provings were mathematically certain we should have less diflBiculty, but whether this is the case, let every candid Homoeopathic physician answer. In very severe and dangerous cases the Chloride of Lime ought to be repeated every half hour or even oftener. In some cases of this kind it was exhibited every ten minutes. This constant application of the remedy undoubtedly also acts locally. Calc. chlor. not only cured the ordinary diphtheria, but also the diphtheritic croup. In two of the most formidable cases of this kind, for greater security, the Chloride of Lime was alternated with the Kali bichromicum. C. R., act. seven, was for several days unwell with a coM in the head, and catarrh, when, suddenly, one night the child was attacked with a suffocating croupy cough, with strangling, bluish countenance, quick, oppressed breathing. The physical examination detected a wheezing, whistling sound in both lungs, with occasional rhouchus. The whole fauces, palate, and tonsils, as far as the eye could penetrate, were covered with a thick whitish membrane. The tonsils were also enlarged ; on the external neck there was a swelling on both sides, par- ticularly on the right side. Considering that the mother had died of consumption, and the child suH'ered from luxation of the left hip-joint, the case was formidable enough. Tho persistent alternate use of the LiE.A.PIIj STI^EET, ISTEVT" 'yopik:. Constantly keeps on hand a good assortment of Homoeo- pathic Medicines, in complete sets or by single vials, in Tinc- tures, Triturations, and Dilutions ; also, Pocket-Cases of Med- icines, Physicians' and Family Medicine-Chests, to Hering's, Small's, Guernsey's, Hempel & Beakley's, Lutze's, and Marcy & Hunt's Practice. Medicine Chests of different sizes, from 12 to 1100 Remedies, high and low dilutions, Jenichen's, Lehrmann's and other high Potencies, by single vials or in cases. Homoeopathic Vials and Corks of the best quality and of all sizes. 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