Notes on the History of Diphtheria in the U. S, By DR. JOHN C. PETERS, of New York. 1'kom the West Virginia Medical Student, June, 1876. 2 DR. PETERS. NOTES ON THE HISTORY OF DIPHTHERIA IN THE UNITED STATES. By DR. JOHN C. PETERS, of New York. was well described by Dr. Cadwallader Colden, . , of New York, in 1753. One of the best treatises in any lan- guage is that of Dr. Samuel Bard, of New York, published in 1771; translated in Paris in 1810, and known to Bretonneau, who wrote in 1821. Then all traces of the disease were lost until Dr. Geddings, of Charleston, S. C., published an article on Pseudo-membranous In- flammation of the throat, in Vol. 24 of the Am. Journal Med. Sciences, 1839, in which he states that he witnessed an epidemic in Charleston. Dr. Ware, of Boston, wrote, in 1841, that he had observed about 20 cases in 12 years. 1 became acquainted with that fact in 1841. He stated that mem- branous croup always commenced as Bretonneau's Diphtheria of the throat, and I always examined the throats of my croup cases from that year on-but as the majority of the cases of croup are not mem- branous, 1 rarely discovered throat disease; and recollect 3 cases of fatal membranous croup in which throat membranes were not present. Dr. Welsh has an article in Vol. 20 of the Am. Journal Med. Sciences, on Diphtheritic inflammation as it prevailed epidemically in Ohio, in 1847-49. In the Boston Medical cr3 Surg'l Journal, Vol. 59, 1858, there is an article on Diphtheria in Providence, R. I. Dr. Willard, of Albany, N-. Y., describes diphtheria as epidemic there in 1858, causing 157 deaths. The first case reported in New York, was, by Dr. Jacobi, on Feb. 15th, 1852, in a German woman, set. 24, residing at 638, Hudson St. It has prevailed ever since in that neighborhood. NOTES ON DIPHTHERIA. 3 Two other fatal cases were reported in 1857; five in 1858; and 53 in 1859. In Feb. i860, it became decidedly epidemic. In i860 there were 415 fatal cases. " 1861 " " 429 " " " 1862 " " 586 " " 1863 " " 944 " " " 1864 " " 805 " " " 1865 " " 512 " " " 1866 " " 435 " " " 1867 ' " " 251 " " 1868 " " 276 " " 1869 " " 328 " " 1870 " " 308 " " " 1871 " " 238 " " " 1872 " " 446 " " " 1873 no icss 1,551 deaths. In 14 years, from i860 to 1873 inclusive, it caused 7,124 deaths. It has steadily increased since 1872. We have had 1,523 cases and 735 deaths, in January, February, and March of this year, 1876 -winter quarter. In the same months last year, there were 1,346 cases. .The 22d Ward, on the west side of the city, from W. 40th North to W. 86th St., west of 6th Avenue, has had the largest number of deaths in January, February, and March, 1876, viz.-97. The 20th Ward, just south of the 22d, extending from W. 40th South to W. 14th, west of 6th Avenue, the next largest, viz.-72. The 19th Ward, with the same boundaries as the 22d, except be- ing east of 6th Avenue, is the 3d on the list, viz.-67. The 23d Ward, is the 4th, with 57 deaths. The disease is mainly located along the North and East Rivers, north of 14th St., in tenement houses. The best wards in the city are comparatively free from it, and the down town business wards, of course. False Diphtheria, or Follicular Tonsillitis is common among the better classes, but true Diphtheria is comparatively rare. NOTES ON THE EARLY HISTORY OF DIPHTHERIA IN THE UNITED STATES. DR. JOHN C. PETERS, of New York. chT2)Y the kindness of Dr. S. S. Purple, President of the New York Academy of Medicine, I have had access to the letter of Dr. Cadwallader Colden, of New York, to Dr. Fothergill, and to the paper of Dr. Samuel Bard, on Diphtheria. Both of these gentlemen refer to Dr. Douglass, of Boston, who described the disease in 1735. Dr. Douglass records the appearance of the '1 throat distemper" at Kingston, an inland town of New England, about the year 1735. Dr. Colden says it spread from thence, and moved gradually west- ward, so that it did not reach the Hudson river till near two years afterward. It continued sometime on the east side of the river, be- fore it passed to the west, and appeared first in those places to which the people of New England chiefly resorted for trade, and in places through which they travelled. It continued to move westerly, till it probably spread over all the British Colonies on the continent. Dr. Colden, continues: "Though what I have mentioned seems 5 DR. PETERS. evidently to show that the disease was propagated by infection, yet children and young people were only subject to it, with the excep- tions of some people above 20 or 30 years old. and a very few aged people who died of it. "Neither did it spread equally to all places that were proportionately exposed to the infection. The poorer sort of people were more liable to it, and they who lived on low and wet grounds and on a poor scorbutic diet. In some places only a few persons or families were seized; while in others, all escaped. In some families it pass- ed like a plague through all their children; in others, only one or two were, seized. Some were attacked at such a distance from the infected, that it could not be conceived in what manner they receiv- ed infection. Some families had the disease mildly, while others in the same place and at the same time had it most violently. "For the last 14 years it has frequently broken out in different families and places, without any previous observable cause; but does not spread as it did at first. Sometimes a few only have it in a considerable neighborhood. It seems as if some seeds, or leaven, or secret cause remains, wherever it goes; for I hear of like obser- vations in other parts of the country. Several have been observed to have had it, more than once. "Nausea, or vomiting is seldom observed to accompany it. The skin is seldom parched. The pulse is usually low, but frequent and irregular. No considerable thirst. The tongue is much furred, and the furring sometimes extends all over the tonsils, as far as the eye can reach. At other times, in the milder kind, the tonsils appear only swelled and dotted with white specks of about % or inch in diameter, which are thrown off from time to time, in tough, cream- colored sloughs; but these are soon again renewed. Sometimes the throat is swelled inwardly and outwardly, so as to endanger suffoca- tion. "In some seasons it has been accompanied with miliary eruptions all over the skin; and at such times the symptoms about the throat have been mild, and the disease generally without danger." (Scar- latinous diphtheria.) "Some have had sores with corrosive humors behind their ears, on the private and other parts of the body." (Cutaneous diphtheria.} "The last complaint commonly is of an oppression or straitness in the upper part of the chest, with difficulty of breathing, and a HISTORY OF DIPHTHERIA. 6 deep hollow, hoarse cough, ending in a livid strangled-like counten- ance which is soon followed by death." [Croupous diphtheria.} "This disease is not often attended with that loss of strength that is usual in Scarlet and other fevers. So that many have not been confined to their beds; but have walked about the room, till within an hour or two of their death. And the complaint has often ap- peared no way dangerous, at first, to the attendants, till the sick were almost in the last agonies; though the patients themselves are gener- ally dejected and apprehensive. Some died on the 4th or 5th day; and others not till the 14th or 15th; some even later. Sometimes nature was not able to raise a fever for the expulsion of the disorder, and the sick generally died suddenly, without a sensible struggle. "When the surfaces of the tonsils, after the sloughs were cast off, appeared of a very fiery-red-color there was some, or even great danger; but when they were covered with a black crust it was often a fatal omen; as also when hemorrhages followed any slight scratch. "When the disease first appeared, it was treated in the usual way, (with bleeding, blistering and purgatives?) for a common angina, and no plague was more destructive. In many families, who had a great many children, all died; and generally, when the sick fell into the hands of physicians not acquainted with the peculiar malignity of the disease the result was not favorable. Depressing and evacu- ating measures, after the disease had continued sometime, were de- structive. The orifices made by the lancet in bleeding, and the ad- jacent parts were apt to become diseased. So likewise the places where blisters were applied. The ichor which issued from them corroded the parts upon which it flowed, and even slight scratches became as it were mortified. . A bloody ichor continued to issue from the body long after death. "Cold air was apt to produce relapses; and Peruvian Bark was useless, but gentle perspiration produced by warm sage, and other teas, or with serpentaria, as an antiseptic diaphoretic, was found use- ful; and if the disease was taken early enough it went through its course mildly, and seldom any of the more terrible symptoms ap- peared. Serpentaria' was even found beneficial after serious and bad symptoms had appeared, and some recovered whoi seemed be- yond hope. "The presence of a miliary eruption was found very salutary in this disease; and when absent, calomel, especially when joined with 7 DR. PETERS. camphor, was useful. The common gargle used was a decoction of sumach berries, with serpentaria, and a little alum dissolved in it. It was thought proper always to gargle the throat before swallowing anything, (in order not to wash any of the infection down into the stomach?) 'The sores on the tonsils were frequently touched with the compound tincture of aloesand honey; when the throat was much swelled fomentations were used with decoctions of aromatic and other herbs, in which sal ammoniac, borax, or common salt was dissolved, with the addition of sharp vinegar. "A girl about 10 years of age, while the throat distemper was pre- vailing, had sores on her private parts like those on the tonsils of others; but no symptom of the disorder appeared in her throat. The ichor which issued from these sores dried up at times, and then she was seized with violent pains in her belly. She was cured with serpentaria and the common diaphoretic medication; being careful, as in all other cases, not to produce profuse sweating, as this was found as prejudicial as any other sensible, or exhausting evacuation." Dr. Colden seemed to think that the disease was seated in the epi- thelium, connective tissue, lymph-spaces and lymphatics, and that the capillaries and blood-vessels and their contents became seconda- rily affected; and that blood-letting and evacuants could not reach the sources of the disorder which lay in the cellular, inter-cellular and lymph-circulations. From this most interesting letter it seems certain that diphtheria prevailed widely in the New England States and New York, from 1735, when recognized by Dr. Douglass, of Boston, till 1753, when described as above by Dr. Colden in a letter to Dr. Fothergill, print- ed in Vol 1 st of the London Medical Observations and Inquiries, pp. 211 to 225. It also seems evident that mild scarlatina prevailed at the same time and was regarded as far less formidable than the so-called throat distemper, or Diphtheria. For the cases "accompanied with miliary eruptions all over the skin, as happened in some seasons" only, were considered as "generally without danger, if not ill treated." It is not absolutely certain that any distinction was made between the diphtheritic throat distemper and scarlatina maligna, although it appears equally undeniable that eruptions were generally absent; and that the malignancy of the disorder was in some measure at- tributed to the non appearance of the skin affection. 8 HISTORY OF DIPHTHERIA. In scarlatina maligna the eruption is dusky and readily noticed. In scarlatina without eruption there is generally some pre-existing or co-existing disease, generally entero-colitis, with severe vomiting or purging; or nephritis, with albuminuria, followed by dropsy. No mention is made of dropsy as a sequel of the Bard or Colden throat distemper, so that it was doubtless true Diphtheria; although paralysis also is not mentioned. Again, the occurrence of diphtheritic croup is stated to have been common; while croup is rare after, or with scarlet fever, although Meigs and Pepper report several cases. Bretonneau, Rayer, and Tweedie never met with it. Guersant and Blache occasionally ob- served it; while although Rilliet and Barthez found false membranes in the larynx in 3 cases, yet they had not been attended with the peculiar symptoms of croiip. On the whole, we may claim positively that a large majority of the cases alluded to by Drs. Bard and Colden, were pure Diph- theria and nothing else. In my next, I will give an abstract of Dr. Samuel Bard's still more important communication made in 1771. from The IT. Va. Medical Student, July No., 1876.] notes on the early history of I DIPHTHERIA IN THE UNITED STATES. By DR. JOHN C. PETERS, of New York, Vice-President of the Public Health Association of the city of New-York. * PAPER No. 3. the kindness of Dr. S. S. Purple, President of the New York Academy of Medicine, whose library abounds in the most valuable books, pamphlets, etc., published in the earlier part of our history as a medical profession in this country, I have also had access to the Treatise of Dr. Samuel Bard, of New York city, on Diphtheria, entitled "An inquiry into the nature, cause, and cure of the Angi- na SUFFOCATIVA Or SORE-THROAT DISTEMPER, AS IT IS COMMONLY called by the inhabitants of this city [New York] and colony. By Samuel Bard, M. D., and Professor of Medicine in King's College.* New York, 1771. Dedicated to Cadwallader Colden, M. D. Esqr., His Majesty's Lieut. Governor of the Province of New York." We will here premise that Dr. Bard's little treatise was translated and published in Paris in 1810, and was known to Bretonneau, the so-called Father of the history of Diphtheria, who quoted from it. Dr. Bard says: "In general this disease was confined to children, though some few grown persons, particularly women, had symptoms resembling it. *Now Columbia College. 10 DR. PETERS. "Unlike the promptness of the onset of scarlet fever,* most of those who had it were observed to droop for several days, * * * and had a bloated livid countenance. Some had a few red eruptions here and there on the face; and in one case a small ulcer on the nose, whence oozed an ichor so sharp as to inflame and cdrrode the upper lip, * * * an uneasy sensation in the throat, but without any great soreness or pain, and upon examining it, 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 general slough. In a few the swelling was so great, as almost to close up the passage of the throat; but this, although a frequent symptom, did not invariably attend the disease; and some had all the other symptoms without it. The breath was either no ways offensive, or only slightly so, and the swallowing was very little, if at all, impeded. "These mild symptoms, with a slight fever at night, continued in some for 5 or 6 days, without exciting alarm; in others, a difficulty of breathing came on within 24 hours, and was often increased to such a degree as to threaten immediate suffocation. In general the difficulty of breathing came on later, and increased more gradually. "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 voice; not easily described, but so sin- gular, that a person who has once heard its could almost certainly know the disease again by hearing the patient speak, or cough. In some the voice was almost entirely lost. [Croupous * * * These symptoms continued from 1 to 3 days; but by that time it was usual for them td be greatly increased in such as died. * * * The difficulty of breathing increased so as to be frequently almost entirely obstructed, and the patient died apparently from suf- focation. [Croupous Diphtheria.'} This commonly happened before the end of the 4th or 5th day; in several within 36 hours from the time the difficulty of breathing first came on. One child however lived to the 8th day, and the day before he died his breath and what he coughed up was somewhat offensive; but this was the only in- stance in which I could discover anything like a disagreeable smell, either from the breath, or expectoration. "Out of 16 cases attended with this remarkable suffocation in breathing, 7 died; 5 of them before the 5th day; the other 2 about the 8th. [Croupous Diphtheria.} NOTES ON DIPHTHERIA. 11 "In the family of Mr. W. W., one of the first to be attacked, 7 children were all affected, one after the other; 3 died. The 3 young- est had not the difficulty of breathing, but in its stead very trouble- some ulcers behind the ears. These began with a few red pimples, which soon ran together, itched violently, and discharged a great deal of a very sharp ichor, so as to erode the neighboring parts, and in a few days spread all over the back part of the ear and down up- on the neck. [Cutaneous Diphtheria.} "After this, many other children had similar ulcers behind their ears and some of them seemed slightly affected with the difficulty of breathing, but it never became alarming while this discharge con- tinued. These ulcers would continue for several weeks, and appeared covered in some places with sloughs resembling those on the tonsils; and at last grew very painful and uneasy. [Cutaneous Diphtheria.} "In some cases they were attended with swellings of the glands under the jaw and behind the ears. "I met with nothing like this complaint in adult persons, * * except the two following cases. They happened about the same time, and both were women; one of them had assisted in laying out two of the children that died of it. At first her symptoms resem- bled rather an inflammatory angina, but about the 3d day, the ton- sils appeared covered with thick sloughs; her pulse was low and feeble, with a moist skin, a dejection of spirits, and some anxiety, though nothing like the difficult breathing of the children. "The other was a soldier's wife, who had a slight fever for some- time before she perceived any complaint in her throat. The tonsils were swelled and entirely covered with sloughs, resembling those of the children; but her breath was more offensive, and she had no suf- focation." Dr. Bard, at p. 10, also says: "I have had an opportunity of ex- amining the nature and seat of this disease, from dissection, in three instances. One was a child 3 years old. Her first complaint was of an uneasiness in her throat, the tonsils were swelled and inflamed, with large white sloughs upon them. * * She had no great sore- ness in her throat, and could swallow with little or no difficulty. Her pulse was quick and soft; the heat of her body was not great; her face was swelled. She had considerable prostration of strength, with a very great difficulty of breathing, a very remarkable cough and a peculiar change in her voice. She drew her breath as if the 12 DR. PETERS. air was forced through too narrow a passage, so that she seemed in- capable of filling her lungs, etc. [Croupous Diphtheria.\ "Upon examining the body * * all the back parts of the throat and the root of the tongue were found covered and interspers ed with sloughs, which still retained their whitish color. * * The epiglottis, which covers the windpipe was a little inflamed on its ex- ternal surface; but on the inner side together with the whole larynx was covered with the same tough white sloughs, as the tonsils or glands of the throat. "The whole trachea quite down to its division in the lungs, was lined with an inspissated mucus, in the form of a membrane, re- markably tough and firm. It was so tough as to require no incon- siderable force to tear it, but it came out whole from the trachea, which it left with much ease, and resembled more than anything, both in thickness and appearance, a sheath of thin chamois-leather. The inner membrane of the trachea was slightly inflamed. [Croupous Diphtheria. ] "Where the membrane extended into the lungs, it seemed to grow thin and finally to disappear. The lungs, too, appeared inflamed as in peripneumonic cases, etc. "The second dissection I attended was of a child 7 years old, who had had all the symptoms with which this disease is commonly at- tended, except that the glands of the throat and upper parts of the windpipe were found entirely free from any complaint, and the dis- ease seemed to be confined to the trachea only, which was lined with this tough mucus, inspissated so as to resemble a membrane. [Pure Tracheal Diphtheria.] We could trace it into the larger di- visions of the trachea, and it was very evident that the smallest branches were obstructed by it. The lungs did not collapse as usu- al, but remained distended and felt remarkably firm and heavy, as if they were stuffed with the same mucus. "The third was a child, 3 years old, who died in 36 hours after the difficult breathing first came on, yet even in this case I found the inspissated mucus lining the trachea." [Tracheal Diphtheria.] Dr. Bard refers to Home's essay on croup, published some years before at Edinburg, under the name of Suffocatio Stridula. or Croup. He says: "Such a remarkable agreement in the symptoms of the two diseases, is in itself almost sufficient to determine them to be the same; but when we compare the appearances from dissection, it is NOTES ON DIPHTHERIA. 13 almost placed beyond a doubt. In eight cases, in which Dr. Home gives the dissection, the membrane I have described was constantly found, of the same appearance, firm consistence, loose adherence to the trachea, * * and it descended into the smallest branches of the wind-pipe, so as to choke these cavities and suffocate the patient. It is true Dr. Home does not mention the swelling of the tonsils, or the sloughs upon them as frequent symptoms; but in some cases here they were also wanting, and he mentions some in which the tonsils, together with all the glands about the root of the tongue were covered with mucus." It will be seen that Dr. Bard almost made a diagnosis between Tracheal Diphtheria, and Membranous Croup. Dr. Bard contin- ues: "Drs. Fothergill and Huxham have both written upon a disease, under the title of Malignant Ulcerous Sore Throat, which in some circumstances, particularly an erysipelatous or scarlatinous eruption with which it was attended and many other symptoms widely differed from the complaint 1 [Bard] have described. And yet they agree in so many other and such remarkable symptoms that I [Bard] cannot help entertaining the opinion, that they bear some relation to each other." Here Dr. Bard almost established a diagnosis between Scar- latinal Diphtheria, and pure Diphtheria. "Do not these resemblances; their being in a great measure pecul- iar to children; their infectious nature; * * * the inflammation, swellings and sloughs on the tonsils and neighboring parts, unattend- ed with any remarkable difficulty of swallowing; the discharge from the nose, and behind the ears; * * * but above all the peculiar difficulty in breathing, the hoarse dry cough, and the remarkable change in the voice, I [Bard] say, do not these symptoms, in which they all agree, justify an opinion, that although these diseases may specifically differ, yet determine them to be somewhat of the same class? And may not the erysipelatous or scarlatinous eruptions and putrid symptoms have belonged rather to the constitution of the air [from the filth of places, and the epidemic tendency of the times] than to the especial nature of the disease? Dr. Huxham particular- ly mentions that all the diseases of that season were attended with some kind of skin eruptions, and that too even in pleuritic and pneumonic disorders; so greatly did the constitution of the air or some other cause-seem disposed to produce eruptions of all sorts. "Dr. Fluxham particularly mentions too, the strangulated breath- 14 DR. PETERS. ing, and hoarse voice as characteristic symptoms, and quotes several Spanish and Italian physicians to the same effect: a strong proof that suffocation must have been among the most striking symptoms. "It is likewise remarkable that some of the first writers, which Dr. Fothergill quotes, call it simply Morbus Strangulatorius, whilst Severinus connects the symptoms of strangulation and putrefaction together; and others again entirely omit the symptoms of suffocation and name it Angina pestilans, gangrenosa, or malignant ulcerous sore-throat. [All these writers confounded Diphtheria and Mem- branous Croup-with Malignant Scarlet Fever.] "The same differences of opinion have been entertained of its in- fectious nature: many declare it to be pestilential and contagious without any restriction; while some, particularly Cortesius, an Italian, consider it contagious, but only in a certain limited sense." "It seems very evident that the disease which Dr. Fothergill treats of was frequently connected with affections of the trachea, and with remarkable suffocation and strangulation. \Scarlatinous Diphtheria. ] "Neither Dr. Fothergill or Huxham made any dissections of per- sons who died of the complaint they treat of; but the latter says pieces of the internal membrane of the wind-pipe were sometimes spit up; and Dr. Monro saw in the dissection of some children who died, at Edinburg, of a disease there considered to be putrid sore throat, the same membrane lining the trachea and descending to its minutest branches, similar to what is found in membranous croup. This membrane was not universal in all he examined, but whenever it was found the children had breathed in the same manner as those who were affected with croup; a pretty evident proof that these diseases are at least allied to and apt to run into each other." Dr. Bard evidently thought, that croup and the ulcerous sore- throat-diseases were the same; only those described by Huxham and Fothergill were more putrid and malignant, like modern cases of Malignant Diphtheria. It is very fortunate indeed that he described exactly what he saw; and separated his comparisons and reasonings from his facts. "One of Dr. Fothergill's cases, a girl of 12 years, died in 24 hours, evidently from strangulation and not from putrid dissolution of the humors, and I [Bard] have been assured by some of the old- est practitioners of New York that they have seen, but a few years NOTES ON DIPHTHERIA. 15 ago, the same disease I have described, attended both with erysip- elatous or scarlatinous appearances and highly putrid symptoms. \Probably Malignant Scarlet Fever, blended with "Upon the whole therefore, 1 (Dr. Bard) am led to conclude that the Morbus Strangulatorius of the Italians, the Croup of Dr. Home, the Malignant Ulcerous Sore-Throat of Huxham and Fothergill, and the disease I have described, and that first described by Dr. Doug- lass, of Boston, however they may differ in symptoms, do all bear an essential affinity and relation to each other; or are apt to run into each other, and in fact arise from the same Leven." This is equivalent to saying that malignant scarlet fever, membran- ous croup and diphtheria are one and the same disease, and makes us doubly thankful that Dr. Bard gave us his facts separate from his theories. "The disease I (Bard) have described appeared evidently to be of an infectious nature, and being drawn in by the breath of a healthy child, irritated the glands of the throat and wind-pipe. The infec- tion did not seem to depend so much on any prevailing disposition of the air, as upon effluvia received from the breath of infected per- sons. This will account why the disorder sometimes went through a whole family and yet did not affect the next-door neighbors. Here we learn a very useful lesson, viz., to remove young children as soon as any one of them is taken with the disease, by which many lives have been saved and may again be preserved." Dr. Bard could not hear of any one who had used blood-letting with success, or any remarkable benefit, and hardly ventured to pre- scribe it, especially as the mucous membrane of the trachea was not red and inflamed enough to produce pus, but only mucus, which then preternaturally thickened into the form of a membrane. But mercury was then supposed to thin all the mucous secretions, particularly those of the mouth and throat, and to prevent the for- mation of this tough membrane, which was then thought to be the proximate cause of the disease and to readily account for all the oth- er symptoms. Dr. Douglass, of Boston, first tried it and meeting with some success recommended it to others, (in all cases not attended with a natural salivation), in order to cast off the sloughs. He thought it as useful as in syphilitic ulcerations of the throat, and says a mild salivation aids "the dispumation of the acrid inquination of the juices in this distemper, the natural crisis of which seems to take 16 DR. PETERS. place from patent and open healthy or salutary emunctories of the throat and skin." Dr. Bard says "there is a singularity in this gentleman's (Dr. Douglass) style; but his experience is founded on real, not imaginary cases," and he himself had seen a case of no trifling degree of se- verity which was cured by a very copious natural salivation. Dr. Bard continues: "Dr. Douglass wrote upon this disease as it appeared in this country in 1735 and under his own immediate ob- servation, which seems accurate and judicious. Calomel in doses of 30 to 40 grains, or indeed a much larger quantity has been given in 5 or 6 days, to a child of 3 or 4 years, not only without any ill effects, but to the manifest relief of breathing by promoting the casting off of the membranes and sloughs beyond any other medicine." Dr. Bard, p. 29, gives the case of a little girl, aged 2% years, who had complained for a week of a sore throat and hoarseness; then she had some difficulty of breathing, which greatly increased. Her tonsils were swelled, inflamed and covered with sloughs of a yellowish color; her breath was not offensive, her pulse was small 'and fluttering, and her skin pale and clammy. She recovered in 15 days except from great weakness, and such a remarkable loss of voice that it was with great difficulty she could be heard, while the moment she attempted to drink she fell into a fit of coughing. "In 2 months, she could hardly walk alone, or speak above a whisper.'' Paralysis.] From the above it is evident that Dr. Bard had met with many cases of pure pharyngeal and tracheal diphtheria. Also with some cases of membranous croup, not complicated with diphtheria, and a few cases of scarlatina anginosa, complicated with diphtheria. He came very near establishing a diagnosis between all these diseases, and far exceeded Bretonneau who confounded scarlet fever with diphtheria, and assumed that all cases of membranous croup were diphtheritic, and were always preceded by pharyngeal diphtheria. His article is among the calmest, wisest, and most accurate that has ever been written on diphtheria, both before and since his time. The city of New York is justly proud of the honor and reputation of this great and honest medical observer. [From the West Virginia Medical Student, August No., 1876.] NOTES ON THE EARLY HISTORY OF DIPHTHERIA IN THE UNITED STATES. By DR. JOHN C. PETERS, of New York, Vice-President of the Public Health Association of the city of New-York. PAPER No. 4. ,>TOY the kindness of Dr. S. S. Purple, President of the New York Academy of Medicine, I have also had access to the brochure of. Dr. Douglass. Dr. Purple's copy is regarded as the on- ly one now supposed to be in existence, and is treasured as a very great prize. It is certainly the only copy that is known to be in the city of New York. It is entitled: '1 The Practical History of a New Epidemical Eruptive Miliary Fever with an Angina Ulcusculosa, which prevailed in Boston, New England, in the years 1735 and 1736. By William Douglass, M. D." It is dedicated to the Medical Society of Boston, of which Dr. Douglass was a member; and he tells us that his colleagues had been fellow-laborers in the management of the distemper and were competent judges of his treatise; as they had invited him to see most of their difficult and extraordinary cases. He says: "In 1735, the distemper continued to spread and pre- 338 DR. PETERS. vail in several townships in this and the neighboring provinces, and he had made minute clinical inquiry during many months of diligent observation of most the varieties of the disease which occurred in this distemper." It had almost subsided in Boston in 1736, but during its continu- ance he could not well have attended more patients than he then had under his care; and make the proper observations and reflections at the same time. He hoped that other medical gentlemen in the dif- ferent provinces and colonies would publish some account of its ap- pearance with them, in order to discover what influences the pro- gress of time, and the varieties of soil and climate had in producing the different appearances which it presented. He says: "It was first noticed in Kingston township, on the 20th of March, 1735, about 50 miles eastward of Boston. As this was an inland place of no considerable trade, or importance, it was thought, (incorrectly perhaps) to be of indigenous origin, and not of foreign importation." "The first victim was a child who died in 3 days; and about a week after, 3 children were seized in another family 4 miles distant; and they also died on the 3d day. It continued spreading gradually, seizing here and there particular families, with that degree of vio- lence, that of the first 40 cases, none recovered. "It was commonly called the throat illness, or the Plague in the throat, and alarmed the Provinces of New England very much. Some of the patients died of a sudden acute necrosis, or mortifica- tion; but most of them were carried off by a sympathetic affection of the fauces, neck, or air-passages; or, by an infiltration and tume- faction of the chops, and forepart of the neck, which became so enlarged and turgid as to bring upon a level all parts lying between the chin and sternum, occasioning a strangulation of the patient in a very short time." Parotitis of Diphtheria, or perhaps of scarlet fever, in which the lymphatic glands lying around and upon the parotid gland, also swell up and render the diagnosis difficult. This so-called secondary or metastatic parotitis, according to Vogel, always arises by absorption from pernicious affections of the deeper structures of the mouth or throat. J. C. P.] "After a few weeks, it spread (by infection or contagion) from Kingston to the neighboring townships, but in a milder form. No reasons could be given for this greater malignity in Kingston, except, NOTES ON DIPHTHERIA. 339 perhaps, the prevalence, of damp places near large ponds, and fresh water, but sluggish streams, like in those localities which produce the rot in sheep. There may also have been bad medical treatment. "Its first recognized appearance in Boston was on the 20th of August, 1735, in a child of Captain Stanny's, at the north end of the city, who had white specks in the throat, and a cutaneous efflores- cence,/[like that of mild scarlet fever.] A few more in the same neigliborhood were seized in like manner, about the same time. To- wards the end of September it appeared in several parts of the town of Boston, with more decided complaint of soreness of the throat. The tonsils were swelled and specked; the uvula was relaxed; there was slight fever, and an erysipelas or-scarlet fever-like efflorescence on the neck, chest, and extremities. But these cases [like those of scarlatina mitior] having no fatal or bad consequences, were sup- posed to arise [not from contagion, or infection,] but from cold, or some other slight disturbance. \F0llicula1 Tonsillitis.] "The first alarming case was in the beginning of October, in a young man named How, and aged 20 years. He had lately arrived from Exeter, to the eastward of Boston [like Kingston] where his brother had died of the same illness. His symptoms were great prostration of strength, a single speck on one of his tonsils, and col- liquative sweats. His pulse was not high and full, but low, hard and stringy, and both more unequal and frequent than natural. His deglutition was unaffected the last; there was no sphacelation of his throat; and no eruption whatever. He was thrice let blood; had some emetics and cathartics; and by these profuse evacuations [and the malignity of his disease] was gradually reduced so, as to die of. a gentle decay of his natural strength, on the 6th day of his illness." [This seems to have been a case of Post-uvular Diphtheria, for Vogel says: "In some few cases a redness and slight swelling of the fauces only are noticeable; and yet all the subjective symptoms of diphtheria may be present. Here we have to deal with a diphtheria of the posterior surfaces of the uvula, soft palate and of the nasal cavities, as may be demonstrated by elevating the soft-palate with a forceps, which can generally only be accomplished in adults." Vogel has often convinced himself at post mortem examinations, that the anterior surface of the soft-palate may remain perfectly free from exudation, while the posterior, on the contrary, may be coated with false-membrane. J. C. P.] 340 DR. PETERS. This was the first recorded fatal case of diphtheria in Boston. "In the beginning of November it spread considerably, especially among children, with more violent symptoms than in August; but it is said that only several persons died of it at varying periods of the disease. But it increased during the winter up to the second week in March, 1736; when it was at its height, there being 24 burials in all, during the week; while in common years, at that sea- son, there were only 9 or 10 interments per week; so that it caused 14 or 15 deaths per week more, than is common in that month. "The disease was so much milder in Boston than in some of the townships, where it first prevailed, that many could not be persuaded that it was the same disorder."- Dr. Douglass, nevertheless, thought that these differences were merely varieties of the same pestilence, as there was no symptom, even the most malignant, that had previous- ly been noticed in the epidemics in New Hampshire, but what the like had also occasionally appeared in Boston. He thought that the dry (?) and healthy air of that city, the good feeding and the better constitutions of the citizens who were less scrofulous, scorbu- tic and psorick, [or scabby and salt-rheumy] than those of the coun- try people who lived upon pork and other pickled provisions, togeth- er with the better medical management of the sick, accounted for the difference in the results of the cases. Thus, it will be seen that Diphtheria and Scarlet Fever had already appeared in New Hampshire. I will further elucidate this point in another communication.-J. C. P. Dr. Douglass repeats that the reasons for its greater fatality in oth- er towns and townships might be the greater dampness caused by the extensive wood-lands, the fresh-water ponds, swamps and damps; the coarse food of the country people, and their prevalent salt-pork diet, which caused the scorbutic or Psoric constitution of the land- folks, which was then the principal endeniial distempcratnre, or disor- der of the inhabitants of New England. He also lays stress upon their bad and unwholesome dwellings, and their bad drainage as in- creasing the malignity of the disorder; while he becomes quite ener- getic when he alludes to the mischievous practice of treating the patients by profuse evacuations, whereby the laudable and salutary or critical eruption became so suppressed and perverted as to be noticed only in a few; while the great debility and prostration of strength peculiar to the distemper was so much increased as to render nature over- DR. PETERS. 341 matched by the assaults of the disease and the doctors; by its con- sequences, and their mismanagement. Hence, Dr. Douglass says: "to the eastward of Boston, at times, i in 3 died; in other places, i in 4; and in scarce any towns, less than 1 in 6; whereas in Boston not above 1 in 35 succumbed." It becomes very evident now, that Dr. Douglass had met with many cases of false-diphtheria, or follicular tonsillitis, and with some cases of mild scarlet fever, or scarlatina mitior, which, at that early period, he was not able-unlike our immortal Bard-to diagnose from true, severe, or malignant diphtheria. Still, he says "there were many varieties or degrees of the pestilence, varying from the most gentle and benign, to the most malignant." [Th be [From the September No. of the W. Va. Medical Student, 1876.] NOTES ON THE EARLY HISTORY OF DIPHTHERIA IN THE UNITED STATES. By DR. JOHN C. PETERS, of New York, Vice-President of the Public Health Association of the city of New-York PAPER No. 5. DOUGLASS says: "The symptoms varied according to the constitutions of families and persons; the scrofulous and Psoric being most susceptible to, and suffering greatly from it." He re- peats, that "the regimen and treatment also had a considerable in- fluence, whereby some, who might have survived were made to suc- cumb by profuse evacuations and Venesections, which increased the most essential peculiarity of the disorder, which was a great prostra- tion of strength." He again suggests that, "the same causes which made the rt?/ in sheep abundant and malignant, increased this throat disease." Mild Form. "In this there was a previous listlessness and a languishing ap- pearance for a day or two. Wet-nurses were apt to lose their milk. The attack commenced with somewhat of a chill or shivering; and soon after there was headache, or some other versatile pains in the back, joints, sides, etc., like from a cold. A vomiting, ora nausea, 370 DR. PETF.RS. [like that in scarlet fever, or small-pox,], was common; but in some, there was only a certain uneasiness, or qualmishness at the stomach. "At the same time, the uvula, but chiefly the tonsils, became tumefied, inflamed and painful, with some white specks, d'hen follow- ed a flush in the face and some miliary eruption there, with a benign, mild fever. The same efflorescence soon after appeared on the neck, chest and extremities. On the 3d or 4th day, the eruption was at its height, with well defined fair intervals of normal skin. The flush- ing went off gradually with a general itching, and in a day or two the cuticle scaled or peeled off, especially on the extremities. At the same time, the cream colored sloughs, or specks in the fauces became loose and were cast off; when the tumefaction in the throat sub- sided. "-\Scarlatinous Diphtheria. ] "The tongue was furred; the urine high-colored; the blood, when let, was more florid than natural; and in the whole, course of the distemper there was a very great prostration of strength, and a tend ency to faintness after recovery; followed by pains and weakness in the joints, particularly in the neck, wrists and ankles, with a univer- sal tenderness of the surface to touch. "A tickling, gutteral, or throat cough was common, attended with some short feverish, Hectic-like flushes, and a loss of flesh. "There was also a peculiar smell, in young persons, proper to the disorder, like that of children with worms; while in grown persons there was a rancid odor like that from foul bed linen. "The faeces were apt to be dark, and very fetid. "This was the most frequent, and normal, or standard mild form of the disease, and when left to nature with a soft warm regimen, it generally ended in recovery in 6 or 7 days. But a hot, cordial method of treatment, or a too great exposure to cold, or profuse de- bilitating evacuations, all rendered the disease more intractable and malignant. When nature required any assistance the cuticular erup- tions, and the little ulcers, or ulcuscula in the throat required most attention. "Mercurials, used with discretion, moistened the throat and mouth, stopped the spreading of the ulcuscula and promoted the casting off of the sloughs. The gentle vomiting which calomel sometimes induced, and the few stools, which.it generally occasion- ed answered best; and did not suppress, confound, confuse, or pre- vent the natural course of the disease, by preventing the out-break of the eruption. NOTES ON DIPHTHERIA. 371 " Turpeth Mineral was t°° severe and caused too strong a revul- sion, thus preventing the appearance of the eruption. The disease did not well bear any other evacuations than those caused by mercurials. "Any detergent gargle, with the addition of the Tincture of Myrrh and Aloes, was of service, especially for the ulcuscula, and promoted the discharge of a tough ropy phlegm which was apt to lodge in the fauces. "As to the cuticular efflorescence, or eruption, it was not a Scar- let suffusion, but a miliary palpable eruption, evident to the touch by its roughness. MiliarisJ] In place of it, there was, in some cases, a gentle healthy sweat, without any eruption what- ever; and, in a few, there was no sensible cuticular excretion of any kind. In all, there was a peculiar odor, or smell, as if from morbid effluvia. "The appearance of the eruption and sweat were favored by the use of Snake-root tea; or when this caused an ardor or burning heat, instead of a gentle mellow sweat, spirits of hartshorn, or any other volatile spirit, given in small herb teas, like those of Catnip, or Balm, answered well. "Blisters and suppedanea, or'irritating applications to the feet occasioned a tedious or protracted eruption at the spot, even when the other symptoms were not violent; but in some, immediately on their application the eruption vanished from the surface, or became less vivid. "When the eruption began to decline a few loose stools were very refreshing to the patient; and when he was up, and had recovered a competent degree of strength, one or two purges to carry off any remaining feculency of the blood .and juices sometimes seemed advisable." Malignant Form. "In this they died on the ist, 2d, or 3d day by an irremediable necrosis, or corruption of the blood. The seizure was sudden, and marked by a sinking pain in the stomach, an extreme prostration of strength, and a titubating or shambling, stumbling pulse. In some there was stupor, at once; in others delirium; and a number had convulsions, all of whom generally died dozie. "There was generally some colliquation, such as continued vom- itings, purgings, or profuse sweats; while seme had a diffuse bloated- 372 DR. PETERS. ness of the habit [like general oedema?] or an infiltration of the neck, similar to that of Mumps. In general the texture of the blood and juices was so much necrosed, or destroyed, as to be ren- dered an incoherent puddle of corruption, attended with an intolera- ble fetor immediately after, or even before death. Bloodletting, and other debilitating evacuations, of course, accelerated the rapid fatal result." Although nothing is said about eruptions, it is probable that the majority of these cases were those of malignant scarlet fever. Still, in the asthenic form of diphtheria, according to Roberts, the gener- al symptoms are of a low type. The sense of illness and prostration becomes very great; the complexion and the whole skin often assume a dirty looking and opaque or yellowish tinge and have a peculiar feverish pungency, though the temperature is not high. The action of the pulse and heart is very frequent, small, weak, and irregular, or greatly lowered. The deposit on the pharynx is of the soft pulpy kind, and the throat discomfort may not be severe; but it is in these cases that extensive ulceration and sloughing are gener- ally met with. The breath becomes very fetid, and the decompos- ing matters are apt to be absorbed into the blood, causing septicaemia, with the usual typhoid symptoms. There is also, great swelling about the neck. Repeated vomiting and diarrhoea make the prog- nosis still more grave. [J. C. P.] Intermediate Form. In this, according to Dr. Douglass, "death, or recovery took place in 6 or 7 days. The symptoms of bad omen in this class were: a very great prostration of strength, dejection and despond- ency of mind, a titubating low pulse, and incessant vomitings, purg- ings, or sweats. "The tonsils became much inflamed and enlarged, endangering strangulation. The specks on the fauces assumed a brownish, or leaden color; and were ragged and jagged. There was a continued jactitation in some, and stupor in others. They refused all food, even diluting common drinks. "The skin was dry and parched; the eruptions appearing or disap- pearing, or else they were of an universal dark-reddish cast, continu- ing crude*for many days; and the darker and more livid they were, the more malignant would be the case. Sometimes the miliary pus- NOTES-ON DIPHTHERIA. 373 tales would be large, distinct and pale like sudamina, or even the crystalline small-pox. When strong cordials were used to sustain the patient, and irritating Alexipharmics to neutralize the morbid poison, the face and eyelids, arms, hands, legs and feet were apt to swell up, and be of a dark-red color, as in the most malignant small pox, or scarlet fever. "In some children the velum palati was much affected with swell, ing and sloughs, and there was an ichorous discharge from the nose, with the expectoration of many mucous masses resembling the [wash-leather-like] cuticle, [or sloughs or pseudo membranes] which form on the surface of blisters. Sometimes pus was brought up, although no sloughs or exulcerations could be seen on the fauces. In the more benign cases the specks or sloughs on the tonsils were cast off naturally; but sometimes mercurials and gargles seemed necessary to aid their falling off. The practice in some country places of pulling them off with forceps and spatulas was very hurtful, because the irritation caused thereby induced a further flux upon the part, and worse conditioned sloughs were formed than those which existed before. "In other cases, without being attended with any difficulty of swallowing, the disease reached far down the throat and bronchiae into the lungs, attended with all the symptoms of the New England Cynanche, or so-called croup, or malignant quinsy, and was often erroneously deemed to be such. The deeper the disease reached into the thorax, the greater was the danger." \Croupous Diphtheria "In some children who had scarce any appearance of disease in the throat, there were spreading ulcers behind the ears. \Cutaneous Diphtheria. "In others the tongue threw off a slough or exuviae which retain- ed the impressions of the papillae, and was formed of an inspissated mucus of the same nature with those mucous [or croupous] linings which were expectorated from the throat, oesophagus, or bronchiae. "Some had impostumations, or abscesses in the fauces followed by a fatal strangulation; while others escaped by their opening and the discharge of an ichorous curdy matter. "The fever was seldom too high, but often too low to produce any, much less a thorough and laudible eruption. In very plethoric subjects with high fever, a little blood could sometimes be taken with apparent advantage, or at least no decided injury. 374 DR. PETERS. "If the tonsils were much inflamed and swrollen, with a great pain or difficulty of swallowing, a small bleeding from the jugulars, or blisters to the nape of the neck, seemed to encourage the appear- ance of the eruption, or its succedaneum, a gentle breathing sweat. But profuse sweating was equally to be avoided as the production of a continued diarrhoea, as both of them confounded, perverted, and suppressed the natural course of the distemper." [Dr. Douglass has inveighed so heavily against bloodletting and blisters in this disease, that we can hardly help suspecting that he mistook some cases of ordinary tonsillitis and quinsy for the diph- theritic throat distemper. At least, it has become more than evi- dent, that unlike Dr. Colden and Dr. Bard, he was unable, or un- willing to separate his cases of Scarlet Fever from those of pure Diphtheria. He was vastly less modest, and infinitely more presum- ing than these great men, and doubtless was led astray by his vanity and enthusiasm. J. C. P.] "For the colliquative discharges, Oil of Cinnamon, decoction of white-oak bark, elixir vitriol, and burnt Rhubarb were useful. "When there were vigilance, jactitation, delirium, coma, or stupor, glysters, vesications, or suppudanea and other irritating applications to the feet and other parts were used" by Dr. Douglass, although he had greatly blamed their employment by others. "When faintness or great prostration appeared, toasted bread soaked in generous wine or small doses of volatile spirits of Harts- horn were good; but bezoars and cordial juleps were surgical shams and dreams." [From the October No., 1876, of the W. Va. Medical Student.] Notes on the History of the U, S. By DR. JOHN C. PETERsTof New York. FrAm the West Virginia Medical Student, June, 1876. 2 DR. PETERS. NOTES ON THE HISTORY OF DIPHTHERIA IN THE UNITED STATES. By DR. JOHN C. PETERS, of New York. BIPHTHERIA was well described by Dr. Cadwallader Colden, of New York, in 1753. One of the best treatises in any lan- guage is that of Dr. Samuel Bard, of New York, published in 1771; translated in Paris in 1810, and known to Bretonneau, who wrote in 1821. Then all traces of the disease were lost until Dr. Geddings, of Charleston, S. C., published an article on Pseudo-membranous In- flammation of the throat, in Vol. 24 of the Am. Journal Med. Sciences, 1839, in which he states that he witnessed an epidemic in Charleston. Dr. Ware, of Boston, wrote, in 1841, that he had observed about 20 cases in 12 years. 1 became acquainted with that fact in 1841. He stated that mem- branous croup always commenced as Bretonneau's Diphtheria of the throat, and I always examined the throats of my croup cases from that year on-but as the majority of the cases of croup are not mem- branous, I rarely discovered throat disease; and recollect 3 cases of fatal membranous croup in which throat membranes were not present. Dr. Welsh has an article in Vol. 20 of the Am. Journal Med. Sciences, on Diphtheritic inflammation as it prevailed epidemically in Ohio, in 1847-49. In the Boston Medical & Surjl Journal, Vol. 59, 1858, there is an article on Diphtheria in Providence, R. I. Dr. Willard, of Albany, N. Y., describes diphtheria as epidemic there in 1858, causing 157 deaths. The first case reported in New York, was, by Dr. Jacobi, on Feb. 15th, 1852, in a German woman, set. 24, residing at 638, Hudson St. It has prevailed ever since in that neighborhood. NOTES ON DIPHTHERIA. 3 Two other fatal cases were reported in 1857; five in 1858; and 53 in 1859. In Feb. i860, it became decidedly epidemic. In i860 there were 415 fatal cases. " 1861 " " 429 " " " 1862 " " 586 " " 1863 " " 944 " " 1864 " . " 805 " " 1865 " " 512 " " 1866 " " 435 " " " 1867 " " 251 " " " 1868 " " 276 " " 1869 " " 328 " " " 1870 " " 308 " " " 1871 11 " 238 " " 1872 " " 446 " " " 1873 no less than 1,551 deaths. In 14 years, from i860 to 1873 inclusive, it caused 7,124 deaths. It has steadily increased since 1872. We have had 1,523 cases and 735 deaths, in January, February, and March of this year, 1876 -winter quarter. In the same months last year, there were 1,346 cases. The 22d Ward, on the west side of the city, from W. 40th North to W. 86th St., west of 6th Avenue, has had the largest number of deaths in January, February, and March, 1876, viz.-97. The 20th Ward, just south of the 22d, extending from W. 40th South to W. 14th, west of 6th Avenue, the next largest, viz.-72. The 19th Ward, with the same boundaries as the 22d, except be- ing east of 6th Avenue, is the 3d on the list, viz.-67. The 23d Ward, is the 4th, with 57 deaths. The disease is mainly located along the North and East Rivers, north of 14th St., in tenement houses. The best wards in the city are comparatively free from it, and the down town business wards, of course. False Diphtheria, or Follicular Tonsillitis Is common among the better classes, but true Diphtheria is comparatively rare.