NOTES ON THE EARLY HISTORY OF 
DIPHTHERIA 
I.N 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 
.Sft)Y 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. DR. PETERS. 
10 
“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 countenan'ce. 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 corrode 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 bv hearing the patient speak, or cough. I11 
some the voice was almost entirely lost. \Croupous Diphtheria.] 
* * * These symptoms continued from 1 to 3 days; but by that 
time it was usual for them to 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 8 th. [ Croupous Diphtheria. ] NOTES ON DIPHTHERIA. 
11 
“In the family of Mr. W. W., one of the first to he 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 lever 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 I 2 
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 laiynx 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. 
J3 
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 Merpbranous 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 I [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. Huxham 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 
I)r. 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. 
*5 
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 Diphtheria.] 
“Upon the whole therefore, I (Dr. Bard) am led to conclude that 
the Morbus jStrangulatorius 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 trilling 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]/z 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 writh 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.” 
[ Diphtheritic Paralysis. ] 
From the above it is evident that I)r. 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, 
'l'he 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.]