SIR MORRELL MACKENZIE.

SIR MORRELL MacKENZIE, born in Essex, England, 1837, died in London, 1892.  In 1863 he founded the Throat
   Hospital.  His skill and dexterity in operating and the fertility of his resources combined to give him the largest
   practice in his specialty in England.  His writings consist principally of "Treatise on the use of Laryngoscope,"
   " Growth in the Larynx," " Manual of Diseases of the Throat," " Hygiene of the Vocal Organs."
§   J, E,  COPELAHD,  I,  D„
        ROUND HILL,  VA-
NATIONAL LIBRARY OF MEDICINE
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                  Gift of

  The New York Academy of Medicine
 
 
 
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(' --J.

^
 
 
    DIPHTHERIA;





ITS NATURE AND TREATMENT, ETC. 
OTHER WORKS BY  DR. MORELL  MACKENZIE.
GROWTHS IN" THE LARYNX; with Reports and an Analysis of
    One Hundred Consecutive Cases treated hy the Author.  Profusely illus-
    trated with wood engravings and chromo-lithographs. Octavo. Price, 82.00.

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satisfactory tabular record that any laryngoscopist has ever presented to  the
profession."—New York Medical Journal.
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the surgical treatment  of laryngeal tumors can afford to forego the study of
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last and decidedly the best section of the book is upon treatment. It is especially
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parative merits of the  different  operations and instruments."—Philadelphia
Medical Times.
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' . ( *,«. <. 'a *■> '
DIPHTHERIA;
ITS
NATURE AND TREATMENT,
Varieties and Local Expressions.
            BY


   MORELL MACKENZIE, M.D., Lond.,

 BENIOE PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THE THEOAT AHD CHEST,
  CONSULTING PHY8ICIAN TO THE NOETHEASTEBN HOSPITAL FOE CHILDREN,
AND LECTDEEB ON DISEASES OF THE THEOAT AT THE LONDON HOSPITAL MEDICAL COLLEGE.
     PHILADELPHIA:
LINDSAY & BLAKISTOX.
         18 79. 
tX6
' 11 tar9 
PREFACE.
   Nearly twenty years having elapsed since any English
work has appeared on the subject  of Diphtheria, and
medical views as to the  nature and  treatment  of the
disease  having  undergone  considerable  development
during that period, it  has  appeared  to me that a short
sketch of the affection, from one who has had consider-
able opportunities of studying it, might be of interest,
and possibly of use, to the profession.
   A malady which, under various names,  has existed
for so man}' thousand years, which  has been  so  widely
diffused,  and  which has caused such  dire havoc, must
always be of interest to the student  of medicine.
   The victims of the disease have generally  been chil-
dren of tender years, but vigorous youth has frequently
fallen under the scourge, and anxious  parents have too
often  suffered for their watchful solicitude.  In  its at-
tacks it shows no respect for distinctions of sex or social
position.   Rich  and  poor, strong and weak,  alike fall
beneath its  onslaught, and its  ravages are  greater  in
scattered villages than among  the crowded denizens  of
our great cities.
  Sanitary science  has not yet learned to bar its prog-
ress, and, in some instances, arrangements—professedly
hygienic—have even appeared to favor its entrance. 
VI                     PREFACE.
  Although  epidemics of  this  disease  have  not  in-
fluenced the progress  of civilization  like those plagues
of  the  Middle  Ages,  which  more especially attacked
adults, yet the historian may chronicle the fact that the
illustrious  "Washington died  from the disease  in  the
course of a few hours;  that the unfortunate Empress
Josephine,   whose  family  had  previously  shown  a
marked  susceptibility to  the  affection, quickly suc-
cumbed to  it; and that—since these pages were in type
—our  own country has  been plunged  into profound
grief through this fatal pestilence.
  Long shall we all deplore the loss  of the  gentle and
accomplished Princess whose soothing ministrations had
so often alleviated the sufferings of others.

                                             M. M.
  19 Harley Street,
          December, 1878. 
CONTENTS.
                    CHAPTER I.
                                                PAGE
Definition and History,.......13
                    CHAPTER II.
Etiology,...........22
                    CHAPTER III.
Symptoms,.........    .    .33
                    CHAPTER IV.
Paralyses,..........4o
                    CHAPTER V.
Diagnosis,...........50
                    CHAPTER VI.
Pathology,..........53
                   CHAPTER VII.
Prognosis,...........63
                   CHAPTER VIII.
Treatment,..........65
                    CHAPTER IX.
Laryngo-Tracheal Diphtheria,......79
                    CHAPTER X.
Nasal Diphtheria,........97
                    CHAPTER XI.
Secondary Diphtheria,.......98 
  " Un subietto cosi interessante per la scienza, cosi doloroso per le
famiglie, che mette tanta paura e tante apprensioni pur troppo guis-
tificate ai genitori che vedendo  scherzarsi all' intorno i loro figli dalle
bianche  e vermiglie  guancie, dai biondi e riccioluti capelli, dai
festevoli modi, dagli  innocenti solazzi, pensano che  in  poche ore
tanta copia di affetti,  tanta speranza di avvenire puo essere troncata
da questo morbo cosi spesso inaspettato, infrenabile dall'arte, e forse
incompreso dalla scienza."
                                                     Zannetti. 
DIPHTHERIA.
                      CHAPTER I.

                DEFINITION AND HISTORY.

   Diphtheria is a specific, communicable disease, occurring epi-
demically, cndemically, and solitarily * and  characterized  by
more or less inflammation of the mucous membrane of the pha-
rynx, larynx, or air-passages, and, by the formation on the sur-
face of those parts—especially on the mucous membrane  of the
fauces and windpipe—of  a layer  or layers of lymph or false
membrane, generally showing signs of bacteroid mycosis.   Dur-
ing an epidemic other mucous surfaces exposed to the air, and
wounded surfaces of the common integument occasionally, but less
frequently, become covered with a layer of lymph, subsequently to
or independently of a formation of membrane in the more ordi-
nary situations.  The disease is generally of an adynamic char-
acter, is often associated with a disturbance of the renal function
(cdbuminuri<i), and is frequently followed  by lesions of innerva-
tion rarely giving rise to permanent par<dysis.   The  symptoms
as rei/ards respiration, vocalization, and deglutition vary with the
site of the disease.   By far the larger proportion of fatal cases
terminate by gradu(d apncea, but a certain percentage sinl-from
asthenia, blood-poisoning,  and cardiac thrombosis.
   Several pages  might  be written  of  synonyms  which,  at
different times, have been  employed  in  describing diphthe-
ritic affections, but simple inflammatory diseases, distinctly
pellicular affections, and lesions of innervation have been  so
confused  together by the  earlier writers on medicine, that
  * I have used this wcrd in preference to the term "sporadic,"
which is commonly employed in connection with diseases supposed
to be' of spontaneous origin, or at any rate is applied to those which
it is presumed arise from accidental causes, independently of any
contugious influence.
                             2 
14
DIPHTHERIA.
there is little or no advantage to be gained by collecting
the numerous synonyms employed by different authors  at
various times.   The  term diphtherilis was  originally sug-
gested by  Bretonneau, who, observing that  the disease was
differentiated from other similar maladies by the formation
of a  false skin or membrane, coined  the word diphtherite
from the Greek  8>.<p0ipa, a skin or  parchment, and ite, from
hrjs  (el/Jit), hasty, impetuous, the well-known  termination
used in medicine to  imply inflammation.   Trousseau sub-
sequently  modified  the word to diphtherie,  in order to get
rid of the etiological  doctrine of inflammation which  the
affix indicated, and the term diphtheria was adopted by our
Registrar-General.   Names indicative of inflammation still
hold their ground, however, amongst German and  Italian
writers.
  The presence of a  membraniform deposit in the fauces
seems to have been regarded as a morbid condition, attended
with considerable danger to life, from the earliest times.  At
a time nearly coeval with that of Pythagoras, D'hauvantare,
an Indian physician,  had included in his "System of Medi-
cine"* a description which is very suggestive of diphtheria.
The  writer mentions  a  disease in  which "an increase of
phlegm and blood causes a swelling in the  throat, charac-
terized by panting and pain, destroying the vital organs, and
incurable."f  He also says, " a large swelling in the throat,
impeding  food and drink, and marked by violent feverish
symptoms, obstructing the passage  of the breath,  arising
from phlegm combined with  blood, is called 'closing of the
throat.' "J It has been supposed by  some that Hippocrates§
recognized the disease more than two thousand years ago,
  * This systematic work on medicine is written in Sanskrit by
D'hanvantare,  and compiled  by his pupil, Susruta.  A  Latin
translation, by  F.  Hessler, was published at Erlangen in 1844,
and is in the British Museum; it  has the following title:  " Sus-
rutas Ayurvedas ; id est Medicinae System a a Venerabili D'han-
vantare Demonstratum a S. Discipulo Compositum."   It is from
this translation that the quotations in the text are taken.
  t Ibid. p. 202.
  X Ibid. p. 205  The following passage may also possibly describe
diphtheria: "Si quis valde  lugens semper suspirat, interruptam
vocem, et aridum  solutumque sonum habet in respirationis viis,
phlegmate oblitis. hie morbus propter suspirium vocis occisor cog-
noscendus est."  Ibid. 206.
  \ " De Dentitione." 
HISTORY.
15
but it is extremely doubtful whether his observations really
referred to  diphtheria.   On  the other hand, " the Syriac
ulcer,"  described by  Aretseus* (prbhably  in  the time of
Augustus) is generally considered to have  more  points of
resemblance to the diphtheria of to-day than any other dis-
ease of  antiquity.  Describing ulcers on the tonsils, Aretseus
tells us that some are mild and harmless, while  others are
pestilential  and fatal.   The former—which  are common —
are  clean, small, and  superficial,  and are  unaccompanied
either  by pain or inflammation.   The latter—which are
rare—are extensive, deep, putrid,  and covered with white,
livid, or blackish concretion.   Aretseus theu goes on  to de-
pict the way iu which, in fatal  cases, the disease progresses,
stating  that " if it extends rapidly to the chest through the
windpipe, the patient  dies on the same day by suffocation."
About a century later, Galenf referred to the expectoration
of a membranous tunic from the pharynx, but did not actu-
ally describe diphtheria.  Coelius  Aurelianus,^ at the  end
of the third  century, describes the  " barking " sound of the
voice and its occasional  complete extinction, the  stridulous
breathing, and lividity of face.   His reference to the defect-
ive  articulation  sometimes present, and to  the  passage of
fluids iuto  the nose  in  swallowing, probably refer  to the
paralytic symptoms of the disease.  It is supposed that the
Askara frequently mentioned in the Talmud§ as a fatal
epidemic was, in fact,  diphtheria.  Rashi, the learned com-
mentator of  the  Talmud and Old Testament, remarks
with reference to the Askara, that  "sometimes it breaks out
in the  mouth  of a man, and he  dies from it."  He fur-
ther observes that " sudden death ensues from suffocation."
  * Aretacus: " De Causis et Signis Acutorum Morborum," lib. i,
cap.  9.
  f " Do Locis Affectis," lib. i, c. i.
  % " Dq acutis Morbis," lib. iii, c  2 et c. 4.
  | The word '' Askara " ({ODDN or rTODtf) means literally " clo-
sure," and is allied to the wurd Sakar (i^q), " to shut up " or " to
close."  Askara is frequently used in the Aramaic dialect of the
Babylonian and Jerusalem Rabbins.   Its effect is compared to
strangulation, and ils danger consists in its being communicable
to others.  Some modern lexicographers translate " Askara " by
"Croup."   Buxtorf,  in the Basle edition of the Talmud (1630)",
renders it by " Angina."  I  am indebted to the well-known He-
brew scholar, the Itev. A Lowy, for most of my information on
this subje'et. 
16
DIPHTHERIA.
Aetius, of Amida,* in the sixth century, delineated the dis-
ease as presenting white and ash-gray spots in the pharynx,
slowly ending in ulceration.  There is no record of the dis-
ease from that period until  the sixteenth century,  when  its
occurrence at Alkmaer, in Holland, in  1557, was described
by Peter Forest ;f its features were most accurately  sketched
by Von WoerdJ a few years later.
  It is not until  we  arrive  at comparatively modern times
that we find  diphtheria forcing itself upon the attention of
physicians as a  distinct disease.  Baillou, a  distinguished
French physician, who flourished in  the last half of the six-
teenth century, was the first to publish an accurate descrip-
tion.   It  is  in  his writings that we find the  first definite
mention of a false membrane.§   A few years later the same
appearance was noted by several Spanish physicians as oc-
curring in the  course  of an  epidemic  disease, which they
minutely portrayed under the name of "garrotillo."  The
best description  is that of Villa Real  (1611), who states
that he has seen a thousand times (millies vidi) in patients
at the first onset of the disease, a white matter in the fauces,
gullet, and throat.  He adds, that  this matter is  of such
nature  that  if you stretch it with  your hands  it  appears
elastic, and has properties  like  those of wet leather—facts
which he noticed, not only by observing the matter  ccjughed
up by the living, but also by the examination of it in  the
dead.|| The descriptions of Fontecha^f (1611)and Herrera**
(1615) are less  satisfactory,  as  containing no account  of
post-mortem  appearances;  but they are valuable  in so far
  * Petrabibl. Sermo  viii, cap. 4G.   Basil, 1535.
  f Obs. lib. vi, De febribus, etc
  X Chronik durch Sebastian Franken Von Woerd, bis auf die
Reirierung des Grossmechtigsten Kayser's  Carlo V, in das Jahr
1531,  angefangen, etc.,  1585.  (Cited by Zahn : " Beitriige zur
Patholniriscben Histologic der Diphtheric."  Leipzig, 1878.)
  \  Gulielmi Ballouii: " Epidemiorum etEphemeridum." Geneva,
1576,  libri ii.  " Pituita lenta contumax qua? instar membranre
cujusdMm arterise asperae erat obtenta."
  ||  Johannis de Villa lieal :  " De Signis, Cansis, Essentia, Prog-
nostico et Curatione Morbi Suffocantis."  Compluti, 1611, p. 35,
et .teg.
  f  " Disputationes Medicae," etc., opus Doctoris Fontecha.  Com-
pluti,  1611.
 ** " De Essentia Causis, Notis, Pnesagio, Curatione et Prsecau-
tione  Morbi Suffocantis  Garrotillo Hispane Appellati,'.'  auctore
Doctore Herrera.  Matriti, 1615. 
HISTORY.
17
as they confirm the fact of the prevalence of garrotillo in
Spaiu between the years 1581 and 1611.  Some years sub-
sequently to the latter date diphtheria appears to have pre-
vailed as a fatal epidemic in Naples and other parts of Italy.
Sgambatus* tells  us that in 1617  a highly contagious affec-
tion of the throat appeared, attacking the children of rich
and poor  alike, and often sweeping away  whole families.
In  referring to this  epidemic, some years later, Severinof
for the first time clearly described  diphtherial paralysis.
The same epidemic is  depicted  by Nola| and Carnevale,§
and the latter asserts that  it was identical with that which
had been  prevailing in Spain, under the popular name of
"garrotillo."  The writings of Cortesius|| (1625) renders it
nearly  certain that  the  same disease extended somewhat
later to Sicily.  A membrane in the throat, which could be
readily torn away, is distinctly described as  being one of its
symptoms.  The  works of Alaymus^[ (1(532) and of Aetius
Clelius** (1636)  have  also  been  quoted as affording cor-
roboratory evidence of the prevalence of diphtheria in Italy
and Sicily during the seventeenth  century.  Medical litera-
ture is then silent on the subject for nearly a century, but
after that  time follows  a rapid series of observations from
different parts of  Europe. In 1713 Dr. Patrick Blair,ft in
a letter to Dr. Mead, described a  disease as " the  croops,"
which, he says, " was epidemic and  universal " at  Coupar
Angus, and which was no doubt diphtheria. In 1748  Ghisi^|
observed  an epidemic of the disease in  Palermo, and no-
ticed the paralytic  phenomena;  and in  the same year Dr.

  * " De Pestilente Faucium Affectu, Neapoli Sasviente  Opuscu-
lum," auctore Andrea Suambato.  Neapoli, 1620.
  f "De Pedanchone Maligna," etc.  Neapoli,  1643.
  X " De Epideinico Phlegmone Anginoso  Grassante  Neapoli,"
Franciscus N<>bi.   Venetiis, 1620
  \ " De Epideinico Strangulator^ Affectu in Neapolitan! urbem
Grussanti et per regna Neapolis et  Siciliae Vngante,"  auctor Jo
Baptista Camevale  Neapoli, 1620.
  || Johannis Baptistae Cortcsii :  " Miseellaneorum Medicinaa De-
cades Denae."  Me.-sunae, 1625.
  *l Marci  Antonii Alaymi : " Consultatio  pro  Ulceris Syriaci
nunc Vagantis Curatione."  Panhormi, 1632.
  ** " De Morbo Strangulatorio," opus Aetii Cletii Siguini. Roma,
1636.
  |f " Observations in the Practice of Physic," etc. London, 1718.
  + + " Lettere Medicue del Dottore  Martino Ghisi."  Cremona,
17J9. 
18
DIPHTHERIA.
Fothergill* described an outbreak of scarlet fever, in which
the throat-symptoms often led  to a fatal  result.   Most of
these  cases were  undoubtedly examples of oedematous  in-
flammation, but it is  possible that some were of the nature
of secondary diphtheria.   In 1749  Marteau  de  Grandvil-
liersj" described an outbreak of the disease  in Paris, and the
elder  Chomel.J in detailing the symptoms, accurately de-
picted diphtherial paralysis.  In 1750  the formation of a
niembraniform concretion  in  the throat  is  distinctly de-
scribed by Dr. John Starr,§  as occurring as an epidemic in
Cornwall, and in 1757 a  similar observation was made by
\Vilcke|| in Sweden.   In the same year  Dr. Huxham^[ de-
scribed an epidemic which had been  prevalent at Plymouth,
in which some of the cases were examples  of scarlatina an-
ginosa. whilst others  were undoubtedly cases of  secondary
diphtheria.
  At  length the attention  of the profession was fully called
to the peculiar characteristics of diphtheria by Dr. Francis
Home,** who, in 1765, under the name of croup, described
an acute affection of the larynx and trachea, coming on in-
sidiously, attended with the formation of a  membrane in the
pharynx and air-passages, and often causing deatn  by suffo-
cation.   Home appears to  have been  the first to notice the
quick, weak  pulse  which  is  often  present in the disease.
The treatise of the Scotch physician attracted the attention
of Dr. Michaelisff of Gottingen, who, in an essay published
in 1778, confirms and supplements his observations.  From
time to time epidemics of scarlatina were described in which
the throat symptoms predominated,  and some of these nave
  * "An  Account of the  Sore Throat attended with Ulcers," by
Dr. John  Fothergill.  London: Fifth edition, 1769.
  f "Dissertation Historique sur l'espece de Mai de Gorge Gan-
greneux qui a regne parmi les Enfants l'annee dernieie."  Pai is,
1749
  X "Dissert. Hist,  sur l'aspect du Mai  de Gorge Gangreneux,"
etc.  Paris, 1749.
  \ " Philosophical Transactions."  1752, vol. xlvi, p. 435.
  || " Dissertation Medica de Angina Infantum in Patria Reeenti-
oribus annis Observata."  Wilcke, Upsalse, 1764.
  \ " A Dissertation on the Malignant  Ulcerous Sore Throat,"
1757.
 ** " An Inquiry into the  Nature, Cause*, and Cure  of Croup,"
by Francis Home, M.D.  Edinburgh, 1765.
 ff " De Angina Polyposa Membrancca."  Gottingen, 1778. 
HISTORY.
19
been wrongly supposed to have been examples of diphtheria.
The next record of the disease  comes from America, where
in 1789, Dr.  Samuel  Bard,* of Philadelphia,  published a
minute  account  of "an  uncommon and highly dangerous
distemper" which had recently proved fatal to many chil-
dren in  New  York. Dr. Bard was a careful and painstaking
observer, and his monograph contributed very considerably
to the accuracy  of contemporary knowledge with regard to
diphtheria. In 1798f another American physician, Dr. John
Archer, published an interesting paper, and recommended a
new remedy for  the disease. In the year 1801, Dr. Cheyne,|
a British physician, published  an essay, in which  he dis-
tinctly  portrays diphtheria, under the name of cynanche
trachealis or croup.   He  recognizes it as the same disease
as that  referred  to by Baillou, Ghisi, Home, and Michaelis,
and gives a minute description and plates of the false mem-
brane found in the trachea after death.  In 1802, Dr. Cul-
len,§ the well-known professor of the practice  of physic in
the University of Edinburgh, gave a description  of cynanche
trachealis, in  which we cannot fail to recognize the diphtheria
of modern times.  For many years after its appearance Dr.
Cullen's work was the favorite  textbook ou medicine, with
all British practitioners and students, and its author, there-
fore, may claim the credit of having rescued diphtheria from
the region  of discussion and monographs, and of having
given it a fixed and recognized position in  medical science.
The disease,  however, was  evidently still  a rarity in  the
British  Isles, and it probably only occurred in the isolated
form.   In France the case was otherwise;  the disease was
well known as a frequent visitor, under the name of croup,
and, having caused the death of some of the members of the
Imperial family in 1807, a prize was offered by Napoleon I
for the  best essay on the subject.  This led  to  the  publica-
tion of  the valuable works of  Albers, Jurine, and Royer-
l <ollard, works which were  worthy predecessors of the clas-
  *" Transactions  of the American  Philosophical  Society."
Philadelphia, 1789.
  f " An Inaugural Dissertation on Cynanche Trachealis, com-
monly called Croup or Hives."  Philadelphia, 1798.
  X " Essays on the Diseases of  Children, with Cases and Dissec-
tions," by John Cheyne, M.D.  Edinburgh, 1801.
  $ " First Lines of "the Practice of  Physic," by William Cullen
M.D.  Edinburgh, 1802, vol. i, p. 219. 
20
DIPHTHERIA.
sical memoirs of Bretonneau.*   The latter owed their origin
to an alarming outbreak of the disease  at Tours, in the latter
partoftheyearl818. The epidemic was carefully investigated
by Bretonneau, who published an account of his researches
in 1826.  An accurate description of " diphtherite" was given
by Dr. Abercrombie, in a  work published in 1828.f   The
disease appears to have  prevailed in an  epidemic form in
Edinburgh, in  the year 1826, but otherwise  it  was  by no
means a  common  affection  in  this country.   In fact, after
the brief notoriety conferred on  diphtheria by the works of
Dr. Bretonneau, the disease seems to  have passed from the
minds of English  physicians, and its very  existence to have
been almost forgotten.  It  still occurred from time to time
in all parts of Europe, but it did not excite attention to any
great extent, until the year 1853, when it broke out with
some  violence in Paris.  In 1855, an epidemic at Boulogne,
which was especially fatal  to the resident English, excited
considerable attention, and during the two following years,
serious outbreaks  were reported from different parts of
France.   The first case of the greatest epidemic of the dis-
ease, which, as far as is known, has  ever occurred  in  this
country,  was imported from Boulogne to Folkstone in 1856,|
but it was not till  1858 that the disease attained very alarm-
ing proportions in this country.   Spreading, as it seemed,
from  many independent centres, it raged as  a  widespread
and fatal epidemic during 1859, and  continued very seri-
ously prevalent during the three following years.§   Since

  *  " Des Inflammations Speciales du Tissu Muqueux eten particu-
lier  de la  Dipbth6rite."  Paris 1826.  The tirst mention  of  Bre-
tonneau's memoir, which was read before  the Academy, appeared
in Guersant's "Diet, de Med.," t. ii, vi, and xix,  1821-1823, but
his essay  was not issued till three  years  later.  This memoir, as
well as those subsequently published by  the same  author, was
translated (together with other selected essays by different French
physicians) by Dr.  R. H. Semple, for the New  Sydenham Society,
in 1859.   The work is entitled " Memoirs on Diphtheria, from the
writings of Bretonneau, Guersant,  Trousseau, Bouchut,  Empis,
and Daviot."  Mr.  Chatto added a very complete bibliography to
this work, which the author has found of great service.
  f " Pathological and Practical Researches on the  Diseases of the
Stomach," etc., by John Abercrombie, M.D.   Edinburgh, 1828.
  X  " Reports of the Medical Officer of the Privy Council."  No.
ii.  London, 1860.
  I The best accounts of the epidemics of that  period, are those of
Mr. Ernest Hart: " Diphtheria," London, 1859, and  Mr. Netten 
HISTORY.                      21
that time diphtheria has not appeared in England with any-
thing  like  the  same  malignancy;  it  still claims several
thousand victims annually,  but its  invasions are, for  the
most part, circumscribed in area, and  both in this country
and on the Continent, only expand from time to time into
limited epidemics.*
Radcliffe : " The Recent Epidemic of Diphtheria," " Trans, of the
Kpidem. Soc."   February,  1862.  The  main features of this epi-
demic, as it appeared in London, are graphically depicted by Sir
William Jenner, in his two lectures on " Diphtheria, its Symptoms
and Treatment," London, 1861, and a  more detailed description
of the disease has been given by Dr Headlam Greenhow, in his
classical monograph " On Diphtheria," London, 1860.
  * This short historical sketch is only intended  to give a general
idea of the occurrence of the disease at previous periods.   Ekr an
exhaustive treatment of the subject, the reader is referred to the
following works, as well as  those mentioned in subsequent notes  :
Deslandes:  " L'Angine Couenneuse et le Croup, consideres sous le
rapport de l'etat local  qui  les  constituent, sont  ils identiques?"
"Journ.  des Progres des Sc. Med.," t. i, p. 152, 1827.  Fuchs  :
" Historische Untersuchungen tiber Angina Maligna und ihr Ver-
haltniss zu Scarlach und Croup."  Wurzburg, 1828.  Geddings  :
"On Pseudo-membranous Inflammation of the Throat."  " Amer.
Journ. of Med.  Sci.," vol. xxiv, p. 73, 1839.   (These three  author-
ities are cited by Chatto : loc. cit.)  Jacobi's article on Diphtheria,
and Rauchfuss's contribution to  Croup, the former contained in the
second volume,  and  the latter in the  third volume (second part) of
Gerhardt's magnificent work, " On Diseases of Children,"  Tubin-
gen, 1877-78, contains  the  most complete  bibliography since the
end of the last century. 
22
DIPHTHERIA.
                    CHAPTER  II.

                       ETIOLOGY.

  The exciting cause is a specific contagium, and those cases
which appear  to originate  de  novo, probably always arises
from the virus—often long  dormant and forgotten—of pre-
vious cases.  Tender age is  the principal predisposing cause,
but the accidendal existence  of pharyngeal  catarrh, or of
any disease which lowers the system, probably increases in-
dividual receptivity.   Family constitution also often exer-
cises an unfavorable influence.
  The  natural history of the  contagium has not yet been
elucidated.  Some information has been obtained as to the
atmospheric conditions and temperature under which  the
poison  exists  and flourishes, but considerable  uncertainty
exists as to the laws which govern its development and ef-
fect its  diffusion.   The mode  or  modes  also in which  the
disease-producing virus enters the system, and its period of
incubation, have not yet been accurately determined. These
various points will now be considered in detail.
  The  Nalural History of the  Contagium.—The contagious
principle has not been isolated, although it is highly prob-
able that it consists  of minute particles of  matter, which
are capable of floating in  the atmosphere, and attaching
themselves to rough surfaces (see Mode of Diffusion).   The
doctrine has been put forth by Oertel,  Hueter, Nassiloff,
Letzerich, and others, that a minute fungus is the essential
contagium.  The views of  these authors  will  be referred to
in detail in treating of the  pathology, and it is  sufficient to
state here that the observations are not sufficiently conclu-
sive to  warrant us  in considering that the essence of the dis-
ease has yet been  discovered.  Low vegetable  organisms
probably play an  important part in the propagation of the
disease, but the.exact relation  between  the disease and the
organisms has not yet been made out.   The experiments of
Oertel, Letzerich, and others, if uncontradicted, would only
show that micrococci are an invariable concomitant of diph- 
ETIOLOGY.
23
theria;  that they are the sole or even the main agent in its
causation cannot as yet  be considered proved.  Dr. Mac-
lagan* has, however, clearly shown that " the germ theory"
explains all the phenomena of the specific fevers, and in a
matter, which is at present beyond inductive proof, analogy
is of  the highe.-t value.  For a further consideration of this
subject, the reader is referred to the section on Pathology.
  In  considering the etiology of the disease, it is  most im-
portant to determine whether it can originate de novo or not.
Although the disease so often arises in connection  with  bad
drainage, foul habits, and impure water supply ; and although
it is so often impossible to trace the remotest channel ot con-
tagion,  yet the  whole tendency  of sanitary science is op-
posed to the doctrine of the spontaneous origin of specific
diseases.|   It  must  not  be forgotten that in those cases
where the disease appears  to enter  the system through the
use of  drinking-water contaminated with excrementitious
matter, the specific germs  of the disease, derived from  per-
sons previously suffering from it, may have found their  way
into the water.   I have frequently known the disease occur
suddenly in remote country districts, where careful inquiries
have  failed to discover the smallest  evidence of infection,
but similar  phenomena  are often observed  in  connection
with  scarlatina and small-pox—diseases which  no one would
now  attribute to a  spontaneous  origin.J  A very remark-
able  instance of the apparently spontaneous  origin of the
disease  was  observed last  year  by Dr. Semou, at a small
health  resort, called  "Bad Fusch " in  the Tyrol.   The
place, consisting only  of two  houses,  is situated at  an
elevation of from  3000 to 4000  feet above the sea, and  is
celebrated for its fresh air and pure water.  In one of these
houses a little girl, five years of age, who had left Vienna
  * " The Germ Theory," etc.   London, 1876.
  f Simon: "Sixth  Report on  Public  Health," quoted by Dr.
Aitken : "The Science  and Practice of Medicine."  Sixth Edi-
tion.  Vol.  i, p. 338.  See also Sir Thomas Watson's article  on
"The Abolition  of  Zymotic Disease"—"Nineteenth Century,"
May,  1877.
  X" Dr. Kelly also states as the result  of his experience as the
sanitary officer of a wide tract of country, that diphtheria often
appears in lonely  outlying places, far away from any main road ;
and often no history of contagion can be traced at all.   "Second
Annual Report of the Combined Sanitary Districts of West Sus- 
24
DIPHTHERIA.
five weeks previously, was suddenly attacked with diphthe-
ria, which  was  subsequently followed  by paralysis.  The
visitors consisted almost entirely of tourists, ascending the
high  mountains  in the  neighborhood.   Although other
children had been playing with the little girl up to the day
on which she was attacked, no other case of the kind occur-
red.   It need scarcely be said that the outbreak of the dis-
ease in this case may, however, also be explained in accord-
ance with the theory of contagion.
  Climatic and Atmospheric  Conditions under which the Con-
tagium Lives and Flourishes.—The  disease exists in  almost
every country, but it is most common  in temperate climates.
The contagion lives under ordinary atmospheric conditions,
but it is probable that dampness favors its development.  It
occurs in the tropics, but does not appear to have been no-
ticed in the Arctic regions.   It seems likely that the germs
may remain dormant, external to the body, for a  considerable
period, and may only develop under  the  stimulus of  some
particular atmospheric conditions,*  or when a suitable nidus
presents itself.   In making  statistical inquiries, with refer-
ence  to  the registration of disease in  sub-districts, Dr.
Thursfieldf found  in certain  isolated hamlets and houses
where in recent  years he  had been called upon to investi-
gate cases of diphtheria, that at intervals of five, ten, fifteen,
twenty-five, thirty, and even more years, there had  been
previous outbreaks of fatal sore throat.  An instance  is  re-
corded  by  Dr. William Squire,% in  which the  virus  re-
mained  latent eleven months, and then led to  the develop-
ment of the disease when a person occupied  the  room in
which a case of diphtheria had previously occurred.  I  have
known the  poison to remain dormant for four, seven, and
fifteen months, and in one instance for three years, and then
again to become active. From the above considerations the
vitality of  the disease-germs would  seem to be considerable.
  In Great Britain  the disease  has generally been preva-
lent in those parts of the country where the rainfall is great,
in villages  situated  in valleys, or in places where there  is
not sufficient fall to get rid  of the  surface drainage, but  it
* Sanne :  " Traite de la Diphtheric"  Paris, 1876, p. 231.
f " Lancet,"  vol.  ii, 1878.  Nos. vi,  vii. viii.
X Reynolds's  '■ System of Medicine," vol. i, p. 379. 
ETIOLOGY.
25
has also been  frequently met  with, and  shown  great  epi-
demic  persistency, in high, dry, and  exposed situations.
  The disease is much more common  in rural than in urban
districts.  Whether, however, this fact points to the greater
humidity which prevails in the country, or to the absence
of proper drainage, is  not  at present certain.  According
to Dr. Thursfield,* whose experience as a sanitary inspector
extends over twelve hundred square miles, "with a popula-
tion of rather more than two hundred thousand, of which
rather more  than  one  hundred  thousand are rural,  the
number of fatal cases of diphtheria in the rural portion  is
nearly three times that in  the  urban  portion."   The same
author remarks that whatever conditions seem  to promote
fungoid growth, would appear to favor the incidence  and
persistence of the disease, and the explanation of the com-
parative immunity of towns may be  the  presence of some-
thing in their atmosphere inimical to such growth.
   Until recently the extension of the disease was considered
to be  independent of season, but the  observations of Wib-
merj"  and ThursfieldJ tend to  show  that it  prevails more
extensively  during the winter months than at other periods
of the year.  Many severe epidemics have, however, steadily
raged  through the whole round of the year, in spite of the
most varied changes of weather and temperature.
   Mode of  Diffusion.— Considerable  difference  of opinion
exists as to  the mode in which  the poison is diffused.   The
disease may be imparted to others by a  person  actually or
lately  suffering from it, but the extreme  difficulty of effect-
ing artificial implantation would tend to show  that direct
contagion is rare.   From this fact, it would seem  probable
that  the contagium, when  set free from  the affected indi-
vidual, undergoes  further  development (as in the case of
cholera and typhoid fever), which increases its disease-pro-
ducing properties.  It is asserted  that the  poison may be
conveyed by a person not actually affected  by the disease.
Dr. Thursfield^  has reported a  very remarkable case, in
  * Loc. cit.
  f " Statistiscber Bericht iiber die Munchener Epidemien, 1864-
69," quoted bv Oertel : Ziemssen's " Cyclopaedia," vol. i, 590 ; also
"Deutsch. Arch. f. kl. Med.," 1870, vol. viii,  p. 242;  " Experi-
mentelle  Untersuchungen iiber Diphtheritis," p.  346.   See  also
Rauchfuss, loc. cit. p. 150.
  X Loc. cit.                        \ Loc. cit. 
26
DIPHTHERIA.
which a woman living in an infected house, but not at  any
time suffering herself, walked a mile  or  two and  crossed a
ferry to visit a friend.  She only remained a short time in
the house, but sufficiently long to leave the germs of diph-
theria, which broke  out  a day or two  afterwards.  This,
however, is such an exceptional example, that the possibility
of the malady having arisen from other  sources  must be
borne in  mind.   In one instance I have known the disease
caught from a patient who had entirely recovered from it
four months previously; but whether it was conveyed by
the person or the clothes of the individual, it was impossible
to determine.   In solitary  cases,  the  contagion does not
usually assume  a virulent  form, and proper measures are
almost invariably successful in confining the disease to a
limited area.  The distance at  which the contagious  prin-
ciple can operate, as a rule, appears to be more limited than
is the case in typhus or small-pox.   Thus I have known an
instance  in which seven  children  were affected in a house
which had a residence on each side of it and a  third oppo-
site, at a distance of only twenty-four feet.   Although in all
these buildings there were young children, no other case of
diphtheria occurred.  Other similar illustrations of this fact
are on record.*  Under certain circumstances, however, the
diffusive powers are increased, and, as appears to be the case
in epidemics of influenza, the  poison may be wafted over
extensive tracts of country.
  The germs of diphtheria appear to have an affinity for
the walls of rooms, and, according to some observers,  may
attach themselves to clothes and articles of furniturcf  It
is probable that, by the introduction of such  things, the
poison is often diffused.
  Manner in ivhich the Poison enters the System.—The poison
may be received into the system (a) by direct implantation ;
(b) through the  circumambient air; (c) through  the water
that is drunk or the food that is eaten.   Further, it is pos-
sible that it may occasionally be introduced by inoculation,
either  with portions of false membrane or with  the blood of
a patient suffering from the disease.
   (a) The  melancholy deaths of Valleix and Henri BlacheJ
  * Thursfield, loc. cit.
  f Sanne, op. cit.
  X Trousseau, " Clin.  Lectures,"  New  Svd Soc. Trans., vol. ii,
p. 497. 
ETIOLOGY.
27
show that the disease may occasionally originate from direct
implantation.  M.  See* has reported a  case  of the  same
character, in which a woman suckled a child  affected with
diphtheria.   In consequence, her own child, which she was
nursing at the same time, contracted labial diphtheria, and
communicated it to the mother, who frequently kissed her
infant.  An instance of direct implantation has been related
by Professor Bossi,f in which a greyhound was seized with
symptoms akin to those of diphtheria four days after  swal-
lowing the excrement of a child who died of that disease ;
after  death, a membranous  exudation  was found on the
 animal's fauces.!
  (b)  The contagion which exists in the  secretions and ex-
halations of the sick, may pass into the air and find its way
directly into the healthy organism  by absorption through
the lungs or through the mucous membraue of the throat;
or the secretions of the sick may pass into drains, and sewer
gas, holding the disease germs in  suspension, may be after-
wards inspired.
  (c)  The  poison may be conveyed through food or water
(or other fluid used for drinking purposes), as in the analo-
gous case of typhoid fever.   Here it may be mentioned that
Bossi's case, referred  to above, may be an example of the
manner in which the poison is absorbed through the aliment-
ary canal, not an example of direct implantation.   In many
of the cases of diphtheria which I have seen during the last
few years, the drinking-water was  found to be contaminated
with excrementitious matter.
  As regards direct inoculation with diphtheritic membrane,
the experiments made with false membrane, by Trousseau,§
Peter, and   Duchamp,|| upon   themselves, and  by Dr. G.
  * " Bull de la Soc. Med. des Hop.," t. iv, p. 378.
  f Sir J. R. Cormack, " Clinical Studies," vol. ii, p. 273 ; " Lo
Sperimentale," 1872, p. 230.
  X Dr. Sanderson has placed on record a somewhat analogous illus-
tration :  Three sows which had access to a piece of waste ground
oh which " the discharges or concretions " of some patients suffer-
ing from diphtheria were thrown, quickly died with symptoms of
suffocation, enlarged  submaxillary glands, and, in one case, with
diphtheritic membrane in  the fauces.—" Reports of the Medical
Officer to the Privy Council." London, 1860.
  I Op. cit. p.  335.
  || " Du role des parasites  dans  la diphtheric."   "These de
Paris."   1875. 
28
DIPHTHERIA.
Harley,* upon animals, gave only negative results.  In the
experiments of Trendelenburgf and Oertel,J  on rabbits, a
diphtheritic membrane formed in the  trachea, as the result
of direct  irritation of that part with diphtheritic matter,
and the animals died on the second or third day, with acute
kidney disease and symptoms of general infection.   Nassil-
off'§ and Eberth||  have produced diphtheritic keratitis  by
direct inoculation, while Hueterand Tommasi^f and Oertel,
in their experiments on  the muscles, found that soon after
inoculation, a diphtheritic layer appeared round the edges
of the wound, hemorrhagic  inflammation was  induced in
the muscles, and the  animals died on the second day from
general blood-poisoning.  Although, in  some of these  ex-
periments, a false membrane was produced, the  septicaemia
may have been merely the result of inoculation with decom-
posing animal matter,  and it cannot be considered that true
diphtheria, with  its  specific manifestations, has  yet been
artificially produced  by inoculation of  the lower animals,
though  certain local  phenomena of great interest  and  im-
portance have been induced.  The remarkable case related
by Dr. Paterson,** has an important bearing on the question
on the inoculation with diphtheritic membrane:  A man  put
his finger down  the throat of a child suffering  from diph-
theria.  The finger had a wound upon it at the time,  which
shortly  after  became  ulcerated.   All  the  constitutional
symptoms  of diphtheria subsequently appeared, and were
followed by general paralysis of the extremities.
  A few cases are on record in  which medical practitioners
are said to have been inoculated with blood, i. e., to have be-
come  infected  through the  accidental  prick of  a lancet
smeared with blood of a patient suffering from  diphtheria,
but as it is extremely difficult to inoculate successfully with
blood in other diseases of much  higher contagious power, it
is very improbable that diphtheria can originate  in this
way.jf Moreover, it must not be forgotten, that in the cases
  * " Pathological Transactions," vol. x, p. 315.
  t " Arch, fur Klin. Cbiiurgie," 1869, x 2.
  X Loc. cit.            \ Virchow's " Archiv.,"  1870, p. 550.
  || " Correspondenzblatt," 1872.
 \  " Centralblatt f. Med. Wissenscbaften," 1868, p. 34.
 ** " Medical Times and Gazette," 1866.
 ff Dr  Klein, Experimental Contribution to the Etiology of
Infectious Diseases."  "Quarterly Journal of Microscop. St'.,"
vol. xviii, p.  169, et seq. 
ETIOLOGY.
29
referred to, the medical men attacked were exposed to the
general influence of the contagion.
   Period of Incubation.—The period of incubation is exceed-
ingly short—generally two or three days ;  but on the other
hand, the germs of the disease may remain about the per-
son subsequently attacked for some weeks before  the com-
plaint makes its appearance.  In  illustration of the first-
named fact, the following case, which came under my own
observation,  may be cited :  A girl, aged six, who had been
absent from home for five weeks, returned  one afternoon at
four  o'clock.   Her  young  brother, aged four, had  shown
symptoms  of sore-throat the same morning, but no suspicion
was entertained that the disease was diphtheritic. These two
children remained together till  bedtime, but did  not sleep
in the same room.   The next morning  both of them  had
marked diphtheria, with an abundance of  false membrane.
The little girl had not been subjected to any infection before
reaching her home.  On the other hand, I  have known one
instance in which  the disease occurred  fifteen  days after
exposure to contagion ;  a  young lady,  aged  eighteen, in-
sisted, contrary to the advice of her friends, in paying a visit
to her cousins  living  in  London,  who were  convalescent
from  diphtheria.    She spent about two hours in their  so-
ciety, and  then returned to her home in  the country.   Fif-
teen days after her visit, she was attacked with diphtheria.
   Prcdispoiiarfs.—The most obvious  predisposing  cause, is
age.   From an analysis* of nearly 70,000 fatal cases con-
tained in the returns of the Registrar General, it appears
that in every thousand fatal cases,  the age at  death is as
follows:—

      Under 1 year, .......    00
      From 1 to  5 years,.....4",()
       "   5 to 10   " .    .    .   .   .   .   260
       "   10 to 15   "......90
       "   15 to 25   "......50
       "   25 to 45   "......,3f,
       "   45 years and upwards,  ....    25

  Again  in the Florentine epidemic,f  out of 1546 cases,
  * Thursfield, loc. cit.
  f Dr. Borgiotti, Capo medico del UffizodTgiene e Bencficenza,
in the "Rendiconto amministrativo della Giunta al  Consi^lio
Communale di Forenze," collected a series of the most valuable
                           3 
30
DIPHTHERIA.
occurring in the years 1872  and 1873, in only fifteen were
the patients over  thirty years  of age.  These  figures  are
markedly different  from any which could  be compiled of
other zymotic diseases.   It will  be seen from the Registrar-
General's figures, quoted above,  that the disease is compara-
tively rare  in children in their  first year, and it was once
generally supposed that the infection invariably passed over
the recently born.   It has  been conclusively shown, how-
ever, that such is not always the case. Bretonneau,* De\vees,f
and Billard,! have recorded cases in  which diphtheria at-
tacked infants  at  the breast, and  M. G. Siredey§ has re-
cently collected  several similar  observations, the disease in
one case manifesting itself on  the third day after birth.
Sex does not influence the incidence of  the disease to any
appreciable extent; for  although, according  to  the Regis-
trar-General's returns, the mortality of females from diph-
theria is rather higher than  that of males,  the reverse  ap-
plies  to "croup," a term under which  a  very  large  propor-
tion of the cases of diphtheria are  returned.  Next in  im-
portance to age as  a predisposing cause would  seem to come
family susceptibility.\\   The liability of diphtheria to attack
the members  of certain  families is well  proved.   Sir Wil-
liam  Jenner^[ lays great stress  upon family constitution as
being "one of the  most  important  elements favoring  the
development  of the disease and determining  its progress."
statistics  on the Florentine epidemic, of 1871-73, but unfortu-
nately they are buried in the municipal archives.  I am indebted
to Dr.  "Wilson, of Florence, for most  kindly copying Borgiotti's
figures from the source referred to.   Dr  Borgiotti's views are,
however, given with considerable detail in the " Atti dell'Acade-
mia Medico-tisica Fiorentina,"  1871, '72, '73.  Some of the tables,
as well  as much other valuable information, are contained in the
" Istoria  Clinica della Difterite osservata nella Citta di Firenze e
suoi intorni dai 1862 al 1872."  Per  Carlo Morelli  e Leopoldo
Nesti.  Firenze, 1873.
  * " Traite de la Diphtherite," p. 36.
  f " Diseases of Children," p. 426.  Philadelphia.
  + "Traits des Maladies des Enfants Nouveau-nes," p. 522, etc.
  g "The.se des Paris."  1877, No. 338.
  || Two  very painful  examples of intense family susceptibility
have been  recently reported ,  in one case eight, and  in another
case six children in one family  were cut off by the disease within
a few days.  See " Lancet," 1877, vol.  i,  p. 919, and " Return of
the Registrar-General of Ireland for the last quarter of 1876 "
  If Op.  cit. p.  51. 
ETIOLOGY.
31
He quotes one case in which five members of a family took
the disease, two in which four, and eight in which two were
affected.   In the Florentine epidemic, in four cases diph-
theria  proved fatal  to  three members, and in twenty-two
cases to two members of the same family.  Some remark-
able instances of family susceptibility have come under my
own notice.   In one case a poor woman had three children
of her own, and took care  of two others in no way related
to herself; her own  children were attacked by the disease,
and one  of them  died.  The  two other children, not her
own, who were constantly in the same room with the little
patients, never suffered  from the disease.  In another case
four families occupied a house near Woodford, in Essex.  In
all of them there were several children.  Two of the families
were related, the mothers  being  sisters.   All the children
who were related  to each other had  diphtheria severely,
whilst the children  of  the other two families escaped  en-
tirely.  During the progress of the disease no attempt  at
isolation was  made, the healthy children frequently enter-
ing the rooms of the patients.
   Social position has very slight, if any, influence on the dis-
tribution of the  disease.  In its  endemic form it is true that
it rarely attacks those  who live in  healthy and well-ven-
tilated  houses, but where it is epidemic, it manifest no  re-
spect for social rank or wealthy surroundings. Under these
circumstances, as  Dr. Green how remarks, "station  of  life
and the enjoyment  of  affluence or exposure  to the priva-
tions of poverty seem to have but small influence either in
predisposing persons to take or to suffer severely from  the
disease."*- ' The statistics  of Dr. Borgiott'rf  tend to show
that daring an epidemic of diphtheria no importance is to be
attached  to the  hygienic condition of a locality as a cause
of the malady.   In the Florentine epidemic  many persons
fell victims who  lived in lofty, well-ventilated, and, in  all
respects, salubrious  habitatious.  It  must not be  forgotten,
moreover, that when diphtheria becomes epidemic in a town,
an elaborate system of  drainage is calculated to convey the
poison by means of  the sewers, and that water-closets afford
a ready means of contaminating  cisterns  and introducing
sewage gas  into residences.  Hence, the wealthy are some-
times s-ubjected  to the causes of infection which the  poorest
may escape.

        * Op.  cit. p.  134.                    f Loc. cit. 
32
DIPHTHERIA.
  When an epidemic exists, the accidental occurrence of a
catarrh often seems to attract the specific virus tothe throat,
and  children suffering from  enlarged tonsils and relaxed
throats are especially liable to contract diphtheria.
  Certain acute diseases, as well as those of a chronic char-
acter accompanied with  great  debility, predispose  to the
disease, and when it attacks persons who  have been previ-
ously suffering  from some other affection, it is called sec-
ondary diphtheria.  This subject is considered in chapter xi.
  Much  still remains to be explained with regard  to the eti-
ology of diphtheria.  No satisfactory theory has yet  been
offered  as  to -the reason why in  certain years the disease
should spring  up in epidemic form and  resist all our  at-
tempts to arrest it, while at other times it arises, perhaps, in
some remote hamlet, without any traceable antecedent, and,
after flickering for a time, dies away as suddenly as  it ap-
peared.
  Protective Lifltienee  of an  Attack of  Diphtheria.—As in
the case  of typhoid fever and cholera, an attack  of the dis-
ease  probably  affords  a  protection—though  a very  slight
one—against recurrence.  In estimating the protective power
exercised by an attack of diphtheria, it must not be forgot-
ten that even in diseases, such as small-pox aud scarlatina,
where previous attacks afford great subsequent immunity,
recurrence does sometimes take place,  and that there are
many well-established  cases on record in  which these affec-
tions have occurred more than once in the same individual.
The  fact that diphtheria recurs,  in some rare  instances,
does not, therefore, by any means disprove its protective in-
fluence  in  the majority of  cases.   That  the  disease does
sometimes recur, I am well aware, for I have myself known
three instances in which children have died from  the second
attack.  In two of these, the  first attack (occurring a year
previously in one case, aud seven months in the  other) was
seen by  another practitioner; but, from the circumstances
of there having been  slight  paralysis  in each instance, I
have no doubt as  regards the diagnosis.  In my own case,
I saw a  child aged four with pharyngeal diphtheria in  May,
1874, who died of laryngeal diphtheria under my care in
July, 1875.  I have seen the  disease occur, in  a  mild  form,
three times in the same individual,at intervals of five months,
a year, and two years. 
SYMPTOMS.
33
                    CHAPTER  III.

                       SYMPTOMS.

  The symptoms of diphtheria vary in different cases from
those of quite a slight sore throat  to those of the most seri-
ous and  malignant  blood-poisoning.   Between  these two
extremes we meet with every gradation  of intensity.  The
presence of " false membrane" in the throat is the char-
acteristic symptom, but sometimes, in  slight cases, the dis-
ease passes  off' without the formation of any membranous
exudation, and occasionally the patient dies before it is de-
veloped.   Again, the  local affection is, in some cases, ac-
companied with considerable inflammation, whilst in others
there is  scarcely a trace  of it.  Hence it is convenient, in
describing the symptoms, to classify the varieties  of the dis-
ease.   The  following are  the different constitutional forms:
(1) the typical form; (2) the mild,  or catarrhal form; (3)
the  inflammatory form ; (4) the malignant form ; (5) the gan-
grenous form;  (6) the chronic form.  An attempt has  been
made to establish another variety,—the insidious form ; but
whilst one  author* finds  its expression  in the sudden de-
velopment of laryngeal symptoms, anothert considers that
the patient either dies "from the  progress of marasmus,"
"or suddenly from an effort," or quickly succumbs to one
of the unfavorable complications which supervene.   It will
be seen, therefore, that the insidious character cannot be re-
garded as constituting a special form of the disease.
  The student must not expect to find the first three forms
always clearly defined  ; on the contrary, they are  apt to run
into one another, or their special  features may be more or
less combined.   The differences dependent on site are—(a),
nasal diphtheria ; and  (b), laryngeal diphtheria  or croup. It
would be foreign to the scope  of this work to enter into the
subject of  cutaneous  diphtheria,  or to  consider the  local
manifestations of the  affection,  when it attacks any of the
* Jenner, loc. cit. p. 20.        f Sanne, loc. cit. p. 123. 
34
DIPHTHERIA.
various organs whose  mucous covering is susceptible to the
poison.
  The course of (1) typical diphtheria  is somewhat as  fol-
lows : After a  period of incubation varying  from two to
five days, during  which the patient suffers from general
malaise and depression,  with  occasional chilliness, the  dis-
ease announces itself by a definite constitutional disturbance.
  The first stage commences with a rapid rise in the tem-
perature  and pulse-rate—the  former often  reaching 103°
and occasionally 104° F. within a few hours—an increased
feeling of chilliness, loss of appetite, nausea,  and in  some
instances vomiting or diarrhoea.  If the patient  is an adult
he complains of pain  in the  loins, of headache, and  often
of giddiness.  His attention is,  however, soon diverted from
these  general symptoms to his throat, which  in a very short
time begins to feel hot and  dry, and  to cause  pain in swal-
lowing, whilst the neck  feels stiff", swollen, and tender.  In
a child these subjective symptoms are to a great  extent lost.
The practitioner, called to a case such as is here described,
will at once proceed to inspect the patient's throat, and  will
probably find the tonsils, the pillars of the fauces, the uvula,
and the back of the pharynx  red, swollen, and turgid.  But
the false  membranes which  are  characteristic of  the disease
will very possibly  have not yet made their appearance.   If
they have not, a few hours  will probably suffice to develop
them.
  The second stage  will then be present.    On carefully
watching the progress of the case a viscid, yellowish secre-
tion will  be seen gradually accumulating in  the  depressions
on one or both tonsils;  a little later the superficial  layers
of mucous membrane become infiltrated at certain  points
with a yellow substance, which raises them above the level
of the surrounding normal tissue.  The infiltrated patches,
which are at first more or less translucent,  soon become
opaque, at the same time changing in color  from yellow to
a grayish white, extending at their periphery, and coalescing
with similar adjacent patches.  In this way a considerable
surface of the  fauces and  pharynx becomes coated  with
false membrane, which, being constantly reinforced  by ad-
ditions to its under surface, gradually assumes  a leathery.
consistence  and a lardaceous  appearance.   Strips of  this
membrane may now  be torn off, and in some  cases  with
care the  whole of it may be removed in the form of a  cast 
SYMPTOMS.
35
of the parts on which it is deposited.   The mucous mem-
brane beneath will be found robbed  of its epithelium, of a
vivid red  color, and covered with numerous hemorrhagic
points.  Externally, the neck is  more or less swollen  aud
brawny, whilst the parotid,  submaxillary, and lymphatic
glands are frequently enlarged, hard, and tender.
  The temperature in most cases gradually subsides as the
exudation extends, but sometimes it remains at a high point.
and may even increase as the local process develops.   Ac-
cording to  Faralli,* however, who made a series of careful
observations on the temperature in sixty cases of diphtheria
in the Florentine epidemic, it usually falls to normal by the
fourth or fifth day, though  in  moderately severe cases  it
again shows a tendency to rise after  that date.
  The patient still complains  of difficulty in  deglutition,
and suffers from a constant " hawking," caused by his en-
deavors to  get rid of the tenacious secretion which is poured
out  from the mucous membrane.  Unless the mouth  is re-
peatedly washed  out  with a disinfectant gargle the breath
becomes horribly offensive, from  the decomposition of the
morbid secretions in the throat.  The primary blood-poison-
ing is shown by the extreme debility, and by the character
of the pulse, which  is  frequently weak  and compressible,
and often either exceptionally rapid  or exceptionally slow,
while the first sound of the heart is  muffled, and devoid of
tone; the specific septicaemia is further shown by the albu-
minuria, which is an almost constant symptom  in this class
of cases, and appears at a very early period of the disease.
The urine  itself  is scanty and high-colored, containing  an
excess of urea, and  numerous  hyaline,  granular,  and epi-
thelial casts.
  It is at this period that the diphtheritic process, instead
of limiting itself  to the pharynx, may spread  in  a down-
ward direction, and  attack the  larynx and trachea, thus
exposing the  patient to  the  serious  risk of  death  from
asphyxia.  This  extension, when  it occurs,  usually takes
place within three or four days of the invasion of the dis-
ease, and is in most cases announced  by unmistakable signs.
The voice  becomes  hoarse  and  muffled, the breathing  is
more or less stridulous, aud there  is  a constant  dry and
  * " Sul ciclo termico della difterite"—" Imparzialc." Marzo,
1873. 
36
DIPHTHERIA.
toneless cough.  To these symptoms succeed those of em-
barrassed  respiration, viz.. distressing dyspnoea, gradually
increasing cyanosis, swelling of the face, and  drowsiness,
passing into fatal coma.  We have, in fact, a case of laryn-
geal diphtheria or true croup—one of the most  fatal dis-
eases to which humanity is liable.   This important subject
will be found treated in detail in chapter ix.
  The other extensions are  less important, but are of un-
favorable significance.   The implication of the nasal cavity
generally announces itself by the discharge of a fetid, dark-
colored, watery fluid, which  excoriates the margins of the
nostrils.   This  condition may remain until  the  patient
recovers or dies, or  it may be followed by the  formation of
false membrane on  the lining  membrane of the  nose, and
the discharge  of  fibrinous  lumps through  the  anterior
or posterior nares.  It is sometimes accompanied by re-
peated, and, perhaps, fatal epistaxis.  More rarely there is
blocking up of the lachrymal duct, and consequent overflow
of tears.  Cases, indeed, occasionally occur in which the
diphtheritic process extends  by this route to  the conjunc-
tiva, and a plastic exudation  takes place on that membrane.
If the inflammation pass along the Eustachian tube, com-
plaint will be made of roaring noises in  the ears, of darting
pains, and of deafness, which may be followed by perfora-
tion of the  membrana tympani, and  the discharge of a
purulent fluid.
  Supposing that the disease has not attacked the larynx,
the third stage now sets in, and the disease pursues one  of
two courses: it  may subside, and  the patient  may slowly
recover; or it may  quickly end in death.
  If the disease terminates  favorably a marked  improve-
ment in all the symptoms takes place, as a rule, at the end
of the first or at the beginning of the second week.   The
swelling and injection  of the mucous  membrane steadily
subside, the exudation  ceases to extend, and  portions are
successively loosened and thrown off.  All the local discom-
fort rapidly disappears, and the general symptoms improve.
The temperature and  pulse-rate fall to normal  and remain
so, the appetite returns, the urine becomes of natural color
and quality, the skin resumes its functions, and with the ex-
ception of a certain degree  of muscular weakness the pa-
tient feels quite well.  He is not, however, as yet quite out of
danger ; it is not at all an unfrequent event for a relapse 
SYMPTOMS.
37
to occur, with a fresh formation of false membrane, and a
return of all  the  most serious symptoms ;  or  the  heart's
action may show signs of failure, and  he  may die of syn-
cope.  Even if he escape these contingencies, he may at
a  later period experience  the  discomforts of diphtheritic
paralysis.
   If the disease, instead of yielding, take an unfavorable
turn, the patient  may either  sink  from  secondary blood-
poisoning, with typhoid symptoms, or gradually deepening
coma; more often, however, death occurs from cardiac em-
bolism or simple syncope.
   (2.) In mild or catarrhal  diphtheria the symptoms are
often so slight that the practitioner hesitates to attribute
them to  a  disease, the very name of which is  heard  with
consternation.  Indeed it  is, as a  rule, only when  his  at-
tention is  aroused by  the proximity  of other undoubted
cases,  that  he is  at all  likely to recognize the affection
in its earlier stages.   The symptoms are simply those of an
ordinary catarrhal sore throat.  The diphtheria, in  fact,
has been arrested at the first stage of its development.  The
constitutional disturbance is very slight;  the temperature
rises a degree or two above  the normal, and  the pulse is
quickened in proportion.  There is slight pain, and a feeling
of dryness in the throat, and, as  a rule, some  degree of
difficulty in  swallowing.   The submaxillary and cervical
glands are  not unfrequently swollen and tender.  On in-
specting the patient's fauces, no characteristic exudation is
seen.  The tonsils, soft palate, and back of the pharynx are
of a  bright-red color, and somewhat swollen.   In  many
cases the redness and swelling are limited to one side of the
throat, the opposite side presenting an  appearance of per-
fect health.  At first the throat is dry, aud there is a marked
diminution  in  the quantity  of the natural  secretion;  but
this  stage soon passes, and then minute  accumulations of
yellowish matter,  not much  exceeding  the  size of a pin's
head, may be seen adhering to the surface  of the tonsils, or
to the posterior wall of the pharynx. These  may be readily
removed with  a camel's-hair brush.  As a rule the patients
quickly recover, and  by the  third  or  fourth day may be
declared convalescent.  They often, however, suffer from a
considerable degree of prostration during the  illness, and
a sense of weakness  may  remain for some  days  or weeks
after the disappearance of the local  affection.   The symp-
                           4 
38
DIPHTHERIA.
toms above sketched are sometimes associated  with a trace
of albumen  in the urine, but occasionally the first evidence
of the true nature of the throat affection is the occurrence
of the characteristic paralysis.   The appearance of one or
other of these symptoms often forms  the only clue which
the physician has to the nature of the  primary affection,
which, in all other respects, closely resembled a simple sore
throat.   In some instances, however, the catarrhal affection
serves  only to introduce the  more serious form of  the dis-
ease.   In such cases, after the more trivial symptoms have
lasted for three or four days,  there is a sudden accession of
fever, with marked constitutional disturbance and  increase
in the local  symptoms.  Exudation  forms rapidly in the
throat, and with  it the disease  assumes all the  characters
which  have already been described under " typical diph-
theria."
  (3.)  The inflammatory form of diphtheria is characterized
by the active hyperemia which precedes and  accompanies
the exudation of lymph.  On  examining  the throat,  the
appearance is that of acute pharyngitis, the mucous mem-
brane  of the uvula  and fauces  being  greatly inflamed.
Within twenty-four hours, a thick false membrane  usually
covers  the inflamed parts, but I have met with one  case in
which the exudation did  not  take place till four days after
severe  inflammation commenced.  The  tonsils are often
increased in  size, and the glands  at the angle of  the jaw
are generally enlarged and tender.  There is  severe odyn-
phagia.  The pulse is  very frequent, and the patient  has
a hot dry skin, and often complains of great thirst. It  is
in this  form of  diphtheria,  as Sir William Jenner*  has
pointed out,  that  the joints sometimes become swollen and
inflamed.
  (4.)  In malignant  diphtheria,  the  attack  begins  with
severe  rigors, headache, and  vomiting, and there is often,
also, bleeding of the nose.   The  patient is at once, as  it
were, knocked down by the virulence of  the disease.  The
throat  symptoms are not generally severe, but. the secre-
tions rapidly undergo decomposition and cause the breath
to have a most intolerable fetor.   The temperature is  not
high, but the pulse is rapid, small, and irregular.   Restless
at first, the patient soon becomes apathetic  and drowsy ;
* Loc. cit. pp. 17, 18. 
SYMPTOMS.
39
his  face grows pale, and his skin cold and clammy.  The
tongue is brown, dry, and tremulous, and sordes form upon
the  teeth.  Haemorrhages  may occur  from the various
mucous surfaces, and  petechias  often appear  beneath  the
skin.  In short, all the symptoms of the typhoid state are
present, aud the patient finally becomes delirious and dies
comatose, or succumbs to an attack of syncope.
  (5.) Gangrenous diphtheria is very rare in this country,
except as  a secoudary phenomenon following scarlet fever.
The gangrene  frequently supervenes  with great rapidity
after the formation of the false membrane, so that in two or
three days a large portion of the pharyngeal mucous mem-
brane may be sphacelated.   In some cases there is consider-
able swelling of the cervical  glands, but this  lesion is not
invariably present.  As  the  morbid process becomes fully
developed it is, in all instances, accompanied by a remark-
able  prostration  of the vital powers.  A state of collapse
comparable to that which occurs in  cholera indicates the
intensity of the blood-poisoning; there is great loss of body-
heat, aud  the pulse soon becomes slow and infrequent.  The
extremely feeble condition of the circulation  is shown  by
the  pallor, coldness, and bluish discoloration of the skin,
especially of the extremities.  The expression of the face is
strikingly altered and  pinched.   The patient generally dies
from syncope, the intelligence often remaining intact to the
last.  In  some cases, however,  he becomes comatose, aud
occasionally symptoms indicative of profound lesions of the
thoracic or abdominal  viscera are manifested.  These cases
always terminate fatally.
   (6.) Chronic  diphtheria  is a  rare disease.  In the years
1863 and 1864 eleven  patients (seven men and four women)
came under  my care,  in whose cases there  was false mem-
brane in the pharynx.   In three of them at the same time
there was deposit in the larynx.  The patients were all able
to attend  as out-patients at the hospital, and though in sev-
eral cases they were weak, yet they showed  no very great
degree of debility.  In four instances there was albuminuria;
in two of these it was intermittent and in two constant.  The
longest duration of any of these cases was three months, the
shortest seven weeks, the average being nine weeks.  In  all
the  cases, when  the  false membrane was  mechanically
removed,  bleeding occurred and a fresh formation quickly
took place.  Various local treatment was adopted, but with- 
40
DIPHTHERIA.
out any decided success.  The power  of maintaining the
false membrane seemed to be lost after a time, and the lymph
was at last separated without reproduction.   Barthez* has
also described a case where the false membrane lasted for
several weeks and  showed  a highly persistent power of
reproduction ; and Isambertf mentions an instance in which
a student became affected with nasal diphtheria and con-
tinued for several months to expel pieces of false membrane
on blowing his nose.   More  recently M. Hybre| has pub-
lished two cases observed in the Hopital  Sainte-Eugenie, in
which false membranes were expelled for eight or teu weeks
respectively, after the performance of tracheotomy for laryn-
geal  diphtheria.  The  patients were young children ; they
recovered rapidly from the operation  and appeared quite
well,  except for occasional attacks of suffocation, generally
followed, at an interval, by the expulsion of pieces of false
membrane from the wound in the throat. In neither  case
was there any albumen in the urine or  any extension of the
disease to the bronchi.  The false membranes expelled pre-
sented all the microscopic characters of diphtheritic exuda-
tion.   Both children completely recovered.  M. Hybre has
described  these cases  as examples of chronic,  non-febrile
diphtheria, but he has also collected several  cases in which
the disease, though  running a chronic course, was associated
with  more or less febrile  disturbance.
   Some of the symptoms of diphtheria demand a more de-
tailed discussion than has been accorded them above.
   The occurrence of albuminuria in cases of diphtheria was
discovered by  Dr.  W. F. Wade,§ of Birmingham,  in the
year  1857,  and some  months later, it was independently
observed  by Dr.  Germain See, of Paris.||   In  the  greater
number  of cases of diphtheria,  the urine is found to be
albuminous at some  period of the disease.   The albumen
usually makes  its appearance within the first few days, and
sometimes within the first  twenty-four  hours of the iuva-
  * " Bull de la Soc. Med. des Hop," 1858.
  •(• Lorain et Lupine, " Nouveau Diet.," 1869.
  X " These de Paris," 1875, No. 462.
  | " Midland Quarterly Journal of the Medical Sciences," April,
1858.
  || " Union Medicale," 1858, p. 407. 
SYMPTOMS.
41
si on,* but it may be delayed until as late as the third week.
Its  presence is  rarely constant in any case.  It may fluc-
tuate considerably in quantity from  day to day and  from
hour to hour, and  it may disappear and reappear more than
once before recovery sets in.   The severity of the case fur-
nishes us with no  indication as to the probable occurrence
of albuminuria; it has been searched for in vain  in  some
most malignant cases and it has been detected in the course
of very mild attacks.  It is never associated with any tan-
gible amount of haematuria, but the urinary deposit usually
contains hyaline, granular and epithelial casts of the  renal
tubules.  The urine itself is generally more or less highly
colored and of high specific gravity,  and" it contains a  con-
siderable excess of urea, as is the case in most other diseases
of a pyrexial character.   The albuminuria of diphtheria is
almost always a transient phenomenon, and it  is quite ex-
ceptional for it  to persist after recovery.  It seldom results
in anasarca, and only very rarely in uraemia. It is true that,
according  to M. Moizard.f Bergeron has, in several cases,
observed attacks of eclampsia supervening on diphtheritic
albuminuria in  children, and the former writer has recorded
a fatal case of  pulmonary oedema occurring under similar
circumstances;  but the general tendency of the evidence is
to show that the albuminuria of diphtheria is  by no means
a dangerous symptom, and recent observations have  fully
confirmed  the dictum  of Trousseau,! that ^ has on^y a
limited signification in relation to prognosis and  treatment.
   The exudation  of false membrane  is an almost invariable
phenomenon of diphtheria.  There are only two classes  of
cases in which it may be absent, viz., those in  which death
from  blood-poisoning occurs before the exudation has  time
to form, and those in which the local process is  not severe
enough to result  in the formation of a definite membrane.
This class has been described  by  Dr. Michel Peter§  as
" Diphtherite  sine  diphtheria."   False membranes   may
  * Dr.  Burdon Sanderson quotes a case in which it appeared
eighteen hours after the patient had been apparently in perfect
health.  " Contributions to the Pathology of Diphtheritic Sore
Throat," etc., " Brit, and For. Med.-Chir. Rev.," January, 18o0.
  f Moizard, " These de Paris," 1876, No. 493.
  X Trousseau, op. cit.,  vol. ii, p. 538.
  | « These de Paris,"  Paris, 1859, No. 270. 
42
DIPHTHERIA.
form, in  the  course of the disease,  upon any part of the
mucous surfaces which are exposed to the air.  As a rule,
they attach themselves by preference to the more prominent
parts.  They may extend from the pharynx to the epiglot-
tis and aryepiglottic folds, and  from thence by the ven-
tricular bands and vocal cords, into  the  trachea, and may
only be arrested in the smaller bronchi.  They may spread
upwards  into the nasal passages, covering the whole cavity
and following the windings of the turbinated bones.  They
may appear at the orifices of the nares and attack the ex-
coriated skin around them  ; they may extend  up the lach-
rymal duct and show themselves upon the conjunctiva.   In
some rare cases they have been known to invade the oesoph-
agus, and they occasionally cover the tongue and  the mu-
cous membrane  of  the lips.  In women who  are suckling
infants, the disease  sometimes appears on the nipple.   In
both  sexes it may attack  the mucous membrane near the
orifice of any of the internal passages.  External wounds
of every  sort are liable  to be covered by false membrane.
In short,  no part of the body which is at once open to the
air  and  uncovered  by a thick epidermis, is free  from  the
liability of local infection and the consequent  formation of
false membrane.   The exudation may take place within a
few hours of the invasion of the disease, or may be delayed
for four or five days.  The first sign  of it consists in the  in-
filtration  of  the  superficial  layers of mucous  membrane
with a yellowish  substance, which raises  the affected parts
above the level  of the surrounding surface.   The further
changes  which take place have  been already  described.
When the first membrane has been removed artificially, fibri-
nous exudation may again form, or the surface may gradually
heal.   When, however, the membrane has become detached
of its own accord, recurrence to the same spot is rare.
  The symptoms of fever in diphtheria may either be very
marked or almost absent.  In the severest and most malig-
nant  cases the temperature is often  quite low.   There is
never any tendency to extreme hyperpyrexia.  In the usual
run of cases  it would appear that the variations of tem-
perature  follow a fairly definite  course.   Trousseau states
that there is  a rather acute development  of  fever at the
time of the attack, but that the feverish symptoms diminish
on the second day, and cease on the following or next day.
Wunderlich considers that the temperature in  diphtheria is 
SYMPTOMS.
43
of little  prognostic value,* but Faralli, to whom I have
already referred, has shown that there is a definite pyrexial
cycle in cases of diphtheria, which furnishes data both for
diagnosis  and prognosis.   The observations which  he has
made prove that fever is a phenomenon commonly present
in diphtheria.   The elevation of temperature is rapid, and
even in slight cases it  frequently rises as high as 104° in a
few  hours,  falling gradually until  the  normal point is
reached  on the fourth or fifth day.  In cases of moderate
severity  the temperature again  rises  towards  the fourth
day, but seldom regains the  height of the first elevation.
The exacerbation is due  to the appearance of  fresh diph-
theritic  patches on  parts previously  healthy, or, more
frequently,  to the  appearance of glandular enlargements,
the  result  of  secondary  infection.  The  effects  of this
secondary infection are  clearly  observed  in severe cases
which pass into the typhoid  state.  In these the tempera-
ture at first follows the same  course as  in the milder cases;
that is, it rises  rapidly and falls steadily until  the third or
fourth day.  At that date it rises again, with some irregu-
larity, but with a certain relation to the extension of the
local disease, and  to the  putrefactive changes in the mem-
branes.   In favorable cases a second  steady fall succeeds
the second  elevation, while in fatal cases  the  temperature
continues to rise until the last.  The natural course of the
temperature may at any time be modified by the superven-
tion of impeded respiration, which will have the effect of
reducing it.  Dr.  Faralli's observations were  not simply
confined to pharyngo laryngeal diphtheria.  In a  case in
which diphtheria affected a  wound he obtained  the same
results.   The temperature rose within  a few hours  to over
105°, before the false  membrane was clearly developed.  It
fell to normal  on  the  third day, while  the infiltration was
at its maximum.
   Similar results to those obtained by Faralli were arrived
at  independently at about the same time  by M. Labadie-
Lagrave,f who made  careful  thermometric observations in
fifty-five cases  of the  disease.  From a comparative study
of these cases he deduced the following general rules:  (1.)
  * " Temperature in Diseases " (New Sydenham Society's Trans-
lation), p. 367
  f " These de Paris," 1873, No. 117. 
44
DIPHTHERIA.
 The temperature generally rises to 104° on the first  day,
 and remains at about that point for two or three days, with-
 out  any marked morning  or evening remissions.  (2.)  It
 begins to fall on the third or fourth day of the disease, and
 then invariably continues  to fluctuate  between 99.5° aud
 101.5°, unless some complication develops. (3.) Tracheotomy
 exerts no marked influence  on  the  temperature.   (4.) In
 favorable cases, after the initial  pyrexia has subsided, the
 temperature never  rises  above 102°.  A sudden ascent to
 103° or 104° on the fifth or sixth day of the disease points
 to the  development of some complication, either  lobular
 pneumonia, acute  nephritis,  or  acute  endocarditis.   M.
 Labadie-Lagrave attaches considerable  importance to the
 last-named  complication and its results;  his views on this
 subject will be treated in greater detail under Pathology.
   Cutaneous eruptions are not uncommon in some epidemics
 of diphtheria,  especially  among children.    Their  most
 common situations  are  the neck and chest; occasionally
 they make  their appearance on  the face, abdomen,  and
 thighs.  A rash is most frequently met with in  the severest
 cases.   The date of its appearance is not definite,  and its
 duration is  very variable.   Sometimes  it disappears in a
 few hours, in other cases  it persists for several  days.   The
 rash of diphtheria  generally more or  less resembles the
 rash of scarlet fever, and  consists of minute red isolated
spots, which disappear on pressure.  It differs from that of
scarlet fever in the fact that it is never followed  by  des-
 quamation. 
PARALYSES.
45
                    CHAPTER IV.

                      PARALYSES.

  Setting aside extreme  debility  and a  disposition  to
cardiac syncope, which may be considered rather as charac-
teristics of the disease itself, the  only serious sequelae of
diphtheria are various local  paralyses.  As  has already
been pointed out, the occurrence of paralyses was noticed
by Ccelius Aurelianus, Severino, Ghisi, and Chomel.   We
might  add the names  of several  other physicians who in
the seventeenth and  eighteenth centuries  incidentally re-
ferred  to  the subject.  It is  sufficient, however, to remark
that the first important work on diphtherial paralyses was
the thesis of M. Maingault,* published in 1864.   These
paralyses  are liable to follow any case, however slight.  M.
Mansordf has collected from various sources  1117  cases
of diphtheria, in which  the  presence  or absence of subse-
quent  paralyses was noted.  They were found in 111 cases,
or barely  10 per cent.  Probably, however, the  proportion
varies  considerably in different epidemics.   The character
of the paralyses is also very varied.   They may be partial
or complete,  and they may either limit themselves to single
groups of muscles, or may involve in succession almost  the
whole  voluntary muscular system.  Their advent is always
gradual, and as a rule they declare  themselves during  the
second or third week  after the complete healing of the local
lesion.  Trousseau,^ however, quotes a case in which they
became manifest three days before the disappearance of the
false membrane.   On the other hand, they  may be delayed
until as late as the sixth week of convalescence.  In any case
their advance is gradual, and they may continue to extend
for weeks after their  first appearance.  The muscles most
frequently affected are those of the soft palate and pharynx,
* Paris, 1864.
f Mansord, " These de Paris," 1874, No. 52.
X " Gazette des Hopitaux," 1860, Nos. 1 and 5. 
46
DIPHTHERIA.
 of the eye, and of the extremities.   It  is much more rare
 for the muscles of the  larynx and trunk to be implicated,
 while those of the bladder and rectum are still more seldom
 affected, and those of the face, almost  always, though  not
 invariably, escape.  Concurrently with  the paralysis, there
 is impairment  of muscular, and sometimes of cutaneous
 sensibility. The  muscles generally respond languidly  to
 both galvanism and faradism, while the patient complains
 of numbness and  prickings in the paralyzed parts.   More
 rarely there is pain or hyperaesthesia.  The affected muscles
 occasionally  undergo  a  slight  degree  of wasting, and  in
 some cases their diminution in bulk is very considerable.
   The first muscles to be affected are usually those  of  the
 soft  palate and  pharynx.  The nerve cells of the ganglia
 supplying the pharynx would appear to  have a special pre-
 disposition to give way, for even in cases of cutaneous diph-
 theria, the palate is the first part to be paralyzed.*
   On inspection, the velum pendulum palati and uvula are
 seen  to be relaxed, and although  during inspiration and
 expiration the uvula moves backwards and forwards  under
 the  force of  the current of air, the power of voluntarily
 raising it  is, to a great extent, lost.   This feature is gener-
 ally   unilateral, and when  bilateral, it  always affects one
 side much less than the other, giving rise  to a mere paresis of
 the muscles on the side least affected.  There is also gener-
 ally  loss of sensibility  in  the veil of the  palate.
   The voice  acquires  a characteristic  nasal timbre, the
 modification of certain articulate sounds  being very charac-
 teristic, owing  to the  impossibility  of closing the  naso-
 pharyngeal passage.   Thus rub, head, and egg become rum,
hent, and en/cf
   The pharyngeal affection often gives rise to dysphagia.
The  patient first perceives  the  difficulty of swallowing in
taking fluids,  which  frequently regurgitate  through the
nose or pass into the larynx, and occasionally life can only
be sustained  by the use of  the oesophageal  feeding-tube.
The  dysphagia, as  will presently  be explained, is partly
due  to the implication of the depressors of the  epiglottis.
* Morelli (loc. cit. p. 122) thinks that there is a frequent, but
)t invariable coincidence  between the paralytic manifestations
id the cervical adenitis.
f Donders,  "New Sydenham Soc. Trans.," 1864 
PARALYSES.
47
The  power of expectoration is often  lost, and  mucus  accu-
mulates about  the lower part of the pharynx, and is only
dislodged by an effort of vomiting.  In some cases a con-
stant pricking sensation is  felt in the throat.  The taste is
always more or less blunted.
  Paralysis of the larynx is much  less common than  the
palsies already described,  but in rare cases it  may appear
even without other parts being affected.  The paralysis may
involve the  whole muscular apparatus of the larynx or may
limit itself to single muscles.  In the former case the  vocal
cords will be seen, on laryngoscopic examination, to remain
motionless during phonation, occupying  the post-mortem
position,  the voice is almost entirely lost, and any increased
exertion  leads to considerable dyspnoea, not from paralysis
of the abductors, but from loss of'power of the abductors and
consequent inability " to hold the breath "—an  act which is
especially necessary for delicate persons when making an
effort. When the paralysis only involves single muscles, it
is the abductors which generally suffer, but often only one
cord  is affected.  Two cases of permanent  paralysis of  the
recurrent nerve, following  diphtheria, have come under  my
notice.  The muscular  paralysis of the epiglottis is  occa-
sionally  associated with loss of sensibility of its mucous
membrane, in which case portions of food  are  more likely
to make their way into the larynx than when the pharynx
alone is affected.   Such an accident may give  rise to very
serious symptoms.
  The muscles  of the eye  are the next to  suffer.  Indeed,
in some cases they become  paralyzed at the  same time as
the muscles of the palate.   The  patient first notices that it
is getting  more  and  more difficult for him to read small
print.  The effort tires him and causes pain  in his  eyes;
soon his vision  becomes quite indistinct and he  suffers from
flashes of light before the eyes.   He does not, however, lose
the power of seeing distant  objects.   At a later period  there
may be double-vision, giddiness, and squinting, from  palsy
of the oculo-motor muscles.  The earlier symptoms are due,
according to Donders,* to  impairment of accommodation,
from  palsy of the ciliary muscles.  The  chief affection of
the sense of sight, therefore, depends on paralysis of  parts
  * " Ophthalmology in its relation to General Medicine," " Brit-
ish Medical Journal,""  May J2th, 1877, p. 505. 
48
DIPHTHERIA.
supplied  by  the  lenticular ganglion of  the sympathetic
chain, as the pharyngeal paralysis appears to be due to im-
pairment  of Meckel's  ganglion, and  these  facts have led
Dr. Hughlings Jackson* to inquire, in cases of diphtheritic
paralysis, for a corresponding affection of the sense of hear-
ing, such as would be likely to result from interference with
the function of the  otic ganglion.  He has hitherto only
met with one such case—that of a medical  man.  The affec-
tion was  not sufficient to impair his  hearing  for ordinary
purposes, but " enough to render music unintelligible."  In
fact, as  Dr. Jackson says,  we  should not expect  deafness
as the result of diphtheritic paralysis, but  only slight inter-
ference with the power of appreciating high-pitched sounds.
It is impossible to tell, as yet, how frequent  such an  affec-
tion  may be in cases of  diphtheritic paralysis.  As far as
our knowledge at present goes, it is little more than a patho-
logical curiosity.
   Next in order to the muscles of the eye, those of the ex-
tremities  most frequently show  signs  of paralysis. The
lower extremities are usually the first to be affected. The
patient first suffers from numbness and tingling in the feet.
Soon, on attempting to walk, his legs begin to tremble and
he feels as though he were walking on air.  In very severe
cases the difficulty gradually increases; his movements
grow more and  more clumsy, until at  length he  loses  all
power over his legs, and becomes  a helpless cripple.  Dr.
Hermann Weberf has  especially called  attention  to the
want of power of muscular co-ordination, as shown  by the
choreic movements.  The muscles of  the affected parts feel
flabby to the touch, and they  refuse  to respond  to the
electric current.   Cutaneous sensibility is  also much im-
paired or entirely abolished, especially in the soles of the
feet.  The same symptoms may  occur in  the upper ex-
tremities.  There  is, first, numbness and formication in the
fingers; then increasing clumsiness of movement, and finally
complete paralysis.
   The last muscles to be affected are  generally those of the
neck and trunk.  Paralysis of the former,  in its worst forms,
deprives the patient of the power of raising or turning his
head, which  falls helplessly backwards  and forwards,  or
* Op. cit.
f Loc. cit. 
PARALYSES.
49
drops to one side.  Paralysis of the trunk renders turning
or moving in bed impossible, and at the same time  causes
considerable embarrassment to respiration from  the  impli-
cation of the intercostals.  When  the diaphragm is  also
paralyzed,  as in rare cases it is, the  difficulty of breathing
is  enormously increased, and the patient  runs the greatest
risk of dying from asphyxia.  If, however, the paralysis be
not complete, the danger may be warded off, and the patient
may gradually recover.   Concurrently with the paralysis
of the extremities, in the most severe  cases,  there is often
incontinence of urine and faeces from palsy of the sphincters
of the bladder and rectum.
   Having continued for a period varying from six  weeks to*
half a year, these paralyses, as a  rule, gradually disappear
in the order in which  they appeared, the duration being, in
each case, proportionate to the degree of paralysis.   Suit-
able treatment, no doubt, expedites recovery; but in these
cases,  there  is a natural tendency to the  restoration of
function.   If no unfortunate complications lead to a fatal
result, eventual  recovery of muscular power may almost
invariably be counted upon ; but in most cases the patient
continues for a long time  to  experience some degree of
weakness in the affected  parts.  Lastly, it is well to remem-
ber that the severity of the paralytic symptoms bears no
proportion whatever to  the  severity of the antecedent dis-
ease.  The loss of power may occur in a marked degree after
even the most trivial attacks. 
50
DIPHTHERIA.
                     CHAPTER V.

                       DIAGNOSIS.

   In some cases of diphtheria an absolute diagnosis may
 be almost a matter of impossibility, at any rate, in the earlier
 stages of the disease.  The difficulty generally  arises in
»those cases which  deviate  from the  normal type  in the
 direction either of unusual mildness  or of unusual severity.
 Very mild cases, in  which the false  membrane  is  either
 absent or late in appearing, may easily be confounded with
 ordinary catarrhal sore throat.  The diagnostic  criteria are
 both  few and indefinite.  A history  of infection,  or the
 epidemic prevalence of diphtheria, may in some cases be of
 service  in forming an opinion, but more often the prac-
 titioner has to trust to other data.  In the case of the diphthe-
 ritic sore throat, without false membrane, the  congestion is
 at once more limited  and  more intense than in pharyngeal
 catarrh ; it often  affects one lateral half of the soft palate,
 or one tonsil, while the catarrhal process has usually a more
 general distribution.   In  simple sore throat, the surface of
 the tonsils  may be covered  here aud there with  patches of
 deposit, which might  possibly  mislead an ignorant  or in-
 cautious observer;  but such  deposits will invariably be
 found to be soft, semifluid, and easily removed.  They are,
 in fact, nothing more than the modified secretion  of the
 congested  mucous  structures.   In  diphtheria,  moreover,
 there is often albuminuria, aud a degree  of prostration  out
 of proportion to the severity of the local changes. In  many
 cases, in the absence of false membrane,  the practitioner must
rest content with a  diagnosis founded  upon unsatisfactory
criteria.  In other cases, however, the  sudden  development
of exudation and the appearance of serious symptoms of
general  infection may clear up all  doubt; while in still
rarer  instances,  the  supervention  of muscular paralysis
during convalescence  will  solve the problem in a quite  un-
expected manner.   It is  hardly necessary to add that, in
all cases of  suspected diphtheria, it is  the' bounden duty of 
DIAGNOSIS.
51
the practitioner to make a most thorough examination of
the interior of  the  throat, supplementing  it, if possible,
by  the use of  the  laryngoscope and  rhinoscope.  These
instruments will often bring to light patches of exudation,
and will thus give very material help towards a satisfactory
diagnosis.
  The cases in which diphtheria appears in an exceptionally
severe form may offer still greater difficulties in the way of
diagnosis than even  mild cases.   A patient, for instance, is
suddenly struck down by intense general blood-poisoning,
and rapidly passes  into  what is named the typhoid  state.
If  inspection of the fauces is neglected in such a case, the
physician may experience the greatest perplexity as to the
nature of the disease. Even the fauces may appear healthy,
and the case be still one of diphtheria; for the membrane
may not as yet have had time to form, or  may have formed
beyond the range of sight. The only aid to diagnosis in such
a  case will be  found  in  the character of the  prevailing
epidemic.   Malignant diphtheria very rarely occurs in an
endemic form.
   Apart from the above difficulties, diphtheria may simulate,
and be simulated by, scarlet fever, confluent herpes of the
throat, acute tonsillitis, and acute laryngitis.   There can be
no doubt that, in many cases, diphtheria has been mistaken
for scarlet fever. The severe constitutional disturbance, the
sore throat, and the rash, which is a common symptom in
some epidemics of diphtheria, are all liable to mislead the
observer.  But  the points of  difference are fairly  well
marked.  The constitutional symptoms are  usually slighter
in  diphtheria; there is,  as a rule, less  auorexia, but more
prostration.  The throat in scarlet  fever is uniformly red-
dened, aud if it be the seat of any membrauiform deposits,
these are soft and easily detached.   The larynx, moreover,
is only very exceptionally attacked.  There may be albumi-
nuria in either disease, but haematuria, which is scarcely ever
known to  occur in diphtheria, is not uncommon in scarlet
fever.  The distinctive characters of the rashes have already
been described.
   Acute tonsillitis at its  outset may simulate the inflam-
matory form of diphtheria.  In both  there is considerable
constitutional disturbance and  difficulty of swallowing; iu
both, the throat affection has a more or less unilateral ten-
dency, and commences with intense congestion.  In tonsil- 
52
DIPHTHERIA.
litis, however, the  inflammation either subsides, or  rapidly
passes  into suppuration,  and  thus removes  all cause  of
difficulty.
  Confluent herpes of the throat is  not a common disorder,
and is not, therefore, often likely to give rise to difficulties
in practice.   Trousseau,*  however,  has laid down the diag-
nostic distinctions  between the two diseases with consider-
able detail.   Herpes is usually ushered in with considerable
constitutional disturbance, but the temperature rarely rises
higher than 102° or 102.5° Fahr.,  and it quickly subsides.
The  pain in the throat is of a peculiar smarting character.
Herpes  has no tendency to spread  beyond the seat  of its
first  efflorescence.   Thus, if in a doubtful  case the morbid
process is found extending to the tonsils, to the larynx, or
the nose, herpes may be  excluded.  Of course the simul-
taneous appearance of herpes on the lip will be of great help
in forming a diagnosis.
  The diagnostic distinctions between laryngeal diphtheria
and  catarrhal laryngitis  will be found  under the  head of
"Croup."
* Op. cit., vol. ii, p. 439. 
PATHOLOGY.
53
                    CHAPTER VI.

                      PATHOLOGY.

   The characteristic product of diphtheritic inflammation
—the  false membrane—is  a tough, dry substance, resem-
bling fibrin, or the buffy-coat of the blood.   In color it is
  ellowish or grayish white; it  is  firm  and elastic, but it
  reaks  across suddenly  when stretched.  The addition of
acetic  acid causes it to swell up and  become transparent;
it is dissolved by caustic alkalies.  It is insoluble in water,
and yields to it neither  gelatin  nor  albumen.   It thus
closely resembles fihriu in most  of its qualities.  The mem-
brane  may vary from  a thin and transparent pellicle to a
skin of considerable thickness, its  character differing very
much  according to its age.  In  the earlier stages, the  dif-
ferent  patches of membrane are  more or less isolated ;  they
are surrounded by  mucous membrane  in a state of intense
hyperemia;  they project only very slightly above the mu-
cous surface, and they cannot be removed without consider-
able force.  Later  on, the patches  are found  to have coa-
lesced ; they have become firmer and thicker, and evidently
project higher above the surrounding surface.   lu the next
stage these edges become loosened,  and show a tendency to
curl up, giving the  exudation a more or less cupped appear-
ance.  Pus gradually  accumulates  beneath  it, until it de-
taches  itself, leaving the  subjacent  mucous membrane  in a
state of catarrh.
   According to the most recent  researches, the exudation
in pharyngeal diphtheria is  seen, under the microscope, to
consist exclusively of cells.   The naked-eye resemblance to
coagulated fibrin  is due to a peculiar degeneration  of the
epithelial cells, aud to an equally peculiar fusion of them,
one with another.   The cells manifestly  contain more solid
matter than normally, but the precise character of the infil-
tration  is as yet uncertain.  On examining  a section  of
membrane under  the microscope, it is seen to consist of thin
changed cells,  fused together  in various directions, and
                            5
I 
54                  DIPHTHERIA.
leaving a system of branching fissures, which permeate the
whole membrane.  The most  superficial cells are twice as
large as lymph-corpuscles.   They  gradually decrease  in
size  as we proceed deeper, until those which are in imme-
diate contact with the mucous surface are almost indistin-
guishable  from normal  cells.  Here  and. there,  scattered
throughout the membrane, are often seen minute extravasa-
tions of blood, which, originally formed on the mucous sur-
face, have  become separated from  it  and encapsuled  by
successive layers of degenerated cells.  To  sum up in the
words of Rindfleisch,* " the false membrane is undeniably
produced  by the separation  of young elements  from the
irritated  mucous surface, and by their gradual  stiffening,
sclerosis, glassy swelling, or whatever term we may choose
to apply to  their degeneration."   In course of  time the
mischievous process comes to a standstill.  The cells secreted
by the mucous membrane no longer undergo the abnormal
degeneration  ; pus-cells appear in increasing quantities be-
tween  the  mucous surface and the false membrane, and
soon lead to the final separation of the latter.  The exuda-
tion  also disappears to some extent by undergoing  a process
of softening, the cells becoming granular and fatty, and the
network undergoing gelatinous degeneration.  This, though
not an uncommon termination in favorable cases of tracheal
diphtheria, is much rarer when the  false  membrane is
formed in the pharynx.
  In describing the symptoms of diphtheria, it  has  been
pointed out that in the earliest stages of the disease the
mucous membrane is inflamed and swollen, but is  soon
coated with false membrane and becomes hidden from view.
If the  disease progresses favorably and the case is not very
severe, on separation of  the lymph,  the mucous membrane
is seen to be smooth and often somewhat paler than  in a
state of health ;  but if the affection  has been at all violent,
more or less ulceration  of the mucous membrane will  be
present.  Occasionally the morbid process does not stop at
ulceration, but  gangrene results and there  is considerable
loss of tissue.  In many fatal cases  the gangrenous process
is in active operation, aud its peculiar odor becomes evident
on the post-mortem table, if not during life.  The  idea,
  *"Lehrbuch der Pathol.  Gewebelehre," II Auflage, p. 310.
Leipzig, 1871. 
PATHOLOGY.
55
entertained by the ancient physicians, that  the  disease was
of a gangrenous nature, was, it need scarcely be observed,
derived from the appearance of the false membranes them-
selves, which,  whether white  or  subsequently discolored,
have very  much the aspect of an eschar or slough.  This is,
of course,  only a  delusive  appearance, and our  modern
knowledge of the gangrenous process in diphtheria  is based
on the post-mortem  examination of the  tissues  beneath the
false membrane.   In the severer forms of the disease there
is, in addition to the changes above described, an exudation
of fibrin into the subepithelial connective tissue.   The ex-
udation and infiltration sometimes compress the  nutrient
vessels of  the  part, and thus arrest its blood  supply.   Ne-
crosis of the involved tissues results, and leads to the forma-
tion of a slough, which is, in course of time, separated from
the healthy parts.  On the slough becoming finally detached,
there is  left an ulcer of variable depth and extent.   In
several cases  I have kuown  the  patient recover  with the
loss  of the uvula, and with a portion of  one or both tonsils
destroyed.   It is more common, however, in cases of recov-
ery after gangrene,  to find large  and puckered cicatrices,
resembling those which are seen as the  result of syphilitic
ulceration.
  In addition  to the inflammatory products of  diphtheria,
there are certain parasitic phenomena.  The idea that diph-
theria is of parasitic origin was first put forward by Profes-
sor Laycock* and subsequently revived  by Jodin.f  More
recently Oertel J has maintained the parasitic theory with
great vigor, and  has beeu  followed  by  many German ob-
servers.  Oertel contends that  certain definite forms of veg-
etable life,  especially the spherical bacteria, called micrococci,
and  the smallest forms  of bacterium termo, are  invaria-
bly associated with the diphtheritic process.  The  grayish-
white hoarfrost patches, which  appear on the mucous mem-
brane at the very commencement  of the disease,  contain,
he says, luxuriant growths of micrococci.  They are always
present in  diphtheritic membranes, and they are also fouud
in varying  quantity  in  the blood, whenever such  mem-
  * " Medical Time-and Gazette," May 29th, 1858.
  f " De la  nature et du  traitement  du  croup," etc., "Revue
Mod ," t. i, pp. 22 and 134, Paris, 1859.
  X Zieinsscn'8 " Cyclopaedia of Medicine," vol. i, p. 589. 
56
DIPHTHERIA.
brane exists.  The quantity of them present in any case,
moreover, bears, it  is  affirmed, a direct relation  to the
intensity of  the morbid  processes; they  multiply as the
disease  advances, and  diminish with its  retreat.  Oertel
states that the special form of micrococcus is never present
in  simple  inflammation  of the  fauces  or in  mercurial
stomatitis; but that, if the diphtheritic process supervenes
on  these disorders, it  at  once  makes its appearance,  and
quickly displaces the more  common forms of bacteria pre-
viously  present.   According to Oertel  and some other ex-
perimentalists (see Etiology), after the  inoculation of the
different tissues  of animals with diphtheritic exudation, it
has been found  that the micrococci force their way amongst
the cellular elements, crowd  into the blood and lymph ves-
sels, which they render impermeable, infiltrate the muscles,
and lead to their degeneration, and even reach the kidney,
where they excite the  inflammation which is so  common a
complication of diphtheria.   Eberth* has  gone so far as to
declare that without micrococci there can be no diphtheria;
while, in Italy, Giacchif thinks that a parasite is as neces-
sary in  the pathogenesis of the affection, as the o'idium vitis
is in  the  production of disease of the  grape.   Letzerich |
has found  another fungus—the zygodesmus fuscus—which
he believes  is the essential cause of the disease.   The con-
clusions of Oertel  and Letzerich  have, however, been di-
rectly controverted by Senator,§ who has found the leptothrix
buccalis in diphtheria, and who considers the minute  round
bodies described by Oertel  (as the spherical  bacteria) to
be  the  spores of the  leptothrix.  According to  Senator
the same fungi  are found in diphtheria as in ulcerative,
aphthous, and mercurial  stomatitis.  And M. Duchamp ||
states that  the  growths  he found in  numerous cases of
diphtheria were  declared by M. Chauveau  to  present no
difference from  those  observed in variola,  vaccinia,  etc.
In February, 1874, I examined seven cases for  epiphytes,
and succeeded in finding what is  commonly described as
  * " Zur Kenntn. der bacterit. Mykosen," 1872.
  f "NaturaeTerapiadell'anginadifterica," " Lo Sperimentale "
Nov. 1872.
  X Virchow's " Archiv.," Bd. xlv, et seq.
  ^ "Archiv. fiir Pathol. Anatouiie u. Physiol.," Bd. lvi, No. 12,
1872.
  || Duchamp, "These de Paris," 1875, No. 339. 
PATHOLOGY.
57
" the leptothrix buccalis" in five instances.  In every case,
however, the  fungus was  in the  superficial layer of the
lymph.   The  importance of the presence of fungi in diph-
theritic deposits is controverted by Dr. Beale,* whose au-
thority, as a microscopist, must carry great weight in this
country.  This observer maintains that " vegetable germs
are present in every part of  the body of man and the
higher  animals, probably from the earliest  age, and in all
stages of health. .  .  .  Millions of  vegetable germs are
always present on the dorsum of the tongue and in the
alimentary canal."  Dr. Beale further statest that "active
bacteria introduced amongst the  living matter of healthy
tissues  will die,  although the  most minute germs present
which escape  death may remain imbedded in the tissue in a
perfectly quiescent state."  He thinks also  "that there are
 very few morbid conditions that are unquestionably solely
 due to  the growth and  multiplication  of vegetable fungi."J
   The  changes which may take place  in other tissues in the
 course  of an attack of diphtheria  are  very various.
   The parotid and submaxillary  glands, which Dr. Samuel
 Bard § first pointed out as being frequently swollen, have
 been recently shown by Doctors  Balzer and  Talamon || to
 be the subject of distinct pathological changes.  The  cells
 of the acini are  generally either  swollen and filled with a
 homogeneous mucoid material, or replaced  by quantities of
 small  round  cells.   Here and there are  also  frequently
 minute collections of  pus.  The lymphatic glands of the
 neck are almost invariably found  to be more or less en-
 larged.  On  section they  are redder  than  natural, and
 there is  an evident increase   in  their cellular  elements.
 The  tissues around them, which  during life were brawny
 and  tender, are found at the autopsy  to be infiltrated with
 serum  and  with scattered pus-cells.   Often they present
 minute extravasations, while, in rare  cases,  considerable
 masses of  blood have been found effused in the cellular
 tissue surrounding the glands.
   The lungs may be the seat of very  varied changes.  The
 bronchial tubes are always inflamed—the inflammation gen-
 erally  being  catarrhal, but sometimes  purulent;  in many

   * " Disease Germs," London, 1872, p. 65, et seq.
   f Ibid. p. 71.            X lbitl- P- 78-         § Loc- cit-
   || "lievue Mensuelle," Le 10 Juillet, 1878. 
58
DIPHTHERIA.
 cases, however, it is plastic, and  then it most commonly
 occurs on the fourth or fifth day of the disease.  On laying
 open the bronchi, the  false membrane is found attached to
 their  walls,  or lying  loose in their  channels.   The mem-
 brane is never  equally  extended throughout  the whole
 system of tubes, but seems to have a preference for those
 branches which  run in  a vertical direction.  The fact of
 one of the lungs  being  bound  down by pleuritic adhesion
 would seem especially to  attract the morbid  process in  that
 direction.  Exudation is not unfrequently found to extend
 to  the minutest bronchial ramifications, in which  case the
 alveoli are usually more or less implicated,  and  contain
 fibrinous threads, pus-cells,  and, in some cases, blood-cor-
 puscles.   As a rule, the  lungs are more  or less engorged
 and oedematous, especially at their bases; and  frequently
 there  are extensive patches  of  pneumonia of a low type,
 with emphysema, or more often mere insufflation of the
 air-cells* in  the  immediate vicinity.   In other cases scat-
 tered  lobules are found  collapsed and void of air from
 occlusion of  the smaller bronchi, or one of the lobes is the
 seat of more or less extensive pulmonary apoplexy.   Ac-
 cording to Peter,f 59.50 per cent, of  the cases of broncho-
 pneumonia occur between the second  and sixth day.
  The heart has often an appearance of perfect health, but in
 cases where death has occurred from general blood-poisoning,
 its muscular tissue is soft and friable, and contains scattered
 extravasations of blood. Under the microscope the muscular
 fibres  show signs  of fatty degeneration, and the blood  is
 fluid and tarry.   In other cases the opposite condition is
 sometimes found, coagula of considerable size being met with
 in the  cavities of the heart and in the large vessels.  Of late
 years, indeed, the  cardiac complications  of diphtheria have
 been the subject of considerable discussion among the French
school.   Dr.  Richardson % was the first to call attention to
the  existence of coagula in the heart in fatal cases in diph-
theria, but he  attributed their  formation  to an excess of
fibrin in  the blood.  The same explanation of the phenom-
enon was put forward two years later  by M. Beau,§ but in
  * Jenner, loc. cit. p. 38.        f "Gazette hebdom.," 1864.
  X Richardson,  "Med.  Times and Gazette,"  March 8th,  1856.
"Brit. Med. Journal," February 115th and April 7th, I860.
  | Beau, "Gazette des Hopitaux," April 10th, 1858. 
PATHOLOGY.
59
 1864 Dr. Meigs* traced an analogy between the intracardial
 coagulation and the fibrinous deposit in the throat, and as-
 sumed  the  previous existence or concurrence of an acute
 endocarditis, a supposition, however, which he was unable to
 prove by direct observation. In 1872 Dr. Beverley Robinsonf
 put forward, as the result of a careful comparison of many
 accurately recorded cases,  the view that cardiac thrombosis
 is of very frequent occurrence in  cases of  diphtheria,  and
 is a very fertile cause of their fatal termination.   He also de-
 scribed in detail the physical  signs by which its occurrence
 might be diagnosed during life.  Dr.  Robinson's views have
 been combated with considerable  energy by M. Callaudreau-
 Dufresse,J who admits that coagula are found  post-mortem
 in at least half the fatal cases of diphtheria, but denies that
 they are the immediate cause of death. Out of forty autopsies
 he did not succeed in finding a single case in which the fatal
 issue could  be traced solely to cardiac thrombosis.  The most
 important researches on the subject, however, are those of M.
 Labadie-Lagrave,§ whose views are a most distinct advance on
 those of former authors.  His conclusions, which are deduced
 from a comparison of 100 carefully-recorded cases, are briefly
 as follows : In nearly half of the fatal cases of diphtheria the
 heart shows signs of having been the seat of an acute endo-
 carditis, resulting in vegetations and fibrinous deposits on the
 valves. The part most usually affected  is the upper surface
 of the mitral valve, which is reddened, and presents  at a
 distance of some millimeters from its free border a festoon of
 minute granulations of a  bright-red color, the valve itself
 appearing swollen and opaque.  On microscopic  examination
 the morbid process can be traced  into the layer of flattened
 cells which correspond to the upper surface of the valve, the
 interstices between them being filled by spherical embryonic
 cells arranged in parallel lines. The lining membrane of the
 auricles is  occasionally the seat  of a similar change.  The
 process does not end here, but leads in its turn  to a general
 dispersion of emboli throughout the circulation.  Thus the
lungs are frequently found to present scattered haemorrhagic
infarctions, due to arterial and capillary embolism, as well as
minute  venous thromboses between the lobules.  Haemor-
* " American Jour, of Med. Sci.," April, 1864.
f Beverley Robinson, " These de Paris," 1872.
X Calland'reau-Dufresse, " These de Paris," 1873, No. 37.
| Labadie-Lagrave, loc. cit. 
60
DIPHTHERIA.
rhagic infarctions are also found beneath the pericardium, in
the muscular ^stance of the heart, and in the subcutaneous
cellular tissue. The pia mater, the venules of the dura mater,
the substance of the brain, the liver, and other organs are the
seat of venous thromboses.   In the most malignant cases of
the disease the cardiac muscle is frequently found degenera-
ted, while occasionally the lining membrane of the small arte-
ries is inflamed, and the kidneys are the seat of parenchyma-
tous changes. These lesions are almost always associated with
an excess of white cells in the blood, and in the severer cases
the leucocytosis is very marked.   According to M. Lagrave
the endocarditis of diphtheria is the antecedent of the cardiac
thrombosis described by other authors, but while the latter
manifests itself during life by unmistakable signs, the former
is often extremely difficult to discover.  In the more rapid
cases of cardiac thrombosis, the symptoms declare themselves
in the most unexpected and alarming way. The little patient
suddenly sits up in  bed, flings himself about, and throws the
clothes off; his face is pale, and his features drawn, while his
eyes are expressive  of the greatest agony.  The  cardiac con-
tractions at the first  onset  are loud  and tumultuous,  but
they gradually become muffled, irregular, and intermittent,
and the heart seems  every  moment about to stop beating.
The pulse  is thready and irregular,  and the jugulars  are
gorged and prominent.  There  is  extreme dyspnoea, which
steadily increases, till the patient succumbs after from two to
six hours from the first attack.   When  the coagula form
slowly, the symptoms are of a similar character, but much
less marked.   It is only fair to state that M. Lagrave's con-
clusions  have not met with  general acceptance, and it has
been stated on the authority  of M. Parrot * that  the granula-
tions described have no relation to any inflammatory process.
For the present,  therefore,  it would  appear that  the  part
played by cardiac complications in diphtheria, is one which
still requires much elucidation by further research and obser-
vation.
   The spleen  and liver are  often perfectly natural, but oc-
casionally  they are much  engorged, and sometimes their
capsules present extravasations of blood.   The inner surface
of the stomach may be the  seat of ulcers and sloughs, and
* Beau-Verdeney, "These de Paris," 1874, No. 136. 
PATHOLOGY.
61
hemorrhagic exudations are occasionally met with, both in
that situation and beneath the lining membrane of the intes-
tines and bladder.  The kidneys present marked changes in
about half the fatal cases of diphtheria. They are generally
swollen and engorged, and often contain scattered collections
of blood.  In other cases the changes are only visible under
the microscope.  Here the epithelial cells lining the tubules
are found swollen and granular, and they have often under-
gone extensive proliferation, the crowded masses of young
cells filling  the tubes, and forming epithelial casts.  Occa-
sionally theMalpighian tufts and the tubules contain blood,
and the latter are sometimes occupied  by hyaline coagula.
   The changes in the brain depend on the  mode of death,
and, if the  patient succumbs  to asphyxia, there is venous
engorgement of the membranes and cerebral substance, and
minute extravasations of blood.   Pus and lymph have also
been found  on the arachnoid  membrane, when the septicae-
mia has been very marked.  In many cases where death has
taken  place whilst the patient was suffering from extensive
diphtheritic paralysis, the tissues have  presented no marked
alterations;*  and Morel 1 if goes so far as to say that "the
anatomico-histological changes found in such cases are inade-
quate to explain the various forms of diphtheritic paralysis
and paresis."   In fact, the almost  invariable restoration of
the functions  would  seem to argue conclusively against the
muscles of motor  nerves  being the seat of any serious de-
generative change.  In exceptional cases, however, serious
and extensive lesions have been  discovered.  They were first
observed by Charcot and Vulpian X in a case of paralysis of
the velum palati.  The motor  nerves of the part consisted
of tubules emptied of  their medullary substance, their neu-
rilemma containing numerous granular cells, elliptical in
form, and in some instances, nucleated. In one case Buhl§
found the substance of the brain occupied by scattered extra-
vasations  of blood, the nerves thickened at their roots, and
their  sheaths  crowded with lymphoid  cells and nuclei.   In
a case of Oertel's || the muscles had  undergone extensive fatty

  * See two cases, reported by Dr.  Hermann Weber, " Yirchow's
Archiv.," vol. xxiii, p. 115.
  f " L<> Sperimentale," Dccembre, 1872.
  + " (.'ompt. Keiid. de la Soe de Ui<d ," 1862.
  \ Ziem>?cn's " Cyclopaedia," vol. i, p. 656.
  |( Ibid. p. f»o7.
                            6 
62
DIPHTHERIA.
degeneration, while the substance of the brain, spinal cord,
and spinal nerves was theseatof numerous extravasations of
various dates.  There were also other, marked changes in the
spinal cord.  Dr. Hughlings Jackson* has pointed out that
muscles supplied in part through ganglia of the sympathetic
system are especially prone to paralysis.  This  is true of
diphtherial amaurosis,'and of the paralysis of the palate,
and it would  seem  that the nerve cells which  give way are
most largely represented in the higher ganglia of the sym-
pathetic system.
  The most cursory study of the general pathology of diph-
theria  suffices  to  assure us that it is an acute general dis-
ease, with certain local manifestations.  The primary septi-
ccvmia is due to the specific poison, but absorption from the
decomposing lymph is, no doubt, a cause of secondary infec-
tion.  In all cases,  the attack is associated with some degree
of constitutional disturbance, while in the severest forms
there is  extreme disorganization  of the blood and conse-
quent implication of nearly every tissue in the body.  The
general infection is shown at a very early stage, as well as
at a period when the local manifestations have disappeared.
Besides the constitutional disturbance by which the attack
is ushered in, there is the frequent derangement of the renal
function, the marked  prostration of strength, the functional
disturbance of  the  heart, and, at a later period, the exten-
sive implication of the nervo-muscular system.  The local
symptoms—the false membrane, with its parasitic growths
—must be looked  upon as the first  evidence of constitu-
tional  poisoning;   in fact, as the first of the  secondary
phenomena.
* Loc. cit. 
PROGNOSIS.
63
                   CHAPTER VII.

                       PROGNOSIS.

  The  mortality of diphtheria varies chiefly according  to
the age of the patient and the  character  and stage of the
epidemic, and these points must consequently be borne  in
mind in giving a  prognosis.  The  relative proportion  of
deaths  to  cases is  by no  means constant.   In some epi-
demics  it has exceeded  fifty per cent.  According  to Dr.
Borgiotti's statistics*  of the recent Florentine epidemic, out
of 1546 persons attacked in the years 1872  and 1873, 881
died ; but  as Dr.  Borgiotti  elsewheref remarks, owing  to
the incompleteness of the health returns, or, in other words,
the  probable omission of slight cases, these figures  should
be looked upon rather as the relation of "the gravely affected
to the dead"
  The dangers which are most  to be dreaded at the outset
of an attack are, on the one  hand, extension of the disease
to the  larynx, and on the other, severe blood-poisoning.
In the fonmr case the patient is exposed  to imminent risk
of death from asphyxia.  In the latter, a fatal result may
occur from collapse,  or the patient  may rapidly sink with
typhoid symptoms.   At  a later period, a  fatal result may
be  brought about by  repeated attacks  of syncope,  by gen-
eral prostration without manifest cause, by exhaustion from
constant and uncontrollable vomiting or from severe haem-
orrhages,  or  by  inflammatory  complications, such  as
secondary  pneumonia or acute nephritis.   In the  case  of
infants, death has resulted from inability to suck, owing  to
implication and consequent stoppage of the nasal  passage.
Death during  convalescence most commonly results from
paralysis  of the heart or of the muscles of inspiration,  or
from intercurrent  disease of the lungs or pleura, or from
general failure of nerve-force and exhaustion.
* Loc. cit.        f " Atti dell Accademia," etc. p. 16. 
64
DIPHTHERIA.
  With regard then to the data on  which a prognosis must
be formed, the most important general consideration is  the
character and  mortality of the prevailing epidemic.   It
may, perhaps, be laid down as a  rule that of the cases in
which  a definite false membrane  is present, one-third, at
least, will probably prove fatal.   Apart from  other  less-
known  causes, the  mortality in any epidemic will vary ac-
cording to the form of the di>ease and according  to  the
proportion of children to adults attacked, diphtheria being,
for obvious  reasons, far more fatal  amongst  children than
adults.   It must also  be borne  in  mind  that, in certain
families, diphtheria has an exceptional tendency towards a
fatal result.  With  regard to the special symptoms on which
to found  a  prognosis, the  following considerations  chiefly
deserve attention:  high  temperature, extreme prostration,
haemorrhages, or urgent vomiting at the  commencement of
an attack, are signs  indicative of extensive general infection,
and  must, therefore, be looked  upon  as of very  serious
prognostic import.  Valuable information may be  gained
from  the character and extent of the  false membrane.
Cceteris paribus, the prognosis is serious in proportion to the
thickness and extent of the exudation.   When the exuda-
tion  shows a disposition  to  extend rapidly, the danger is
very considerable, as the extension  is most  likely to take
place  in the direction of  the  larynx.   Prostration and a
tendency  to  syncope are  alarming  signs  at any  period
of an attack ; their  advent is often heralded by a very rapid
or a very slow pulse, with muffling of the heart's  sounds
and intermittency of its pulsations.   The presence of albu-
men  is not,  as I have  already pointed  out, a symptom of
much importance.  During convalescence,  the extension of
muscular paralysis  to the muscles of respiration is  the most
alarming sign. 
TREATMENT.
65
                   CHAPTER  VIII.

                      TREATMENT.

  The symptoms of diphtheria are due, as  I  have shown,
in part to a general blood  infection, and in  part to a local
specific inflammation. Each of these pathological processes
appears to run a cyclical course ;  in each the deviation from
health is  only a temporary one, which  after lasting for a
variable period, shows a tendency to subside and to termi-
nate in the re-establishment of normal action.   Each pro-
cess,  however, is attended  with  its own special danger,
which may lead  to a fatal  issue, before the return to health.
As regards the general  condition it is the intensity of the
morbid changes which constitutes the great danger;  locally,
the risk lies in the  occurrence of the exudation in a perilous
situation.
   General  Treatment.—This  should be directed  towards
husbanding and supporting the patient's strength by every
available means.  He should be placed, if possible, in a
large, cheerful, and well-ventilated room, the air of which
must be at once warm and moist.   The temperature should
be kept as  nearly as possible between 60° and  65" Fahr.
The patient's  diet must  be both nutritious and  digestible.
Concentrated  beef  tea, or  beef-tea jelly,  milk, and egg flip
must be  regularly  given at short intervals.   Dr. Massei,*
who has  seen  a  great deal of the  disease  at Naples, has
pointed out that milk is  often digested with  difficulty in
these cases, and under such circumstances it must be com-
bined with lime-water.  Especial attention must be paid to
feeding during the night, when the vital power of the patient
is usually at its lowest ebb.   There is often great distaste
for food;  in other cases  swallowing is attended  with con-
siderable  pain, while occasionally everything that is  swal-
lowed is immediately rejected.  It is, however, the duty of
* " Intorno alia Cura dell'Angina Difteiica," Napoli, 1875, p.54. 
66
DIPHTHERIA.
the attendants to secure the due nourishment of the patient
in spite of every difficulty. There are few cases of diphtheria
in which systematic feeding  does  not  constitute the most
important part of the medical treatment.   The administra-
tion of alcohol in small quantities is almost always advisable.
In some cases, it is true, it may not be called for during the
whole of the attack, but  very often it supplies us  with the
best chance of saving the patient's life, and it must then be
pushed with  a boldness rarely  needed in other  forms of
disease.  Small doses of alcohol will usually be found suffi-
cient in the earlier stages of an attack; two ounces of brandy
or four ounces of wine in the  twenty-four hours may be pre-
scribed for an adult, and proportionate quantities for a child.
In other cases,  however, larger doses are required  from the
very commencement.   But whatever be  the earlier symp-
toms the physician must always be prepared to increase the
dose rapidly,  if the appropriate indications—attacks of syn-
cope, irregular, very  frequent, or very slow pulse, and de-
lirium—present themselves.   In these circumstances a high
temperature does not in itself contraindicate  the  employ-
ment of stimulants.   In all  cases  it is necessary to keep a
careful watch  upon the pulse, which will give  invaluable
information as  to the need for alcohol.  Rapid and fatal
failure of  the heart  often supervenes quite suddenly  and
unexpectedly, and the first indication  of such failure is the
signal for the unsparing use of the drug.  Patients  suffering
from the exhaustion and prostration of diphtheria bear large
amounts of stimulants without any of the usual intoxic ating
effects, and as much as twenty ounces of brandy have been
given to an adult within twenty-four hours with  manifest
benefit. Champagne may  occasionally be substituted for
brandy, but this wine, in  the active state of the disease, often
causes  pain in deglutition, and, as a  rule, is  more useful
during convalescence.  Whenever there are signs of ap-
proaching cardiac failure, it is important to keep the patient
in bed  with his head low, and  to interdict any movement
whatever.   The neglect of this precaution  has  often been
attended with fatal  results.
  Before passing to the strictly therapeutic treatment it is
necessary to make a few remarks on bloodletting.   It was
at one  time thought that general bleeding had a favorable
influence on the spread of the exudation.   Home  strongly
advocated it,  and recommended in addition the application 
TREATMENT.
67
of leeches to the upper part of the throat.   Bretonneau in-
variably used the lancet in his earlier cases. But experience
soon taught  him  that depletion  neither  extinguished  the
disease nor prevented the  formation of false numbrane, and
he reluctantly abandoned it.  Guersant^Trousseau, Bouchut,
and Empis all came to a similar conclusion, and since their
time  the  treatment by venesection  has not been revived.
Considering the serious danger of death from syncope and
exhaustion to which patients are exposed when suffering
from  diphtheria, it is a matter for wonder that such treat-
ment was ever thought  of.  The same may be said with
scarcely less emphasis, of local depletion.  The  application
of leeches to the  throat  may indeed  relieve the pain aud
swelling, but such relief is dearly bought at the loss of even
small quantities of blood,  and the serious risk of diphtheritic
infection of the leech-bites.
   Sir William  Jenner*  recommends that  the  treatment
should be commenced with a purgative, the bowels being
well  cleared  out  by a dose  of calomel  and jalap or by a
calomel and colocynth pill, followed in the inflammatory
form  of  the  disease, by a saline aperient.  Mr. De Berdt
Hovell,f of  Clapton, unaware of Sir William Jeuner's ob-
servations, has also adopted  this  plan, and has employed it
occasionally for the last twenty years with  marked success.
He considers that elimination of the poison is thus made to
take place by the intestinal canal, and that the extension of
false  membrane is arrested.
   Of the general remedies which have been recommended
in diphtheria there are four kinds, viz.: (1) The recupera-
tive agents;  (2)  the alleged specifics;  (3) the  antiseptics;
and (4) the expectorants.  Some  remedies it will be at once
perceived, belong to more than one of these divisions.
   (1.) Of the recuperative agents, iron and quinine are the
most entitled to consideration. Of these iron is undoubtedly
the  most useful,  and the profession is  indebted  to  Dr.
Heslop.J; of Birmingham, for proving its value in diphtheria.
It should be administered frequently  aud in  large doses.
Thirty  minims of the tincture of the perchloride  may be
  * Op. cit. p. 66.
  ■j- Mr. Hovell's views on this point will shortly be published in
extenno in one of the medical journals.
  X Medical Times and Gazette, May 29, 1858. 
68                   DIPHTHERIA.
given to adults every two or three hours, aud proportionate
doses to children.  It is well to combine it with glycerin,
and, of course, it must be diluted with  water.  The general
effect of the drug is often extremely favorable, and its local
influence is equally well marked, the soreness and  pain in
the throat being considerably relieved ai'ter each dose.  The
double effect is more surely procured by prescribing one of
the persalts in preference  to the less astringent protosalts.
Quinine is  occasionally  required in  the course of an  attack
of diphtheria.   The special indications for its use are head-
achewith high temperature, vomiting, and the symptoms of
septic poisoning.   In  such cases the drug should  be given
in full doses, aud should not be persisted in if benefit fails
to result in thirty-six or, at the most, forty-eight hours. As
a rule, however, quinine is more  useful after the more serious
symptoms have abated, when it may be very suitably com-
bined with iron and a  mineral acid.  Morphia aud chloral
are occasionally necessary to combat continued sleeplessness,
and to ward off the exhaustion which is its invariable con-
sequence.
   (2.) The principal alleged specific remedies are : mercury,
sulphide of potassium, bromine,  aud the balsams of copaiba
and cubebs.   The treatment of diphtheria by mercurials
was at one time not less common .than the practice of deple-
tion, and it received  a certain degree  of support  from the
favorable influence  which  dusting  with  calomel  is found
to exert on diphtheritic wounds.  But experience  has  long
taught  us  that  the  general influence of mercury  on the
system rather  promotes than checks the spread of the exu-
dation.  At one period  mercury was vigorously pushed  by
Bretonneau,*  but with  very unsatisfactory results.  From
that time the use of mercury has been gradually discarded,
and with such general consent that no one has since ventured
to reintroduce  it.  Of the other alleged  specifics, sulphide
of potassium has long  been regarded by Swiss physicians
as a valuable  specific, but it often  produces both sickness
and diarrhoea, and  should not be employed.   Bromine,
which is best administered in the form of  bromide  of potas-
sium, has not  answered the expectations of its first advo-
  * New Sydenham Society's "Memoirs  on Diphtheria," Lon-
don, 1859, pp. 77-93. 
TREATMENT.
69
cate.*   The  well-known  action of copaiba  and cubebs on
the mucous surfaces, led Dr. Trideauf to try these remedies
in croup  and diphtheria, and his experiments have been
still  further elaborated by Bergeron.^   Dr. Beverley Rob-
inson§ has also  lately' strongly recommended the  use  of
cubebs in the catarrhal form of diphtheria.   This physician
lays great stress  on the  importance  of  making use  of  the
freshly-ground powder.   In catarrhal cases I  have found
distinct benefit from the  use of the perles of copaiba.   None
of the various drugs just enumerated, however, can legiti-
mately  lay claim to anything  like  a certain and specific
action.
  (3.) The general antiseptics include iron, chlorate of pot-
ash, carbolic acid, aud salicylic  acid with its  compounds.||
The value of iron has already been explained.   Chlorate
of potash, so  useful in many affections of the throat and
mouth, has also been largely used in diphtheria.  Isambert^f
and Seeligmuller** have carefully studied the effects of this
drug, aud the general weight of evidence is very much  in
its favor.  Ten to twenty grains may be given  every two
or three hours.   I have not employed carbolic acid  myself
as an internal  remedy, but the  sulphocarbolates  as  recom-
mended by Dr. Sansomff have often proved of service  in
my hands, in the secondary poisoning of diphtheria.  In  the
primary septicaemia, these remedies  have appeared  to  me
quite useless.  Five grains of the sulphocarbolate of soda
in a little water may be given to a child of two years every
three or four hours.  Salicylic acid  has been  strongly rec-
ommended by Fontheim,|!  and  I have used  it myself  in
  * Ozanam,  " Comptes  Rendus de l'Acadeinie des Sciences,"
1856.
  f "Trait, de l'Ang. Couen. par le Baume de Cop. et le Poivre
Cub ," Paris, 1866.
  X " Diet, de Med. et de Chir. Prat.," t. x, p. 361.
  \ "American Journal of Med. Science," 1876, p. 30, et seq.
  || The sulphites introduced by Polli (" Brit. Med. Journ ," vol.
ii, p. 441, 1867) have been strongly recommended  by Giacchi and
Ferrini (whose papers are referred to in the body  of the  article),
but I have not tried them myself.
  '  " Etudes Chim. sur l'emploi du Chlor. de Potasse dans les Aff.
Couenneuses," Paris, 1856.
 ** " L'Union Medicale," 9 Juillet, 1878.
 ff "The Antiseptic Treatment," London. 1871.
 XX "Journal fin- Praktisehe Chemie,"  1875, vol. ii, p. 57. 
70
DIPHTHERIA.
three cases with apparent advantage.   The following is the
formula which I have employed : &.  Acid, salicylic. 3iss.;
spirit rect. |iiss.; aquam  destill. ad  3yj. M. Ft. liquor.
One to two  teaspoonfuls of this solution  may  be given
every three hours.  Great success is claimed by  Dr. Hauow,*
of Erlangen, for this remedy administered internally in half-
grain doses every hour ;  but these observation require con-
firmation.  The salicylates of  soda and potash have also
been  strongly reccommended.   I have given the former
remedy in two cases, but in both instances the disease was
too far advanced  for benefit to  result.  Salicylate  of soda
and salicylic acid have been recently  found useless  by Drs.
Cadet de Gassecourt and Bergeron respectively.f
   (4.) The use of expectorants has loug been more or less in
vogue.  The  principal remedies of this kind which  have
been  found useful  are senega,  carbonate of ammonia, and
the balsams.   Senega was recommended as an expectorant
by Dr. Archer | nearly one huudred years  ago.  It has
since  been frequently employed in  this country, and  is
highly esteemed by Dr. West.§  A dessert-spoonful of the
officinal infusion, sweetened with a little syrup, should be
given every two hours, but the  effect of the  remedy should
be watched,  and  the  quantity reduced  if any vomiting
occur.  Carbonate of ammonia (two  or three grains)  may
be given  with  the senega, or  it may be administered  in
water.  The balsams of copaiba and cubebs, though placed
under the list of alleged specifics, probably act in  a  great
measure as expectorants.
   Local  Treatment.—This  has  varied greatly at  different
times, and there  still  exists  considerable  divergence  of
opinion as to  which method is  most appropriate.   Caustics
and  astringents, solvents aud  antiseptics,  heat aud  cold,
have all been in favor at different times and with  different
observers.
   The use of caustics has, perhaps, been more  general than
that of any other class of local  application.   Bretonneau ||
  * "Mediz. Neuigk.," Erlangen, Mav, 1875.
  f " L'Union Medicate," 9 Juillet, 1878.
  X Op. cit.
  g " Diseases of Infancy and Childhood."  Si*th edit. London,
1874.
  || •'Memoirs on Diphtheria." (New Syd. Soc. Trans.) London,
1859. 
TREATMENT.
71
strongly recommended a mixture of hydrochloric acid and
honey, in the proportion of one part of the former to three
of the latter, as a means of checking the local exudation.
The caustic was to  be applied only once in twenty-four or
thirty hours, and its  effects were to be carefully watched.
Subsequent experience has shown that besides being attended
with very considerable pain, the use of strong hydrochloric
acid has no effect in controlling the spread of false membrane.
The use of a solution of nitrate of silver, and even of the solid
stick, at one time met with considerable support,and has been
recommended by Bretonneau, Guersant, Bouchut, and Trous-
seau,*  but it is  being  gradually abandoned by those who
have had experience of recent epidemics.  The same remark
is true of sulphate of copper, and the acid nitrate of mer-
cury, both  of which have been recommended for the  local
treatment of diphtheria.  In fact, the profession has given
up  the use of caustics altogether, being convinced that they
rather aggravate than check the local process.
  Various astringents, such as tannic acid, powdered alum,
and perchloride of iron, have been used for many years, and
still are largely employed. Tannic  acid and alum are most
conveniently administered by insufflation.   Their effect  is
increased, as Dr. Loiseauf has pointed out, by using them
alternately.  Half a grain of tannin with half a  grain of
starch  will be   found  the most convenient strength, whilst
alum may  be employed in the proportion of  three-quarters
of  a grain  of  the  salt to a quarter of a grain of starch.
Insufflations are recommeuded to be used  (by those  who
believe in  their  beneficial action)  at least  every hour or
two.  Perchloride of  iron is best employed  in the form of
the tincture, which should be freely applied every two or
three hours.  The disease is sometimes checked by this class
of remedies, but on the other hand, it sometimes irritates
the throat—especially if there  is  much hyperaemia—and
frequently  increases the  nausea  and dislike to food which
are so common.   I now seldom  use these drugs, with the
exception of iron, which, when employed as a constitutional
remedy, also acts topically.
  Local agents which  act as solveirfs have been introduced
  * "Memoirs on Diphtheria."  (NewSyd. Soc. Trans) London,
1859.
  f " Gazette Medicale de Paris," 1862. 
72                   DIPHTHERIA.
in modern times in diphtheria, with the view of getting rid
of the false membrane without violence.   The chief of these
are :  lime-water, solution of caustic potash, chlorate of pot-
ash, aud lactic acid.  Added to pieces of detached mem-
brane in a test-tube, each of these substances has certaiuly
the  power of dissolving them ; and whilst the false mem-
brane is  in  contact with the living  tissues, they  have a
similar, though less active  effect.  Lime-water  has been
particularly recommended by Steiner,* and is certainly use-
ful when the false membrane is not very thick.  Sanuef has
recently suggested a saccharate of  lime, which has the ad-
vantage of being a more stable compound than lime-water.
These preparations of lime can be applied either in the form
of spray  or  by  means of a camel's-hair pencil.  Liquor
potassae (one part of the liquor to four parts of water) can
also be used in the same way.   Of  all the solvents, how-
ever, lactic acid is the most reliable.  I generally apply it
freely with a brush, or by means of a  piece of lint attached
to a wooden rod ;  the latter instrument permits of very free
application.  I have never met with the inconvenient results
from the  use of lactic acid which Kuchenmeister| has de-
scribed—viz., ulceration of the mucous membrane of the lips
and mouth.
   In most cases of diphtheria antiseptics are  very useful.
The  best antiseptics are carbolic acid, permanganate  of
potash, chlorinated soda, glycerin of  boi'ax,  chlorate  of
potash,  and  hydrate  of chloral.   Carbolic acid  may be
applied in  solution (gr. iij to 3j), or in the form of Glycer-
inum Acidi Carbolici,  B. P.,§ or the Vapor Acidi Carbolici
of the Throat Hospital Pharmacopoeia may be used.  Dr.
Masseifl specially  recommends the use  of the alcoholized
carbolic acid, the carbolic acid being  in proportion to the
alcohol  as  one  to three or one to five, according to the se-
verity of the local exudation.  Permanganate  of potash is
  * " Zur Therapie der Diphtherie," " Jahrbuch fiir Kinderheil-
kunde," 1870.
  f Op. cit. p. 429.
  X " Die Behandlunsjder diphth. Anginadurch zerstiiubte Milch-
saure," Dresden, 1870.
  \ Dr Sansom has, however, shown that the antiseptic qualities
of carbolic acid are greatly diminished by the addition of glyce-
rin (op. cit. p. :0, et seq.).
  || Op. cit. p. 43. 
TREATMENT.                  73
most serviceable when employed at the strength of gr. v to
5j.   The best formula for chlorinated soda  is:  Liquor
sodae  chloratae, 5'iv; aquae, £x.   Chlorate of potash  may
be given in  almost any strength, though  gr. xx to |j is gen-
erally found sufficient.   Hydrate of chloral has aiso  been
found very serviceable by several  practitioners.   It was
first recommended by Dr. Accetella,* and subsequently by
Dr. Ferrini,f of Tunis, and has since  been highly extolled
by  Dr. Caesare Ciattagli,! of Rome, and Dr. Massei,§ of
Naples.   In this country it has been  employed with  great
success during the last two years by Mr.  Hughes Hemming,
of Kimbolton, to  whom I  am indebted for its recommenda-
tion.   Mr. Hemming uses the syrup of chloral  (gr. xxv ad
5j), and directs that it should be employed every hour  or
two.  It does not, as a  rule, cause any pain, and the  nurse
can be  easily taught to apply it.  Mr. Hemming  observes
that " whilst it rapidly gets rid of the fetor, it  is  beautiful
to see the  membrane  loosen  and come away, leaving a
healthy surface underneath."  This remedy has also  been
very successfully used by Dr. Charles Hemmiug, of Bishops
Waltham.
  Jodin|| first recommended sulphur as a local agent, and
it has since been  administered internally.   The following
Italian  physicians speak  favorably  of  it:  Nesti^[  found
iui-ufflations of sulphur a most efficient remedy in the  Flo-
rentine epidemic,  and Dr. Calapinto** used the flowers of
sulphur, mixed with honey, with  great success.  Dr. Stefan,)
Becchinijf  also speaks favorably of its employment.   Sev-
eral  practitioners, however, who have  employed  it,  have
informed me that  it has not answered  their expectations.
  Oue of the solutions!! above mentioned should be perse-
  * " Campania Mcdica," No. 12, 1873.
  f " Storia Clinica della Diiterite osservata nella Citta di Tunisi
neirli  anni  1872-73."  (Lo  Sperimentale,  Lujjlio e  Settembre,
1874 )
  X " Gazzetta Medicale do Roma," Maggio, 1876.
  I Op. cit.                      || Loc cit.
  1] Op. cit. (Nella 2» parte).
 ** 11  Morgagni, II e III, 1873.
 ff LoSperinn-ntale, Febbraio, 1873.
 XX In the.late epidemic at  Highgate, borneic acid, dissolved in
glycerin (1 in  30), was found  very serviceable by Dr. Simpson and
others.  It  was applied first hourly,  and  afterwards  every  two
hours, until the membrane ceased  to re-form. 
74
DIPHTHERIA.
veringly employed in all cases of diphtheria where there is
much false membrane.  The antiseptic may be used either
as a gargle or a spray ;  or the patient's mouth  may be
washed  out with it by the attendant.   In this way  the hor-
rible fetor of the breath, which is so commou in diphtheria,
will be prevented.  It must not, however, be expected that
the use of antiseptic solutions  will have any restraining
influence on the exudative process, though it may,  to some
extent, destroy the parasitic fungi so  frequently present in
the exudation.  There  is also a class of remedies which,
though  not strictly speaking antiseptic, still, by exclusion
of air from the false membrane, appears to  have  antiseptic
influence.   These  are,  in fact,  varnishes,  and  consist of
gummy matters  dissolved  in  a  fluid  which  evaporates
quickly. I have tried gum benzoin, gum tolu, mastich, and
resin.  These substances can be dissolved in rectified spirits
or in ether, or a tincture of the gum or resin may be mixed
with ether.   On the whole, I prefer the ethereal  solutions
(1 in 5), and tolu is most pleasant to the patient, and, last-
ing longest as a varnish, has to be least frequently reap-
plied.   The surface of the false membrane should be dried
with blotting-paper* before the application is made.
  There yet remain two local applications to be considered,
viz., ice aud steam.
  In many cases  the  patient will derive great comfort from
frequently taking a piece oi' ice into  his mouth.  The annoy-
ing dryness and heat of the throat, as well as the dysphagia,
will be thereby materially alleviated and the  inflammation
sometimes arrested.   The application  of ice to the  neck, in
a bladder or ice-bag, is  sometimes agreeable, and  probably
generally beneficial.  The use of ice is  especially indicated
in the first stage of the disease, particularly in those cases
where there is much inflammatory tumefaction.
  On the other hand, heat is a very useful agent when the
false membranes have attained any considerable degree of
thickness.  Hot  fomentations  applied  externally to  the
throat are often found to relieve the pain in a remarkable
way, while the use of steam inhalations appears to exercise
an extremely favorable influence on the local  process.  As
a vehicle for conveying a volatile  medicament, steam has

  * For  holding the blotting-paper, a miniature paper-clip, which
can be fixed at different angles to a long stem, is sold by Messrs.
Mayer & Meltzer, 71 Great Portland Street. 
TREATMENT.
75
been  recommended by many physicians, but as a remedy
in itself, for diphtheria, it was first suggested by Dr. Prosser
James.*  The theory on which it is now used, however, is
due  to  Oertel,f who has earnestly advocated  the  employ-
ment of steam  on scientific grounds.  When it is  found
impossible to  check the formation of lymph by the  use of
local remedies, the rational treatment is to convert, as far as
we can, the inflammatory into a suppurative process.  Such
a  transition invariably takes  place before the  return of
normal  conditions, and to promote this transition is equiva-
lent  to  hastening the  restoration of  health.   Oertel has
found that the internal use of moist warmth facilitates the
occurrence  of suppuration  more than  any  other  agent,
and  he  recommends repeated inhalations of hot vapor.  He
has  observed  that, at  the  end of from twelve to eighteen
hours,  during  which  the  inhalation  has  been  practiced
hourly or half-hourly for ten or fifteen minutes each time,
the margins of the diphtheritic deposits, which  previously
passed  imperceptibly into  the surrounding tissue, become
more sharply defined,  and contrast strikingly with  the in-
tensely  reddened mucous membrane.  The patches, there-
fore, at first sight seem  enlarged.  Besides this, the  opera-
tion  of the hot vapor  has been  to  induce  a  considerable
excretion of pus-corpuscles.  If the inhalations be continued,
the  false   membranes  will  be seen to become gradually
thicker  and raised up from the mucous membrane.  At the
same time  they change in color  and their surface  becomes
wrinkled and uneven.  After some days they are completely
detached and the mucous membrane is healthy, except for
a variable degree of catarrhal inflammation.  The  inhala-
tions may be  made to serve  another purpose, viz., that of
cleansing  and disinfecting the mouth, ami with this  object
the Vapor Acidi Carbolici,or Vapor PLui Sylvestris (Throat
Hosp. Ph.) may be used.
   As young children cannot generally be induced to  inhale
the steam from an inhaler, "a croup-tent" should be erected
over the cot for this purpose.  An excellent portable appa-
ratus! has  been made for me by Messrs. Mayer. • When the
parts of the tent are put together,  and a blanket thrown
  * "Sore Throat," 1861, p. 39.
  f Ziemssen's " Cyelopa'dia," vol. i, art. " Diphtheria," p. 675.
  X The " portable croup-tent" consists of eight metal rods.  Two
of these representing the length of the tent are four feet long, and 
76
DIPHTHERIA.
over it, it represents, on a small scale, the upper part of an
old-fashioned four-post bed (with the curtains drawn) such
as is  still common in the  country.   The  tent method  of
administering inhalations  has  been in vogue  at the Chil-
dren's Hospital for many years.*  The steam-kettlef should
then be placed  near the tent, and steam passed within it.
  The detachment of the false membranes, which has by
some  been advocated  as a preparatory step to the  applica-
tion  of remedies, cannot  be recommended, except  in cases
where it  may be necessary for the relief of urgent dyspnoea,
or where putrefying membrane is lying loose in the throat.
As a rule, the false membrane, when thus removed, rapidly
reappears,  and  often  with  increased  activity and over a
wider area.
  The above are the modes of treatment and kinds  of reme-
dies  which are  suitable in different  forms of diphtheria.
Many others might have been enumerated.  As in the  case
of all  diseases  which  are very fatal, a vast  multitude  of
remedies have been most enthusiastically recommended, but
I have referred  to those only which I have myself tried.!   It
will perhaps give a more precise idea of the management of
the disease it we suppose  a certain typical case before us,
and go through the various phases of treatment that may
be required :
  A child is attacked with a sore throat during an epidemic
of diphtheria, and an examination  of  the fauces shows  that
the disease has already commenced, thin patches of false
membrane being present.   The little patient should at once
be put to bed in a large, well-ventilated room, and should
be made to suck ice constantly, whilst a bladder of ice
should be applied to  the neck.   A  simple but  highly-
two representing the wjdth are two feet six inches long. The four
supports sire two feet four inches in height. The eight pieces screw
together, and when  separated can chmIv be carried  in the hand.
A special cloth or blanket, sold with the framework, completes
the apparatus.  The croup-tent i> exceedingly useful, not  only in
cases of diphtheria and true croup, but also in laryngitis stridulosa,
for  saturating the atmosphere with the fumes of nitre and stra-
monium.
  * Jen nor, op. cit. p. 83.
  f An excellent  steam-kettle is sold  by Messrs. Allen, of Mary-
lebone Lane.
  X Bromine and  sulphide of potassium as general  remedies, and
chloral hydrate as a local  antiseptic, are almost the only excep-
tions to this statement. 
TREATMENT.
77
nourishing diet  of beef-tea, eggs, etc.,  should  be ordered,
and stimulants as a rule be given from the very commence-
ment.   If there be  evidence  of primary  blood-poisoning,
twenty to thirty  drops of the tincture of perchloride of iron
and the  same quantity of glycerin and five to ten  grains
of chlorate of potash, in half  an ounce of  water, should be
administered every three hours; if, on  the other hand, the
catarrhal symptoms be very marked, the balsamic treatment
should be tried,  and a capsule or perle  of copaiba contain-
ing four minims of the  balsam should be given every four
or six hours.  Local solvents should now be employed, and
the throat should be sprayed every two or  three hours with
lactic acid solution, or, if the child will not allow this to
be done, the pharynx must be  forcibly swabbed with this
remedy, or the syrup of hydrate of chloral may be applied
in the manner already advised.  If, in spite of this  treat-
ment, the disease advances, and the false membrane be-
comes thick and abundant, it should be  painted with an
ethereal solution of  tolu (1 in  5), the  surface of the false
membrane being first dried with blotting-paper.   This ap-
plication,  if thoroughly made,  need  not be applied more
than once, or at the most twice, a day.   Ice should now be
given up, and warm inhalations, made antiseptic from time
to time, constantly employed, by means of the croup-tent,
in order to  bring about suppuration aud cause the  false
membrane to separate by the normal pathological process.
It is useless continuing  the copaiba any longer,  and the irou
often appears to lose its effect.   It is at this period that the
sulphocarbolates sometimes have a wonderfully beneficial
effect, and at this stage also quinine, in  large doses, may be
given at the same time with advantage.   If the disease
extend  to the larynx or nose,  the appropriate  treatment
hereafter detailed  should be pursued:   The  third  stage
being  characterized in  favorable  cases  by  the natural
tendency to the  separation of false membrane, the hot in-
halations must  be  industriously continued, whilst the pa-
tient's strength  is kept  up by the use  of  highly nutritive
drinks and stimulants.   Such  is the plan of treatment that
may be  pursued iu an ordinary case  of diphtheria.   Com-
plications  of course require  special  remedies,  aud the
sequela? need appropriate restorative measures.
  The impaired  innervation of the lungs, which proves fatal
in so many cases of diphtheria, is difficult to cope  with.
                           7 
78
DIPHTHERIA.
The most reliable measures consist in the assiduous admin-
istration of food and stimulants.   The  inhalation of weak
ammonia has been recommended to meet this condition.
  During convalescence the patient must still be carefully
watched.  The weakness and anaemia  are best treated by
iron and other tonics, by cod-liver oil, and by residence  at
some  bracing watering-place.  These  measures  are  also
appropriate  in  cases of muscular  paralysis, but they then
require to be supplemented by other therapeutic measures,
according to the special symptomatic indication. The slight
palsy of the pharynx and soft palate, which is the commonest
form of post-diphtherial paralysis, generally passes off in a
few weeks without  treatment.   Where, however, there  is
marked loss  of the power of the pharynx, epiglottis, or
oesophagus, so that the food  is only swallowed with great
difficulty, it  may  be necessary to feed by  means  of the
oesophageal tube ;  indeed, this procedure may be absolutely
necessary  to prevent the  patient dying from inanition.  In
less extreme cases  the  use of the feeding-tube will serve  to
prevent the food from passing into the  larynx, an accident
which is likely to be followed by inflammation of the lungs,
and is always attended with great danger to the life of the
patient.  Sometimes it is sufficient to  feed  the patient on
thickened liquids.   When  the  paralysis  is obstinate, and
when it extends to the muscles  of locomotion, the employ-
ment  of electricity  is indicated.  Both  the faradic  and
galvanic currents are useful, but they should be applied  in
a mild form.   For the extremities, this  treatment  may be
combined with friction and shampooing of the affected parts.
  Prophylaxis.—Before concluding the treatment of diph-
theria, it may be well to add a few words on its prophylaxis.
When inspecting the patient's fauces, or cleaning or chang-
ing the tracheotomy tube, the practitioner should  be very
careful to prevent  any of the morbid secretions from coming
into contact  with  his lips or mouth, fatal results having
followed the  neglect of this precaution.  Like precautions
should also  be impressed upou  the  attendants who have
charge of a case of diphtheria.  Orders should  at the same
time be given that no one but the attendants should enter
the sick-chamber  except upon  urgent  necessity; and all
linen, spittoons, or other articles  which the patient  may
have used should  be carefully disinfected.  By adhering
strictly to these rules, it is generally possible to prevent the
extension  of the disease. 
LARYNGO-TRACHEAL  DIPHTHERIA.      79
                    CHAPTER  IX.

           LARYNGO-TRACHEAL  DIPHTHERIA.
                   (Formerly called Croup.)

  The  term croops, or croup, has been  used popularly in
Scotland from an early period.   The  word "croops" was
first employed by Dr. Patrick Blair in 1713, and "croup"
by  Dr. Home, a little more than  a century ago.  Since then
it has been somewhat vaguely used,  both by the public and
the profession in  all parts of the world to describe a certain
train of laryngeal symptoms. The word is probably derived
from the crowing breathing, which  is such a frequent ac-
companiment of the disease it was intended to describe.   It
has  many  allies in other languages, the closest being  the
Dutch Geroop, a, cry ; but the following  are doubtless all
derived from the same root, viz., Icelandic, Hrbpa; Anglo-
Saxon,  Hvojimi,; Gothic, Hropjan; Old  German, Hrof;
Modern German, Ruf;  all words intended to lepresent the
sound of the  voice.*  The Scotch word Roup—hoarseness,
has the same derivation.  On the other hand croup may be
derived from the Gaelic crup, signifying a contraction,  i.e.,
contraction of the throat.
  History (The Relation of Croup to Diphtheria).—Though
the history of diphtheria has been already briefly sketched,
it is necessary to  make a few remarks to explain how a form
of diphtheria came to be regarded as a distinct disease, and
to point out how  other laryngeal affections have been aud
still are—at least in this country—included under the name
of  croup.  Iu  the  seventeenth  and eighteenth  centuries
diphtheria and putrid sore throat were not  differentiated,
but were classed together  in this country under the head of
Cynanche Maligna.  A few years before Dr. Home pub-.
lished his celebrated work, Ghisi  and  Starr had  described

  *" Edinburgh  .Monthly Medical  Journal," February, 1856.
" Observations on Croup," by Charles Wilson. 
80
DIPHTHERIA.
diphtheria as it now exists, but unfortunately, Dr.  Home
was not aware of their labors, and there is no doubt but that
his Treatise  on   Croup  suspended the progress of observa-
tion for nearly sixty years, and even now warps  the judg-
ment  of  many  accomplished  practitioners.  Immensely
impressed with  the  laryngeal phenomena* of diphtheria,
" Francis Home," as Bretonneau remarks, "persuaded him-
self that he had just met with an  affection  which  had
hitherto  escaped the  attention of  his  predecessors,  and
thought  that he ought to give it the popular name under
which  he found it designated in  a Scotch  county.  The
novelty of the  discovery was widely diffused, and the new
denomination so fascinated all persons  that  it  prevented
them from  recognizing a disease observed from  the. most
remote antiquity, and  which, in  our own days,  is  accom-
panied by all the symptoms which  it has uniformly exhib-
ited."  Until diphtheria  appeared in Englaud in 1858 the
term croup was  employed to describe an acute affection of
the larynx, believed to be inflammatory and non-contagious,
in which false  membrane  was present.   The tendency of
modern investigation, however, is to show that cases formerly
described as typical examples of croup were in fact examples
of isolated laryngeal diphtheria.   French physicians, who
since the time of Bretonneau  had been more familiar  with
diphtheria  than the  profession  in this  country,  almost
universally  regarded the two affections as identical.  When
the violent epidemic of diphtheria  broke out in  England,
in the year 1858, it  was  natural  that  practitioners  should
fail to  connect the epidemic affection with the typical croup
(previously  generally isolated or endemic) with which  they
were familiar.   Although the antiphlogistic  theory  was on
the wane, croup was still described in textbooks as a disease
requiring active and lowering remedies ;f  whilst it was soon
perceived that  diphtheria could only be combated by ana-
leptic treatment.  Hence from the very outset an artificial
distinction was  created in the minds of practitioners.
  * Introduction to First Memoir.
  f Even Dr. Squire  in his able and comprehensive article pub-
lished so lately as 18ob (" Russell Reynolds's System of Medicine,"
vol i, p. '234, et seq )  recommends in certain cases bloodletting to
the extent of three or  four ounces for a child of four or five years
of age. 
LARYNGO-TRACHEAL DIPHTHERIA.      81
  Whilst the term croup had been strictly applied to the
pellicular inflammation  of  the  larynx, many laryngeal af-
fections in which a shrill cough, or a crowing inspiration,
was present,  had been described as varieties of croup; and
the terms "false croup,"  "spurious  croup,"  "catarrhal
croup" were in common use.   These affections, which are
still often mistaken for true croup (see Diagnosis, p. 88) had
still  further  warped  the judgment of the  profession  as re-
gards the true nature of laryngeal diphtheria.  Near the
termination of the great epidemic, 1858-62, in this country,
the identity  of the two  affections was, however, advocated
by the late Dr. Hillier,* and in my Jacksonian Prize Essayf
(1863), I maintained the same view.  The doctrine of iden-
tity has subsequently been urged with great earnestness and
ability by Dr. Sernple,"!; and his writings must  have exer-
cised  considerable influence in  this  country.§
   The  advocates of the duality theory have  based  their
views  (1) on  the supposed  pathological differences, and (2)
on the alleged clinical differences.
   (1.) The supposed  pathological differences in the struc-
ture of the two kinds of false membrane were formerly put
forward as matters  of  great importance.   Virchow,|| the
originator of these hypothetical distinctions, though admit-
ting that the diphtheritic exudation was very similar to that
of croup, maintained than the former was  poured out into
the substance of the mucous membrane, while the latter was
only a coagulation upon its surface.  On this hypothesis he
founded what was once  esteemed  a most important point in
practical diagnosis.   The  diphtheritic  membrane,  he  as-
  * " Med Times and Gaz.," April 26, 18<>2.
  f This essay is in the 'library of the Royal College of Surgeons,
and an  extract from it referring to the subject of diphtheria  and
croup was published in the " Brit. Med. Jour ," March 5th, 1870.
  X " Croup and Diphtheria "  London, 1872.
  | Most physicians in thi.- country who have had the opportunity
of studying the disease in the wards and in the deadhouse now re-
gard croup as a form of diphtheria.  At an early period Dr. George
Johnson (" Brit.  Med. Jour.,"  Feb.  19th, 1870) maintained the
identity of croup and diphtheria ; and later, our great  clinical
teacher, Sir William Jenner (" Lancet, Jan. 2d and lfith, 1875)
gave in his adhesion to thi> doctrine.   The renowned Traube, of
Germany, bad previouslv accepted the unity theory (" Berlin Klin.
Wochenschrilt," No 3*1, 1872).
  || " Archiv," 1847, p.  253, et scq. 
82
DIPHTHERIA.
serted, could not be removed without tearing away portions
of the underlying tissues, and  leaving a  bleeding surface.
The croupous "pellicle, on the other hand, could  be easily
detached, and the denuded surface would be found  quite
healthy,  with the exception, perhaps, of a variable degree
of hyperemia.   Before  long, Virchow found  himself com-
pelled to surrender this  distinction, as it was found in prac-
tice that the two forms of exudation  passed into each other
by insensible gradations.   He  now  changed his ground,*
and promulgated the view that death (necrosis) of the sub-
jacent tissues was the characteristic and essential  feature of
diphtheritic exudation.   Practically, however,  this distinc-
tion was found to be no more satisfactory than the former, for
cases  came under observation which  clinically  answered to
croup, but iu which there was distinct death of tissue.   It
was also pointed out that the difference in the degree of ad-
hesion of the croupous and diphtheritic exudations is due to
the difference in the structure of the parts on which  they are
thrown out. The false membrane is naturally more closely ad-
herent in the pharynx, where the epithelial layers on  which it
is deposited are not marked off from the subjacent tissues by
any definite homogeneous basement membrane. On the other
hand, in the larynx and trachea the presence  of the base-
ment  membrane favors the  separation of the lymph.  It
has thus at length been  generally admitted that there are no
sufficient naked-eye appearances to  distinguish the croup-
ous  from  the diphtheritic exudation.   Nor have micro-
scopical observers met with  any better  success  in their
endeavors  to differentiate  the  two diseases.  Dr. E. Wag-
ner,f  who has done the  best  work  in this  direction,  has
openly declared that his preparations of croupous and diph-
theritic membranes are very much alike.   The diphtheritic
deposit he describes as a transparent, homogeneous, lustrous
network, the interspaces of which are, for the most  part,
filled with  lymph and pus corpuscles, though some  of them
are void of contents.  The croupous membrane consists of
a close network  of delicate  threads, the meshes of which
contain  numerous elements resembling pus-cells.   Wagner,
however, differs  from many other observers, holding that
  * " Handbuch der Spec. Path,  und Therapie," 1854, vol. i, p.
292.  See also  " Berl. kl. Woohenschrift," 1865, No. 2.
  f " Archiv.  der HeilUunde,"  1866, vii, p. 481. 
          LARYNGO-TRACHEAL DIPHTHERIA.      83


the network in both cases has its origin in a peculiar fibrin-
ous degeneration of the epithelium, and not in  the separa-
tion of a coagulable fluid  from  the blood.  Rindfleisch*
admits that the pathological process iu "pharyngeal croup"
is the  same  as  that  which takes  place  in  " laryngeal
croup," and  thus gives iu his adhesion to the views main-
tained in the present article; but in spite of their anatomical
identity, he feels  bound to oppose any clinical fusion of the
two diseases.
   It will  be seen  from a consideration of the  above facts that
the pathological differentiation of the phenomena must be
abandoned.  We hence come to
   (2.) The clinical difference.  The supposed differences are
   (a)  The site of the disease; and (b) its manifestations.
   (a)  Diphtheria is said to be an affection  of the pharynx
occasionally  spreading  to the larynx,  whilst croup,  it is
asserted, is essentially a disease of the  larynx  or trachea.
The fact  is,  that croup is a disease  which commonly com-
mences in the pharynx,and only in about 10or  12 percent.
of cases originates  in the larynx or trachea.  Difference of
site, moreover, iu constitutional diseases does not constitute
a specific  difference.  Cancer is always  cancer, whether the
pharynx alone, or the larynx alone, is  affected, or whether
the two parts are attacked at the same time or consecutively,
and  rheumatism  is still  rheumatism, whether it affects  the
heart or the ankle.
   (6) As regards the manifestations of  the disease:
   (1) Croup is said to be a local disease, (2) to be a sthenic
inflammation, in  which  (3) the lymphatic  glands are  not
affected ; and (4) in which there is no albuminuria, nor (5)
paralysis;  whilst
   (1) Diphtheria is  a  constitutional disease, (2) of ady-
namic type, in which (3) the cervical glands are inflamed,
and (4) in which  there is albuminuria and (5) paralysis.
  To discuss  these briefly :
   (1.) It  is true that in croup the general symptoms are not
so severe as when the membrane is thrown out on an exten-
sive portion of the pharynx.  This fact  admits of ready ex-
planation, ou the  view that the septic symptoms are in part
secondary to  the local processes. For whilst the lymphatics
  * "Lehrbuch der Pathologisehej^Gewebelehre," Third Edition,
pp. 311-12. 
84
DIPHTHERIA.
of the mucous membrane of the soft  palate, of the tonsils,
and of the back of the pharynx have very free communica-
tions with the numerous  glands below the angle of the jaw,
the absorbent vessels of the mucous membrane of the larynx
and trachea  are conveyed only to  the solitary  gland just
below thegreater horn of the hyoid bone, and the small gland
at the side of the trachea.*   There is, therefore, much  less
liability to general infection when the local process has seized
only on the latter part.  When the primary septic poisoning
is  powerful the  constitutional  symptoms are,  however, as
marked in so-called croup as in diphtheria.
   (2.) Cases  of sthenic croup are very rarely met with, and
the same remark  applies  to diphtheria.  On the  other
hand, there are medical  men who assert  that bleeding  can
be employed in diphtheria with  success.f  Hence distinc-
tions  based  on differences of type  in the  two  diseases can
have  no weight.
   (3.) The cervical glands are not  often affected in  croup,
because the  mucous membrane of the larynx has no com-
munication  with the superficial cervical  glands; on  the
other hand, as stated above, there is  an elaborate connec-
tion between the pharynx and the lymphatic glands.
   [In cancer of the pharynx, also,  the cervical glands are
always enlarged, whilst iu cancer of the larynx the  glands
are seldom at all affected.]
   (4.) In croup, albuminuria is often present.
   (5.) Paralysis  is  rare in croup, because nearly all the
cases  terminate fatally,  but  it is occasionally met with in
those that survive.
   I  have entered into these details because details  must
always have  a certain amount of significance ; but  it is more
satisfactory to look at the question from a  broad and philo-
sophical point of view.  Classifications are, after  all,  mere
arbitrary arrangements by which knowledge may be placed
in an accessible form for further use.  The oldest classifica-
tions  are purely symptomatic.  When anatomy came to be
mastered, we had an anatomical basis for classification, aud
we are still obliged to make considerable use of this system ;

   * LuschUa, " Der Schlundkopf des Memehen," Tubingen, 1871,
p  156.
   f "  Courier Medical," Sept  7th, 1878   Dr.  Simorre reports
fifty-three cases of diphtheria treated by Needing. All the patients
recovered—most of them in twenty-lour hours. 
         LARYNGO-TRACHEAL  DIPHTHERIA.      85


but as medical science progresses, the disposition is to track
disease to its origin and seek out its hidden causes.   Hence
we see arising at the present day an etiological classification.
The cause of disease, when  it can  be discovered, is now
regarded as the essence of its specific nature.  The ordinary
inflammation of mucous membranes  is attended with en-
gorgement of the tissues and the  formation  of pus ou the
surface; under the influence, however, of a certain poison-
ous contagium. the inflammation,  instead of being attended
with the formation of pus, leads to the exudation of layers
of lymph, which  become adherent to the free surface of the
mucous  membrane.  This disease is called "diphtheria,"
and whether the  lymph is deposited on  the mucous  mem-
brane of the pharynx, or larynx, or trachea, or bronchial
tubes, or  any other mucous membrane, or on a wounded
surface, the disease is still "diphtheria."  To suppose that
there are two  kinds of pellicular inflammations  of the
larynx, one  in which the cause is the diphtheritic poison,
and the other in  which the cause is some other undiscovered
influence, is totally opposed to all probabilities.
   Etiology.—This has already been discussed under diph-
theria.
   Symptoms.—The disease develops in three different ways.
It may originate in the larynx.  This is typical croup, and
probably does  not occur in more than ten or twelve per
cent, of cases.*   Most commonly  it  commences in the pha-
rynx and extends downwards, constituting descending croup.
Occasionally, but very rarely, it commences in the bronchial
tubes or trachea, and ascends into the larynx.   This is
ascending croup.   If, as is  commonly the case, the  disease
commences  in the pharynx, the  practitioner will  be con-
stantly on the watch  to note the first invasion of the larynx,
but in typical croup  or primary laryngeal diphtheria, it is
otherwise, aud the symptoms  of croup have  been conve-
niently divided into three stages.
   The first  stage  is often preceded  by slight catarrh.  So
insidious is the invasion of the disease that the serious char-
acter of the child's illness is often quite  unsuspected.   The
little patient is  noticed to be languid and feverish ;  he is
  * See  Sanne,  op. cit.  p. 195.  Sanne  gives 142  cases out of
1172.  Compare also Simon, " Nouveau Diet, de Med. et de Chir.
Prat."
                           8 
86
DIPHTHERIA.
thirsty, and  refuses food, and  at the same time there is
slight hoarseness, which the nurse attributes to an ordinary
cold, until  her apprehensions are aroused  by a  frequent,
short, dry, shrill cough.  The voice, which  was at first only
a little harsh, very  quickly loses its resouant character and
becomes  a whisper.  On examining the  chest, both the
inspiratory and expiratory sounds are found to be prolonged,
and the normal respiratory murmur is lost in the laryngeal
stridor which  occurs in inspiration.   The  supra-clavicular
spaces are usually somewhat more depressed during inspi-
ration than in the condition of health, and  the slight diffi-
culty of  breathing  which is present is more marked during
sleep.  The pulse now becomes considerably  increased in
frequency,  and the febrile symptoms generally  more pro-
nounced.  If a laryngoscopic examination  can be  accom-
plished, the mucous membrane of the larynx  is seen to be
of a bright-red color, and when the disease has existed for
a few hours, some thin patches of false membrane may be
perceived on it.  I have often succeeded in seeing the false
membrane with  the  laryngoscope,*  and  still  more  often
have been able to prove that cases of supposed croup were,
in fact,  examples  of catarrhal laryngitis.  The  usually
pendant position of the epiglottis in children, however, often
prevents a satisfactory examination even in  those of tract-
able disposition; and  the timidity of early life is, in  itself,
often  sufficient to render the employment  of  the laryngo-
scope impossible.   It is most important, at this stage of the
disease, to  make a  very careful examination of the sputa.
Children, very often, do not expectorate at all,  but anything
that is brought up  must be put into a glass vessel and gently
shaken with a little pure water.  The mucus dissolves, and
flocculi,  or small shreds of false membrane, if present, be-
come visible.
   The second stage is  characterized  by increasing dyspnoea
and by the attacks of suffocation which suddenly supervene
from time to time.   When the attack comes on the child  is
generally found sitting up in bed, with  red and swollen face,
with an anxious, terrified  look.  The  nostrils are rapidly
  * See  also—Semeleder, "Die  Laryngoscopies' 1863,  p.  42.
Tiirck,  " Kehlkopfkrankheiten," p.  172 et  seq.   Munch, " Wie-
ner Med. Wochenschrift," 1865, No. 10.  Gottstein, " lierl. klin.
Wochenschrift," 1867, p. 329. 
         LARYNGO-TRACHEAL DIPHTHERIA.       87


working, inspiration  is hurried  and " croupy," and  is evi-
dently performed with the greatest  difficulty, all the auxil-
iary muscles of inspiration being called into play. The voice
is almost inaudible, and there is a constant hoarse and stifled
cough, without expectoration.   The attack generally lasts
three or four minutes, and the patient subsides into a heavy
sleep, which often continues  for several hours.   Sometimes
unmistakable pieces  of membrane are thrown up with  the
cough, a phenomenon which is  often most  important as a
means of diagnosis, as in many children suffering from laryn-
geal diphtheria there are  no patches of exudation to be de-
tected on a casual inspection  of the fauces.  It is only on
careful  and  persevering examination with the laryngoscope
in  cases favorable  for examination that the  membrane,
which is the  source of all the  trouble,  can sometimes be
recognized adhering to, or perhaps lying  loose, in the  chink
of  the glottis, and obstructing  the  passage of air.   Occa-
sionally  the vomiting which is induced by the  constant
fits of coughing, or  by the administration of emetics, may
lead to the separation and ejection of large pieces of  mem-
brane, in which case the urgent symptoms of dyspnoea  are
often most strikingly relieved.  The mode in which separa-
tion  takes  place  is exactly the same in the  larynx and
trachea as in  the pharyngeal region ; the process, however,
is rendered easier by the arrangement of the mucous mem-
brane, which, in  the trachea and in the  lower parts of the
larynx, is separated from  the submucous tissues by a distinct
basement membrane.  But  the improvement  due  to  the
expulsion of  the concretions  is generally only temporary;
exudations again collect, aud the symptoms return in greater
intensity than before.  At this stage of the disease the pulse
is very rapid, aud generally irregular. The little patieut is
exhausted and is constantly bathed in sweat.
   The third stage uow supervenes.   As the disease advances
the suffocation becomes more urgent, and there is no  remis-
sion between the  attacks, the dyspnoea being constant, though
fearfully aggravated every few minutes.  The lips assume a
livid color and the nails  become blue.  The sternum and
the intercostal spaces are forcibly  drawn inwards during
each  effort at inspiration, whilst the agony of impending
suffocation is most distressing to witness.   The child throws
his arms wildly about, or clutches his throat to tear away, as
it were,  the  obstruction,  or he  thrusts his  fingers into his
mouth to seize the offending substance.   The symptoms of 
88
DIPHTHERIA.
fever are intensified, the thirst is urgent, the tongue thickly
furred, and the pulse quicker but weaker.  The little pa-
tient dies  in  an  attack of dyspnoea  or soon  succumbs  to
gradually increasing coma, to syncope, or exhaustion.
   Diagnosis.—In children it is  sometimes  very difficult  to
distinguish catarrhal laryngitis, of a severe form,  from croup.
Indeed  in  the early stages  it is often  impossible to differ-
entiate the two affections.  In the young children, from the
small size of the  larynx, and the great tendency to reflex
irritation, slight  irritation of the larynx  quickly gives rise
to spasm   and produces stridulous  breathing, laryngitis
stridxdosa, as it is technically called.    When, however, the
disease is  fully developed, the two affections are easily dis-
tinguished,  for whilst  catarrhal laryngitis nearly  always
ends in recovery,  in diphtheria  the prospect of a fatal ter-
mination is soon apparent. Croup very often commences at
night, but  catarrhal laryngitis  almost  invariably comes on
at that time;  hence we have in  the time at which the dis-
ease first manifests itself a possible diagnostic sign.   It has
already been pointed out that the laryngoscope cannot often
be successfully used  in  young children, but the expectora-
tion  must  be  examined  in the way already described, and
false membrane, if present, will  always be detected.
   Further, there  is a pure neurosis, a  spasmodic action of
the adductors of the vocal cords, giving rise to  laryngismus
stridulus, which has been called  "spurious croup,"  "false
croup,"  and  "nervous  croup,"  with which true croup  is
sometimes confounded.  This disease very frequently comes
whilst the mother is suckling or dandling the child.  Carpo-
pedal contractions also occur in marked cases of laryngismus,
but above all there  is the absolute intermissio>t of all dyspnoea
between the paroxysms;  whilst  in  true croup,  when  fully
established, slight dyspnoea  is  always present between the
attacks of  suffocation.   Many fatal cases of  laryngismus,
however, no doubt lose their qualitative affix and appear in
the Mortality  Returns as simple "croup."*
   Pathology.—The false membrane does not differ essentially
from that  described in connection with the pharyngeal form
of the disease. The membranous  exudation  is more fre-
quently found on  the epiglottis and the ary-epiglottic folds
  * The above considerations tend to show  that the substantive
use of the word " croup " is altogether objectionable. 
         LARYNGO-TRACHEAL DIPHTHERIA.       89


than on the lower  portions of the larynx, but occasionally
it invests the whole of the lining membrane of the larynx,
extends throughout  the  ventricles,  and  passes  along the
trachea to the  smallest ramifications of the bronchi.   It
rarely  happens that the lymph is so  abundant  as to com-
pletely occlude the larynx, and in many fatal cases only a
very thin, transparent membrane is  found.   The dyspnoea
in croup is primarily  due  to  the inflammatory tumefaction
and  plastic exudation, which, however, soon give  rise  to
spasm  of the adductors.   The muscles are  infiltrated with
serum,  but there is no  paralysis  of the  abductors, nor
atrophy of their structure.   M. Callandreau-Dufresse* has
described these changes in detail.   The muscles especially
affected  are  the thyroarytenoid, which  are found pale,
friable, and extremely cedematous.   Under  the  microscope
the fibrils are seeu to be greatly  swollen,  and  infiltrated
with fat-cells, while  their strire  have disappeared, and the
nuclei  of the sarcolemma have undergone considerable in-
crease  iu number.   Similar changes are fouud only excep-
tionally in the extrinsic laryngeal muscles.   The  lymph is
found  more closely adherent  iu the  supraglottic  than in the
subglottic  region,  and on  removing  it the  mucous mem-
brane  is generally almost  normal below the level  of the
vocal  cords,  but above that line it is often  swollen  aud
inflamed, and  sometimes ulcerated.  It has already been
stated  that the membrane which  forms in the trachea can
be much more easily detached thau  that which  is  found  in
the pharynx.   There is nothing special as regards  the false
membrane in the trachea, which is generally more adherent
in the  upper  than  iu the lower portion of the tube.
   Prognosis.—The prognosis  is most unfavorable. Probably
not more than 10  per cent, of the  patients recover under
suitable treatment without tracheotomy.  In this country
tracheotomy  is, comparatively, so little  practiced  in croup
—in proportion to the number of cases—that nearly all the
remainder  prove fatal.  If, however the remaining  90 per
cent, were  tracheotomized,  00 per  cent, might recover, ac-
cording to  the most  favorable statistics (see page  94), or,
according to an average, based on 4603 operated on in the
  * " These de Paris," 1873, No. 87;  see also  an interesting case
recently published by Dr. Baginsky, "Central. Zeitung fur Kin-
derheifkunde," October 1st, 1878. 
90
DIPHTHERIA.
Children's  Hospitals  of Paris, 23.91  per cent,  Accepting
the latter figures, out  of 100  cases of undoubted croup we
might expect that 68.49 would terminate fatally, and 31.51
recover—10 without tracheotomy and 21.51 (i.e., 23.91 per
cent.) after the operation.   If the trachea were not opened
in the proper proportion of cases the fatality would of course,
be proportionately  greater;  whilst if the operation were
performed earlier than is commonly the case, the mortality
would probably be considerably less.   The fatal termination
may be expected  in the first  three or four  days, certainly
within the first week.
   Treatment, First Stage.—The child should be placed in a
warm, well-ventilated room, an  ice-bag should  be applied
to the neck, and ice constantly sucked.  Spray inhalations
of lactic acid (gr. xx ad gj) should be employed.   The
inhalations should be given  at  least  every hour, and con-
tinued for five minutes at a time.  In the second stage, or as
soon as it is believed that false  membrane has formed, emetics
must be employed.  A number of instances are recorded in
which children have  been saved from imminent asphyxia
by the spontaneous  expulsion of false membrane, and this
natural mode of cure  has sometimes  been happily imitated
by the administration of emetics.  According to Valleix,*
in thirty-one cases  so treated, fifteen recovered, whilst of
twenty-two in which  this class of remedies was neglected,
only one cure resulted.  Trousseau concurs with the state-
ments of Valleix.  In many cases,  however, the  relief is
merely temporary, the membranes quickly re-forming in the
larynx,  and  the  dangerous symptoms returning  with in-
creased severity.  Moreover,  the practice is not altogether
unattended by danger, for the tracheal membrane may be
forced up by the act of vomiting in such a  way as to entirely
obstruct  the  passage of air.   This ri.*k must  be incurred,
though valuable time should  never be wasted  on the use of
emetics, when the only alternative is the performance  of
tracheotomy.   Tickling the fauces will occasionally be suf-
ficient to excite the desired action, but as a rule it  is neces-
sary to resort to drugs. Cardiac depression is so common an
accompaniment of  diphtheria that it is unwise to employ
any emetic  by which  it  is likely to  be increased.  Tartar
emetic must, therefore, be especially avoided.  Strange as
* "Guide du Med. Prat.," t. i, Art. " Diphtherite." 
         LARYNGO-TRACHEAL DIPHTHERIA.       91


it may seem, this drug has in times past been very widely
employed in diphtheria.   Trousseau,* indeed, strongly con-
demned its use, terming it the most dangerous of all emetics.
But Bouchut,f as  late as 1859, published three  cases in
which  he  attributed  a successful  issue to the energetic
employment of tartar emetic.  His example should not be
followed, especially as we have at our  command emetics
which are not less  certain in their action  than antimony.
Should  the practitioner distrust the efficacy of ipecacuanha,
it is quite open to him to add from fifteen  to twenty grains
of sulphate of zinc.  If the administration  of these  agents
is not quickly followed by vomiting and the expulsion of
the membrane it  is useless to repeat them,  and even where
the breathing has once been temporarily relieved  by their
use, it is very questionable  whether they should be again
employed. In no case should the physician place too much
reliance upon them.
  When it is judged that there is  false  membrane loose in
the larynx, the removal of the membrane by direct mechan-
ical means should be attempted.  The best instrument used
for this purpose  is a brush attached to a piece of  soft alu-
minium wire. Instead of the common laryngeal  brush I use
one made of squirrel's tail.   The hairs cover the  sides of the
laryngeal portion of the brush, and are  directed upwards.
As  tiie laryngoscope cannot generally be used, the brush,
guided  by the forefinger of the  left  hand, should be carried
down into the interior of the  larynx.   The windpipe can
generally be freed from exudation by to-and-fro  movements
combined with a  certain amount of rotation. I have several
times employed this brush with marked  advantage.   Even
if the practitioner is successful, however, in detaching por-
tions of membrane, fresh  exudation  often recurs.
  I must here briefly refer to the subject of catheterism and
" tubage " of the  larynx. Catheterism was first recommended
by  Loiseau,^ as a means of removing false membrane and
introducing remedies into the windpipe.  I  have  only to say
that the false membrane can be much more easily removed
with a proper croup-brush, aud that solutions or powders can
be more readily applied with a common  laryngeal brush or
insufflator.  " Tubage," introduced by Bouchut,§ consists in
* Trousseau, op. cit. vol. ii, p. 578.
f " L'Union Medieale," April 5th,  1859.
X " Bull, de l'Aead. de Med.,"  1837.     \  Ibid. Sept. 183s. 
92
DIPHTHERIA.
the introduction of a small tube, from three-quarters of an
inch to an inch in length, and leaving it in the larynx.  It
causes so  much irritation that it cannot be retained and its
use has been quite given up.
   It is at  the close of the second stage of croup, when inhala-
tions  and emetics have failed, that tracheotomy is  called for.
Marked  recession of the sternum and  chest-walls  is the
indication for  its performance.   The credit of having been
the first to establish this operation on a secure basis as a justi-
fiable part of the treatment of croup is due to Bretonneau,*
who published his first successful case in July, 1825.  Ten
years later Trousseau f reported that he had  performed the
operation  thirty-six times with nine recoveries.   From this
time  the  position  of the operation was secured,  and it has
since been performed many thousand times in France alone.
Before his death, Trousseau f published a series 466 of cases
in which the operation had been performed in the  Children's
Hospital in Paris, between  the years 1849 and  1858.  Of
these, in  spite of unfavorable surroundings, 126, or more
than  1  in 4,  recovered.  Later statistics have given  still
more  favorable results.   In 1863,- Fischer and Bricheteau §
collected all the facts within their knowledge at the Hopital
des Enfants Malades, the Hopital Sainte Eugenie,  and in the
city and  the  provinces, and  the general results were as
follows : At the Hopital des Enfants Malades the operation
had been  performed  in 1011  cases, and  the  proportion of
recoveries was 1 in 4; at the Hopital Sainte Eugenie the
proportion was 1 in 6 ; while  the facts collected from other
sources, though confessedly incomplete, showed in Paris  1
cure to  2.6 cases, and 1  to 3.6 in  the provinces.  According
to M.  Sanne, however, who has published the most extensive
satisfies from the  Paris hospitals, during recent  years the
proportion of  recoveries after  tracheotomy  has  been less
favorable, especially at the Hopital Sainte Eugenie,|| as will
be seen  from the appended tables:
  * Bretonneau, " Memoirs" (New Syd. Soc), p. 59.
  f Trousseau, Ibid. p. 243.
  X Trousseau, " Rapport a l'Acad. de Med.," "Bull de l'Acad. de
Med.," vol. xxiv, p. 112/
  I "Nouveau Dictionnaire de Medeeine et Chirurgie," 1869, vol.
x,  p  308.
  || The results at this hospital for the first nine months of 1876
were .still more unfavorable, the proportion of cures being only 1 in 
LARYNGO-TRACHEAL  DIPHTHERIA.        93
HOPITAL SAINTE EUGENIE.
				Operations	lor Croup.		Proportion of
Years.			Dis-				
			charged	Dead.	Left	Total.	Cures.
1854, . .			Cured.		Uncured.		
			2	7	0	9	1 in 4 50
1855,			4	9	0	13	1 " 3.25
1856,			5	19	0	24	1 " 4.80
1857,			5	24	1	30	1 " 6.0
1858,			93	95	4	122	1 " 5.29
1859,			17	88	4	109	1 " 641
I860,			7	31	2	40	1 " 5.71
1861,			16	45	3	64	1 " 4.0
1862,			23	67	7	97	1 " 4.21
1863,			35	68	3	106	1 " 3.02
1864,			26	85	4	115	1 " 4.42
1865,			44	87	6	137	1 " 311
1866,			36	76	3	115	1 " 3 19
1867,			29	63	4	96	1 "- 3.31
1868,			31	101	3	135	1 » 4.35
1869,			31	70	2	103	1 " 3.35
1870,			42	85	4	131	1 " 3.11
1871,			12	78	3	93	1 " 7.75
1872,			39	138	10	187	1 " 4.79
1873,			32	170	11	213	1 " 6.65
1874,			23	132	7	162	1 " 7.04
1875,			27	175	9	211	1 " 6.48
			509	1713	90	2312	1 in 4.54
8.31.   This steady increase in the mortality after tracheotomy is
attributed  by M. Moizard (These de  Paris, 1876,  No. 493), partly
to the progressive extension  of the  operation to more and more
hopeless casesr and partly to the more malignant  character of the
disease in Paris during recent years. 
94
DIPHTHERIA.
HOPITAL DES ENFANTS  MALADES.
			Operations for Croup.				Proportion of Cures.
Years.			Dis-				
			cli a r^ed	Dead.	Left	Total.	
			Cur<d.		Uncured.		
1851, . .			14	17	0	31	1 in 2.21
1852,			18	43	0	61	1 " 3 38
1853,			9	52	0	61	1 " 677
1854,			14	29	0	43	1 " 3.07
1855,			12	34	0	46	1 " 3.83
1856,			16	31	3	52	1 " 3.25
1857,			16	54	0	70	1 " 4.87
1858,			34	73	2	10!)	1 " 3.20
1859,			41	115	4	160	1 " 3.90
1860,			24	101	3	128	1 " 5.30
1861,			29	72	1	102	1 " 3 49
1862,			27	112	6	145	1 " 5 37
1863,			46	86	10	142	1 '• 3.08
1864,			40	105	8	153	1 " 382
1865,			40	86	4	130	1 " 3.25
1866,			27	71	3	101	1 " 3.74
1867,			15	57	4	76	1 " 5.06
1868,			26	36	0	"2	1 " 2.38
1869,			12	54	0	66	1 " 5.50
1870,			21	43	0	64	1 " 3.04
1871,			16	27	0	43	1 " 2.67
1872,			30	71	9	110	1 " 3 66
1873,			26	79	2	107	1 " 4.11
1874,			23	81	4	108	1 " 4.69
1875,			38	130	13	181	1. " 4.76
			614	1661	76	1351	1 in 3.82
   At the Hospital for Sick  Children, in the  twelve years,
 1864  to  1876, sixty cases  of croup and  diphtheria were
. operated  on.  Of these, thirteen, or 21.6 per cent., were suc-
 cessful.   According to Kronlein's* recent statistics at  the
 Hospital  in Berlin, the percentage of cures after the opera-
 tion was  30.f   This was the result of  567 operations, per-
 formed between January 1st, 1870, and July 30th, 1876, in
  * " Langenbeck Archiv.,'' Bd xxi, hft. ii.
  fSee also Hiiter, " Laryngotomie und Tracheotomie," Pitha-
Billroth's Chirurgie, vol. iii, part i, Nro. 5,  p. 26 et seq. 
         LARYNGO-TRACHEAL DIPHTHERIA.       95


Professor Langeubeck's clinic.   By selecting the best indi-
vidual series of statistics, for the most part from  private
practice, Dr. Solis Cohen* has  brought together 166 cases
of tracheotomy in  croup, with 110 recoveries.
   Considering  the enormous  mortality of laryngeal  diph-
theria, even the most unfavorable figures prove that in such
cases tracheotomy  is not only justifiable, but  that it is a
positive duty.  The chief questions to be considered in con-
nection with the operation are what are the indications and
what is the  best period for its performance?
   The cases most  favorable for the operation are  those  iu
which the symptoms of general infection are slight or absent
and the strength of the patient is unimpaired.  It is where
the patient  has still some vigor;  where the pulse is  strong
aud  regular, the  powers of assimilation  good,  and the
asphyxia,  though  very  marked, is not yet  too advanced,
that tracheotomy  becomes most imperative.  In such cases
there can  be no doubt  that the operation has saved, and
doubtless will still save, many thousands of lives.   It is now
generally admitted that tracheotomy  should be performed
without delay, as soon as it has become clear that  it is im-
possible to relieve the asphyxia by other means.  It is clear
that  an early insertion  of the canula gives the patient a
much better chance of recovery than when there is a  long
delay ; and it is owing  to the disregard  of this fact that
tracheotomy in  diphtheria has, in some quarters, acquired
such  an evil repute.  For the description of the operation
and the precautions which must be taken in performing  it,
I  must refer the leader to the textbooks on  surgery, but I
would  here call  attention to the extreme  importance  of
endeavoring, immediately after  the operation,  to draw out
any loose false membrane, either with the croup-brush  or
an aspirator accurately applied to the  mouth of the canula.
The  after-treatment  is  very important, aud  the patient
requires most assiduous attention for some days.  The tem-
perature aud due  moisture of the room must be carefully
maintained ; the tube must be constantly watched and freed
from secretions or pieces of ejected  membrane,  and the
wound must receive daily attention.   At the same time the
administration of  food  and stimulants must be the subject
* " Croup in its Relation to Tracheotomy,' Philadelphia, 1874. 
96
DIPHTHERIA.
of the greatest care and regularity, and antiseptic sprays
should  be administered through the canula.   The  chief
dangers to be feared in the after-treatment of tracheotomy
are extension of the exudation into  the bronchi, occlusion
of the tube, and failure in the innervation of the lungs.  The
effects of extension of the membrane may, iu some cases, be
averted by removing the tube and extracting fragments of
lymph from the trachea with forceps or with the croup-brush.
Long strips of exudation and, in rare cases, almost entire
casts of the windpipe have  been  removed  in this  way.
Occlusion of the tube is only to be prevented by placing the
patient  under the charge of a trustworthy attendant,  who
will  not fail, in  cases of emergency, to remove the canula
and free the passage.
   In the third stage, tracheotomy remains the only hope of
saving the patient's life.  If the operation has, unfortunately,
not been performed  in the second stage, the chance of suc-
cess is very much diminished.   The operation is not contra-
indicated, however, even when theapncea is extreme and the
patient  is  apparently on the point of suffocation, provided
only that the heart's power is still good.  In some cases the
patient has been saved by it when literally at the last gasp.
Such  instances,  however,  are quite exceptional.   Some
authorities have  maintained that even in quite  hopeless
cases, where the patient is dying from dyspnoea, tracheotomy
should be performed with the view of promoting the euthan-
asia.  It is true that death from syncope or gradual exhaus-
tion  is much less painful than death from apncea, and it
may be  advisable to secure this substitution  by a surgical
operation.  But  it  is not in these cases that  tracheotomy
finds its really valuable application.   Further, when it is
found, on  auscultation, that air enters one  lung and does
not penetrate the other, it is clear that the false  membrane
has extended down  one bronchus, and  tracheotomy is then
much less likely  to be of any use.  In the same way, if ex-
tensive  pneumonia  has supervened, the operation is likely
to be of little benefit.  Where the patient is already dying
of cardiac  failure or exhaustion, it is, of course, in vain to
attempt to  save life by the surgical operation. 
NASAL DIPHTHERIA.
97
                    CHAPTER X.

                   NASAL  DIPHTHERIA.

   In some epidemics of diphtheria the disease  commences
with nasal catarrh, and this phenomenon was so common in
the epidemics witnessed  by Bretonneau, that he regarded it
as the ordinary course of the disease.  Further  experience,
however, has demonstrated that  catarrh of the nose is far
less usual than it was at one time supposed, and that true nasal
diphtheria is generally due to the extension of the plastic
inflammation  from the  pharynx.  The disease commonly
first shows its  presence  by an unhealthy brown  ichorous
di.seharge, which  causes abrasion, and  even ulceration, of
the skin in the neighborhood  of  the  nostrils.  Soon after-
wards the parts are covered with  false membrane which can
be seen extending  through the nose.  At other times the
false membranes do not reach  the external orifice, but, on
using the speculum, a  few  scattered  deposits of lymph can
be perceived on the mucous membrane of the septum or the
turbinated bones.  The false membrane, however, is  gen-
erally most abundant at the posterior nasal orifices.
   In  this  form of diphtheria it  is especially necessary to
endeavor to prevent the products of  the disease from accu-
mulating and putrefying in the nasal cavities, for experi-
ence  has  shown that,  under such circumstances,  they are
extremely  liable to be absorbed  and to lead to secondary
septic poisoning.   It is all-important, therefore, to keep the
passages as clear  as possible, by the use of astringent  or
solvent liquids.  With this object, weak solutions of alum,
tannin, carbolic acid, permanganate of potash, or lactic acid,
should be repeatedly syringed over the affected parts.  If
epistaxis occurs, as it frequently does in nasal diphtheria,
an astringent snuff or lotion is usually sufficient to arrest it.
Plugging the nares, should, if possible, be avoided. 
98
DIPHTHERIA.
                   CHAPTER XI.

               SECONDARY DIPHTHERIA.

  When diphtheria attacks persons already suffering from
some other disease the new complaint is called "secondary
diphtheria." The etiological influence of small-pox, measles,
and whooping cough was first noticed byHome,*and further
observations have since been made by Peter, Sann6, Rauch-
fuss, West, and others.  The following table, abridged from
Sanne,f shows the diseases  which furnish the greatest num-
ber of cases, but, as Sanne has pointed out, measles  is a
much more common disease than scarlatina, and  in a given
number of cases of each of  these diseases, scarlet fever fur-
nishes by far the larger number :
Disease.						Cases.
Meases,.........137						
Scarlatina,						95
Whooping-cough,						20
Typhoid Fever, .						8
Small-pox,						2
Nettle-rash,						2
Bronchitis,						4
Pneumonia,						4
Pleurisy, .						4
Tuberculosis,						. 19
Various cachexia? (sc	".ofult	i, chr	onic	diarr	hcea, etc.)	, 34
229
  Secondary diphtheria^ is a characteristic phenomenon of
scarlatina maligna.  In these cases  the common inflamma-
tory pharyngeal lesion is more tardy in its appearance, and
the patient often seems at first  to be suffering from a mild
attack of the malady.   The disease generally  attacks  the
  * Op. cit.                        f Loc. cit p. 353.
  X See Fuchs, " Historische TJntersuchungen iiber Angina Ma-
ligna und ihr Verhaltniss zu Scharlach und Croup." "Wiirzburg,
1828. 
SECONDARY DIPHTHERIA.
99
pharynx about the ninth day, when the eruption has disap-
peared and the  feverish  symptoms have  abated, and in a
few hours swelling takes place in the glands at the angle of
the jaw.  The tonsils  and  fauces are covered with diph-
theritic exudation, a fetid sanious  discharge proceeds from
the nares, and the breath  becomes tainted with a foul odor.
The pharynx is nearly always  the seat of the false mem-
brane, and when the plastic exudation attacks the  larynx,
it is almost invariably  by  extension—not as a  primary phe-
nomenon.  Out of 903 cases of scarlatina in the St. Peters-
burg  Children's  Hospital,*  there were  nineteen  cases of
pharyngeal diphtheria, and  two  in  which the disease  at-
tacked the laryngo-tracheal membrane.  The extension of
the morbid process to the  larynx  has been noticed to occur
more  frequently in some epidemics than in others.   Guppf
described  an  outbreak in  Wiirtemberg  in which,  in the
greater number of cases,  croupy  symptoms appeared from
the third to the fourth day of the illness; aud in some cases
death  took place before  the exanthem  appeared.   As in
primary diphtheria, on separation of the lymph, ulceration
of  the mucous membrane is often found.   A characteristic
specimen of ulceration  (No.  36, Series W.) is  contained in
the Museum of St. Thomas's Hospital.  The larynx, which
was taken  from  an adult patient who died of scarlatina, has
a  very thin layer  of  lymph covering the entire  mucous
membrane, and  the right arytenoid cartilage is laid  bare by
a  large  ulcer.  Gangrene  not unfrequently  attacks the
pharynx, larynx, and  oesophagus, the  pulse becomes weak,
the surface of the body is blanched and cold, collapse super-
venes, and the patient dies  in  a state  of coma.J   In some
cases large vessels are  opened by the ulcerative process, and
death occurs from haemorrhage.  A somewhat rare compli-
cation of the scarlatinal diphtheria requires some mention,
/.  e., " scarlatinal buboes."  The glands of the neck become
suddeuly inflamed about  the tenth or twelfth day, and in
five or six days a large abscess is formed.
   In  measles, false membranes may become developed after
the subsidence of the general pyrexia, and occasionally even
  * Rauchfuss, op. cit. p. 154.
  f Riihle, op. cit. p. 243.
  X See Graves,  " Clinical Lectures on the Practice of Medi-
cine," Leet. xxii, Dublin, 1848. 
100
DIPHTHERIA.
gangrene of some portions of the pharyngeal tissues may
occur.*  Out of 1176 cases occurring in the St. Petersburg
Children's Hospital,f there were eleven cases of pharyngeal
diphtheria, nine cases of pharyngo-laryngeal  diphtheria,
and thirteen in which  the laryngo-tracheal membrane was
the seat of plastic inflammation.   Laryngeal diphtheria, or
croup, is, however, much more common  than  pharyngeal
diphtheria.   "This  variety of croup," observes Dr. West,
"seldom begins until the eruption of measles is on the de-
cline or the process'of desquamation has commenced.  Its
occurrence is most frequent from the third to the sixth day
from the appearance of the eruption, but it oftener occurs at
a later than at an earlier period."|  The  proguosis is  more
unfavorable than in  scarlatinal diphtheria, eighty per cent.
of the cases terminating fatally.
  Secondary diphtheria  is not uncommon in typhoid fever,
but from the unconscious condition of the patient, it is very
often overlooked during life and only discovered at the
post-mortem examination.  Though  it most frequently com-
mences in the larynx and is often  confined to that part, the
diminished supply of air causes little inconvenience, owing
to the medulla having, to a great extent, lost its sensibility
to impressions.  The obstruction to  respiration  is also less
marked, from the fact of the disease, in most  cases, attack-
ing adults.  Diphtheria  rarely occurs before the end of the
second week.  The prognosis is most  unfavorable, the un-
conscious  condition  of the patient  preventing  the use of
antiseptic inhalations or local applications.
  In small-pox, diphtheria is seldom met with in this country.
Riihle,§ however, who witnessed a bad epidemic of small-pox
in Greifswald, in 1856-57, and who  made no less than fifty-
four post-mortem  examinations,  observes:  " Although  I
have seen, here and  there, pustule-like elevations, I never-
theless consider the  essential  peculiarity  of the laryngeal
affection  to be a croupous or diphtheritic  inflammation."
This author adds that, as " out of the fifty-four cases there
was  not a single instance in which the larynx and windpipe
  * See Barthez and Rilliet, " Traite des Maladies des Enfants,"
Paris, 1853.
  f Rauchfuss, loc. cit. p. 153.
  X " Diseases of Infancy and Childhood," Sixth edition, p. 488.
  £ " Die Kehlkopfkrankheiten," Berlin, 1861, p. 247. 
              SECONDARY  DIPHTHERIA.          101

were iu a normal state, he cannot but attribute  a certain
proportion  of the  mortality  to  the laryngeal  affection."
Pathological  examples of the diphtheritic  complications
of small-pox are to be found in the museums of St. Thomas's
and St. Bartholomew's Hospitals, and in other collections.
  In  the  nineteen  cases of tuberculosis collected by Sanne
(see page 98), every patient attacked died.
  In the various acute and chronic affections in which diph-
theria occurs, the treatment, both local and  general, must
be the same as in the primary disease.
9 
 
INDEX.
Albuminuria, 35 and 40

Beale, Dr., his views on bacteria, 57
Blood-letting, 66
Borgiotti, Dr., statistics of mor-
  tality, 63
Brain,  changes in, 61
Bretonneau, his first essay, 2U

Catarrhal diphtheria, 37
Catheterism of larynx in croup, 91
Causes of death in diphtheria, 37
    "      "      croup, 88
Chronic diphtheria, 39
Constitutional treatment, 65
Contagion, 25
Contagium, climate  and  atmos-
  pheric conditions favorable to, 24
Contagium, mode of diffusion of, 25
    "      natural history of, 22
Croup, 79
  "    pathology of, 88
  "    prognosis of, 89
  "    symptoms of, 85
  "    treatment  of, 90
Cutaneous eruptions, 44

Death,  immediate causes  of,  37
  and  88
Definition, 13
Diagnosis of diphtheria, 5(J
       "     croup, 88
Diphtheria, catarrhal, 37
     "      chronic, 39
     "      gangrenous, 39    [38
     "      inflammatory form of
     "      laryngo-tracheal, 79
     "      malignant,  38
            typical, 34
            pathology of, 53
     "      prognosis of, 63
     "      symptoms of, 33
     "      treatment of, 65
Donders,  on pharyngeal  paraly-
  sis, 47

Eruptions, cutaneous, 44
Etiology, 22
False membrane, 34 and 41
Faralli, Dr., observations ou tem-
  perature, 35 and 43
Gangrenous diphtheria, 39
Greenhow, Dr., influence of social
  position, 31

Heart, condition of, 58  to 60
Hemming, Mr.  Hughes,  on  hy-
  drate of chloral, 73
Heslop, Dr., treatment  by  per-
  chloride of iron, 67
History, 14
Home, Dr. Francis, on croup, 18
  and 79
Hovell, Mr. de  Berdt, on purga-
  tion, 67

Incubation, period of, 29
Inflammatory form of  diphtheria,
  38

Jackson, Dr. Hughlings,  on influ-
  ence of ganglia of sympathetic
  in producing paralysis, 48 and 62
Jacoby, historical reference, 21
James, Dr. Prosser,   on  use  of
  steam, 75
Jenner, Sir W., on family suscepti-
                bility, 30
    "    "    identity of  croup
               and diphtheria, 81
   "    "     inflamed joints,  38
   "    "     his  work on diph-
              theria,  21

Kidneys, condition of,  61 
104
INDEX.
 Laryngo-tracheal diphtheria, 79
            "    pathology of, 88
            "    prognosis in, 89
     "      "    symptoms of, So
            "    treatment of, 90
 Leptothrix buccalis, 56
 Liver, condition of, 60
 Lungs, condition of, 57

 Malignant diphtheria, 38
 Massei on treatment, 65 and 72
 Measles, secondary diphtheria in,
   100
 Micrococci, 56
 Morelli, Dr., on pathology of diph-
   theritic paralysis, 61

 Nasal diphtheria, 97
 Natural history of the contagium,
   22

 Oertel on bacteria, 56
   "   on the use of steam, 75

 Paralyses, 45
 Pathology, 53 and 88
 Period of incubation, 29
 Poison, manner in which it enters
   the system, 26
 Predisponents, 29
 Prognosis in croup, 89
            diphtheria, 63
 Protective influence of a previous
   attack, 32

 Rauchfuss on  secondary diphthe-
   ria, 99
 Bindfleisch on pathology, 54 and 83
 Robinson, Dr. Beverley, on the use
            of cubebs, 69
          on condition of heart, 59
 Riihle on secondary diphtheria in
   small-pox, 100

 Sanderson, Dr. Burdon, on albumi-
   nuria, 41
Sanne on contagion, 26
    "    saccharate of lime, 72
    "    typical croup, 85
 Sanne' on mortality after tracheo-
   tomy, 92
 Sansom, Dr., on sulpho-carbolates,
   69
 Scarlet fever, secondarv diphthe-
   ria in, 98
 Semon, Dr., his case, 23
 Semple, Dr., his views on identity
   of croup and diphtheria, 81
 Small-pox,  secondary  diphtheria
   in, 100
 Spleen, condition of, 60
 Squire, Dr., his case, 24
 Stages of croup, 85
 Statistics of  Paris  hospitals,  93
   and 94
 Stimulants, 66
 Stomach, condition of, 60

 Temperature, 42
 Thursfield, Dr., remarks on con-
   tagion, 24
 Tracheotomy, 92
 Treatment of croup,  90
      "      diphtheria, 65
 Trousseau  on the significance of
                albuminuria, 41
             fever, 42
       "     tracheotomy,  92
 Tubage in croup, 91
 Tuberculosis, secondarv diphtheria
   in, 101
 Typhoid  fever, secondary  diph-
   theria in, 100

 Urine, condition of, 35 and 40

 Virehow on pathology, 82

 Wade, Dr., on albuminuria, 40
 Wagner, Dr.  E., on pathology, 82
 Weber, Dr. Hermann, on paraly-
   sis, 61
 West, Dr., on the use of senega, 70
             secondary diphtheria
              in measles, 100
 Wunderlich on temperature, 42

Zygodesmus fuscus, 56