DIPHTHERIA; 
A 
PSI1IIIS1I« 
BY 
E. S. GAILLARD, M. D., Richmond, Ya. 
RICHMOND, YA. 
MKB-S-CA& JF68&&AL Mmg. 
1867. DIPHTHERIA 
ITS HISTORY, PATHOLOGY, NATURE AND TREATMENT. 
AN ESSA Y WHICH RECEIVED THE FIRST PRIZE OF THE MEDICAL 
•ASSOCIATION OF THE STATE OF GEORGIA, June, 1866. 
By £. S. Gaillard, M. D., Richmond, Va. 
[Reprinted from the Richmond Medical Journal, 1866.] 
We have, in this Essay, made it our chief object to elucidate and 
establish the pathology of the disease which forms its subject, whilst, 
at the same time, there has been given careful attention to all else 
of interest and importance connected with it. 
With the treatment and general history of diphtheria, very 
many of the Profession are of course familiar, but any one, who 
has bestowed even a cursory attention upon its literature, can not 
have failed to perceive the obscure, injurious, and even antagonistic 
views, that have been offered and received, in regard to its 
pathology. 
It is in consequence of this confusion and contradiction, that the 
disease is still regarded as “ lis sub judice,” and therefore a most 
appropriate subject for analysis and examination. 
In preparing this essay, we have sought to give it a practical 
character, by corresponding with the most distinguished gentlemen, 
in this branch of the profession, both in America and Europe ; and 
from more than one hundred autograph letters, we have selected 2 
DtPHTlTETtlA. 
much of the original and important testimony, that is now offered 
for consideration. 
The literature of the subject, as represented by published works, 
monographs, essays and reports, has been carefully studied, and if, 
as a result, the views now presented, are not correct and just, it has 
not, at least, been for a want of material, or opportunity. 
Whether these have been logically, or even judiciously used, it 
must of course be for others to determine. 
We are fully aware of the extended field that has been entered 
and painfully sensible of the feeble power which has been brought 
to its cultivation ; yet we have patiently tilled it, hopingHhat the 
harvest, such as it is, might, with its defective and unripened ma- 
terial, be received into the Professional garner. 
No disease has, in recent years, attracted more of the notice of 
the Profession; its supposed novelty and obscure etiology; its in- 
sidious advent and treacherous departure ; its peculiar history and 
unusual results have aroused the attention that induces study, and 
inspired an interest wThich promises better comprehension. Phy- 
sicians, both in Europe and America, have examined, reflected, 
written, and the Press, in its mission, has widely disseminated the 
fruits of their labours. 
We have received, and are daily receiving, the great essentials 
for scientific progress-—the indispensable requisites for investiga- 
tion, in all branches of pathology—testimony and fact. Theory 
and hypothesis seem to have become a part of the Past; demonstra- 
tion and proof only receive the cautious seal of the Present. A 
growing skepticism has at last made fact the touchstone, in all that 
is offered for currency. The genuine material stands the ordeal and 
receives the stamp of validitywhilst the spurious is at once de- 
tected and rejected, as counterfeit. 
Hypothesis and theory should then, as far as practicable, be aban- 
doned, and testimony and fact be made the basis of every investiga- 
tion. With such views and purposes, we undertake the analysis 
and consideration of our subject. 
History.—We will first examine the history of diphtheria, to show 
that it is not, as has been so often declared, a disease of modern 
times ; and then give (as well as the limited character of such a DIPHTHERIA. 
paper will admit) a concise account of its prevalence, to any extent, 
in Europe and America. In this, we will, of course, be unable to 
present more than a passing allusion, and then only to those sections, 
(not localities) where the disease has prevailed to any extended or 
malignant degree. 
Although, according to Brettonneau, from whom all writers must 
quote, this disease was known in the earliest periods of Grecian his- 
tory, when the blind son of Maeon chaunted his immortal verse in 
the streets of Smyrna and along the bridle-paths of Ionia, yet we 
cannot take the obscure allusions of Homer, whose very existence 
has been doubted, for the establishment of historic facts. Bretton- 
neau states, that at the time to which we have alluded, it was de- 
scribed as the Malum Egyptiacum. There is one period, however, 
from which we can historically date this disease. Ten centuries 
after the supposed existence of Homer, Aretoeus of Cappadocia 
writes of an epidemic, in most respects similar to this malady. As 
to the exact period, at which this writer lived, it would be, perhaps, 
impossible accurately to state ; this is not important; he is men- 
tioned, as a contemporary of Galen, and again as living in the time 
of Vespasian; he is however one of the earliest and best writers, 
among the Greek Physicians. 
Aretoeus writes of this disease as the Malum Egyptiacum, while 
at the period immediately preceding, it is mentioned as the Ulcus 
iEgyptiacum, Ulcus Syriacus. The Cappadocian author enters 
fully into all of the details of his subject, and writes particularly of 
its history and treatment; his description of the symptoms is often 
quoted, and it will be seen at a glance, that the disease could have 
been no other than that which now attracts so much attention.— 
“ Ulcera in tonsillis hunt, aliqua mitia, aliqua pestifera, necantia. 
Pestifera autem sunt lata, cava, quodum concreto humore albo, 
livido, aut nigro sordentia. Quod si concreta ilia sordes altius des- 
cenderit; affectus, ille eschar est, atque it4 Graecb vocatur Latinh 
crusta.” 
Again he Writes: “ Crustara verb cireumveniunt rubor excel- 
lens et inflammatio, et exiguae raraeque pustulae orientes, hisquo 
aliae supervenientes in unum coalescunt, atque inde latum ulcus 
efficitur.” 4 
DIPHTHERIA. 
It will be seen, that Aretoeus describes the tonsils, in an ulcer- 
ated condition, covered with a white, livid and black crust. 
Dr. Cartwright, of New Orleans, always wrote of diphtheria, 
under the name selected by Aretoeus. We may copclude then, as 
this point has been carefully examined by Rilliet and Barthez, by 
Brettonneau and others, that the history of this disease, if not its 
existence, must be dated from the writings of Aretoeus of Cappadocia. 
Macrobius speaks of its existence in Home, A. D. 380. It is 
next after this time mentioned by Coelius Aurelianus. Hecker 
speaks of an epidemic, of this character in England, in 1517. Dr. 
Slade mentions an epidemic in Holland in 1337. Another epidemic, 
in Holland, is mentioned by Pierre Forest, as having prevailed in 
1557. It is next described, as existing in Paris in 1576. Fontecha, 
a Spanish Physician, states that it prevailed with him in 1581 ; and 
epidemically in 1599 and 1600. Villa Real, also of Spain, de- 
scribes it as existing in Andalusia in 1590. A few years after this, 
the disease seemed to have swept over Europe. In Naples, where 
it destroyed five thousand persons, it is described by Carnevale, 
Nola, Zactus, Lusitanus, Marcus, Aurelius Severin, Syambati, and 
others. Herrera, Villa Real, Fontecha, Mercatus, Tamayo, Nunez, 
and others, write of it as an epidemic in Spain, in the early part of 
the Seventeenth Century. Alaymus and Cortesius describe the 
disease, as it, about this time, prevailed in Sicily. It visited the 
Island of Jamaica in 1636. These authors all write of it under 
different names, but the disease is the same. In Sicily, it was 
called guise morbus ; in Spain, garrotillo, or morbus suffocans ; in 
Holland, the suffocating complaint; in England, angina maligna, 
etc. In the early part of the Eighteenth Century, we find the 
disease very generally mentioned, by medical writers, in almost all 
countries Rev. Jonathan Dickinson, of Elizabeth Town, New 
Jersey, America, in 1738, wrote a letter on the subject of an epi- 
demic, then prevailing in that neighborhood, which was undoubtedly 
this disease. He speaks of it, as the “ throat distemper.” In de- 
scribing its symptoms, he states that “ it frequently begins with a 
slight indisposition, much resembling an ordinary cold; with a list- 
less habit, a slow and scarce discernible fever, some soreness of the 
throat and tumefaction of the tonsils; perhaps a running of the DIPHTHERIA. 
nose ; the countenance pale and the eyes dull and heavy. The pa- 
tient is not confined, nor any danger apprehended for some days,, 
till the fever gradually increases, the whole throat and sometimes 
the roof of the mouth and nostrils are covered with a cankerous 
crust, which corrodes the contiguous parts, and frequently termi- 
nates in a mortal gangrene, if not by seasonable applications pre- 
vented. The stomach is sometimes, and the lungs often covered 
with the same crustula. The former is discovered, by a vehement 
sickness of the s;omach, a perpetual vomiting ; and sometimes, by 
ejecting of black and rusty, or foetid matter, having scales like bran 
mixed w'ith it, which is a certain index of fatal mortification. When 
lungs are thus affected, the patient is afflicted with a dry and hollow 
cough, which is quickly succeeded with an extraordinary hoarseness 
and total loss of the voice, with the most distressing asthmatic symp- 
toms and difficulty of breathing, under which the poor, miserable 
creature struggles, until released by a perfect suffocation, or stop- 
page of breath. This last has been the fatal symptom, under which 
the most have sunk, in these parts. And indeed there have but 
comparatively few recovered, who suffered thus, and whose lungs 
have been thus affected. All that I have seen to get over this 
dreadful symptom, have fallen into a ptyalism, or salivation, equal 
to a petit flux de bouche, and have, by their perpetual cough, ex- 
pectorated incredible quantities of a tough, whitish slough from 
their lungs, for a considerable time together. And on the other 
hand, I have seen large pieces of this crust, several inches long and 
near an inch broad, torn from the lungs, by the vehemence of the 
cough, etc. * * * The first assault, seen by me, was in a family, 
ten miles distant from me, which proved fatal to eight of the chil- 
dren in about a fortnight. * * * I have frequently observed, 
that once having this disease is no security against a second attack. 
I have known a person to have it four times in one year; the last of 
which proved mortal. * * * The lungs and the throat, and 
especially the epiglottis, are inflamed, and the last much tumefied. 
* * * This may be distinguished from an angina by the crus- 
tula in the throat.” The Professional reader at once detects the 
errors of examination here, and if the trachea and larynx (as the 
seat of the disease, when it extends beyond sight) were mentioned, DIPHTHERIA. 
in the place of the lungs, he will recognize, in this language, the 
description of a simple, and again of a malignant attack of diph- 
theria. The same writer speaks of eruptions in his letter ; but it is 
evident that, when these are mentioned, he confounds scarlatina at 
one time, and then erysipelas and other diseases, with diphtheria. 
Scarlatina, measles, and erysipelas were prevailing at the time, and 
it is manifest, that either he confounds the diseases with each other, 
or that they were blended, which frequently occurs ; and if not 
blended, succeeding each other, as has repeatedly been observed, in 
the history of diphtheria, during the last few years. Dr. Greenhow, 
of London, Dr. Clark, of New York, and many gentlemen of Eng- 
land and of America have published such cases ; and in the scarlet 
fever epidemics, published by Fothergill and Huxham and others, 
such instances are frequently detailed. 
We cannot find space for many such lengthy quotations, but this 
has been given, because it furnishes clear and undoubted evidence 
of the malignant prevalence of diphtheria in America, as early as 
1738, when on the contrary all writers, in England and America, 
state that it did not here exist before 1771, at which time it was 
graphically and first described by Dr. Samuel Bard. It is given 
merely as an historical fact, connected with diphtheria in America. 
The disease described by Dr. Douglas, of Boston, in 1736, to which 
Dr. Bard alludes in his essay, was evidently not diphtheria. The 
disease is generally and fully described, about the period of its preva- 
lence in New Jersey, by most of the authors in Europe. In 1743 
it made its appearance in Paris, and seemed to have prevailed there 
until 1748. This epidemic is described by Chomel, Malouin, and 
others. Chomel, speaking of the exudation, tell us, that about the 
third day, an unpleasant odour was apparent, and that this soon be- 
came insupportable. There was ichorous discharge from the nos- 
trils, the trachea ulcerated, and death occurred about the tenth or 
twelfth day. 
Ghisi, of Cremona, lias given a description of the epidemic which 
prevailed there from 1740 to 1748. The epidemics of diphtheria, 
during the 18th Century, in England, are described by Fothergill, 
Starr, Cotton, Huxham, Wall, Wethering, Rumsey, and others. Dr. 
Fothergill described the disease as itoxj»*'viin London abon*-1750 ; 7 
DIPHTHERIA. 
Dr. Starr as he saw it in Cornwall in 1749 ; Dr. Cotton as it ap- 
peared at St. Albans in 1748 ; Dr. Huxham as it prevailed at Ply- 
mouth 1753 ; Dr. Wall as manifested at Worcester; Dr. Wethering 
as he saw it at Birmingham in 1778, etc. In America, it prevailed 
in New York in 1771, and was classically described by Dr. Samuel 
Bard. It is mentioned, as prevailing in France, about the middle 
of the Eighteenth Century, by Dr. Slade, who quotes from the 
writings of Arnault and Marteau de Grandvilliers. It prevailed in 
Sweden in 1755, 1759, 1761 ; it existed epidemically at Upsala in 
1762. Rosen describes the history of this epidemic : it is also de- 
scribed by Wilcke. There seemed to have been an arrest or absence 
of this disease, from the latter part of the Eighteenth Century, until 
one-fourth of the next Century had expired; when it reappeared, 
and has prevailed, with deadly violence, at different periods, up to 
the present time. 
We have thus concisely traced the history of this disease, from 
the time of Aretoeus, to the early part of the Nineteenth Century. 
It has been impracticable to quote from the authors given, as such 
a course would be adapted to a volume, and not to a paper of this 
limited character. 
The history, symptoms and general cause of the disease, as de- 
scribed by these authors, are for the most part similar, and such 
quotations would have presented more of literary, than pathological 
interest. For the same reasons given, we have deemed it unneces- 
sary, and certainly not important to describe the epidemics, as de- 
tailed by these innumerable writers. 
We find, in the history of diphtheiia, during the present century, 
that it has prevailed most malignantly in France, England and the 
United States, and that this malignancy would be represented, by 
the order in which these countries have been named. Although, in 
the description of this disease, it would he interesting to give a brief 
sketch of the manner of its prevalence, in the large cities that have 
have been subjected to its epidemic desolations, yet (as each 
one of these epidemics would alone, furnish material for a a more 
extended paper than the present) it will only be possible to give the 
localities involved. Furnishing thus an historical abstract, from 
which the proper references may be obtained, by any one desiring 8 
ntrm'MfckiA. 
to investigate the character of the disease, as it may have prevailed, 
in each country or locality. 
The first epidemics, of which we have any records, during the 
present century, prevailed at Tours, in 1821 ; in La Ferridre in 
1826 and in Chdnusson in 1827. These epidemics, as is well 
known, furnished the subjects for the classic essays of M. Bretton- 
neau, of Tours, France. It Was supposed, by the author of these 
essays, that the disease was first introduced into the population of 
Tours, by the military legion of La Vendde. He named the disease 
diphtherite, and, with some modifications, it has been the name, 
selected by many authors, for the description and history of the 
malady. We will postpone an examination of the name, until we 
make its etymology a subject of brief consideration. The disease 
is next seen at Marseilles in 1826 ; and in Orleans in 1828. In 
1843 it prevailed, as a slight epidemic, in Paris ; Becquerel has 
given a description of this. M. Empis gives a brief account of its 
prevalence, as seen by himself in 1848. Boulogne became, in 1855, 
the scene of its earliest malignant appearance, and to M. Perro- 
cheaud, we are indebted for a graphic description of its desolations 
there. With very little interruption, the disease prevailed in that 
city until 1857, and in this period we are told it destroyed 275 
persons; it chiefly attacked the English residents. About the same 
time, it commenced to gradually extend over France, and we find it 
visiting Mont Martre, Causery, Vernuis, and many other 
described by Pichenot, in his account of the epidemic at Causery. 
Lespian has described its history, at Avignon in 1854, and Lemaire 
its course, at Cosned. It appeared in Paris at this time, and may 
be said, with slight exceptions, to have prevailed there ever since; 
it seems to have become one of the Parisian endemics. During the 
years 1855 and 1856, it prevailed with very great severity in that 
City. There are interesting descriptions of its history, as it pre- 
vailed at St. Omer, Haute Marne, Ingrandes, L’Yonne and other 
places. The first reliable writings on this subject were published, 
as has been said, by M. Brettonneau, of Tours. Since this period, 
diphtheria has been the theme, for the most brilliant writers in 
France. We mention the well known names of Louis, Lemaire, 
Trousseau, Guersant, Isambert, Bouchut, Andral, Chomel, Barthez. DIPHTHERIA. 
Empis, Lemoine, Lespian, Duchd Penant, Rilliet, Pichenot, 
Loisseau, Ollivier, Faure, Becquerel, Aubrun, Duliquier, Charnaux, 
Isnard, Peter, Andre, Desmartis, Bouchet de Yitray and many more, 
the works of whom may be, with profit, consulted by those partic- 
ularly interested in the study of this subject. With this brief 
notice, but correct record, of the history of diphtheria in France, 
from the commencement of this century, to the present time, we 
pass to the consideration of its course in England, during a similar 
period. 
The first case authentically recorded, as having taken place in 
England, was at Spalding, Whaplode Drove, Lincolnshire, July, 
1856. Of course other cases must have occurred, but this was the 
first recognized case of diphtheria. This was placed under the care 
of Mr. Wilkinson. A few months after, other cases were reported, 
and it soon prevailed as an epidemic. We find the disease, now 
existing in Leek, Pinchbeck, Birmingham, Brewood, Water-Orton, 
Erdington, and other localities soon to be mentioned. At the same 
time, the disease was carefully studied, and the materials now col- 
lected furnished the basis for some of the best papers on diphtheria, 
that have yet been published. From the period of 1856, the disease 
gradually extended over England, and the names of the following 
places represent the scenes of its epidemic visitations: Wolver- 
hampton, Dudley, Clapham-Rise, Tattershall-Thorpe, Horncastle, 
Dursley, Christ-Church and Strouden, London, Manchester, Cam, 
Brentwood, Malden, Coningsby, Belper, Nantwich, Coltishall, 
Hanley, Sussex, Norfolk, Kent, Essex, Cornwall, Holdenhurst and 
Islington. 
Webster, of Dulwich, gives cases that occurred in his practice, 
from 1824 to 1829, which must have been diphtheria, and Ryland, 
writing in 1837, furnishes cases that must have been true diphtheria. 
There are cases reported from Herefordshire in 1849 and 1850, 
that were most undoubtedly instances also of this disease. There 
is of course a history connected with the prevalence of diphtheria at 
each and all of these places, but, however instructive, it must all be 
omitted, and our course limited to the concise relation of the local- 
ities thus visited. To conclude the abstract, that we have thus 
prepared of these places, we will farther mention the remaining 10 
DIPHTHERIA. 
names : Liverpool, Muscliffe, Whitham, Penn, Red- 
ditch, Canterbury, Suffolk, West-Bromwitch, Yorkshire, Bagshot, 
Erdington, Rumford and Wirksworth. We are not aware, that up 
to the present time, any epidemics of diphtheria have prevailed in 
England, the localities in regard to which have not thus been ob- 
tained and recorded. Of course sporadic and occasional cases have 
occurred, wdiich, not being reported, are not here noticed, but all 
of the epidemics, strictly so called, are most probably represented 
in these lists. In England, the medical writers have paid very 
general attention to the study and elucidation of this disease, and 
we consequently have a full and valuable literature, connected with 
it. Including those who wrote of this disease by description, if not 
by name, we have the familiar names of Sir E. Home and Dr. Wat- 
son ; Baillid, Hart, Sanderson, Semple, Farr, Greenhow, Ranking, 
Hillier, and others of London; Wilkinson, of Spalding; Heslop, 
Wade, West, Fleming, Russell, Schofield, and Keyworth, of Bir- 
mingham ; Palmer, of Water-Orten ; Oates, of Erdington ; Topham, 
of Wolverhampton ; Webb, of Wirksworth; May, of Malden; Lainb- 
den, of Conningsby; Dodge, of Cornwall; Ballard, of Islington; 
Monckton, of Kent; Stiles, of Pinchbeck; Blount, of Bagshot; 
Davey, of Rumford ; Cammack, of Spalding, with others whose 
localities are not definitely known ; Gull, Lambden, Plaskitt, Bris- 
towe, Keysworth, Birch, Leonard, Morris, Houghton, Nicholson, 
Bellyse, Rigden, Wigan, Hulme, Kingsford, Whitehead, Bottomley, 
Camps, Davey, and many others, who are not so well known to the 
Professional reader. It is proper to say, that this disease has not 
been much seen in the large hospitals of London, and this will ac- 
count for the absence of so many names, that are, to the Public, 
“ as familiar as household words.” Dr. Peacock, of London, writes: 
“ I have not seen very much of diphtheria, for in London, at least, 
the disease has been quite local in its appearance, and has rarely 
been seen in the General Hospitals.”—(Autograph letter to author, 
December, 1860.) This is also the testimony of many others, con- 
nected with the largest Institutions of Europe and America. We 
pass now to consider that portion of the history of diphtheria, which 
is most interesting to the American reader : the course and preva- 
lence of the disease in the United States. DIPHTHERIA. 
11 
Soon after the appearance of diphtheria in an epidemic form in 
England, it prevailed in California. As was the case in England, 
the Profession had no practical acquaintance with the disease, for 
those who had seen it in a former century, had long since been re- 
moved. All readers were familiar with the general description of 
the disease, as given by Fothergill, Cotton, Starr, Huxham, Bard, 
Wall, and more recently by West, Copland, Evanson, Tweedie, 
Maunsell, and others; but these descriptions were not yet recog- 
nized, as applicable to diphtheria specially, and on its first appear- 
ance, there was of course much speculation as to its pathology, and 
much doubt as to its proper treatment. Dr. V. T. Eourgeaud has 
given a partial description of the disease, as it prevailed in Cali- 
fornia in 1856, 1857, and 1858, though the greater part of this 
(one of the earliest American papers on the subject) is devoted to 
discussing the diagnosis and pathology of the disease. He regarded 
it as a strictly local affection. Dr. Blake, of Sacramento, California, 
has given us an account of diphtheria, as it prevailed in that sec- 
tion of his State in 1857, 1858 and 1859. He regarded it as a 
distinct disease, different from croup, cynanche tonsillitis and scar- 
latina—a disease of the zymotic class. The disease has prevailed, at 
intervals, up to the present time, and having seen perhaps as much 
of it as any one in that State, he has not yet had cause to change 
his opinion. In an autograph letter of December, 1860, he thus 
writes: “That the old doctrine of its local character is unsustaina- 
ble, few who have witnessed its effects, during the past two or three 
years, will be disposed to deny. I still regard it, as a strictly con- 
stitutional disease.” Diphtheria has prevailed very generally in 
California since the early part of 1856, up to the present time, and 
its course and history there have been well described by many of 
the Physicians of that State. Very excellent papers have been 
prepared by Dr. V. J. Fourgeaud, of San Francisco; Dr. Blake, 
of Sacramento; Dr. D. booster, of San Francisco, and Dr. J. P. 
Whitney, also of that City. Dr. E. S. Cooper claims to have seen 
and treated quite an astonishing number of cases. Dr. H. W. Nelson 
gives a description of an epidemic of diphtheria which prevailed at 
Dutch-Flat, California; and Dr. Bynum, of Cache-Creek, California, 
has presented an account of the disease, as it prevailed with him. 12 
niPHTHKRIA. 
The disease spread throughout the United States so irregularly, 
that it has been impossible to keep a record of the places and sec- 
tions successively visited; we will not attempt this, but give all that 
is necessary—a list of the chief epidemics, that have appeared up 
to the present time. A malignant epidemic of diphtheria appeared 
at Albany, New York, in 1858 ; an account of this has been given 
by Dr. S. D. Willard, of that City. It prevailed chiefly among 
children under twelve years of age. Dr. Willard regarded it “ as 
nearly allied to scarlatina.” The disease prevailed to a very great 
extent in New Y'ork in 1859, and occasionally there since that pe- 
riod. The epidemic in that City, during the Winter and Spring of 
1859, has been admirably described by many of the Profession, in 
the Journals contemporaneously issued. There have been excellent 
papers prepared by Drs. A. Clark, J. B. Reynolds, Jacobi, and 
others. In the published proceedings of the New York Academy 
of Medicine, the pathology, cause and treatment of this disease will 
be found fully analyzed and discussed. Here will be found, what 
we have not space to give : the views and experiences of many of 
the most generally known speakers in that body—Drs. John Wat- 
son, Gurdon Buck, A. C. Post, Krakowitzer, Jacobi, Sayre, Barker, 
T. G. Thomas, Percy, Green, Peaslie, J. R. Wood, Markoe, and 
many more whose names we have not space to mention. Dr. Jacobi 
testifies, that at the Canal Street Dispensary, he had treated one 
hundred and twenty-two cases. This may serve as an index of the 
general prevalence of the disease at that time. The disease has 
prevailed to some extent in the New England States. Dr. 
Lawrence describes its course at North Adams, Mass., and Dr. 
Holmes gives an account of its prevalence at South Adams, Mass. 
Its appearance and history at the following places have been thus 
described : at West Stockbridge, by Dr. Meacham ; Orange, Conn., 
by Drs. Beardsley and Jewett; in Canterbury, Conn., by Dr. Jewett, 
with a few scattered cases, in the Counties immediately adjacent to 
the last mpued Village. It prevailed in New Hampshire to some 
extent, in 1857 ; in Boston in 1858. Dr. Seymour has given its 
history at Troy, New York; in Rochester; as described by Dr. 
Bostwick, at Red Rock; at Austerlitz, Lebanon, Chatham, and 
Gallatin in the State of New Y"ork. At Buffalo, it prevailed some DIPHTHERIA. 
13 
years since, and its history there was given by Dr. Rochester and 
by Dr. Austin Flint. Dr. J. G. Orton, in an autograph letter of 
January, 1861, states: “The present epidemic of diphtheria made 
its appearance at this place (Binghamton, N. Y.,) about two years 
since, and has continued, almost without interruption, up to the 
present time. It has been, in fact, the only epidemic that has ex- 
tensively prevailed in this region, for the past twenty years.” It 
has prevailed at Providence, R. I.; but Dr. Snow, of that City, 
writes that this has been to only a limited extent; there were seven- 
teen deaths there from this cause in 1859, and six in the year pre- 
vious. In Berkshire County and in Pittsfield, Mass., the disease 
has at times existed epidemically. In Philadelphia, diphtheria has 
at times prevailed to an alarming extent, and the disease there has 
been quite fatal. Its history has been well described by Drs. Con- 
die, Meigs, Wood, Nebinger, Beasly, and others. Dr. Condie’s 
reviews of this disease are instructive and interesting. One of the 
best papers that has appeared, anywhere, on the subject of diph- 
theria, was presented by Dr. Henry Hartshorne, of Philadelphia, in 
March, 1860. Dr. W. H. Thayer, of Keene, N. H., and Dr. I). 
D. Slade, of Boston, have each written most valuable essays on this 
subject. In Ohio, diphtheria has prevailed to a great extent. The 
epidemics at Cleveland and at Cincinnati have been very severe.— 
Dr. C. A. Hartmann, of Cleveland, has contributed quite an inter- 
esting paper on the disease, as seen by himself; and from Dr. 
Comegys we have a letter, giving a graphic description of the 
disease, as it prevailed at Cincinnati. Diphtheria has made its ap- 
pearance, as an extensive epidemic, in Kentucky, Mississippi and 
Tennessee. Dr. S. A. Cartwright, of New Orleans, has given a 
description of the disease, as he saw it in that State. Dr. Warren 
Stone, who, in the death of his son by diphtheria, has had a mel- 
ancholy yet practical experience with that disease, has contributed 
his views in regard to it. Dr. R. II. Goldsmith, of Oakland Col- 
lege, Miss., has published his experience; and he has had 
“ three hundred cases in his practice.” 
But this branch of our subject has already extended beyond the 
limits that can be assigned to it, and we must terminate its consid- 
eration by briefly giving an abstract of the chief epidemics, whose DIPHTHERIA. 
history has been published, and adding, in conclusion, whatever in- 
formation, of a practical character, that has been furnished us by 
letter. Diphtheria has prevailed at Baltimore, Md.; at Charleston, 
S. C., (American Journal of Medical Sciences, vol. xxiv, page 82 ; 
a paper by Dr. E. Geddings) ; at Nashville, Tenn.; at Louisville, 
Ky. ;.at Iowa City; at Milwaukie, Wis.; and in many of the Coun- 
ties of the States thus named. Dr. Meranda has described an epi- 
demic at New Carlisle, Ohio; Dr. Coskery, of Baltimore, an epi- 
demic in South Pennsylvania. Epidemics have prevailed at the 
following places, and their published description given by the fol- 
lowing writers. At River View, Ky., by Dr. Duerson ; at Mil- 
waukie, Wisconsin, by Dr. W. S. Wells, (whose paper is both ex- 
tensive and interesting) ; at Jacksonville, Illinois, by Dr. Prince ; 
at Sacramento, California, by Dr. Blake; at Milton, Ind., bj Dr. 
V. Kersey ; at Sacramento, Cal., by Dr. Hatch; at Falmouth, Ky., 
by Dr. J. H. Barbour ; at Hopewell, Ohio, by Dr. J. A. Reamy; 
at Petersburg, Va., by Dr. W. M. Turner; at South Onandaga, 
N. Y., by Dr. J. Kneeland; in Lehigh County, Penn., by Dr. A. 
M. Sigmund; at Newrton, N. J., by Dr. J. Ryerson ; in Kentucky, 
by Dr. S. P. Bryan; at Flushing, Long Island, by Dr. C. M. 
Allen ; at Homer, N. Y., by Dr. G. W. Bradford; at West Stock- 
bridge, Mass., by Dr. Levitt; in Sligo County, Kentucky, by Dr. 
J. H. Wheeler; at Iowa City, by Dr. W. M. Cochran ; Platts- 
mouth, Nebraska, by Dr. R. R. Livingston ; at Baltimore, (to a 
limited extent,) by Dr. F. Donaldson; and at Cincinnati, Ohio, by 
Dr. J. A. Thatcher. 
Dr. Sweat writes, that he has seen cases at North Parsonfield, 
Maine ; Dr. Woodward, that the disease has prevailed epidemically 
at Brandon, Vermont; Dr. James A. Reeves, of Fairmont, Va., 
that the disease has prevailed with “ appalling mortality” in Pres- 
ton, Taylor, Barbour, Randolph, Marion, and other counties in Vir- 
ginia; Dr. W. S. Chipley, that he has seen it at Lexington, Ky.; 
Dr. A. B. Palmer, that it has prevailed to a limited extent, in Ann 
Arbour, Michigan; Dr. C. S. Webber, that it has been seen at 
Charlestown, Mass.; Drs. Borland, Bowditeh and Gould state, that 
the disease has never prevailed, to any marked extent, at Boston, 
Mass.; Dr. Cain, that he has frequently seen the disease in Charles- DIPHTHERIA. 
ton, S. C.; and Dr. Bemiss, of Kentucky, that it had very gene- 
rally prevailed in that State ; Dr. M. L. Linton, of St. Louis, Mo., 
states that he has frequently seen the disease in his City, but that 
it has not prevailed to any great extent. Some parts of the United 
States have almost entirely escaped the visitations of diphtheria. 
Dr. Lee, of Pensacola, Fla , writes that the disease had notappeared 
there ; such is also the testimony of Dr. Westmoreland, of Atlanta, 
Ga.; Dr. G. W. Dove, District of Columbia, writes that “ it has 
been my good fortune not to have encountered a single case of 
diphtheria;” Dr. Bozeman states, that up to the time of his leaving 
Montgomery, Ala., he “had not met with a single case of diphthe- 
ria, nor had any other practitioner ;” Dr. S. Howard, of 
of Virginia, writes, “ I have not met with a single case of the 
disease here;” Dr. Brown, of Yanceyville, N. C., states, that, if at 
all, it had only prevailed to a limited extent in his State. 
Diphtheria has prevailed in Scotland and in Ireland ; in Sweden, 
Switzerland and Germany ; in Spain and Italy ; in Mexico and in 
Peru ; but we can not, with regard to the history of the disease, go 
any farther into details. • Drs. MacKenzie, Abercombre and Brown, 
of Glasgow ; Drs. Laycock, Crigbton and Alison, of Edinburgh ; 
Dr. Corrigan, of Dublin ; Dr. Adriazala, of Lima, have all written 
on this subject, and their papers can be consulted, by those taking a 
special interest in the epidemics of these countries. In addition to 
these, we may mention the names of Friedereich, Virchow, Roki- 
tansky who have described the epidemics of Germany ; and Laman 
and Mestizzi, who have described the disease, as it has existed in 
Mexico. The etymology of the word will next be considered. 
Name.—There has been much contention, as to an appropriate 
name for this disease; it is almost beyond conception to see the titles, 
under which it has been described. Nothing, better than this, can 
explain much of the antagonism, obscurity and contradiction that 
have prevailed, in regard to its pathology. We have selected the 
names given by different authors and writers, as indicative of the 
controversies that have arisen in relation to them, and give them as 
folio .vs,: Morbus Strangulatorius (Dr. Starr;) Malignant Sore 
Throat, (Fothergill;) Suffocative Angina, (Bard ;) Malum iEgyp- 
tiocum, (Aretoeus ;) Ulcus Syriacum, Diphtheritis, (Brettonneau ;) 16 
DIPHTHERIA. 
Diphtheritica Maligna (Trousseau;) Diphthorite, (Rilliet, Barthez 
and others ;) Malignant Ulcerous Sore Throat, (Huxham ;) Angina 
Maligna, Angina Gangrenosa, Angina Pellicularis* Angina Pestil- 
lentiel; Angina Suffocante ; Epidemic Angina, Scaflatina 
Angina Couenneuse, Pharyngite Couenneuse, Pharyngitis, Pulta- 
ceous Pharyngitis, Plastic Pharyngitis, Cynanche Maligna, Cynanche 
Gangrenosa, Epidemic Cynanche, Membranous Cynanche, Mem- 
branous Tonsillitis, Membranous Disease, (Cutting;) Pseudo-Mem- 
branous Pharyngitis, Putrid Sore Throat, Throat Distemper, Garro- 
tillo, Male do Canna, Guise Morbus, Morbus Suffocans, and infinitely 
contradictory names, in other languages. It will thus be seen, that 
it was not an easy matter to reconcile these endless differences and 
disputes and to select a name which would, at least, be adopted by 
a majority. It is of great importance, that a disease should always 
be described under an invariable name; otherwise, it is almost im- 
possible to properly study its character and history. We can best 
obtain a true conception of a pathological condition, by adopting a 
word so clearly comprehensible that it shall express this condition, 
and by so defining the condition to which the word is to be -applied, 
that such application shall be uniformly and necessarily correct. If 
this is not done, the inevitable result always is, that writers, by the 
same word, symbolize different pathological conditions and the same 
pathological conditions, by different words. This is remarkably 
true, in regard to the written history of diphtheria. We have the 
same word applied to very many and different diseases and the 
same disease described, under entirely different words. Most of 
the writers of England and America have selected the word adopted, 
though not suggested, by Dr. Farr, (The Registrar General of 
England,) Diphtheria. It is the word most commonly used, by 
those who write in English, though many prefer to continue the ex- 
isting confusion, by adopting some of the many titles already exist- 
ing, or to increase it, by forming a word to suit their own fancies. 
It is to be hoped, that however much it may do violence to their 
peculiar rules of etymology, all writers will adopt the word, now so 
universally used, in the valuable medical literature of England.— 
Many writers object to the term diphtheria, as “ barbarous ” and 
unscientific ; and as an absurdity in the uses of etymology. With DIPHTHERIA. 
17 
unscientific, and as an absurdity in the uses of etymology. With 
all deference, we submit, that the word diphtheria is correct in 
etymology, correct in analogy, and correct in euphony. It is based 
on the Greek root dupdzpa, signifying a membrane, skin, or hide. 
Diphtheritis signifies an inflammation of the skin or hide, which is 
false in fact; whereas, diphtheria signifies a disease, characterized 
by the formation of a skin or membrane. It does not define the 
disease, but it certainly suggests its chief characteristic. The 
termination in itis, by the general usages of terminology, signifies a 
a high degree of inflammation ; whereas, in diphtheria this is not 
always the case, and is often a gratuitous assumption. Many of 
the most fatal cases never manifest this inflammation. Again, the 
termination in itis usually implies, that there is an attending consti- 
tutional disturbance, as a result of this inflammation ; whereas, the 
constitutional disturbance is, at times, not a result, sometimes it is 
absent, and, at other times, it precedes the local trouble. 
Death frequently takes place, when the constitutional trouble is 
slight, and occasionally when it is absent. Even granting, that the 
word diphtheritis did not suggest an error, there is no more reason for 
the etymologist to use this word, in the place of diphtheria, than 
there is for his using the term pneumonitis, instead of pneumonia; 
When, however, the term diphtheritis implies not only an error, 
but a pathological condition, not in any degree existing ; and when 
the word diphtheria suggests a disease, whose chief characteristic is 
indicated in the etymology of the word selected, it seems strange 
indeed, that there should be the least difficulty or hesitation mani- 
fested, in making an appropriate and proper choice in the titles pre- 
sented. Etymology, analogy and euphony are all consulted and 
respected, in the name new generally adopted, viz: dipththeria. 
PATHOLOGY. 
This is confessedly the most difficult and important branch 
of this subject; its etiology is not specifically a necessary and 
essential object for study, as even if neglected, it "would but 
place the disease in the long catalogue of those whose causes are 
unknown. Its treatment, however, to be rational, and its inresti- 18 
DIPHTHERIA. 
gation to be successful, must be based upon a correct knowledge of 
pathology. 
What is diphtheria ? The diseases with which it may be con- 
founded are chiefly pharyngitis, muguet, aphthous inflammation of 
the mouth, erysipelas, croup, and scarlet fever. We will examine 
and carefully contrast it with each of these diseases ; but with croup 
and scarlet fever more particularly, as with these diphtheria is 
chiefly confounded. 
The difference between pharyngitis and diphtheria is clear and 
decided. In the first, we seldom find a false membrane present; in 
the last, this is seldom (if ever) absent. In the first, if this mem- 
brane is present, it rarely extends ; in the last, almost always 
present, it seldom fails to extend. In the first, the constitutional 
disturbance is usually severe ; in tho last, it is usually slight. In 
the first, the swelling of the lymphatic glands behind the jaw, is 
seldom present; in the last, this swelling is seldom absent. In the 
first, the fauces are generally of a scarlet colour; in the last, they 
are more nearly of a claret colour. In the first deglutition is inva- 
riably painful; in the last, it is exceptionally painful. The fever 
attending the firet disease is marked, the pulse rising often to one 
hundred and twenty beats in the minute ; in the last, it is slight, 
the pulse rarely exceeding ninety to one hundred beats per minute. 
Convalescence, from the first, is prompt and continuous; from the 
last, it is slow and frequently interrupted. In pharyngitis, we sel- 
dom have complications, and there are no sequelae; in diphtheria, 
we have frequent complications, and we very often have sequelae. 
The prognosis in the first is, as a rule, very favorable ; in the last, 
it is very often unfavorable. The mortality of the first is slight; 
that of the last, often severe. The first is seldom, if ever, epidemic; 
the last is very often epidemic. The diagnosis of the first is simple; 
that of the last complicated. 
The differences between muguet and diphtheria are sufficiently 
numerous and marked, to render a mistake, in regard to them, 
almost impossible. Without entering into the elaborate researches 
of Guersent, Plumbe, Gyot, Guriy, Oesterlein, Empis, Laycock, 
Harley, Rogers, Lebert and others, in regard to the special pecu- 
liarities of the exudations in muguet and diphtheria, it will be suf- DIPHTHERIA. 
19 
ficient to say, that the existence of the parasites, oidium albicans, 
leptothrix buccalis and the haematophyta of microscopists do not 
serve the purpose of a theoretical or practical distinction between 
the respective diseases. Muguet is chiefly and perhaps solely, a 
disease of infants at the breast; whilst diphtheria is not peculiar to 
any age. The first usually commences in the mouth ; the last in 
the fauces. The exudation of the first is curdy and flocculent; that 
of the last membranous, uniform and coriaceous. The constitu- 
tional symptoms of the first are slight and often absent; those of the 
last are often grave and usually present. Muguet is not epidemic ; 
diphtheria is very frequently so. In the first, the swelling of tin- 
lymphatic glands behind the jaw is seldom seen ; in the last, it is sel- 
dom absent. Deglutition is not impaired, in the first; in the last, it is 
troublesome and frequently painful. In the first, there are no com- 
plications, no sequelae, and there is prompt and continuous conva 
lescence; in the last, there are complications, troublesome sequelae, 
and the convalescence is slow, protracted and frequently inter- 
rupted. The prognosis is always good in the first; in the last, it is 
often grave. 
Aphthous inflammation of the mouth is often mistaken for diph- 
theria. The distinction between them is marked and decided. The 
mistake, however, has been made, we have observed, by Bretton- 
neau, Yalleix, Roche, Barthez, and others. The microscopic dis- 
tinctions will not be given, for they are not uniformly recognized, 
even by good authorities on this subject. They are not easily made 
by the majority of the Profession. [Laycock observes, that in 
diphtheria the microscope reveals the spores and mycelium of the 
fungus; in aphthous inflammation of the mouth, there is nothing of 
peculiar or special importance revealed.] The exudation in diph- 
theria is not follicular, vesicular, nor ulcerative ; in aphthous in- 
flammation of the mouth it is follicular, vesicular, and often ulcer- 
ative. In the first, (diphtheria,) there are swellings of the 
lymphatic glands, obstructed deglutition, fever, sequelae, complica- 
tions, notorious mortality, epidemic prevalence, interrupted conva- 
lescence, and frequently a grave prognosis. In the last, (aphthous 
inflammation of the mouth,) there are no swellings of the glands, no 
impairment of deglutition, no fever, no sequelae, no complications, 20 
DIPHTHERIA 
no mortality, no epidemic prevalence, no interruptions in conva- 
lescence, and no doubt as to recovery. 
Erysipelas is considered, by very many, as closely allied to diph~ 
theria. It is stated, by one of our best and most careful authorities, 
“that, in the whole range of nosology, the nearest analogy to diph- 
theria appears to be presented by erysipelas.” We propose, with all 
deference to those more capable of judging, to examine this relation, 
md to show what we believe are the great and irreconcilable dif- 
ferences. 
We will speak of erysipelas, as pathologically restricted to the 
idiopathic form, and that in which the head and face are the chief 
ieats or manifestations of the disease, 
In erysipelas, the throat does not always suffer; if it does, we 
have a simple sore throat (a pharyngitis), with no membranous ex* 
adation, and with a diffused redness of the fauces. In diphtheria, the 
throat is almost invariably affected ; we have a membranous exuda- 
tion (of progressive character) formed, with a claret and not a 
scarlet coloured appearance of the fauces. In erysipelas, we have 
occasionally an ulceration of the throat; in diphtheria, as a rule, 
the inflammation is not vesicular, follicular nor ulcerative. In 
erysipelas, the invariable rule is a cutaneous eruption; in diph- 
theria, cutaneous eruption is the rare exception to the rule.— 
Erysipelas, as a rule, is sporadic and rarely epidemic ; its conta- 
giousness, unless by writers in England and America, generally 
denied. Diphtheria is often epidemic and its contagiousness 
very often admitted. In erysipelas, the constitutional disturbance 
is seldom slight; in diphtheria, it is seldom severe. In erysipelas, 
the eruption (always attendant) is marked by heat, swelling, ting- 
ling, stiffness, and continuous red colour; it has a distinct elevation 
of margin; advances progressively; is sometimes attended with 
bullae or blisters ; is frequently deep-seated, sometimes resulting 
in sloughing; ends generally in desquamation. In diphtheria, the 
eruption (seldom attendant) is not marked by swelling or stiffness; 
is not continuous, but appears in patches ; has no elevated margin; 
does not (on the skin) extend creepingly, or progressively ; is never 
deep-seated ; never attended with bullae ; never causes sloughing; 
ends, very rarely, in desquamation. Erysipelas is classed with the DIPHTHERIA. 
21 
exanthematous diseases; diphtheria is generally regarded as a 
specific disease. 
In erysipelas, there is often cerebral disturbance and, in bad cases, 
there is delirium, stupor and coma. In diphtheria there is never 
any mental disturbance, and, in bad cases, the patient dies with in- 
telligence and consciousness unimpaired. Diphtheria attacks chil- 
dren chiefly ; erysipelas, chiefly adults. Metastasis is frequently 
seen in erysipelas; it is never seen in diphtheria. Cerebral effu- 
sion is not uncommonly the cause of death in erysipelas; it is never 
the cause of death in diphtheria. (Edema of the glottis is one of 
the terminations of erysipelas ; exudation there being never seen. 
In diphtheria death, from oedema of the glottis, never occurs. 
Typhoid symptoms, (cerebral disturbance, frequent pulse, subsultus 
tend in um, floceitatio, dry and brown tongue, diarrhoea,) frequently 
occur in erysipelas ; they never occur in diphtheria. 
With traumatic erysipelas, erysipelas of the body, and infantile 
erysipelas, we do not think it necessary to contrast or compare diph- 
theria. If they be compared, however, the membranous exudation 
of the throat; the usual absence of cutaneous eruption ; epidemic 
prevalence; contagiousness; slight constitutional disturbance at 
first; absence of swelling, stiffness and elevation in regard to the 
eruption ; swelling of the lymphatic glands; superficial nature and 
character of the eruption, with invariable absence of sphacelation 
and sloughing; slight desquamation ; freedom from metastasis, 
typhoid symptoms, mental disturbance, stupor and coma; peculiar 
complications, sequelae (chiefly different forms of paralysis) and 
cerebral effusion always absent; laryngeal symptoms, etc., which 
are all characteristically peculiar to diphtheria, will serve to distin- 
guish it readily from each and all of these forms of erysipelas. We 
do not see how, with these distinctions, they can ever be con- 
founded. 
Croup differs radically from diphtheria. We shall, by the term 
croup, always mean true croup; the disease as it has been described 
by Cullen, Cheyne, Home (who originated the name), llosack, 
Stokes and others ; cynanche trachealis, tracheitis. We shall not 
have any reference to false croup, (the spasmodic laryngitis of 
Barthez, Rilliet and others,) or to spasmodic croup, but to* the 22 
DIPHTHERIA* 
disease, as investigated by the concours of Napoleon I, in 
the disease, with which diphtheria is most frequently confounded. 
Diphtheria is a disease of the blood (a toxaemia) with local man- 
ifestations ; croup is a sthenic phlegmasia. (Dr. Hauner, of the 
Children’s Hospital, at Munich, declares, that “ it can not be 
shown, that croup is connected with any peculiarity of the blood 
crasis.”) In diphtheria, the blood is always primarily affected, 
whilst we may or may not have any local manifestation ; in croup 
the blood, if at all, is affected secondarily, whilst we always have 
local symptoms. Diphtheria commences in the blood, and first 
exhibits itself, locally, in the fauces; croup does not commence 
with blood changes, and exhibits itself in the trachea. Diphtheria 
begins above the rima glottidis, and never extends below, unless it 
subsequently becomes complicated with croup; croup begins below 
the rima glottidis, and never extends above it. Diphtheria is a 
constitutional disease and asthenic ; croup is a local disease and 
sthenic. In diphtheria, the constitutional symptoms are primary, 
and the local symptoms secondary. In croup the local symp- 
toms are primary and the constitutional symptoms secondary. The 
first is often contagious ; the last is not contagious. The first (though 
attacking children most frequently,) is not peculiar to any age; the 
last is peculiar to childhood; seldom attacking any one over the 
period of puberty. (In 91 cases of croup, Jurin reports only one 
over ten years of age.) In diphtheria, at first, the respiration is 
not affected, and not at all, unless the disease extends downwards. 
In croup, the altered and impaired respiration is immediately a prom- 
inent symptom ; when the disease continues, it is the chief symp- 
tom. In diphtheria, there is no cough, unless croup supervenes; 
in croup, there is always a cough. (Croup is just as much a compli- 
cation of diphtheria, as is bronchitis or pneumonia, and there is as 
much reason for calling diphtheria bronchitis or pneumonia, as there 
is for considering it croup ; they are all complications of diphtheria ; 
symptoms which are merely incidental.) The membranous exuda-' 
tion of diphtheria always commences above the rima glottidis ; the 
exudation of croup always below. There is, occasionally, a cutane- 
ous eruption in diphtheria ; in croup, there is none. The first is 
often epidemic; the last always sporadic. There is, as a rule, DIPHTHERIA. 
23 
swelling of the lymphatic glands in diphtheria; in croup, as a rule, 
it never occurs. Diphtheria generally lasts two or three weeks; 
the mildest case, several days. Croup usually terminates in one, 
two or three days; the mildest cases, in a few hours. (Craigie 
affirms, that it is never protracted beyond the eleventh day.) In 
diphtheria the exudation is fibrinous ; in croup it is albuminous. 
Dyspnoea (if it exists) in diphtheria is uniform ; in croup it is 
spasmodic. In the first, it is not produced, or increased by deglu- 
tition ; in the last, it generally is thus produced and thus increased. 
Diphtheria invades at all hours ; croup invades (if it does not 
always commence) at night. Dampness and cold cannot produce 
diphtheria; they are the chief causes of croup. In true croup, 
anti-phlogistic treatment is demanded, and produces decided benefit. 
In diphtheria such treatment is forbidden, and produces decided 
danger, if not death. The testimony of Cullen, Craigie, Cheyne, 
Home, Hosack, Gregory, Stokes, Alison, Watson, Farre others, 
on croup, and that of Brettonneau, Trousseau, Barthez, Billiet, 
Sanderson, Greenhow, Hart and others on diphtheria, will verify 
this declaration. The statistics of tracheotomy prove, that there is 
a resiliency, a constitutional elasticity in croup; that there is none 
in diphtheria. [Note : Trousseau, whose experience on this sub- 
ject, is the largest on record, states, that the indications for 
tracheotomy should be promptly and early met, unless the patient 
be suffering from diphtheria. This is now his rule.] In diphtheria 
we have, as a result, paralysis and other consequences manifested. 
In croup, we have nothing of this kind. In diphtheria foetor of the 
breath is constant and invariable ; in croup, it is slight, and seldom 
occurs. In croup, there is no “ dissolution” of the blood ; in 
diphtheria, it is a chief pathological characteristic. In diphtheria 
the constitutional symptoms precede the local; in croup, the local 
precede the constitutional. In diphtheria, the membranous exuda- 
tion of the fauces is almost always present, and can always be seen. 
In croup, this exudation does not even frequently take place, and 
when existing, can seldom be seen without the laryngoscope ; in 
diphtheria, it is present as the rule ; in croup it exists as the excep- 
tion. In diphtheria, the exudation is thick and coriaceous; in 
croup, it is neither thick nor coriaceous. The membrane of croup 24 
DIPHTHERIA. 
is renewed, as an exception; that of diphtheria, as the rule. In 
croup death, usually occurs from apnoea; in diphtheria, uncompli- 
cated, from asthenia. In croup, the sound of the cough is sonorous 
and metallic ; in diphtheria, when cough exists, its sound is soft and 
moist. In croup, the convalescence is generally uniform and easy ; 
in diphtheria it is slow, interrupted, unreliable and complicated with 
the frequent sequelae of the disease. In the worst forms of croup, 
where death does not take place, the patient is usually in perfect 
health in a few weeks. In bad cases of diphtheria, convalescence 
progresses slowly, through a period of many months; many cases 
extending thus through six, eight and twelve months; the patient 
even, at the end of this time, dying from asthenia. These recog- 
nised differences will, with care, always prevent a confounding of 
these two diseases. Yet, croup and diphtheria have been considered 
synonymous terms, by many of* the best writers on these subjects. 
Brettonneau, Barthez, Jodin, Blache, Duch4, and almost all of the 
French writers, regard these diseases as identical. The English 
and American authors usually regard the diseases as specific and 
entirely different. Dr. Cotting, of Roxbury, Mass., considers the 
diseases as being identical, and writes of them as “ the membranous 
disease.” Drs. Cheyne, Tweedie, Watson, Geddings, and a host of 
writers, have pointed out occasional differences between the two 
diseases. Accumulated testimony and facts have served to make 
this distinction broad, clear and abruptly defined. Diphtheria and 
croup being considered identical, by the writers in France, and 
giving rise to so much confusion and contradiction, is not more to 
be regretted, than the trouble that has arisen, from the views advo- 
cated by so many of our English and American authors, that diph- 
theria and scarlet fever are one and the same disease. 
We propose to show the great difference that exists between these 
two diseases, and as we have done in regard to the other subjects, 
shall avoid the literature, based on the identity of these two diseases. 
It may be interesting, to quote the endless views offered, in this 
connection, by the hosts of English, French, American, and other 
authors, but such a style is not adapted to a paper of this kind.—* 
Folios could easily be thus filled, and, when read, could only be 
regarded as so many literary curiosties. There is nothing practical DIPHTHERIA. 
in such a method of treating a subject. We prefer to avoid all 
theories and views, whether presented by societies, academies, or 
individuals, and to present facts, based on the oral and lvritten tes- 
timony of the Profession. When these are given and read, each 
reader will be in a proper position to form his own conclusion. If 
the facts are sufficient, they must bring conviction ; if not, theories 
and views can never be accepted, as a useful or efficient substitute. 
We have endeavoured to accumulate all the facts in this con- 
nection, and, in their presentation, to establish a satisfactory and 
recognized difference, between these two diseases. We shall con- 
sider scarlet fever and scarlatina, as, for the most part, identical. 
An attack of scarlet fever, as a rule, produces a decided immu- 
nity from future attacks of the same disease. An attack of diph- 
theria produces no such immunity. The first attack only of scarlet 
fever is usually severe; the second, -when rarely occurring, is mild; 
a third is seldom seen. Diphtheria occurs repeatedly; there are 
many instances of a second and a third attack, and it has prevailed 
four times, with one individual, in one year. The succeeding 
attacks of diphtheria are usually more severe and malignant than 
the first. In scarlet fever, the heat is intense, at the outset, and 
subsides slowly; in diphtheria, it is very moderate and subsides 
quickly. In scarlet fever, the eruption is present, as the rule ; in 
diphtheria, as a rule, it is absent. The rash, (when present), in 
diphtheria is of a uniform erythematous redness—without a punc- 
tuated appearance—appearing suddenly in patches. The rash, 
(almost invariably present), in scarlet fever is without a uniform ery- 
thematous redness—with a punctuated appearing in 
patches. The exudation in diphtheria occurs in various localities, 
on almost all mucous surfaces not exposed to light, and is almost 
invariably present. The exudation in scarlet fever appears only in 
one locality; it never appears on other surfaces, while in diphtheria, 
it appears on the conjunctiva, in the meatus auditorious, in the va- 
gina, etc. In scarlet fever, the exudation is not generally present, 
and if present, does not extend or show a disposition to extend. In 
diphtheria the exudation is generally present and does extend. In 
diphtheria, the tongue is coated white or yellow, and when this dis- 
appears, the tongue is not red or glossy, and does not show elevated 26 
DIPHTHERIA. 
papillae. In scarlet fever, the coat on the tongue soon disappears, 
and then the tongue appears of a deep, glossy red; the papillae are 
much elevated, and we have the “ strawberry tongue,” which is so 
characteristic of the disease. The convalescence from scarlet fever 
is generally rapid, when the throat ha3 not suffered severely from 
ulceration, and the subsequent trouble is chiefly local. In diphtheria, 
convalescence is slow, unreliable, complicated and interrupted; if 
the throat has suffered severely, the after trouble is not local, but 
constitutional. The sequel of diphtheria is, as a rule, paralysis, 
and very rarely anasarca. The sequel of scarlet fever is anasarca, 
as a rule, and not paralysis. Haemorrhage, in aggravated cases of 
diphtheria, is not uncommon ; in the worst forms of scarlet fever, it 
is very rare. In diphtheria, death, in three-fourths of the cases, 
is produced by membranous laryngitis. In scarlet fever, death, 
from such a cause, is rare. Ulceration and sloughing of the mucous 
tissues is exceedingly uncommon in diphtheria; it is not uncommon 
in scarlet fever. 
Scarlet fever attacks many who have had diphtheria; it is a pre- 
disposing cause of diphtheria. Scarlet fever tends to create an 
exemption from succeeding its attack. Diphtheria tends to create a 
susceptibility to its succeeding attack. We find that those who have 
had scarlet fever, have afterwards diphtheria, and those who have 
had diphtheria, have afterwards scarlet fever. If these are identical 
as is claimed, those having had scarlet fever (which, as a rule, 
secures exemption) should not have diphtheria, unless as an excep- 
tion to the rule. If they are the same disease, those who have had 
diphtheria should not have scarlet fever. Shall the many cases (of 
both examples) that occur be claimed, as exceptions ? It is fre- 
quently urged, that diphtheria is scarlet fever without the rash ; and 
that in malignant cases of scarlet fever, the rash is often wanting. 
This last statement may be, at times, true, that, in malignant cases 
of scarlet fever, the rash is sometimes wanting; but scarlet fever, 
without the rash, is an exception to the rule, and in an epidemic of 
diphtheria, surely no one can be so irrational, as to claim, that we 
are having only exceptions to the scarlet fever rule, the scarlet fever 
without the rash; that the rule (the fever with the rash) has strangely 
become the exception, and the exception (the fever without the DIPHTHERIA. 
27 
rash) the rule ! Yet, if this exceedingly irrational claim is not 
made, it must be admitted, that diphtheria and scarlet fever are 
separate and distinct diseases. As Dr. Thayer justly says of an 
epidemic of diphtheria, in Albany, N. Y., “ of 2,000 cases of 
diphtheria, not one was known to have a rash; such an epidemic of 
scarlet fever would be unprecedented.” Were the 2,000 cases of 
diphtheria, but scarlet fever without the rash ? Were they all ex- 
ceptions to the rule in scarlet fever, or were they not examples of a 
separate and distinct disease ? # 
Scarlet fever tends to produce a susceptibility to diphtheria, and 
an exemption from itself. “ Willan met with only a single in- 
stance of a second attack of scarlet fever in 2,000 cases”—(Bate- 
man’s Synopsis.) Bouchut says he has never met with a single 
well-authenticated case. In forty-eight cases of diphtheria, “ Dr. 
Ballard reports, that twelve had had scarlatina previously.” Diph- 
theria does not tend to produce a susceptibility to scarlet fever, and 
does not produce an exemption from itself. Reverse this and we 
have the truth in regard to scarlet fever. Scarlet fever does tend 
to produce a susceptibility to diphtheria, and does produce an ex- 
emption from itself. Can exactly opposite laws be cited to prove 
the pathology of the same disease. It is more than probable, when 
a rash is manifested in diphtheria, that the disease is complicated 
with scarlet fever ; and that in cases of genuine diphtheria, there is 
no rash whatever. In scarlet fever, albuminuria is a secondary 
symptom; it occurs only when the characteristic stage of the 
disease is past. In diphtheria, albuminuria is a primary symptom, 
and occurs chiefly in the early stages of the disease. The larynx is 
commonly invaded in diphtheria ; it very rarely ever suffers in scar- 
let fever. The sequelae of the two diseases, are very different. 
Anasarca is common after scarlet fever; it is very uncommon, after 
diphtheria. Paralysis is not uncommon after diphtheria, it is exceed- 
ingly uncommon after scarlet fever. Arthritis is not uncommon, after 
scarlet fever ; it is almost unknown after diphtheria. Pericarditis 
is never seen after diphtheria; it is frequently seen after scarlet 
fever. Chorea is a sequel of scarlet fever; it is not known after 
diphtheria. In aggravated cases of scarlet fever, we have great 
cerebral disturbance, delirium, stupor and speedy death. In ag- 28 
DIPHTHERIA. 
gravated cases of diphtheria, we have nothing of this kind ; the 
intellect is invariably undisturbed to the last. Scarlet fever is a 
protection from scarlet fever. Diphtheria is not a protection from 
diphtheria. Can such totally opposite laws and conditions all he 
true, in regard to the same disease ? 
We submit these facts, as being sufficient, we think, to prove 
that diphtheria and scarlet fever are distinct and separate diseases. 
It will be observed, that we have not fortified the different posi- 
tions by appropriate cases, and that we have not thus 
illustrated, from nature, the truth of the views advocated. In a paper 
of such a character as the present, we have not space to devote to 
such a purpose, and indeed, when the reader is assured, that such 
declarations are solely based on cases that have been seen by us, 
published by others, or made known to us, he does not require the 
record; he desires only its result and the truth, as established by 
it. That diphtheria constantly prevails, after scarlet fever, is well 
known; every Medical Journal will furnish cases in support of the 
assertion. Drs. West, Sanderson, Greenhow, Hart; Drs. Alonzo 
Clark, Jacobi, Orton, Hatch and many others, have either seen or 
published such cases ; and indeed the examples of this kind are so 
numerous, as to almost make the record of every epidemic of diph- 
theria a record of this truth. 
That scarlet fever prevails after diphtheria has not been so pub- 
licly and conspicuously known. Dr. Greenhow, of London, Eng- 
land, has published eleven cases of this kind. Dr. J. G. Orton, of 
Binghamton, N. Y., writes, that “many cases have occurred, with 
me, which established, beyond a doubt, that an attack of scarlet 
fever, accompanied with all of its characteristic symptoms, does not 
in the least protect an individual from an attack of diphtheria, and 
vice versa.” (Autograph letter, Jan. 1861.) Dr. Hatch, of San 
Francisco, in a letter of December 1S6U, wrrites that he has had 
such cases. Dr. J. H. Barbour, of Falmouth, Ky., testifies as fol- 
lows : “In my experience, patients that have had the scarlet fever, 
enjoy no immunity from diplitherite ; nor do the diphtherite patients 
' enjoy any immunity from scarlet fever.” Dr. Edward Ballard, of 
Islington, England, reports a very interesting case of this kind. 
Dr. West, of England, furnishes a case also. We could furnish 29 
DIPHTHERIA. 
other examples, hut the testimony given is already more than suf- 
ficient. The writings of almost every author, show that the blend- 
ing of these two diseases in the same locality, and in the same per- 
son, is very common. This blending of diseases is so common, that, 
according to Willan, Sydenham was the first to mention the exist- 
ence of scarlet fever, as a separate and distinct disease. (Willis first 
defined pertussis, etc.) Diphtheria and scarlet fever prevail simul- 
taneously, in the same sections they prevail simultaneously, in the 
same individual; they precede and succeed each other, in persons 
and places. Dr. Greenhow gives a list of over twenty places, 
in which these diseases prevailed simultaneously. Again, he 
gives instances, where one disease precedes or succeeds the other, 
respectively ; where they would, at times, be blended. Dr. A. 
Clark, of New York, gives a case of a child dying, under his notice, 
who had, in succession, suffered from scarlet fever, measles and 
diphtheria. Dr. Jacobi states, that, in thirty-two days, he saw a 
child suffer from “ scarlatina, urticaria, measles and varioloid.” 
The blending of exanthematous diseases, however, is too well known 
to call attention to it in this connection. Though diphtheria can- 
not, of course, thus be classed, its being blended with these 
diseases is a truth, supported by the testimony of the most accurate 
and competent observers in the Profession, yet, with care, it can as 
easily be separated, pathologically, from these diseases, as these 
diseases always are from each other. Diphtheria can as well be 
diagnosticated from scarlet fever, as from erysipelas, croup, or the 
other diseases mentioned. That it is a distinct, separate and speci- 
fic disease, the facts presented, we hope, sufficiently prove. It 
always requires much time to procure a satisfactory collection of 
efficient testimony and available facts, for the defence of any path- 
ological statement; and such a statement should only be adopted 
when thus fortified. The most contradictory and confusing opinions 
relative to a disease, are always offered, until the accumulated re- 
cords, experiences and statistics, in regard to it, furnish sufficient 
proof to establish, beyond a doubt, its true pathology. Only in 
such a way, can this ever be done, and if the records and testi- 
mony, now presented, are not sufficient, for this purpose, it is only 
in this way, that some future writer may hope to succeed. 30 
DIPHTHERIA. 
Among the views of the pathology of diphtheria, may be men- 
tioned those of M. M. Bouchut and Jodin. It is the opinion of 
M. Bouchut, that the disease is limited to the tonsils, and that, if 
these be ablated, the disease is removed. M. Jodin regards diph- 
theria and croup as the same disease, caused by the lodging of a 
peculiar parasite upon the fauces; that any treatment which de- 
stroys this, destroys the disease. M. Sde, in his comments upon 
Bouchut, states that as the disease ‘is frequently manifested in the 
nose, he would ask whether Bouchut would advise the removal of 
this organ. But we will not attempt to give the heterogeneous 
opinions that have been presented. Such a catalogue would be end- 
less, and even if a curiosity, could be neither important nor useful. 
In concluding this portion of our essay, (devoted to the path- 
ology of its subject,) we assert, that diphtheria is a separate, dis- 
tinct and specific disease. 
For the sake of convenience, and to present a clear summary of 
its pathology, we will (by tables) antagonise with diphtheria, the 
diseases with which it is so frequently confounded. These tables 
will show, at a glance, the difference between the pathology of diph- 
theria and the pathology of each one of these diseases— 
Diphtheria. 
Membranous exudation seldom 
absent. 
Membranous exudation generally 
extends. 
Constitutional disturbance slight. 
Swelling of the lymphatic glands 
behind the jaw usually present. 
Fauces generally of a claret 
colour. 
Deglutition exceptionally painful. 
Fever slight and soon termina- 
ting. 
Pulse seldom over 100. 
Convalescence slow and fre- 
quently interrupted. 
Complications frequent and se- 
quelae severe. 
Pharyngitis. 
Membranous exudation seldom 
present. 
Membranous exudation does not 
extend. 
Constitutional disturbance se- 
vere. 
Swelling of the lymphatic glands 
behind the jaw usually absent. 
Fauces generally of a scarlet 
colour. 
Deglutition invariably painful. 
Fever rather severe and not soon 
terminating. 
Pulse seldom under 120. 
Convalescence prompt and not 
interrupted. 
Complications infrequent and se- 
quelae absent. DIPHTHERIA. 
31 
Diphtheria. 
Prognosis frequently unfavour- 
able. 
Mortality often severe. 
Laryngitis frequent. 
Most often epidemic. 
Diagnosis complex. 
Throat lesions not in proportion 
to severity of the disease. 
Pharyngitis. 
Prognosis invariably favourable. 
Mortality never severe. 
Laryngitis infrequent. 
Most often sporadic. 
Diagnosis simple. 
Throat lesions always in propor- 
tion to the severity of the 
disease. 
Diphtheria. 
A disease of adults and children. 
Commences in the fauces. 
Exudation membranous and co- 
riaceous. 
Constitutional symptoms some- 
times grave and never absent. 
Generally epidemic. 
Lymphatic glands behind the jaw 
very generally swollen. 
Deglutition not much impaired 
and not painful. 
Frequent complications and grave 
sequelae. 
Convalescence protracted and in- 
terrupted. 
Prognosis often grave. 
Mortality frequently severe. 
Diagnosis complex. 
Muguet. 
A disease chiefly of infants. 
Commences in the mouth. 
Exudation non-membranous and 
flocculent. 
Constitutional symptoms never 
grave and frequently absent. 
Always sporadic. 
Lymphatic glands behind the jaw 
never swollen. 
Deglutition always painful and 
generally impaired. 
No complications and no sequelae. 
Convalescence neither protracted 
nor interrupted. 
Prognosis never grave. 
Mortality never severe. 
Diagnosis easy. 
Diphtheria. 
Exudation not follicular, vesicu- 
lar, nor ulcerative; but pel- 
licular. 
Lymphatic glands behind the jaw 
swollen. 
Deglutition obstructed, but not 
painful. 
Accompanied with fever. 
Complications frequent and se- 
quelae grave. 
Prevails epidemically chiefly. 
Aphthous Inflammation of the 
Mouth. 
Exudation follicular, vesicular, 
and ulcerative : not pellicular. 
Lymphatic glands behind the 
jaw not swollen. 
Deglutition not obstructed, but 
painful. 
Not accompanied with fever. 
No complications and no sequelae, 
Prevails sporadically only, DIPHTHERIA. 
Diphtheria. 
Convalescence slow and inter- 
rupted. 
Mortality frequently severe. 
Laryngitis frequent. 
Prognosis often grave. 
Diagnosis complex. 
Aphthous Inflammation of the 
Mouth. 
Convalescence prompt and not 
interrupted. . 
Mortality always absent. 
Laryngitis infrequent. 
Prognosis never grave. 
Diagnosis simple. 
Diphtheria. 
The fauces most generally suffer; 
there is, then, a membranous 
exudation of a progressive 
character exhibited. 
The fauces are most generally of 
claret colour. 
Exudation is pellicular ; ulcera- 
tion rare. 
Cutaneous eruption the excep- 
tion ; rare. 
Chiefly epidemic and seldom spo- 
radic. 
Contagiousness seldom denied, 
out of America. 
Constitutional disturbance sel- 
dom severe. 
Eruption, when present, not 
marked by stiffness or swell- 
ing ; is not continuous but ap- 
pears in patches ; has not an 
elevated margin; does not 
(when cutaneous) extend 
creepingly; is never deep- 
seated ; not attended with bul- 
lae ; does not cause sloughing ; 
very little desquamation. 
No cerebral disturbance, and, in 
bad cases, no delirium, stupor 
and coma. 
Attacks children chiefly. 
Metastasis unknown. 
Cerebral effusion never the cause 
of death. 
Erysipelas. 
The fauces most generally escape; 
if not, there is a simple pha- 
ryngitis, with no exudation, of 
a progressive character. 
The fauces are most generally of 
a scarlet colour. 
Inflammation is follicular ; ulce- 
ration being then common. 
Cutaneous eruption the rule; in- 
variable. 
Chiefly sporadic and seldom epi- 
demic. 
Contagiousness admitted only in 
England and America. 
Constitutional disturbance sel- 
dom slight. 
Eruption always present, marked 
by stiffness and swelling; is 
continuous and not in patches; 
has quite an elevated margin ; 
almost alway extends creep- 
ingly ; is often deep-seated ; 
often attended with bullae; 
often causes sloughing ; very 
general desquamation. 
Frequent cerebral disturbance, 
and, in bad cases, delirium, 
stupor and coma. 
Attacks adults chiefly. 
Metastasis frequent. 
Cerebral effusion often the cause 
of death. DIPHTHERIA. 
Diphtheria. 
Laryngitis common. 
(Edema of the glottis not a cause 
of death. 
Typhoid symptoms (cerebral 
trouble, frequent pulse, sub- 
sultus tendinum, dry and 
brown tongue, diarrhoea, de- 
lirium, stupor and coma) never 
occur. 
Mortality chiefly from membra- 
nous laryngitis. 
Erysipelas. 
Laryngitis very rare. 
(Edema of the glottis one of the 
causes of death. 
Typhoid symptoms (cerebral 
trouble, frequent pulse, sub- 
sultus tendinum, dry and 
brown tongue, diarrhoea, de- 
lirium, stupor and coma) fre- 
quently occur. 
Mortality never from membra- 
nous laryngitis. 
Diphtheria. 
Disease of the blood ; a toxaemia; 
a constitutional disease, with 
local manifestations. 
Blood primarily affected ; some- 
times there are no local mani- 
festations. 
First exhibits itself in the fauces, 
locally. 
Commences always above the 
rima glottidis. 
Does not extend below the rima 
glottidis, unless complicated 
with croup. 
Asthenic disease ; constitutional 
symptoms primary; local symp- 
toms secondary. 
Depression often manifested with- 
out dyspnoea. 
Contagious. 
Not peculiar to any age. 
Respiration not affected, unless 
the disease extends downwards; 
dyspnoea not a prominent 
symptom. 
No cough, unless croup super- 
venes. 
The membranous exudation of 
fibrin always commences above 
the rima glottidis. 
Croup. 
Not a disease of the blood; a lo- 
cal disease, with constitutional 
manifestations. 
Blood, if at all, affected second- 
arily ; local manifestations in- 
variable. 
Locally, first exhibits itself in 
the trachea. 
Commences always below the 
rima glottidis. 
Never extends above the rima 
glottidis. 
Sthenic disease ; local symptoms 
primary, and constitutional 
symptoms secondary. 
Depression not often manifested 
before dyspnoea. 
Not contagious. 
Peculiar to infancy and child- 
hood. 
Impaired and difficult respiration 
always a prominent symptom; 
often the chief symptom. 
Cough almost invariably present. 
The membranous exudation of 
albumen always commences 
below the rima glottidis. 34 
DIPHTHERIA. 
Diphtheria. 
Exudation only extends below, as 
a complication. 
Occasionally there is a cutaneous 
eruption. 
Epidemic chiefly and seldom spo- 
radic. 
Swelling of the lymphatic glands 
behind the jaw frequently oc- 
curs. 
Duration, one to three weeks, 
with sequelae. 
Exudation fibrinous. 
Dyspnoea rare and, when present, 
uniform. 
Dyspniea not produced or in- 
creased by deglutition. 
Invades at all hours. 
Not caused by cold and damp- 
ness. 
Prognosis generally good ; mor- 
tality slight. 
Antiphlogistic treatment inju- 
rious. 
Tracheotomy contraindicated and 
generally forbidden ; no con- 
stitutional resiliency. 
Sequelae; paralysis, strabismus, 
amaurosis, etc. 
Foetor of the breath constant and 
great. 
“ Dissolution of the blood ; ” loss 
of its coagulating power. 
Constitutional symptoms precede 
the local. 
Membranous exudation always 
present (as a rule) and always 
seen ; present as the rule. 
Exudation thick, buff coloured ; 
coriaceous. 
Membrane renewed as the rule* 
Croup. 
Exudation never extends above. 
There is never a cutaneous erup- 
tion. 
Sporadic and never epidemic. 
Swelling of the lymphatic glands 
behind the jaw never occurs. 
Duration never beyond the 11th 
day (Craigi6); no sequelae. 
Exudation albuminous. 
Dyspnoea common and invariably 
spasmodic. 
Dyspnoea frequently caused and 
increased by deglutition. 
Invades chiefly at night. 
Generally caused by cold and 
dampness. 
Prognosis grave ; mortality .se- 
vere. 
Antiphlogistic treatment cura- 
tive. 
Tracheotomy indicated and ad- 
vised; constitutional resiliency 
very decided. 
No sequelae. 
Foetor of the breath generally 
absent. 
“ Dissolution of the blood” never 
seen ; increase of its coagu- 
lating power. 
Local symptoms precede the 
constitutional. 
Membranous exudation seldom 
present and never seen ; pre- 
sent as the exception. 
Exudation thin; not buff coloured; 
not coriaceous. 
Membrane renewed as the ex- 
ception. DIPHTHERIA. 
Diphtheria. 
Death, when disease is uncom- 
plicated, from asthenia. 
Sound of the cough sonorous and 
moist. 
Convalescence slow, unreliable, 
and complicated with the se- 
quelae of the disease; inter- 
rupted. 
Diphtheria. 
One attack produces no immu- 
nity whatever from succeeding 
attacks. 
One attack not influencing the 
severity of the next; if at all, 
generally increases the sever- 
ity of the second, third, or 
fourth attack. 
Heat, at the outset, very mode- 
rate and subsides quickly. 
Cutaneous eruption present, as 
the exception ; of a uniform 
erythematous redness; with- 
out a punctuated appearance; 
appearing in patches. 
Exudation appears in various lo- 
calities ; present as the rule. 
Tongue coated white or yellow ; 
when this disappears, tongue 
is not red and glossy ; papillae 
not elevated. 
Convalescence slow, unreliable, 
complicated and interrupted ; 
bears no proportion, in length, 
to severity of the throat le- 
sions ; trouble chiefly consti- 
tutional. 
Sequels—paralysis and very sel- 
dom anasarca. 
Arthritis unknown ; pericarditis 
never occurring ; chorea never 
seen. 
Croup. 
Death from apnoea. 
Sound of the cough sonorous and 
metallic. 
Convalescence easy and uniform; 
no sequelae; uninterrupted. 
Scarlet Fever. 
One attack produces almost a 
complete immunity from suc- 
ceeding attacks. 
One attack always influencing 
the severity of the next; se- 
cond attack seldom seen and 
mild ; third hardly known. 
Heat, at the outset, very intense 
and subsides slowly. 
Cutaneous eruption present, as 
the rule; not of a uniform 
erythematous redness ; with a 
punctuated appearance; not 
appearing in patches. 
Exudation appears only in one 
locality; present as the ex- 
ception. 
Coat very light and soon disap- 
pears ; tongue is then red and 
glossy ; papillae elevated ; 
“ strawberry tongue.” 
Convalescence (when the throat 
has not ulcerated) usually con- 
tinuous and uniform ; bears a 
marked proportion, in length, 
to severity of the throat le- 
sions ; trouble chiefly local. 
Sequels—anasarca and very sel- 
dom paralysis. 
Arthritis often seen; pericarditis 
often occurring ; chorea often 
seen. 36 
DIPHTHERIA. 
Diphtheria. 
Laryngitis frequent; “ causes 
three-fourths of the deaths.” 
Ulceration and sloughing of the 
mucous surfaces not seen. 
Creates a susceptibility to a se- 
cond attack. 
Albuminuria a primary symptom; 
occurs in the early stages. 
In aggravated cases, no cerebral 
disturbance; no delirium, no 
stupor, no coma ; intelligence 
and consciousness unimpaired. 
Not peculiar to any age. 
Desquamation very slight always. 
Deafness not caused by it. 
Strumous ulcers, boils, swelling 
of the cervical glands, inflam- 
mation of the eyes, diseases of 
the scalp, etc., never seen as 
the sequels of an attack. 
Scarlet Fever. 
Laryngitis not seen ; does not 
cause any deaths. 
Ulceration and sloughing of the 
mucous surfaces often seen. 
Creates an exemption, usually, 
from a second attack. 
Albuminuria a secondary symp- 
tom ; occurs in the latter 
stages. 
In aggravated cases, much cere- 
bral disturbance; delirium, 
stupor and coma not uncom- 
mon ; intelligence and con- 
sciousness often impaired. 
Chiefly peculiar to children. 
Desquamation extensive and gen- 
, eral. 
Deafness a frequent sequel. 
Strumous ulcers, boils, swelling 
of the cervical glands, inflam- 
mation of the eyes ; diseases 
of the scalp, etc., often seen as 
the sequels of an attack. 
With these important facts placed prominently in antithesis, it is 
impossible to confound diphtheria with the diseases mentioned. 
Anatomical and physiological relations. The membranous exu- 
dation of diphtheria varies much in colour and thickness. It is 
white, at times, and again opaque; ash-coloured, grey, buff, brown 
and sometimes black. It presents a great variety of texture ; soft occa- 
sionally, and sometimes, like isinglass softened in water: it is generally 7 
however, membranous, tough, dense and slightly elastic. In rare in- 
stances, it is dry and easily broken. Sometimes, it has the appearance 
of wash letter, or buckskin, saturated with water. I)r. Francis 
Minot, in giving a history of the sickness and death of the late and 
lamented Dr. H. W. Adams, of Boston, says, in regard to a portion 
of the uvula that was amputated, “it resembled a piece of umbilical 
cord, more than anything else.” The exudation varies, from the 
fraction of a line, to two lines in thickness; it has been seen, 
of three lines in thickness. Dr. Sanderson, who has paid DIPETHERtA. 
great attention to this branch of the subject, states that the 
exudation of diphtheria is deposited in layers and that these layers 
can be separated. In lifting this membrane, from the mucous sur- 
faces, it frequently appears attached by small filaments, which extend 
into the mucous follicles. Most generally, no ulceration takes 
place and when the membrane is raised up, though the mucous sur- 
face is tumefied, injected and inflamed, it will be found, as a rule, that 
the texture of the mucous tissue is uninjured; occasionally and in 
rare instances, ulceration has taken place, and when this exudation- 
pellicle is removed, an unbroken, but red and shining basement 
membrane is revealed. It is stated, that when this pellicle is not 
removed artificially, that ulceration more frequently occurs. But in 
our experience the opposite is far more often true—tearing away this 
exudation, forcibly, is well calculated to hasten, or cause ulceration. 
Sometimes, instead of a red and shining basement membrane being 
exposed, on raising the diphtheritic pellicle, the mucous surface 
appears of a dull, red colour, dotted here and there with black and 
ecchymosed spots. 
These membranes appear to be formed, by a coagulation of the 
plastic portion of the blood. Dr. Alonzo Clark considers its texture 
to be “a fibrillation of fibrine; ” with no cells, but containing “ a 
variable quantity of granules.” Dr. Sanderson has mentioned cases, 
where the exudation was non-fibrinous ; “a granular and amorphous 
deposit; ” these he considered mild cases. 
In the very mildest cases, we have a depraved and altered mucous 
secretion; this occurs, in the initial stage of a large proportion of 
the cases of diphtheria. Succeeding this, we have a coagulable 
exudation which never manifests any tendency to organization. 
Sanderson states, that the fact of non-development, in this exuda- 
tion, is characteristic of diphtheria. It would seem from “the state 
of dissolution of the hlood” in diphtheria, that the fibrin of the 
blood had been destroyed, and that the exudation, in this disease, 
could not (reasoning a posteriori) be fibrinous. Such a view has 
often occurred to us and we have bestowed much care in the investi- 
gation of this anomaly—this chemico-physiological paradox. There 
can however, we think, be given a rational explanation of it. What is 
the cause of the fluiditvof the blood whilst in circulation, or rather DIPHTHERIA. 
why, it does not coagulate, is not yet clearly explained. Dr. Rich- 
ardson’s ammonia theory has been, we think, by Dr. Dalton and 
others, proved insufficient to account for it. This is not the place to 
refer to such a subject. We know, however, that 'to fibrine is the 
phenomenon of coagulation invariably ascribed, and when we find 
that in diphtheria the blood seems to lose this property, it appears 
strange, at least, that the exudation, poured out, should consist 
of fibrin. Yet such is the case; the blood is usually “ in a state 
of dissolution” and the exudation is nevertheless fibrinous. Care- 
ful observation will explain this apparent contradiction, and convince 
us of the truth of a most happy aphorism—“ il est toujours temd- 
raire d’attaquer des experiences, par des raisonnemens.” We know, 
that there are many methods (chemical and others) for keeping the 
blood liquid, when out of the body, and yet, when this is done, the 
fibrin nevertheless exists in it, unimpaired. We know, that there 
are many substances, in chemistry, which exist frequently in an 
allotropic state ; where their properties having been changed, their 
constitution yet remains unaltered. Lehman, Liebig, Faraday and 
other authorities give repeated instances of this. It is quite 
rational to suppose, that certain changes may take place in the con- 
stituents of the blood and that an abnormal fluidity might be the 
result of this, * whilst a portion of exuded plasma, removed from 
the operation of such causes, would manifest all the properties, 
naturally belonging to it.f 
It is also very rational to conceive, that the blood, in dipli 
theria, may exhibit this condition of “ dissolution ” chiefly, 
if not solely, because of a loss of its proper proportion of 
fibrin—a proportion sufficient to produce coagulation. It is 
evident, that if blood be deprived by morbid, chemical, or physical 
causes of a certain amount of fibrin, it must (although it may yet 
contain fibrin) have lost its property of coagulation. So in diph- 
theria, the blood may have had a sufficient quantity of its fibrin 
destroyed, or changed to lose its property of coagulation, and yet 
l)r. Sanderson, of London, considers that t,he diphtheritic membrane does not develop, does 
organise, “ on account of a morbid modification of the fibrin ; ” this may be the chief reason for 
absence of coagulation in the blood of diphtheria. 
■f This is the explanation, sent in an autograph letter, by Dr. Henry Ilartshorne, of Philadel- 
phia, Pa. DIPHTHERIA. 
39 
contain far more than enough of fibrin, to compose and constitute 
the membranous exudation of this disease. Whether this explana- 
tion, that we specially offer, be sufficient or not, to explain the con- 
ditions stated, we know that this exudation is chiefly, and almost 
invariably composed of fibrin. 
This exudation always exhibits its characteristic peculiarity of non- 
organization and non-development. The coagulation is not due to 
the action of vital force, or local causes, for M. Empis states, that 
“ at the end of a few hours after tracheotomy, whatever care is 
taken to clear the canula, the instrument is seen to be lined, with a 
layer of whitish concretions; the thickness of which continually 
increases. These concretions are evidently, only the result of the 
coagulation of the liquids, with which the sides of the canula were 
in constant contact.” 
When this exudation first appears, sometimes it consists only of 
altered and depraved mucus ; if the case does not then improve, the 
exudation becomes muco-serous ; then sero-fibrinous, and after this 
entirely fibrinous. The coagulation of this fibrin, as it is exuded, 
builds up the diphtheritic membrane; if it is daily removed, the 
membrane is thin and easily broken; if not removed, it becomes 
thick, dense and coriaceous. This will, in a great measure, explain 
the discrepancies seeming to exist in the accounts of the various 
autopsies. In some, the membrane is thin and soft; in others thick 
and tough, etc. Portions of it become detached, and it sometimes 
thus presents a rough and ragged surface. Not organized, it soon 
begins to decompose, and we have the constant foetor of breath, 
characterizing this disease. When the membrane is artificially 
removed, it reveals apparently a concave, or ulcerated surface. On 
close inspection, it will often be found that there is no ulceration; 
the tonsils in parting with the exuded fluid shrink in bulk; the 
fluid coagulates, and in this process, exerts a considerable pressure 
on the surface beneath ; this pressure soon produces a whitish con- 
cavity, and this concavity has the appearance of an ulceration; on 
removing the exudation, the basement membrane is frequently 
exposed, and we have a shining and smooth-surfaced concavity. 
Generally, the diphtheritic pellicle is seen only about the fauces ; 
most frequently, on the tonsils only ; but sometimes, it spreads over 40 
DIPHTHERIA. 
the entire extent of the buccal surface. Dr. McDonald, of England 
reports cases, where “ the appearance, on opening the mouth, is as 
though it were lined with plaster of Paris.” The exudation extends 
downwards sometimes, as far as the minute ramifications of the 
bronchiae. It is not uncommon for strips of exudation membrane 
to be cast off—sometimes small casts of the bronchiae are coughed 
up. Dr. D. J. Cain, of Charleston, South Carolina, in an auto- 
graph letter, writes: “ I took a small strip of membrane, from a 
lady who died recently, upwards of three inches long and one inch 
and a quarter wide. A larynx and trachea, completely closed and 
solidified, were exhibited a few days ago, at a meeting of our Medi- 
cal Society.” It will thus be seen, that the diphtheritic pellicle, 
varies much in extent; from a simple spot on the tonsils, to a con- 
dition involving the buccal cavity; and, where it extends down- 
wards, invading the entire larynx, trachea, and the minutest rami- 
fications of the bronchiae The rings of the trachea are seen dis- 
tinctly impressed, on the membranous pieces discharged. At times, 
the membrane resembles a piece of old parchment, saturated with 
water. Its leading characteristic, is a disposition to extend,' and 
also to constantly reform. We pass now to consider its microscopic 
appearances. 
The microscopic characteristics of the exudation of diphtheria, 
have been closely studied and investigated. Brettonneau, Trous- 
seau, Empis, in France; Wade, Wilks, Sanderson, Greenhow, in 
England; Rokitansky and Virchow, in Germany ; Laycock, of Scot- 
land; Clark, Hartshorne, Condie, Jacobi, in America; Rogers, 
Vogel, and many others, have laboured zealously in this field. The 
result is chiefly, that the membrane is “ a fibrillation of fibrin,” 
containing, in its net-work, granules, molecular particles, epithelial 
cells, exudation corpuscles and sometimes blood and pyoid cells. 
There are no formative cells. The fibrils of fibrin forma net-work, 
a matrix, in which the other component parts of the membrane rest. 
Mr. Simon, in a paper presented to the Pathological Society of 
London, states, in regard to the microscopic appearance of the 
diphtheritic membrane, that “when seen in thickness, it presented 
a pebbly character, like that afforded by an accumulation of nuclei; 
but the fallacious nature of this appearance was recognised, on DIPHTHERIA. 
41 
looking at the thin edge of a section, or by adding acetic acid, 
which rendered the whole transparent, at the same time expanding 
it, and bringing into view an exceedingly delicate and irregular net- 
work, of well and sharply defined, occasionally bulging, fibres, 
which appeared to be, so to speak, the skeleton of the original net- 
work. In some places, the false membrane consisted of an appa- 
rently uniform layer, composed of an extremely fine and indistinctly 
fibrillated tissue, studded with molecular matter, and presenting 
something of a ground glass character. Imperfect epithelium was 
entangled here and there, in the substance of the membrane, but 
was most abundant on the superficial surface. These microscopic 
appearances and characteristics, have since been fully examined, 
but, beyond what has been stated, there is nothing of special inte- 
rest, or importance known. Dr. Harley has made many micro- 
scopic examinations of the dipththeritic membrane, and thinks there 
is nothing fibrinous in regard to it; in twelve cases he found noth- 
ing of the kind, “ but simply mucus, epithelium and mucus cells.” 
The explanation of this apparent contradiction is very simple; the 
specimens examined, by him, were either from mild cases, or ob- 
tained during the initial stage of other cases. Dr. Laycock, of 
Edinburgh, in a lecture published, May 29th, 1858, regarded the 
membrane due to a fungous growth, the oidium albicans, as fre- 
quently exhibited in ordinary thrush. He considers the membrane 
due “ to the action of the parasite on the enfeebled mucous mem- 
brane.” This view, which at the time attracted much attention, is 
now entirely abandoned. Dr. W. R. Rogers, in foul teen cases, 
found the parasite absent in all but one. This was read before the 
London Medical Society. It is of course unnecessary to say any 
thing, in reference to the competency of Dr. Rogers as a micro- 
scopist. In twelve cases, Dr. Harley found this parasite present 
only in one, and then the fungus did not grow upon it, until fifty- 
six hours after its removal. He considers the presence of all fungi, 
in these cases, due to accidental circumstances. They occur on the 
teeth and tongue of the most cleanly persons and it is not singular, 
that they should, at times, be found on the diphtheritic membrane. 
According to Berg and Giibler, (as stated by Dr. Thayer) “ this 
fungus may be developed on any acid, thickened mucus of the 42 
DIPHTHERIA. 
mouth and throat, as is seen in many chronic diseases.” Warner, 
Robin, Leidy and others, have reported instances of vegetable, or 
parasitic growths on the diphtheritic membrane. Leidy considers 
these fungi, identical with those of the yeast plant. The membrane 
of diphtheria, Dr. Wade, of Bermingham, considers due to the 
presence of the leptothrix buccalis, frequently seen in the saliva. 
These fungi and algae have, however, ceased to attract attention, 
for their presence is known to be entirely accidental. Dr. Harley 
states that these algae frequently prove to be “ crystals of fatty 
acids.” Dr. Alonzo Clark, of New York, has apparently made the 
same observation; he says “ these granules, under the microscope, 
appear to be fatty.” Dr. Wilks states, that he examined sputa from 
the mouths of persons, suffering with various diseases, and found 
the fungous growths, when present, not differing from those seen in 
diphtheria. The practical fact, in regard to the subject, is, that 
these growths are all accidental, and have nothing, whatever, speci- 
fically to do with this disease. 
Brettonneau, Sanderson and others have imitated in a measure, 
the exudation of diphtheria, by injecting an oleaginous preparation 
of cantharides, into the throat and faucers of the lower animals. 
“The concretion possesses a structure which is identical with that 
of the early conditions of diphtheria; consisting of a fibrinous 
matrix, in some parts of which cells are imbedded.” The chief, 
yet interesting, difference between the diphtheritic exudation and 
that artificially formed is, that in the last, there is a distinct tenden- 
cy to development and organization, whilst in the first there is noth- 
ing whatever of this kind. This as a pathological fact is of much 
importance ; it shows, that in diphtheria, the blood has undergone 
a marked and decided change. It forms a strong link in the chain 
of argument used in this essay to prove, that diphtheria is a blood 
disease. We see thus, that the diphtheritic membrane is not only 
fibrinous, but that it possesses the peculiar and specific character- 
istic of non-development; that it does not organize; that it 
varies in thickness, extent, colour, density, elasticity and tenacity, 
but that, wherever found, it is peculiar, and serves in a great measure 
to characterise this disease. DIPHTHERIA. 
43 
This to the Physician is, next to treatment perhaps, the most 
interesting, if not the most important, branch of the subject.— 
WTth him, must ever be prominent before the mind the Latin in- 
junction, “ prius cognoscere, dein sanare.” 
DIAGNOSIS. 
The diagnosis of diphtheria ought not to be very difficult, after a 
careful study of its pathology. We have almost invariably the diph- 
theritic membrane as a guide, with its characteristic disposition to 
extend, and, in a few days, to cause the marked and peculiar foetor 
of the breath ; its invariable tendency to reform, after removal; the 
facility, as a rule, of its removal, and the peculiar appearance of the 
tissue beneath—swollen, injected, shining, or covered with ecchy- 
mosed spots—concave and red ; the foetid discharge from the nos- 
trils ; its constancy, quantity and irritating effects on the parts 
subjected to its contact; the almost universal swelling of the 
lymphatic glands behind the jaw; the unusual prostration attending 
or resulting from such a slight and brief attack of fever; the fre- 
quent appearance of albuminuria, in the early stages of the disease; 
the infrequent, weak and compressible pulse. These will, when 
taken together, enable one, without much difficulty, to pronounce 
upon the character of the disease. As it is absolutely important, 
to determine very early the existence of diphtheria, we will intro- 
duce a differential diagnosis—serving to certainly distinguish it 
from the diseases with which it may be confounded. 
It will be distinguished from pharyngitis, by the presence of the 
membrane, and its disposition to extend and reform ; by the slight 
and brief character of the fever ; by the early and unusual pros- 
tration ; by the swelling of the lymphatic glands; by the little 
inconvenience and pain caused by deglutition ; by the occasional 
supervention of laryngitis ; by the disease not being, in severity, 
proportional to the lesions of the fauces; and lastly, from its epi- 
demic prevalence, and the constant foctor of breath. 
From muguet, we distinguish it, by its commencement in the 
fauces and not on the buccal surface; by the exudation 
being membranous, and not curdy or flocculent ; by great 
prostration, early manifested; by the disposition of the mem- 
brane to reform after being entirely absent, for a time; by the 44 
DIPHTHERIA. 
great foetor of breath; by the swelling of the lymphatic glands; 
by the little pain in the act of deglutition ; by the presence, at 
times, of laryngitis ; by the severity of the disease not being in 
proportion to y the lesions observed; by its frequent epidemic 
prevalence. 
From aphthous inflammation of the mouth, it is distinguished by 
the exudation being membranous, pellicular and non-ulcerative, 
instead of being follicular and ulcerative; by its disposition to reform; 
by the foetor of breath it occasions ; the facility of its removal; the 
swelling of the lymphatic glands behind the jaw ; the foetid dis- 
charge from the nostrils ; the strange prostration ; the act of deglu- 
tition not being painful, but being physically obstructed ; the occa- 
sional appearance of albuminuria; presence of fever ; superven- 
tion of laryngitis; the weak and compressible pulse. 
From erysipelas, by the presence of a membranous, extending, 
reforming, pellicular, non-ulcerative exudation; instead of a follicular 
exudation, attended with ulceration; the great facility of removing this 
exudation and the non-ulcerated appearance of tissues underneath; 
the foetor of breath being greater; usual absence of cutaneous erup- 
tion and when present, not having an elevated margin, and not 
causing tumefaction ; fever being usually milder-—no cerebral or 
typhoid symptoms manifested ; laryngitis supervening ; great pros- 
tration succeeding a short attack of fever. 
From the croup, by the fauces, and not the trachea being affected ; 
by the constitutional symptoms preceding the local; commencing 
above the rima glottidis invariably; exudation being always seen; 
foetor of breath and discharge from the nostrils being manifested; 
usual freedom from dyspnoea; occasional presence of cutaneous 
eruption; swelling of the lymphatic glands behind the jaw; 
dyspnoea not increased by deglutition ; not invading, as a rule, at 
night; not directly the result of exposure to cold and dampness; 
cough soft and moist, if present, and not being harsh and metallic 
in sound; albuminuria often present. 
From scarlet fever, by less heat, and this subsiding quickly ; 
early prostration ; cutaneous eruption, if present, of a uniform, 
erythematous redness, appearing in patches and non-punctuated 
ip character; tongue not red, shining cr having a strawberry DIPHTHF.RI A. 
45 
appearance ; supervention of laryngitis ; the appearance of haemor- 
rhage, from the mucous surfaces; discharge from the nose ap- 
pearing early in the disease; albuminuria also soon manifested ; no 
ulceration, or sloughing of the mucous tissues; absence of all cere- 
bral and typhoid symptoms. 
With these differences carefully recollected, it will not be difficult 
to form a correct diagnosis of diphtheria. 
SYMPTOMS. 
It is both useless and impossible to give the rare and 
anomalous symptoms that have been, and are developed, during an 
attack of diphtheria. What is chiefly required is, that there shall be 
presented a clear and well defined type of the disease ; the variations 
from this, though constantly occurring, not being sufficiently great, 
in any one case, to render the general description obscure, or inac- 
curate. The division of the disease, into a number of forms, has 
been adopted by a great many writers, but there will be no difficulty 
in referring all cases, to either one, or the other of two forms of 
diphtheria. We have descriptions of the mild, the simple, the ordi- 
nary, the croupal, the ulcerative, the malignant forms of the disease. 
This is confusing to the Student and even to the Practitioner, and 
it is neither necessary nor important. We will speak of diphthe- 
ria, as manifested in two forms: the non-malignant exhibition of 
the disease, and its opposite, the malignant. 
An attack of diphtheria, almost invariably appears insidiously; 
it never invades suddenly. There is usually diminished appetite, 
and this soon gives place to an anorexia, that is persistent and 
embarrassing throughout the disease. There is langour, of more 
than the ordinary kind manifested, in cases of equal constitutional 
disturbance; foreshadowing the nervous prostration and muscular 
debility, characterising this disease. This langour is both mental 
and physical. Usually headache is soon a source of complaint; 
then most commonly a chill, followed by fever, makes its appearance. 
If the patient be now examined, the tongue will be found but little 
changed; coated, perhaps slightly, with a white, or yellow fur. 
The fauces will appear injected ; sometimes of a red, most commonly 
of a purplish colour, soon after this there appears on the tonsils, 46 
DIPHTHERIA. 
(which with the fauces are now swollen,) an ash-coloured spot, or 
exudation. There is some stiffness of the muscles of the neck, 
with more or less swelling of lymphatic glands, behind the jaw. 
Very generally a slight discharge from the nostrils and an increased 
secretion from the salivary glands. With these symptoms, there is 
some dysphagia, with obstructed though not painful deglutition. 
If ordinary care and prudence be observed, these symptoms will 
decline and disappear in from four to ten days, and convalescence, 
at this time, be fairly commenced. This is a fair example of a mild 
case of diphtheria, uncomplicated with any other disease. The fever 
will most commonly disappear, in twenty-four or forty-eight hours I 
. never having been high or troublesome. The pulse rarely exceeds 
one hundred beats, in the minute. 
The diphtheritic pellicle will either disappear gradually, becom- 
ing each day more thin, or it will exfoliate and be discharged in 
pieces. This is of course the mildest manifestation of the disease. 
Sometimes, there is no anorexia; no constipation; the digestion 
being unimpaired. The prostration may amount only to langour, 
or apparent indolence. Headache may be absent. There may be 
scarcely any fever and this preceeded only by an unpleasant feeling 
of chilliness. The swelling of the fauces may be slight; the colour 
of the fauces but little altered; the pellicle may not cover even the 
tonsils, but amount to nothing more than a few spots upon the ton- 
sils, the pillars, and the uvula. There may be only a slight enlarge- 
ment of the lymphatic glands ; the muscles of the neck, not unplea- 
santly affected ; no dysphagia, and deglutition almost unimpaired ■ 
no discharge from the nose; and the patient not even confined to 
bed. With the disease diagnosticated however, the Physician should 
be none the less watchful, for even such cases become suddenly grave 
and dangerous, and are often followed by the most serious conse- 
quences. These symptoms may all be aggravated, and yet the dis- 
ease cannot be called malignant. We may thus have great languor; 
much anorexia; chill with fever, though in the most cases this is 
strangely brief and mild; tongue covered with white, or yellow fur ; 
the fauces injected, tumefied and of a claret colour; tonsils and the 
uvula covered with a whitish, greyish, or yellowish exudation ; great 
foetor of the breath ; foetid and corroding discharge from the nostrils ; DIPHTHERIA. 
4 7 
nostrils plugged with a depraved mucous secretion and Avith the 
SAVollen tonsils and uvula causing a mechanical dyspnoea, Avell calcu- 
lated to suggest laryngeal, or bronchial trouble ; the lymphatic glands 
much enlarged and the muscles of the neck stiff and painful; dys- 
phagia and impaired deglutition manifested; albuminuria present; 
and the patient’s condition, generally, painful and dangerous. The 
profuse secretion of saliva and depraved mucus, with the swollen 
fauces, and elongated uvula, making sleep, or even rest, 
impracticable. 
These instances, with the intermediate degrees of severity in each 
or ail of the symptoms, can be referred to the first or non-malig- 
nant form of the disease. ') 
The malignant form of diphtheria, is so terribly defined in its 
course, that there can be no error in the classification of the cases. 
In the malignant form, we have all of these symptoms aggravated, 
with other symptoms, that are happily peculiar to this exhibition of 
the disease. There is, at first, great headache; prostration; total 
anorexia; well defined chill, Avith low, but prostrating fe\rer ; tongue 
loaded Avith fur; throat enormously swollen ; fauces dark-coloured ; 
a yellowish or brownish, coriaceous exudation on the tonsils, pillars 
and uvula, and sometimes OArer the whole surface of the fauces ; vomit- 
ing and diarrhoea; profuse secretion of saliva and an abundant dis- 
charge of depraved mucus; nostrils discharging a thin, corroding 
and exceedingly offensive lkjuid; tumefied tonsils and uvula, with 
the plugged nostrils, causing great dyspnoea; salivary and mucous 
secretions, rendering the recumbent position impossible ; haemor- 
rhage from the nose, mouth and sometimes from the bowels; foetor 
of the breath and the discharge from the nostrils affecting the entire 
chamber; weak, rapid pulse; complains of heat, Avith the body 
cool; lividity, thirst, and the ordinary symptoms that precede 
death. This form of the disease is happily rare. We have malig- 
nant cases, in which these symptoms are not all present, or where 
they are much milder. The excessive headache ; the Aveak, frequent 
pulse, with no heat of surface ; diarrhoea and haemorrhage ; yelloAV 
or dark, leathery exudation on the fauces ; engorgement of the 
salivary glands ; excessive foetor of the breath serve always to moke 
this form of the disease easily recognised. 48 
niPHTUKKIA. 
With these two forms of the disease as given, and the interme- 
diate examples belonging to each form, we have a fair conception of 
the symptoms of diphtheria. As laryngitis and tracheitis are absent 
in a large number of cases of diphtheria, (chiefly in those which 
recover) we have not introduced the symptoms, peculiar to these 
diseases, in the symptoms of diphtheria. Being totally different in 
pathology, we can not see the propriety of introducing the symp- 
toms of these diseases, with the symptoms of diphtheria ; it would 
certainly be as appropriate to introduce the symptoms of bronchitis, 
or pneumonia, or of any of those diseases which form the complica- 
tions of diphtheria, or which prevail, so as to be blended with this 
disease. We can as well speak of bronchial, pneumonous, scarlati- 
nous diphtheria, as we can of croupous diphtheria. These diseases 
are all complications of diphtheria. We will not enter more mi- 
nutely into the description of symptoms, when croup supervenes in 
diphtheria, than to say, that we have added to the existing symp- 
toms of diphtheria at this time, the symptoms belonging to croup. 
We have, in the same way, when other diseases supervene, the 
symptoms which are peculiar to them. It must not be taken for 
granted, when dyspnoea is manifested, that croup has made its 
appearance. The nostrils occluded with their depraved secretion, 
and the swelling of the tonsils and uvula produce a mechanical 
obstruction which renders breathing difficult, when the larynx and 
trachea are uninjured. When the nostrils are not thus closed and 
the tonsils are not much swollen, we have also impaired respiration 
from bronchial, or pneumonic trouble. If, by auscultation, we have 
evidence that this kind of trouble does not exist, and if, by ocular 
inspection, we find that the nostrils and tonsils are not in the condi- 
tion represented, there is then every reason to believe, that this 
symptom (taken "with others, belonging to the disease) is due to the 
invasion of croup. With this dyspnoea, we have the metallic, 
sonorous cough ; voice much altered; restlessness, etc., which lead 
at once to a suspicion of the existence of croup. 
The existence of the membrane upon the tonsils has been gene- 
rally considered as one of the pathognomic signs of diphtheria. It 
is usually so, but we have cases of diphtheria, where the throat 
presents no such appearance. With the other symptoms ot diph- DIPHTHERIA. 
49 
theria existing, the throat is found very little altered, (sometimes 
not in any respect,) and the diphtheritic exudation is manifested 
elsewhere. It has been found thus on the body, wherever the sur- 
face has been denuded ; on the eyes ; in the ears ; in the vagina ; 
on the anus ; in the nasal fossae ; on the vulva, including the orifice 
of the meatus urinarius ; and has recently been found in the intes- 
tines. Dr. R. H. Goldsmith, of Mississippi, writes thus of this 
disease, in regard to its membranous exudation: “ Diphtheria has 
been endemic in this vicinity (Oakland College) for three years 
and epidemic since January, 1860. It has varied in severity, from 
the slightest disposition of exudatory membrane, to the complete 
plugging of the larynx and trachea. I may add, with the deposi- 
tion of the diphtherial membrane from the fauces to the anus.” Dr. 
Goldsmith states that he has treated 300 cases, and on one planta- 
tion, saw 120 cases. If he is correct, in regarding what he saw, in 
the intestinal tract, as diphtheritic membrane, M. Empis is wrong 
in his assumption, that this membrane is not formed on surfaces 
removed from the contact of the air.” As the disease, even when 
the larynx is covered with this exudation, has not extended to the 
oesophagus, it should require careful and repeated examinations, 
before assuming that it does invade surfaces, not in contact with the 
atmosphere. Dr. Greenhow stages, that Dr. Gull has been led to 
suspect the invasion of the oesophagus by diphtheria, but there is 
no positive proof, that the membrane of this disease has ever been 
found on surfaces, not exposed to the air. Dr. Goldsmith has 
reported the first instance of this kind in America on record.* It 
has been claimed, that as cantharides will produce a membrane, in 
many respects similar to that of diphtheria, that the membrane 
formed on blistered surfaces, is due to the action of the cantharides 
and is not the result of the disease. This may be true, but there 
are repeated instances of the formation of this membrane on wounds, 
when the disease was prevalent. Dr. Greenhow'reports a case of the 
formation of this membrane on the chest of a child ; the skin of 
the chest had been excoriated by the acrid discharges from the 
mouth—the case is reported by him, on the authority of Dr. 
Sanderson. 
*M. Guersent has reported a few such cases. 50 
niriiTiiKRiA. 
The fever, in diphtheria, is usually mild and brief; the pulse rarely 
exceeding one hundred beats per minute. In a Spanish epidemic, 
cases occurred where there was no fever. It usually terminates 
in twenty-four or thirty-six hours. The pulse is sometimes abnor- 
mally slow. Dr. Heslop, of England, found it only forty, in a 
child of five years of age. Dr. Kneeland, of New York, reports a 
case, where the pulse was sixty-five, in a boy ten years of age. 
Dr. Huxham, of Plymouth, England, states that the discharge from 
the nostrils was so acrid, in cases under his observation, that “ it 
corroded the lips, cheeks and hands of the children that laboured 
under the disease and the fingers and arms of the nurses that 
attended them.” 
Dr. L. N. Beardsley, of Milford, Connecticut, states that “the 
first symptom of this disease, (and it is one which we have never 
seen referred to by any writer on the subject,) was pain in the ear. 
It was not only pathognomic, but prominent and almost invariably 
present, in every case that came under our observation, for a 
day or two before the patient made the least complaint in any other 
respect, and before the smallest point, or concretion of lymphatic exu- 
dation could be discoverered, on the tonsils or elsewhere.” Among 
other anomalous symptoms, Dr. Thomas Ryerson, of Newton, New 
Jersey, mentions an ulceration of the toes. “In one of these 
epidemics of diphtheritis, many of the patients were affected with 
an extremely foetid ulceration of the toes, which could not be traced 
to any want of cleanliness.” When there is any cutaneous erup- 
tion, coincident with diphtheria, it appears in patches and is not 
diffused over the surface, as in scarlatina. It is of a uniform 
erythematous redness and has not “the boiled lobster” appearance 
of scarlatina, and, unlike the scarlatinous eruption, it is not 
punctuated. 
When the larynx escapes, the most careful and scientific observers 
are deceived. Children considered safe are, on the next visit found 
dead. When the larynx however does not escape, almost every case 
is fatal. 
/ When the fever has passed oft', the chief feature is prostration ; 
not the prostration of typhoid disease, but something peculiar to 
diphtheria. There is no delirium; no wandering; no empty, fatu- DIPHTHERIA. 
51 
ous look, that speaks of a disordered brain ; no coma ; none of the 
idle comments, that foretell the ending of mortality. The patient 
is calm and quiet. Judging from the symptoms manifested, he 
might be considered convalescent. He is cheerful, perhaps, and 
hopeful, but be not deceived, it is all 
“ The sick man’s lightning, half an hour ere death 
When faintness, the last mortal birth of pain, 
And apathy of limb, the dull beginning 
Of the cold staggering race which Death is winning, 
Steal vein by vein and pulse by pulse away ; 
Yet so relieving the o’er tortured clay, 
To him appears the renewal of his breath, 
And freedom, the mere numbness of his chain—- 
And then he talks of life, and how again 
He feels his spirits soaring, albeit weak, 
And of the fresher air which he would seek : 
And as he whispers, knows not that he gasps, 
That his thin finger feels not what it clasps— 
And so the film comes o’er him; and the dizzy 
Chamber swims round and round ; and shadows busy, 
At which he vainly catches, flit and gleam, 
Till the last rattle chokes the strangled scream, 
And all is ice and blackness.”—Ode to Venice. 
This is no fancy sketch, and will seem strangely familiar to those 
who have witnessed such scenes. The death of the lamented Dr. 
Adams, of Boston, as described by Dr. Minot, of that City, would 
be briefly depicted by these lines. 
As croup sometimes complicates diphtheria, and we have the 
symptoms and termination of croup superinduced, so w'e have thus 
other diseases, with their peculiarities and history. Tonsillitis 
sometimes supervenes, and after much of its peculiar suffering, we 
have the formation and breaking of the abscess. Ulceration is 
occasionally manifested ; if scarlet fever is prevailing coincidently, 
we have the throat symptoms of that disease manifested as a com- 
plication, or as the result of epidemic influences ; and the throat at 
times suffers as it does in that disease. The peculiarities of any 
prevailing epidemic, being impressed upon coincident diseases, is a 
phenomenon universally known and recognised. A prevailing epi- 
demic, of any kind, will manifest its symptoms, as a part of the 
symptoms of coexisting diseases. When we have occasional ulce- 52 
DlPHTHERfA, 
ration of the throat manifested in diphtheria, daring the coincident 
prevalence of scarlet fever, there is as much error in considering 
this ulceration as peculiar to diphtheria, as there would be in pro- 
nouncing the cutaneous eruption, of an intercurrent attack of 
measles, as a feature of this disease. If measles are' prevailing, it 
is not uncommon to see the peculiarities belonging to it, impressed 
upon cases of diphtheria; but no one will, for a moment, confound 
the two diseases. Dr. Alonzo Clark, of New York, saw in the 
same child, and during the same illness, diphtheria, measles, scarlet 
fever and again diphtheria—the child dying of diphtheria ; yet he 
found no difficulty, in diagnosticating these diseases. One less care- 
ful, might have pronounced it simply a rare and marvellous case of 
diphtheria. It will thus be seen, that we may have, during an 
attack of diphtheria, complications of croup, bronchitis, pneumonia, 
scarlet fever, etc., but that care will enable us always to recognize 
the supervention of these diseases, and a want of care, or proper 
knowledge, may lead us to confound the symptoms of these dis- 
eases, -with the symptoms of diphtheria. Again, we have from the 
coincident occurrence of other epidemics, one or more of the symp- 
toms of these epidemics coexisting with the symptoms of diphtheria, 
yet a careful observation will easily preserve us from error and con- 
fusion. The symptoms of croup, tonsillitis, scarlet fever, bron- 
chitis, pneumonia, etc., have nothing whatever to do with the symp- 
toms proper of diphtheria; as well may we classify, wTith the symp- 
toms of diphtheria, those of rubeola, varicella, or variola; for these 
last diseases, as well as the first, have complicated cases of 
diphtheria. 
Albuminuria is often present during an attack of diphtheria, but 
we cannot of course, regard it as one of the symptoms of this dis- 
ease. Dr. Wade, of Birmingham, was the first to observe its pre- 
sence in diphtheria. It has been carefully watched and studied, in 
connection with this disease. The results of these observations may 
thus be stated: It is always a grave and serious circum- 
stance in the history of the case, and most serious, if the quan- 
tity present be large. It usually occurs in the early stages of the 
disease. Its presence, even in large quantity, however, is not 
necessarily a fatal symptom. It is present in cases that recover, and DIPHTHERIA. 
is frequently absent in cases that terminate fatally. It is found in 
the urine, even, of mild cases. It does not give to the urine the 
smoky appearance, caused by the presence of albumen in scarlet 
fever. When present, casts of the urinary tubes are revealed, on 
microscopic examination. 
Phosphates precede and succeed the occurrence of albuminuria, 
as a rule; when the urine is heated, a cloud is produced, which 
disappears on the addition of nitric acid ; this cloud is produced by 
the presence of the different phosphates ; in a few days, the cloud 
produced by heat will be increased, under the addition of nitric 
acid ; this is due to the presence of albumen. Uraemia does not 
coexist with albuminuria, in diphtheria. With the exception of 
albuminuria, the urine is not specially affected. Sometimes there 
is an excess of phosphates, and again an excess cf lithates, but 
there is nothing of special interest or importance in this connec- 
tion. The specific gravity of the urine, in diphtheria, is almost 
always above the natural standard. Heslop, Sanderson, Hart, 
Houghton, Greenhow, Bristowe, Webb, Clark, Jacobi, Isaacs, 
Krakotwitzer and others have paid special attention to the urine in 
diphtheria and much of what is received, as of true pathological 
importance in albuminuria, is based on their observations. 
Ulceration, though most commonly due to the complication or 
epidemic prevalence of scarlet fever with diphtheria, is occasionally 
manifested independently of these causes. It is a symptom very 
seldom occurring and rarely recorded, during the local or general 
history of this disease. 
It sometimes happens, that the premonitory symptoms of diph- 
theria are very slight and the malaise scarcely perceptible, in the 
gravest case?. Sometimes great local and constitutional changes 
occur, with so little suffering, that rvhen at last, the patient com- 
plains, the case is found in a hopeless condition. Malaise of the 
patient is not proportional, with the severity of the disease. Chil- 
dren have died, whilst sitting up, or dressing, witen the parents 
were not conscious of any real illness; and “the ploughman has 
been unable to complete his furrow.” * The diphtheritic exudation 
is not in proportion to the gravity of the case ; sometimes the uvula, 
* Reported by Dr. F. S. Coskery, of Baltimore, Md. 54 
DIPHTHERIA. 
as mentioned by Dr. Comegys, of Cincinnati, appears “ like a 
pearl ear-drop,” so complete is the covering; sometimes the mouth 
appears “as though filled with plaster of Baris;” yet these cases 
may not be grave in character. Again, this symptom may be slight 
and yet the patient irretrievably sink, under the prostrating effects 
of blood-poisoning. 
The degrees of fever, swelling of the lymphatic glands, discharge 
from the nose, foetor of breath, dysphagia, membranous exudation, 
anorexia, etc., vary with the cases, the localities, the epidemics and 
the ages ; it will be unnecessary to give cases in illustration of this 
truth, and we will And, that, in diphtheria, as in all other diseases, 
though we may have a type clearly defined, there will be an inter- 
minable and indescribable variation in the symptoms. We have 
given fair types and, though cases will, in comparison, vary much, 
there will be no difficulty, from the symptoms described, in recog- 
nising the disease. 
Like that of all zymotic diseases, the etiology of diphthe- 
ria is obscure and not in the least understood. Whatever effect 
hygienic influences may have upon its course, they certainly seem 
to exert little or none on its cause. The meteorological attributes 
of Winter seem to have some little influence; yet it would be more 
correct to say, that diphtheria coincides, in its prevalence, with the 
existence of these causes; for we are unable to trace any direct 
relation, between the atmospheric conditions of Winter and the 
resulting invasions of diphtheria. Cold, moisture, dampness, snow*, 
do not seem to bear any direct relation to the origination of the dis- 
ease. In the descriptive language of Mr. Ilart, of England, “it 
visited the open hamlets of rural districts and the crowded courts 
of the great Cities. It reached the seaside, and fell with violence 
upon the infant population of Boulogne. It raged, alike, under the 
intense heat of Summer, and during the cold Winter months. Its 
ravages affected, equally, the inhabitants of marshy, ill-drained land 
and those of dry and elevated situations. Brighton has not escaped ; 
Scarborough has suffered. It has swept across the marshy low- 
lands of Essex, and the bleak moors of Yorkshire. It has tra- 
versed the flowery lanes of Devon, and the wild flats of Cornwall, 
ETIOLOGY. DIPHTHERIA. 
that are swrept by the sea breeze. It has seated itself upon the 
banks of the Thames, scaled the romantic heights of North Wales, 
and has descended into the Cornish mines. Commencing in the 
Spring months, it has continued through the Summer, and if 
extremes of temperature have seemed to lend it new vigour, and the 
heat of the dog days, or the severe frosts of Winter have fostered 
its strength, yet, moderate temperature has not greatly abated its 
influence, and it has struck a blow here and a blow there at all 
seasons.” 
It was observed, that in France, or England, it did not obey any 
known climatic law. Brettonne.au writes in regard to the course of 
diphtheria in France : “ It did not appear possible to ascribe its 
appearances to any climatic or meteorological law. Historical docu- 
ments show, that while it raged with terrible violence amongst the 
towns and hamlets of the Loiret, remarkable for their salubrity, and 
the advantages of their geographical position, it passed over the 
villages of Sologne, seated amid the marshes; while elsewhere it 
seemed to select marshy and ill-drained districts, and to spare those 
which were in a better sanitary condition. In the year 1825, 
remarkable for its dryness, it laid wTaste the communes North of 
Orleans, and in 1828, remarkable for its dampness, it desolated the 
country South of Orleans. ” This total independence of all 
hygienic influences, in diphtheria, seems peculiar to this disease. 
Dr. Thos. II. Peacock, in an autograph letter of December, 1860, 
thus writes: “the cases referred to, occurred in members of a high 
family, living in an elevated and well drained locality, reputed most 
generally healthy ; in a house of unexceptionable character, with 
large and lofty rooms. I am not aware of any atmospheric condi- 
tion which seems especially to influence the prevalence of this dis- 
ease.” Many observers in France, England and America, have 
supposed that malarial influences excited some effect on the disease, 
but these views have all been abandoned, as untenable. Dr. Hatch, 
of California, writes that barometical, meteorologic and hygienic 
causes do not seem to affect the course of the disease. This is also 
the testimony of Fourgeaud, Blake and Wooster, of that State. 
Whilst prevailing at all times, and at all seasons, in America, it has 
seemed to spread more generally during the Winter arid early DIPHTHERIA 
Spring months. Sudden alterations of temperature seem to act as 
exciting, if not as predisposing causes; so on the contrary, preced- 
ing attacks of the exanthemata, or their epidemic prevalence, at the 
time appear to act as predisposing, if not as exciting causes. 
As diphtheria is very generally prevalent, when malaria has been 
destroyed by cold, and as it has prevailed with deadly malignity 
where malaria is unknown, it is irrational to claim any connection 
between them. The Lancet Sanitary Commission thus sums up, 
on this subject—“ it appeared to be equally independent of all 
atmospheric conditions—was a theory formed, that its intensity 
depended upon the solar influence, and that the heat of Summer 
lent fresh force to its destructive attacks; soon it raged with greater 
violence in the Winter months, and during the cold season ; was a 
connection traced between the localities of its invasions, and the 
marshy, ill-drained character of the land; the next season it was 
found to ravage dry and elevated stations with equal rage.” We 
could fill a volume with quotations from writers, in all localities, to 
prove the independence of diphtheria, in regard to atmospheric 
causes; but the testimony advanced, is more than sufficient. Again, 
we can not appreciate the practical good to be derived, in furnish- 
ing farther testimony on this subject, when it all tends to the estab- 
lishment of a similar and well recognised fact. In America we 
find it prevailing amid the granite hills of New England, and the 
rolling prairies of Illinois ; in the elegant mansions of New York, 
and among the poineer hamlets of Wisconsin; on the marsh fiats of 
New Jersey and the eminences, perched 4,000 feet above the level 
of the sea, in California ; in the rapidly alternating climate of the 
Atlantic and the genial and uniform temperature of the Pacific 
slopes ; amid the snows of the North and the malaria of the South; 
the damp atmosphere of the seacoast and the parched airs that ren- 
der grassless the great plains of the trans-Mississippi. 
It may be stated that diphtheria has in its history prevailed with 
an entire independence of all atmospheric causes and conditions. 
Whilst hygienic conditions do not appear to bear any direct rela- 
tion to the production of diphtheria, it can not be doubted that, 
during the epidemic prevalence or presence of the disease, they 
must act as predisposing causes. They certainly, in this disease as DIPHTHERIA. 
57 
in all others, influence the severity and result of individual cases; 
and whilst no atmospheric or hygienic condition can bring immu- 
nity to the opulent, those under the best hygienic influences, fre- 
quently escape death, from the same causes that entail it upon the 
poor, where sanitary influences are ignored and neglected. During 
the prevalence of diphtheria, however great the care and anxiety to 
prevent it, we find the pestilence in the palatial mansions of the 
rich, as Avell as in the hovels of the poor. “ Pallida mors aequo 
pulsat pede pauperum tabernas regumque turres.” 
It has been supposed that humidity had much to do with the 
causation of diphtheria ; such was the conclusion of Ghisi, at Cre- 
mona ; Brettonneau, of Tours, Trousseau, Isambert, Chomel, 
Lemoine and others ; but the recent investigations of this subject in 
France, the report of the Lancet Commission, and the testimony of 
the most distinguished observers in England, France and America, 
have proved, that there is no reason, whatever, for this assumption. 
However humidity may act as an exciting, or even as a predispos- 
ing cause, during the existence of an epidemic, it is quite certain 
that it is powerless in the origination of the disease. As Dr. M. 
L. Linton, of St. Louis, very properly writes, “ cold and variable 
weather, though not causing the disease, seem to favour it; that is 
to increase its mortality.” This is all that can be claimed, for the 
action of these agents. Dr. Michel Peter, of the Hopital des 
Enfants, at Paris, gives the same testimony—“ a cold and damp sea- 
son, with abrupt changes of temperature, has increased the number 
of diphtheritic affections.” 
The statistics furnished by Dr. Jacobi, of New York, also cor- 
roborate this view ; whilst the number of cases during the months 
of January, February and March, vary each from 12 to 25; the 
Summer months furnish from 3 to 5. In 1859, the month of 
January exhibits 5; March, 21; April, 17 ; May, 14; June, 8; July, 
4; etc., showing a gradual increase, during the variable weather of 
Spring, and a proportionate decrease, as the Summer, and less varia- 
ble months come on. This, by many, may be supposed to be 
accidental, but we will find that the records of the next year tell 
the same story. In 1860, we find in January, 18 cases; February, 13; 
March, 26 ; April, 12 ; May 4 ; etc. These statistics are taken from 58 
DIPHTHERIA. 
the records at the Canal Street Dispensary, and serve, with others, 
to show that though cold, dampness and variable weather are pow- 
erless in the production of diphtheria, they are, during the exist- 
ence of an epidemic, greatly instrumental in contributing to its 
extension and mortality. It is proper to state, that Dr. 
Jacobi’s statistics are taken, during the years which marked the 
prevalence of the chief epidemics of diphtheria, that have prevailed 
in New York City. 
It is thus seen, that these causes do very conspicuously contrib- 
ute to the extension of diphtheria, and yet they have nothing 
whatever to do, apparently, with its origination. In the severe 
epidemic which desolated parts of Wisconsin, and which has been 
well described by Dr. Wm. L. Wells, of that State, we find that 
“ the epidemic commenced in July, and ended in the latter part of 
October. It seemed to have arrived at the height of its violence, 
about the middle of August; it then abated, and in September 
appeared to have entirely ceased, but in October, it broke out again 
with increased severity. The morbific agency ceased to act, as 
suddenly as it began, and in November it had entirely disappeared.” 
The deduction here is very plain indeed—the disease did not begin 
in a cold and damp month ; but in the variable weather of October 
it reached its greatest severity. Dr. Semple stated to the Medical 
Society of London, that, in an epidemic at Bagshot, the disease 
“did not specially attack the puny and ill-fed, nor those living 
under unfavourable hygienic conditions.” We mention this state- 
ment, because it is often quoted, and is calculated, if taken as the 
rule, (which was not by any means intended) to do great injury. 
It is, of course, the exception, and the testimony of all competent 
observers serves to show, that, as a rule, during an epidemic of 
diphtheria, a neglect of hygienic precautions always tends to pro- 
mote the extension and mortality of the disease; it is, in this 
respect, like all other diseases, and it is calculated to produce a most 
inexcusable injury, to inculcate any other view. In the epidemics 
of Paris and Boulogne “ those children who possessed feeble con- 
stitutions, or were surrounded by the concomitants of depraved 
hygienic influences, for the most part became the chief victims of 
the disease.” Dr. Blake, of California, states, that, in his expe- DIPHTHERIA. 
59 
rience, dampness seems to have no relation to the etiology of diph- 
theria, “ the most fatal epidemic that has fallen under his observa- 
tion, occurred at an elevation of about 4,000 feet above the level of 
the sea, at Dutch Flat, and again at Grass Yalley, 2-3000 feet above 
the level of the sea.” Dr. Wooster, of California, gives the same 
testimony. 
There is one point which should receive attention, in this connec- 
tion : it is that, however powerless in regard to the causation of 
diphtheria, the variable weather of Spring and Autumn seems to 
increase its prevalence. The researches of Wade, Peter, Jacobi, 
Wells and others, justify such a declaration. What can then be 
defintely said of the etiology of diphtheria ? - We have examined 
the subject, in its climatic, meteorologic, and hygienic relations, 
and find that the etiology of diphtheria is entirely independent of 
these agencies. That, however much or little they may contribute 
to the extension of an epidemic of diphtheria, they are powerless in 
the origination of this disease. We have, however, been able to 
state, from the examination of the subject, that though diphtheria 
originates in all climates, it is chiefly found prevailing in those, 
marked by frequent and great changes of temperature. That when 
existing, it is increased by variable weather; that prevailing at all 
seasons, it extends most in Spring and* Autumn; that the extremes 
of heat and cold, dryness and dampness of atmosphere, do not 
originate the disease, and do not specially increase it, but that 
rapid alterations of these agencies, if not originating, tend always 
to extend it. That hygienic agencies do not originate the disease, 
but that, with all allowance for the statements of Dr. Semple, in 
regard to the epidemic at Bagshot, Dr. Odriazala, relative to that at 
Lima, Dr. Ileckstall Smith, in England, and a few others, they do, 
as in all other diseases, increase the extension and mortality of 
diphtheria. We find, in conclusion, that (as in zymotic diseases) 
though there is great obscurity in relation to the etiologic agencies 
of diphtheria, there is no obscurity whatever, but much unanimity, 
in regard to those circumstances which give, to these agencies, a 
general, diffusive and fatal tendency. We are in possession of 
this practical fact; that if we can not analyze and understand the 
causes of diphtheria, we can fully understand the method, by which 60 
diVhtheria. 
the effect of these causes can be definitely and certainly diminished. 
However obscure the etiology of diphtheria, its study inculcates 
this practical lesson; that when diphtheria is epidemic, every 
hygienic precaution should be rigidly adopted; thp,t alternations of 
temperature and of the hygrometic condition of the atmosphere, 
should produce prudence and diminish exposure. 
The sudden appearance and rapid existence of this disease, 
in sections of Europe and America where distance and impos- 
sibility of communication forbid the idea of contagion, demon- 
strate that its sporadic generation is undoubted. Dr. M. L. 
Linton, of St. Louis, Mo., writes that “ most of the cases, he has 
seen, have been sporadic.” Dr. Peacock, of London, in his letter, 
states that he has “ seen the disease, in its sporadic and epidemic 
forms, though he regards the latter as chiefly characteristic.” Dr. 
D. J. Cain, of Charleston, S. C., states, that “he has seen it spo- 
radically for very many years.” Dr. Greenhow, of England, writes 
of a certain epidemic, “ it is at least an important point, in its his- 
tory, to have ascertained, that it began spontaneously in several 
centres, sufficiently remote from each other, to prove their com- 
plete independence.” Dr. Abercrombie has described an excellent 
type of diphtheria, that occurred as a single and isolated case ; it 
was severe and terminated fatally. Dr. Webster, of Dulwich, Eng- 
land, has given a description of six cases of this kind. In the wards 
of St. Thomas’s Hospital, London, several cases of sporadic diph- 
theria have occurred; they are described by Dr. Bristowe. 
It is not necessary to give farther proof of the fact, that diph- 
theria at times prevails sporadically; when thus prevailing, it is 
usually mild, though occasionally we find its several types mani- 
fested. There is nothing peculiar in regard to sporadic diphtheria, 
that deserves special notice. 
SPORADIC PREVALENCE. 
Epidemic prevalence. 
It is this manifestation of diphtheria, that has afforded all that is 
valuable and interesting in regard to the disease. It has inspired 
that alarm and terror which leads to investigation and study.' 
Were it not for its epidemic visitations, the disease would have 
been comparatively unknown and unnoticed. This subject has been DIPHTHERIA. 
61 
so fully examined, when writing of the history of the disease, that 
it would be but a repetition, to farther allude to it. There is one 
fact of special and practical interest in this connection ; all epidemics 
of diphtheria begin and end, with mild and benign cases. It may 
be useful to bear this in mind, in connection with the treatment of 
the disease. 
Watson states, that diphtheria is endemic in Picardy and 
Touraine; Orton, that it has been endemic at Binghamton, N. Y., 
etc. We question the propriety of the use of the word in this con- 
nection. It is an established fact, that the disease is not due to any 
peculiarity of population or locality. 
Endemic prevalence. 
CONTAGIOUSNESS. 
There is no part of our subject, which we approach with 
more care and circumspection. Pathologists have yet to acquire 
definite ideas, and to submit clearly intelligible laws, on the 
whole subject of contagion. In the obscurity and confusion 
now prevailing on this subject, there is an almost ludicrous disposi- 
tion to take refuge in the welcome labarynth of words. One terms 
a certain pathological condition, contagion ; another infection; a 
third, personal contagion; a fourth, immediate infection, and so 
with the endless catalogue, specific contagion, specific infection, 
immediate contagion, etc. We will not, in the use of the word con- 
tagiousness, have reference to the technicality of any particular 
authority; wre will assume, for our brief purpose, that the word 
contagiousness shall signify, the contraction of a disease not epi- 
demic, when exposed to its influences. When the disease is epi- 
demic, it is manifestly very difficult to establish the fact of its con- 
tagiousness. It is illogical and unjust to claim, that any combina- 
tion of circumstances demonstrates the contagiousness of a disease, 
when these circumstances coexist, with the epidemic prevalence of 
the disease. Sporadic cases are usually and confessedly mild, and 
it is no proof of the non-contagiousness of a disease, that it is not 
propagated by such cases. It is thus manifest, that reasoning and 
argument are inadmissible in this connection, and it only remains, 
to state facts, as developed in certain well authenticated cases, and 
to leave the reader to draw his own conclusions. We will first pre- DIPHTHERIA. 
sent instances, serving to show the non-contagiousness of the dis- 
ease, by inoculation, or by personal contact with the diphtheritic 
matter. 
Dr. Peter, desiring to prove the incorrectness of the position 
assumed by Brettonneau, Yalleix, Rillidt, Barthez and Bard, that 
diphtheria was propagated by contact with the diphtheritic matter, 
inoculated himself with the matter, taken from a child, on whom 
he had just performed the operation of tracheotomy. He expe- 
rienced no inconvenient results. In 1858, such matter was dis- 
charged from the throat of a child, and lodged on the ball of his 
eye, a portion resting between the lid and the globe of the eye ; 
twenty-four hours afterwards, no change had taken place. From a 
case, on wdiich tracheotomy had been performed by Coulon, he 
took some of the matter and inoculated himself with it, in the lip. 
In twrenty-four hours afterwrards, nothing wras perceived, as a result, 
but “ a slight ecchymotic projection.” In 1859, he saturated a 
piece of lint with diptheritic matter, and coated with the secretion, 
the tonsils, uvula, and posterior part of the pharynx. Not to dilute 
the matter, he abstained from eating and drinking ; no evil resulted. 
Trousseau could not succeed in propagating this disease, by inocu- 
lation ; he experimented upon himself and several of his pupils. 
Dr. Harley inoculated three dogs and a snake with diphtheritic 
matter; no result followed. Granting that these are fair and true 
examples, it does not prove that diphtheria is not contagious, but in 
the words of Trousseau, “ that inoculation is not the means of trans- 
mission.” But even this negative proof is destroyed, as we find 
that, in addition to other ways of transmission, diphtheria has been 
directly propagated by inoculation. 
The London Lancet mentions the case of a Practitioner, whose 
finger was wounded, during the operation for tracheotomy, upon a 
diphtheritic patient; an abscess formed, and in a fortnight after, on 
exposure to cold, diphtheritic exudation occurred on the tonsils. The 
Practitioner’s wife became affected afterwards; they both recovered, 
though one had, as a sequel, diphtheritic paralysis. Again, a medical 
student, in making a post mortem examination of a child, who died 
of diphtheria, pricked his thumb ; in spite of every precaution— 
“ washing, bleeding, and sucking” of the thumb—the disease was DIPHTHERIA. 
contracted, and false membranes formed on the throat. It was con- 
tended, when these cases wTere presented to the Medical Society, 
that in the case of the Practitioner, diphtheria must have resulted 
from epidemic influence; as the period of incubation (fourteen days) 
was too long, to infer that the disease was the result of inoculation. 
Although M. C. Roger has found the period of incubation to be from 
two to seven days, it is proper to add, that Dr. Hatch, of California, 
has seen a case of diphtheria manifested, after an incubative period of 
twenty-one days. In the case of the student, the false membranes 
on the throat formed on the fifth day; here, at least, the period of 
incubation was not too long, to make the inference of the disease 
resulting from the inoculation, in any manner objectionable. 
Brettonneau has presented the following case: “A child, seized 
with diphtheria, who had transmitted the disease already to its 
nurse, was placed under the care of Mr. Herpin, Surgeon to the 
Hospital at Tours, and Professor at the School. At one of his 
visits, by access of cough, part of the diphtheritic matter was 
ejected from the mouth, while the process of sponging the pharynx 
was being performed, and it lodged on the aperture of the nostrils 
of Mr. Ilerpin'. Occupied with his task, he neglected for a moment 
to remove it. A severe diphtheritic inflammation of the part 
ensued, which spread over the whole nostril and pharynx. Con- 
valescence, from the attending prostration, occupied more than six 
months.” 
Dr. Gendron, of Chateau de Loire, received, on his lips, a por- 
tion of tracheal diphtheritic exudation ; laryngeal diphtheria ensued 
and prompt treatment alone saved his life. 
In 1826, at the military school at Tours, a boy, with frost-bites 
on the foot, used a hath that had been employed for a diphtheritic 
patient; the toe became the seat of diphtheritic inilammation. At 
Avignon, a soldier used the teaspoon of a diphtheritic patient; he 
suffered from buccal diphtheria. A boy, in one of the French hos- 
pitals, trod with hare and wounded foot, upon diphtheritic sputa; 
he had diphtheritic inflammation of the foot. Dr. J. B. Greely, of 
Nashua, N. II., writes, that “ the wufe of one of our most respect- 
able citizens, while preparing, for the grave, the body of a child, 
who had died from diphtheria, unfortunately allowed one of her fin- 64 
DIPHTHERIA. 
gers, upon which was a fresh wound, to come in contact with some 
of the fluids of the body, which soon produced the effects, usually 
following dissecting wounds; superadded to these, were all the 
symptoms of diphtheria; under these she sank.” It will, at least, 
be admitted, that the testimony, in regard to the propagation of 
diphtheria by inoculation, is as strong as that presented, for prov- 
ing the contrary ; we will see in addition to this how convincing is 
the proof of the disease being, in other ways, contagious. 
According to Dr. Greenhow, Cortesius, in describing the Sicilian 
epidemic of diphtheria, reports a case, wherein a friend was requested 
to verify the truth of a patient’s complaint, that there was a foul and 
constant emanation from his mouth. This fact was verified by 
smelling. Inflammation of the fauces and tonsils resulted and the 
case terminated fatally. Mr. Wade, of Birmingham, states that 
frequent ablution and cleanliness, in houses, where diphtheria pre- 
vailed, appeared to produce a marked immunity ; but if the utensils 
used by the sick, were also used by the well, the disease usually 
extended. Dr. Greenhow states, that at a boarding school, at Whit- 
ham, England, diphtheria prevailed, and proved fatal to one of the 
pupils ; others caught the disease and the school was disbanded ; one 
pupil, who was convalescent, returned home to an isolated farm- 
house several miles distant. About a week after her return, a sis- 
ter was taken sick with diphtheria, and died in twenty-four hours. 
The child from the boarding school was still suffering, voiceless, 
tonsils swollen and fauces congested. On the day after the death 
mentioned, another sister, aged seventeen, contracted the disease 
and died, in three days. Four cases of sore throat then occurred 
in this family, two of them with specks of exudation. In another 
instance, where a family had suffered, the servant, who was con- 
valescent, visited her friends, in a hamlet several miles distant, and 
at which the disease was not prevailing. A few days after arrival, 
two of her brothers and a sister were seized with the complaint and 
died. 
Mr. Lambden, of England, gives the case of a labourer, at Lang- 
rick, who left his place and went to Coningsby. At the time of his 
arrival, he had sore throat, and soon after diphtheria. The disease 
was prevalent at Langwich, soon after the labourer left, and may DIPHTHERIA. 
65 
have been prevalent at the time of his departure, but the writer 
(Mr. Lambden) could not ascertain this. The two places are five 
miles distant. His brother soon contracted the disease and died. 
These were the first cases in that region. Two other cases followed. 
A little girl returning from Mareham, where diphtheria was prevail- 
ing, to an out-lying hamlet, became sick and died; this was the 
first case at the hamlet. Two other cases soon occurred in the same 
house, but none in the hamlet. One of these cases, whilst con- 
valescent, went to Tattershall Thorpe, where the disease was un- 
known ; here a relapse occurred. A member of the same family 
was soon seized with diphtheria. Mr. Lambden furnishes also 
another instance ; a farmer having two farms, ten miles distant from 
each other ; his family being divided—a part at each house ; at one 
of the houses, the disease prevailed, but not at the other. A child, 
apparently well, coming from the infected to the non-infected house, 
is soon seized with diphtheria; a child, who had never left the non- 
infected house, is soon after taken sick, with the same disease and 
dies. Dr. Greenhow gives an excellent example of the contagious- 
ness of diphtheria, as furnished by Mr. Chavasse, of Sutton Cold- 
field : “ Diphtheria was believed to have been imported into a board- 
ing school, by a day boarder, some of whose family were sulfering 
with the disease. Five cases soon occurred in the school. The 
patient, most severely attacked, was removed home, a distance of 
forty miles from Sutton Coldfield, when convalescent, and is sup- 
posed to have communicated the disease to her family ; two children 
and a servant taking the disease and soon dying of it. Dr. San- 
derson relates the case of a boy, who contracted a case of diphthe- 
ria, which was then prevalent; he was sent to Derrythorpe, several 
miles distant, Avhere the disease had not made its appearance. Four 
days after, his sister was taken sick with the same disease, and 
seven days after his return, a brother and the youngest child of the 
family also. In the report of Mr. Simon, Registrar General of 
England, the following case is contributed by Mr. Eastes, of Folke- 
stone—“ No case of diphtheria had ever been seen in Folkestone 
until Isabella, set. four and three-quarters, arrived from Boulogne, 
on the evening of July 2nd, being then in an advanced stage of the 
disease. She died on the following day. On the 6th of July, her 66 
DIPHTHERIA. 
sister, who had never been in France, was attacked; in three days 
another case occurred in the same house—all terminated fatally.” 
Mr. Rumsey, of Cheltenham, reports the following case : “ A 
school-boy, convalescent from diphtheria, contracted by him at 
Swansea, where it was epidemic, and arriving home, in an open and 
healthy suburb of Cheltenham, where, at the time, there was no 
diphtheria prevailing, was received and embraced by one of his two 
sisters. On the fourteenth day afterwards, (another instance, serv- 
ing to show that the incubative period, before mentioned, was not 
too long, to render the existence of diphtheria, due to inoculation,) 
she was attacked by diphtheria. Her sister, who did not meet the 
brother, helped to nurse her, and was attacked in fourteen days 
(still another instance of a long incubative period) after the first 
sister, by the same disease Strict separation was enforced, with 
thorough ventilation—the mother and nurse only seeing the child ; 
no more cases occurred.” 
Dr. Goldsmith reports, that in an experience of three hundred 
cases, the disease was in the highest degree contagious; persons 
visiting the infected locality carried the disease home with them, and 
it was only by the strictest seclusion of these eases, that the spread- 
ing of the disease was farther prevented. This occurred at Oak- 
land College, Miss. Dr. Hatch, of California, in a letter of Decem- 
ber, 1860, writes that the Physicians of that State, have found 
diphtheria, as it has prevailed there quite contagious. Dr. D. J. 
C. Cain, of Charleston, S. C., writes, that “ this disease, like all 
others, whether contagious or not, must have a spontaneous origin ; 
but when this occurs, it then spreads by contagion. I have seen a 
number of cases,” etc. M. Penant, who observed the epidemic, in 
France, and whose report is considered by the Commission on Epi- 
demics, the best presented to them, regards this disease as conta- 
gious. Wichmann, Boehmer, Migael, Rasen and others, in 
Europe, adopt the same views. Jurin, Barthez, Bricheteau and 
many distinguished observers in England, do not think the disease 
contagious. The committee on epidemics of the French Academy 
state : “ We do not hesitate to declare diphtheria contagious,” and 
the Lancet Commission asserts, that “it is propagated by infection 
and by contagion.” M. Perrochaud, in describing the Boulogne DIPHTHERIA 
67 
epidemic, says the proofs of contagion "were so numerous, that no one 
even pretended to deny them. There are a few distinguished gen- 
tlemen in America, who do not consider the disease contagious. In 
an autograph letter of January, 1861, Dr. D. Francis Condie, of 
Philadelphia, states—“ no facts have been observed, by me, to war- 
rant the conclusion of its contagiousness.” The testimony, how- 
ever, that has been presented to us, by a number of the most prom- 
inent Physicians in America, is overwhelmingly in favour of its 
contagiousness. Those in America who have written upon the sub- 
ject, most generally advocate this view—Hartshorne, Slade, 
Thayer, Wynne, Hatch, Blake, Fourgeaud and many others, whose 
names are familiar to the Profession. Dr. Thos. Peacock, of Lon- 
don, in a letter of December, 1860, writes : “ It has affected a 
large proportion of those brought under its influences ; three chil- 
dren in one family, and an aunt, who only visited at the house, all 
died of it; the disease is most probably propagated, by a specific 
contagion.” Dr. Jennings, of Malmesburg, England, writes of 
its contagiousness : “ I have had such clear proof, that I do not hesi- 
tate to pronounce it of a contagious character; in the first case, 
under my notice, the disease was clearly contracted by nursing an 
adult who sank under it ; two brothers of the deceased, residing a 
mile distant, contracted the disease, either from a casual visit, or 
by attending the funeral.” M. Isambert declares, that “ as to the 
contagious character of the disaase, there can be no doubt, for 
many Physicians have contracted the disease.” M. Empis, who 
has severely studied this subject, advocates the same view. Car- 
mevale, Severinus, Nola, Lusitanus and others of the Seventeenth 
Century, declared its contagiousness. Dr. Edward Ballard, of 
Islington, England, has published the following interesting and 
suggestive case : “ Jane J., set. ten years, resided at Islington, 
with her mother, an aunt and three sisters. On May the 1st and 
2nd, she was on a visit at the house of an uncle, whose daughter 
was kept at home, for what was supposed to be a cold. On the 
2nd, this child (detained at home) manifested decided symptoms of 
diphtheria; the attack was slight and she recovered. On May 6thy 
a servant, in the same house, was taken sick, and died at the hos- 
pital, to which she was removed. Jane J., after remaining with 68 
DIPHTHERIA. 
her cousin two days, returned home. She was immediately taken 
sick and died on May 9th. Her mother and a sister were both 
taken sick on the 11th. The sister, who slept with the mother, 
died on the 14th.” Dr. Bard, of New York, considers the disease 
(suffocative angina) infectious. Daviot, Crighton, Monckton and 
a few others, have not, always, found the disease contagious. Dr. 
Rankin considers it ‘4 infectious to a limited degree.” Dr. Wooster, 
of California, states that diphtheria, “ in its manner of communi- 
cation, is identical with variola, rubeola, scarlatina, and even 
typhoid fever.” Dr. S. L. Bigelow, in a letter from Paris, to Dr. 
Warren Stone, of New Orleans, writes: “ I believe it to be endowed 
with a highly contagious element; an observation founded upon the 
fairest observation of which I am capable, and by no means a theo- 
retical convenience. If there exists a mediately contagious disease 
on earth, it is the angine counneuse.” Dr. L. N. Beardsley, in 
describing the epidemic at Milford, Conn., states “that the disease 
was contagious is a fact which, wre think, must have been apparent 
to every person, possessed of a discriminating mind.” In the pub- 
lications of the Sydenham Society, the contagiousness of diphthe- 
ria is strongly advocated ; the evidence of the disease being propa- 
gated from person to person, and chiefly in the country, is convin- 
cing and most satisfactory. Dr. Peter states, that the contagious- 
ness of diphtheria has been proved by its propagation from bed to 
bed; by its propagation in the same bed ; from’ one side of the 
ward to the other; its propagation among patients confined to bed, 
more generally than among those not so confined, and its extension 
through large families. In Dr. Ballard's cases, out of forty-seven 
families, only fifteen remained healthy. 
We have a very fair example, in the death of the lamented and 
gifted Professor Frick of Baltimore, Md., of the contagiousness of 
diphtheria. The disease was contracted, whilst performing the 
operation of tracheotomy, upon a negro woman at the Baltimore 
Infirmary. He complained next day of sore throat; the next day 
had a severe chill; on the evening of that day, he exposed himself, 
during a bleak March wind, at a funeral. During that night, he 
had a severe chill, and was then confined to his bed. lie was 
attended by Dr. John Buckler, and as a last resort, had the opera- DIPHTHERIA. 
69 
tion of tracheotomy performed upon himself. The case was a very 
severe and painful one. It is well described, by his friend, Dr. 
Donaldson, of the same City. The evidence of contagion here is 
strong. There is also strong presumption of contagion, in the 
details of the fatal illness of Dr. Cooke, of Brooklyn, L. I., as fur- 
nished by Dr. Willard Parker, of New York City. The last and as 
satisfactory proof of the contagiousness of diphtheria, as has ever 
been presented, is furnished by Dr. J. B. Greeley, of Nashua, 
N. H. He thus writes: “ The mother and four children, in one 
family, were carried off, one after the other, by this disease. A 
relative of the family, from a town eleven miles distant, was sent 
for, and assisted in nursing the children. After their death, she 
went home ; ten days after, two of her children were attacked with 
the same disease, and two days after that, the mother was taken 
down. The mother and one of the children died. I am informed 
these were the first cases in the town.” No one, on this accumula- 
tion of the most convincing and satisfactory evidence, can longer 
deny the contagiousness of diphtheria ; the proof, thus given, is 
enough to satisfy the most skeptical and exacting. Whilst the 
disease is undoubtedly contagious, it certainly is not, however, 
always so. The practical deduction to be drawn, from all the evi- 
dence, is this, experience does not justify any panic or alarm on the 
subject of the contagiousness of diphtheria, whilst at the same time, it 
teaches that all unnecessary exposure is reprehensible. That though 
it can not be strictly considered dangerous, for friends and nurses 
to minister to the sick, it is certainly advisable, for those not main- 
taining such relations, to avoid communication with them. That, 
whilst those exposed, do not generally suffer, it is undoubtedly true 
that they do not uniformly escape. 
By a careful examination of all the French records, Dr. 
Peter found that the period of incubation lasted from “ two to 
fifteen days, but most often from two to eight.” Dr. Comegys, of 
Cincinnati, Ohio, writes (November, I860.) that “ during the incu- 
bative stage, in the cases seen by me, there seems to be a state of 
exhilaration, which may be denominated diphtheritic intoxication.” 
INCUBATION 70 
DIPHTHERIA. 
Some of the European writers mention the same peculiarity, although 
it should not be supposed, that this is common or general. The 
approach of the disease is, as a rule, gradual and insidious, and the 
health and condition seem very little impaired. Dr. Cotting, of 
Roxbury, Mass., says: “ I have seen a child, six to seven years of 
age, playing in the melting snows of Spring, within twelve hours of 
his death.” This slight and gradual impairment of physical and 
mental vigour is so insidious, in its course, as to commonly deceive 
the most watchful. It has been a chief characteristic of this disease 
throughout its entire history. Dr. Barbour, of Falmouth County, 
Ivy. states that he has observed frequency of pulse to precede all 
other premonitory symptoms. The Medical Society of London 
were disposed to question the fact of an attack of diphtheria, being 
the result of an inoculation with diphtheritic matter fourteen days 
previously—assuming that the incubative stage was too long to 
render such a position tenable. M. II. Roger had at that time 
stated, that from actual cases the incubative period extended from 
two to seven days. The records of diphtheria in France, England 
and America, the cases cited by Drs. Peter, Ballard, Jacobi, Rum- 
sey and many others prove that the incubative period frequently 
extends to the fourteenth and fifteenth days. Hatch, of California, 
has known it to extend to the twenty-first. It is not necessary to 
say more upon this subject. 
DURATION. 
Dr. Wooster states, in regard to the epidemics of diph- 
theria in California, that the duration is very uncertain, and 
there is no fixed characteristic in this connection. In most of the 
fatal cases, it may be definitely said, that death takes place in from 
two to six days ; in these cases, death is usually caused by laryn- 
geal, or bronchial complication. Death may take place, during 
convalescence, from asthenia. The duration of the attacks, where 
death does not take place, and where there are no complications or 
troublesome sequelae, is from six to twelve days; where complica- 
tions and sequelae supervene, it is protracted to months, and in some 
cases, to more than an entire year. Some cases, where death does 
not occur, last not more than two or three days. In 120 cases that DIPHTHERIA. 
71 
occurred at Hopewell, Ohio, the average duration was eight days. 
This statement was drawn up by Dr. T. A. Beamy of that place. 
In the epidemic at New Carlisle, described by Dr. Meranda, “ the 
average duration of fatal cases, was seven days.” Dr. Wells, who 
has described the Wisconsin epidemic, states “ that, when without 
complications, the disease ran through its stages in a few days. The 
false membrane disappeared in some cases, in two days, in others, 
from ten to fourteen days.” Dr. Cutting, of Roxbury, Mass., 
found that after the seventh day, the crisis was past. From the 
records of the Canal Street Dispensary, New York, where over 
200 cases of diphtheria have been treated, Dr. Jacobi states, that 
“ cases of average severity take from five or six, to ten and twenty 
days to recover—the mild cases will get wTell in five or eight days.” 
Dr. Cochran, of Iowa City, writes that “the duration of the dis- 
ease varied from five to fifteen days, but generally, about ten or 
twelve days.” The records of the French and English Physicians 
furnish very similar testimony. The duration of cases must neces- 
sarily vary ; the testimony given will, however, enable us to approx- 
imate the truth. 
Dr. Greenhow, as the result of an extended experience, 
states, that though “ the severity of the disease is commonly 
in proportion to the continuity and density of the exudation, 
yet cases sometimes occur, in which the membranous exudation 
is inconsiderable, and yet the general symptoms are of a 
very alarming kind.” He has uniformly observed, that the pain 
and difficulty of swallowing afford no index of the intensity of the 
disease—it is frequently, in all epidemics that have occurred, slight 
in severe cases and severe in slight cases. Dr. Heslop, has found 
“ prostration quite disproportionate to the amount of disease in the 
throat, coming on early and remaining, after the throat lesions had 
disappeared.” Dr. Copeman, in his essay, declares “ that the con- 
stitutional symptoms bear but little proportion to the local mischief.” 
(According to almost universal testimony, since presented, Bret- 
tonneau’s idea, that ulcaration never occurred, is incorrect.) Wade, 
RELATION OF THROAT LESIONS TO RESULT. 72 
DIPHTHERIA. 
of Birmingham, writes, that the patient not unfrequently dies, 
when the disease is to all appearances very slight. Dr. Rochester, 
of Buffalo, N. Y., in his letter of November, 1860, writes thus: 
“ the throat symptoms are not always present—in one case, attended 
with great prostration, the exudation was only seen on the roof of 
the mouth ; in another, the skin, at the verge of the scalp and 
behind the ears, was its principal seat, with febrile movement and 
much prostration.” In the Wisconsin epidemic, “ the throat symp- 
toms bore no relation to the severity of the local affection.” A 
writer in the London Lancet, in regard to their epidemics, thus 
writes—“ the severity of the local phenomena, bears no relation to 
the severity of the general affection, nor to the character of the 
convalescence. There are cases, in which the local manifestation is 
from the first overshadowed. In some cases, where the throat man- 
ifestation wras far from being intense, (yielding readily to treatment,) 
the consitutional symptoms were severe. In two of the fatal cases, 
the local symptom was early and easily checked, and was so mild, 
during its continuance, as to give but little annoyance, either to 
patient or Physician. In other cases, this state was reversed, and 
there were severe local symptoms, with no corresponding constitu- 
tional disturbance, and with rapid convalescence.” Dr. Cotting 
testifies, that “ the formation of the membrane does not always cor- 
respond, in amount, to the severity of the other symptoms.” Dr. 
Jacobi observes, in regard to the cases at the Canal Street Dispen- 
sary, “ a great number have come under observation, in which the 
local exudations were, by no means, in proportion to the character 
of the attack.” Dr. Peter states, in regard to the French epi- 
demics—“ the amount of exudation does not indicate the severity 
of the disease, as fatal cases will frequently occur, where the mem- 
branes are few and small.” No argument or reasoning, on these 
subjects, would avail anything, and we must furnish, what is 
demanded to prove the positions assumed—sufficient and competent 
testimony. It is evident, from what has been presented, that it is 
safe to say, there is no direct relation between the lesions of the 
throat, and either mild, or fatal cases, and where this relation does 
exist, that it is the exception, and not the rule. 73 
DIPHTHERIA. 
THE EFFECT OF IIIGIENIC CONDITIONS ON THE COURSE OF THE DISEASE. 
Whatever may be the effect of hygienic conditions, on the etiology 
of diphtheria, their influence on the course of the disease is un- 
doubted. It forms of course no exception to the general law, in 
regard to the course of all diseases, that a strict study and practice 
of hygienic precautions, must contribute to the safety and welfare 
of patients and communities. It would be idle to quote statistics 
or furnish testimony for the enforcement of this patent and inva- 
riable truth. 
CITY AND COUNTRY ATMOSPHERES. 
We have seen that diphtheria prevails, with equal malignity, 
in Town and Country, and that some of the most fatal and 
extensive epidemics have prevailed, in the pure bracing air of 
the Country. Like many non-contagious diseases, it is fre- 
quently seen in the Country, as well as in the City, and, unlike 
contagious diseases, it does not seem to select for general, or most 
frequent prevalence, the great centres of population. It has not 
been observed, that City atmospheres under fair hygienic conditions, 
give increased malignity to this disease. Some of the most malig- 
nant cases have occurred in the retired and clean hamlets of Eng- 
land. and the history of the disease in every Country, is but a 
further illustration of this fact. 
AGE AND SEX. 
Attacking persons of every age and sex, diphtheria may he 
considered as most generally attacking children. In Califor- 
nia, from eighteen to twenty per cent, of the deaths have been 
among children ; Dr. Hatch of that State has examined the records, 
in this connection. In Avignon, eighteen per cent, of the children 
were attacked, in a regiment quartered there, whilst only four per 
cent, of the soldiers suffered. In Albany, N. Y., of one hundred 
and eighty-eight fatal cases, one hundred and eighty-five were 
children. In Boulogne, of three hundred and sixty-six fatal cases, 
three hundred and forty-one were children. Brettonneau, Peter, 74 
DIPHTHERIA. 
Trousseau, and others, in France, state “that the chief subjects of 
diphtheria were below ten years of age. ” Of one hundred and thir- 
teen cases treated by Mr. Leonard, of Dursby, England, sixty-three 
were under ten years of age, and only seventeen above twenty 
years of age. It would appear, that the susceptibility to diphtheria 
diminishes very early in adult life. Greenhow states, that this is 
the case in regard to the fatality of the disease, it being much less fatal 
after puberty. In the Albany epidemic, Dr. Willard states that the 
cases, among females, were ;:::ere fatal. In the statistics compiled, 
however, by Dr. Reamy, of Hopewell, Ohio, the reverse of this 
wras true ; he treated ninety-two boys and forty-three girls ; aver- 
age age of all cases treated, five years. Dr. Kersey, of Milton, 
Ind., states that of twenty adults, treated by himself, all recovered; 
whilst the disease was fatal among children. Dr. Odriozala states, 
that at Lima, Peru, “ the black race has been as resistant to this 
angina, as to yellow? fever. ” * Children wTere the principal sub- 
jects there. In Wisconsin, in one hundred and thirty-three cases, 
twenty-six were adults, and one hundred and seven children ; of the 
adults, there was one aged sixty-three. Dr. Jacobi states that, in 
his cases, “ the male sex was in a slight, but decided majority ; in 
two hundred and thirty-five cases, two hundred were of children 
under fourteen years of age ; the majority of the two hundred cases 
presented an average of three years of age ; cases under one year, 
are infrequent, and over nine or ten, proportionally rare.” In 
twenty cases, seen by Dr. Alonzo Clark, of New York, the oldest 
case was not over thirty-six years of age. It would thus seem, that 
in diphtheria, children are chiefly attacked; the most susceptible 
period, being from two to five years of age; those under one year 
of age and those over fourteen, manifesting a decided loss of sus- 
ceptibility ; that boys are more frequently attacked than girls, 
whilst with girls the disease is more fatal; that it attacks the 
oldest, as well as the youngest persons; that the fatality of the 
disease and the susceptibility to it, rapidly diminish after puberty. 
This is all that is definitely known, in this connection. 
*This is by no means ttie truth in regard to the epidemics in the United States. DIPHTHERIA. 
75 
DISEASES AMONG THE LOWER ANIMALS, COINCIDENT WITH THE PREVA- 
LENCE OF DIPHTHERIA. 
Dr. Greenkow states, that during the prevalence of diph- 
theria, “ a new kind of epidemic, affecting the mouth, lips and 
nose, with aphthous ulcerations, and the teats and feet with vesi- 
cles and ulcerations (hence called the eruptive disease, or the foot 
and tongue disease) appeared among the cattle.” The disease had 
almost entirely disappeared, until recently, when it has again pre- 
vailed very extensively, and often simultaneously with diphtheria. 
An epidemic, in which the lungs are chiefly implicated, called pul- 
monary murrain, or lung disease, and perhaps more appropriately 
named by Professor Gluge, of Brussels, exudative pleuro-pneu- 
monia, likewise prevailed a year or two later than the preceding, 
among the herds of this country, and has never entirely disappeared; 
although, during the succeeding twenty years, there have been some 
periods, when it has very generally declined, and others, when it 
has prevailed in a more epidemic manner. One of the latter 
periods began in 1859 and still continues. What renders these 
cattle epidemics peculiarly interesting, in connection with the pres- 
ent subject, is the fact that, although at the time of their appear- 
ance twenty years ago, they were quite new to the existing genera- 
tion of dairymen, farmers and Veterinary Surgeons (there being 
no record of their prevalence in this country, during, at least, tte 
preceding half century) pulmonary murrain, preceded by an erup- 
tive murrain, prevailed about the middle of the last century, just 
before the outbreak of diphtheria which then occurred. Towards 
the close of the first half of the century, when Fothergill, Cotton, 
Huxham, Starr and other writers wejre describing the diphtheritic 
epidemic, then prevalent, an anonymous member of the College of 
Physicians, and Drs. Brocklesby, Hurd and Layard wrote their 
accounts of the murrain, then prevailing epidemically among horned 
cattle. This may have been indeed a mere coincidence, but that 
the appearance of the eruptive and pulmonary diseases, among cat- 
tle, and of diphtheria, in the human subject, are in some measure 
attributable to the operation of a common cause, seems probable, 
seeing that several of the older writers, on morbus strangulatorius, 76 
DIPHTHERIA. 
mention its coincidence, with certain diseases among cattle. Thus 
Ghizi says, there was a great resemblance between the epidemic 
angina which prevailed at Cremona in the years 1747 and 1748 and 
a disease, affecting the respiratory passages, at that time prevalent 
among oxen. Dr. Wall, speaking of the epidemic in England, 
about the middle of the eighteenth century, says “ this disease has 
so great a resemblance to the epidemic sickness among cattle, that 
I am persuaded it is of the same nature. Severinus, who wrote in 
the seventeenth century, also mentions that a great mortality, among 
preceded the appearance of malignant sore-throat ; and M. 
Malouin, in his account of the epidemic diseases observed at Paris 
in 1746, says that the disease among cows had already appeared in 
France, when children were attacked by epidemic sore-throat. Both 
eruptive and pulmonary murrain have, in many districts, prevailed 
contemporaneously with diphtheria. I have ascertained this fact, 
with regard to London, from several respectable butchers and less 
directly, through professional friends, with reference to other places. 
Mr. Williams and Mr. Dursby testify, that the mouth and hoof 
disease were prevalent, among cattle and pigs in that neighbour- 
hood, during the Spring of 1859, about the time that diphtheria 
prevailed at Cam. At Birmingham, several of the Physicians 
informed me, on the authority of the butchers, that the mouth and 
hoof disease and pulmonary murrain had been very common among 
cattle, during the year 1858 and the early part of 1859. At 
North Walsham and Coltishall, in Norfolk and at West Brom- 
witch, in Staffordshire, the mouth and hoof disease likewise pre- 
vailed among cattle, simultaneously with diphtheria in the human 
subject. Mr. Duncalfe, of West Bromwitch, has favoured me with 
a memorandum, in which he states, on the authority of a farrier, 
that a disease, attended with cough, thirst, discharge of mucus from 
the mouth and nostrils, and inflammation of the lungs and trachea, 
apparently therefore a kind of influenza, had been very prevalent 
and often fatal among horses in that neighbourhood, since 1857.— 
A similar disease appears to have prevailed, in the vicinity of Tal- 
leshunt D’Arcy, in Essex ; for Dr. Walker writes that a veterinary 
Surgeon had informed him, that a low form of influenza, often very 
rapidly fatal, attended with great difficulty of swallowing and a DIPHTHERIA. 
77 
refusal of food, had been common among mammals. Dr. Morris, 
of Spalding, also informs me, that a disease, accompanied with dis- 
charge from the nostrils and foetor of breath was very prevalent 
among cattle, during the epidemic of diphtheria, in the human sub- 
ject. He had also, himself, seen a horse affected with swelling of 
the glands about the jaw, in which the mouth and throat presented 
an appearance, similar to that cf persons suffering from diphthe- 
ria. The horse died, but three others suffered and recovered. 
Influenza was also prevalent among horses, at Wolverhampton, 
about the time when the human population was suffering from diph- 
theria.” It is well known, that during the prevalence of diphthe- 
ria in the New England States, the cattle epidemic was of the most 
fatal and destructive character. In the post-mortem examinations, 
that were made by properly constituted authorities, the lungs, 
trachea, and bronchiae were found seriously affected and the report 
made wa3, that the disease seemed to be a form of pleuro-pneumo- 
nia. Since the disappearence of diphtheria, this cattle epidemic 
has disappeared also. During the epidemics, in New York, of 
diphtheria, cattle, that were kept confined, suffered from a disease 
of the mouth, tongue, hoofs and lungs. It has not given the same 
trouble, since diphtheria has ceased to prevail there epidemically. 
In Kentucky,'where diphtheria has extensively prevailed, the cattle 
have suffered from a species of murrain, which affected chiefly the 
lungs and throat. 
Dr. Goldsmith, of Oakland College, Mississippi, seems to think, 
that there is some connection between diphtheria and a disease that 
has extensively prevailed among the cattle, in his neighbourhood. 
“ This cattle disease prevailed among the stock of our neighbour- 
hood, whilst diphtheria was raging; it is certainly a coincidence, 
that the country adjacent to the plantation, on which ‘ the black 
tongue ’ prevailed, was most affected with diphtheria.” In this 
cattle disease, there is great prostration ; the mouth is sore and ten- 
der, with an abundant discharge from the salivary glands; the ani- 
mal refuses to eat, droops and dies; the tongue becomes of a dark 
and ecchymosed appearance. Dr. Sanderson states that during the 
prevalence of diphtheria, a similar affection was observed among 
swine ; on a post-mortem examination made, “ there was intense 78 
DIPHTHERIA. 
maxillary glands, and the mucous membrane of the fauces covered 
by a characteristic membranous exudation. Death was preceded by 
symptoms of suffocation.” The coincidence of these diseases in the 
lower animals, with the prevalence of diphtheria, in the human sub- 
ject, is most interesting, and is worthy of general and special exam- 
ination. 
Greenhow states, that Dr. Wall saw diphtheria complicated 
44 with scarlet fever, with small-pox, and, probably, also 
with measles. ” M. Lemaire mentions cases of incomplete 
amaurosis, not succeeding, but accompanying the disease. The 
constitutional condition, known as purpura, occasionally is seen in 
cases of diphtheria ; Dr. Greenhow, Dr. Gull, Mr. Williams, M. 
Trousseau, and others, have reported such cases. Haemorrhage, 
while it is general from the mucous surfaces, deserves to be consid- 
ered as a complication. Mr. Clowes, of Stalham, England, has seen 
cases, where there was haemorrhage 44 from the gums, fauces, nose, 
vagina and anus.” These cases were associated with purpura. Mr. 
Hay has seen an eruption, 44 very like the roseoloid eruption of 
typhoid fever; there were no petechiae, and the eruption wTas con- 
fined to the thorax, abdomen and back.” Greenhow has seen erythema 
nodosum, in the course of dipththeria. Trousseau states, that the 
disease is frequently accompanied with an eruption of rupia simplex 
—albuminuria very commonly occurs, and Dr. Wade, of Birming- 
ham, frequently saw instances of haematuria. The urine is fre- 
quently found to contain tube casts and renal epithelium. Wade 
states, that these tube casts are of three kinds, 44 small waxy casts, 
casts of similar size, but granular, and thirdly, ordinary epithelial 
casts.” Wells gives an instance of genuine gangrene, as reported to 
him by Dr. Clark. Dr. Jacobi mentions that, in the course of 
thirty-two days, he diagnosticated, in the same case, 44 scarlatina, 
urticaria, measles and varioloid.” Croup is the most frequent and 
most fatal complication of diphtheria; bronchitis and pneumonia 
frequently supervene ; scarlet fever precedes, accompanies and suc- 
ceeds diphtheria. We may classify the complications thus—croup, 
scarlet fever, tonsillitis, bronchitis, pericarditis, pneumonia, erysip- 
COMPLICATIONS. DIPHTHERIA. 
79 
elas, albuminuria, hsematuria, haemorrhage, purpura, measles, ery- 
thema nodosum, rupia simplex, urticaria, variola, varioloid, roseo- 
loid eruptions, gangrene, etc. The most common complications 
are croup, scarlet fever, bronchitis, pneumonia, tonsillitis and albu- 
minuria; the others are rare. 
CONVALESCENCE. 
The convalesence in this disease is most remarkable 
and peculiar. It is very slow, tedious, interrupted, frequently 
complicated with other diseases, treacherous, unreliable and pro- 
tracted. We do not think it advisable, or necessary, to give cases 
to prove this, as such a course would (if demanded) be only adapted 
to a volume, and not to a paper of this kind. In convalescence 
from diphtheria, we have, at times, existing the traces of the origi- 
nal disease, its complications, and the incipient symptoms of dis- 
eases, which form the not infrequent sequels of diphtheria. The 
utmost care and caution should be bestowed at this time, for relapses 
are very common and very fatal. The slightest exercise or impru- 
dence is frequently the cause of great danger and death. Exercise, 
when the resulting anaemia and prostration from the disease are 
marked, is attended with great danger. Many persons have thus 
caused a fatal termination by heart-clot or by a return of the dis- 
ease, when quiet and rest, until strength was regained, would have 
insured a safe recovery. During convalescence, the urine is fre- 
quently loaded with lithates ; the appetite is very deficient; the 
prostration extreme and characteristic ; the nervous system (even 
when paralysis, amaurosis and other nervous disorders do not super- 
vene) deeply and seriously affected, and the muscular power almost 
destroyed. Here “ non progredi est regredi.” 
RECURRENCE OF THE DISEASE AND ITS SEQUELAE. 
We have seen that in diphtheria, relapses are very fre- 
quent ; it is no less true, that occurrence of the disease, is 
by no means uncommon. Cases where the disease has attacked 
the same person twice, are frequently occurring; sometimes 
the disease returns a third time and even a fourth. In the 
earliest epidemic of diphtheria, in New Jersey, the disease DIPHTHERIA. 
attacked the same person four times, in one year; the fourth 
attack proving fatal. The describer of this epidemic thus writes.— 
“ I have frequently observed, that once having the disease is no 
security against a second attack. I have known the same person to 
have it four times a year, the last of which proved fatal. I have 
known numbers that passed through it,in the eruptive form in the Sum- 
mer season, that have died of it in the succeeding Winter. ” Dr. 
Wynne states, that a persevering use of a tonic treatment he has 
found useful, in preventing a recurrence of the disease. The disease 
usually observes no tendency to recur at fixed periods; there is 
no periodicity generally manifested. Dr. M. 11. Houston, of Rich- 
mond, Ya., states that he has observed this phenomenon, and has 
successfully treated such cases, by the judicious administration of 
quinine. It recurs, from a three weeks interval, to intervals of 
many months in length. In some epidemics, relapses and recur- 
rences have been manifested to an extent of twenty-five per cent, 
of all the cases attacked; this is, of course, higher than the usual 
percentage, which rarely exceeds ten per cent. Guersant per- 
formed the operation for tracheotomy twice, in each of two children, 
after intervals, between the two attacks, of eleven and twenty-one 
months. ” It appears then, that there is usually no fixed interval, 
at which these recurrences are manifested. It may be said to ex- 
tend from three weeks, to many months. Recurrences of diphtheria, 
unlike those of scarlet fever and some of the exanthemata, are 
usually more severe, than the first attack of the disease ; the fatality, 
in such cases, being often very great. Many able observers have 
declared that an attack of scarlet fever, of diphtheria, or of many of 
the exanthemata, acted as a predisposing cause of an attack of diph- 
theria. With the exception of increased severity in the attack and 
the sequels, these cases present nothing of special importance.— 
The sequelae of diphtheria are much more common now than for- 
merly ; indeed the early writers, on this subject, pay but a cursory 
attention to them. In recent years, they have been fully studied • 
Faure, Trousseau, Bouillon, Lagrange, Brettonneau, Blache, Gull, 
Kingsford, Sanderson, Greenhow, Reynolds, Wynne, Slade, Thayer 
and many others have devoted much time to their investigation.— 
A large monograph, by Dr. Y. P. A. Maingault, deserves to be DIPHTHERIA. 
81 
especially noticed in this connection. Ilis researches on paralysis, as 
a sequel to diphtheria, are voluminous and interesting. Maingault’s 
description of the first appearances and effects of this kind of 
paralysis, is graphic and masterly : “ Two or three weeks after all 
throat affection has disappeared, the first symptoms of paralysis 
show themselves; they are developed slowly; the patients may 
even have made considerable progress towards recovery, before they 
occur. The first thing noticed is a paralytic affection of the soft 
palate, characterized by a difficulty of deglutition and a nasal 
speech ; phenomena that may entirely disappear, when the general 
muscular weakness shows itself. In some patients, there is sudden 
emaciation. Vision becomes imperfect and even complete blindness 
may supervene. The strength fails gradually; formication occurs 
in the extremities, accompanied by more or less severe pains in the 
joints. Walking becomes more and more impracticable, until the 
upright position is impossible. The paraplegia is then complete.— 
The upper extremities share this weakness; the head becomes too 
heavy and sinks on the chest; the muscles of the trunk are incapa- 
ble of sustaining the weight of the body. Strabismus, distortions 
of the face, dibbling, defective articulation and paralysis of the 
bladder and rectum also supervene. There is an entire absence of 
fever ; the pulse is small and is reduced sometimes to fifty; at the 
same time, the heart’s action is tumultuous and there are anaemic 
murmurs. With these and other symptoms of defective innervation, 
the intellect remains intact, but the mental powers are sluggish.— 
The disease may proceed to a fatal termination, or, if it terminates 
favorably, the patient’s strength returns gradually, and a cure is 
effected in a period varying from two to eight months. ” This is of 
course the type of a severe and serious case. The most common 
form of paralysis is that of the velum palati; this is quite common 
and is seen in almost all epidemics. It almost invariably precedes 
other forms of paralysis. The sequelae may thus be stated: 
Paralysis of the velum and tongue ; general paralysis ; paraplegia; 
hemiplegia (rare); paralysis of the bladder and rectum ; strabis- 
mus ; amaurosis; paralysis of the iris and ciliary muscles; 
otalgia ; formication ; numbness ; mal-articulation ; pyaemia ;* spa- 
* Reported by Dr. Cooper, of San Francisco. 82 
DIPHTHERIA. 
naemia ; anaemia; hydraemia; abscesses ; diarrhoea; loss of taste and 
hearing. As in most nervous disorders, the alternations in the man- 
ifestations of the paralysis may be very great. Sometimes one 
limb is attacked, and becoming much improved, the paralysis is 
exhibited in another, or perhaps in the muscles concerned in deglu- 
tition. This may be preceded by formication, numbness, tingling 
etc., and frequently these anomalous sensations succeed the mani- 
festations of paralysis. Dr. Cooper, of San Francisco, saw “ many 
of his patients die suddenly from pyaemia. ” Anaemia, spanaemia 
and hydraemia, are the most invariable sequels of diphtheria. Dr. 
Condie, of Philadelphia, had seen abscesses of the tonsils and sali- 
vary glands and diarrhoea, as sequels of this disease. Dr. Jacobi 
has seen cases where, in addition to loss of hearing, seeing, tasting 
and smelling, impotency ensued. He has seen one case in which 
“ intelligence suffered in an equal degree ” with the senses of seeing, 
hearing, etc. Dr. James B. Reynolds, of New York City, has 
contributed a valuable article on “ paralysis, consequent upon the 
poison of diphtheria. ” He presents the records of seventy-seven 
cases. 
The Epidemiological Society of London, in the report on diph- 
theria, does not, strange to say, allude to its sequels, while Chomel, 
of France, and Dr. Bond, of New York, seem to have been familiar 
with paralysis, as a sequel to diphtheria. 
Dr. Reynolds quotes an interesting case of an American lady, 
who, while suffering from diphtheritic paralysis, went from Paris to 
London; the damp climate of this last City made her worse, and on 
returning to Paris, she rapidly convalesced. 
Sometimes the muscles of the heart are paralyzed, and death 
suddenly ensues. One of the incipient signs of approaching 
paralysis, is the inability to pronounce the labial consonants, and a 
marked nasal pronunciation. Dr. Reynolds states that Mr. Dixon, 
of the Ophthalmic Hospital, London, could, with the use of the 
i fhthalmoscope, find no lesion in cases of diphtheritic amaurosis; 
aibumen was, at times, present, and then absent; in the worst cases 
of paralysis it was not manifested. 
The intellect is very rarely affected in the sequels of diphtheria; 
J),\ Jacobi reports one case, and Dr. Ranney another; Dr. T. Gail- DIPHTHERIA. 
83 
lard Thomas reports a case, where there was much mental irritabil- 
ity manifested. Disturbance in the organ of hearing is compara- 
tively rare. Impotency sometimes occurs. Occasionally the gen- 
eral pai*alysis is complete ; it is often accompanied by a sense of 
coldness, and frequently by articular pain. We see cases both of 
myopia and presbyopia manifested, during the sequelae of diphthe- 
ria. Dr. T. Gaillard Thomas, of New York City, reports an inter- 
esting case of myopia, attended with convergent strabismus, great 
muscular prostration, strongly marked paralysis of the velum palati 
and partial paralysis of the limbs. In the acute stage, he describes 
the foetor of breath as having been so great, as to taint the entire 
atmosphere of the room. M. Maingault has described a typical 
case, which admirably delineates the course and history of diphthe- 
ritic paralysis; the details of the case afford a better conception of 
this peculiar condition, than could be possibly formed, from the 
best general description. 
“Boy, set. four years; living at home; of good constitution; 
large and well developed, and never having had any serious 
malady; was attacked with high fever, with extreme difficulty 
in swallowing, August 1st, 1858. Upon the third day, false 
membranes were observed upon the tonsils; there was little 
glandular enlargement, etc. The child was soon convalescing. 
Some days passed without anything particular to note, when sud- 
denly the voice assumed a nasal tone, and liquids were ejected 
through the nose, while solids were swallowed without difficulty.— 
In spite of this complication, the little patient regained his strength ; 
there was some appetite, and the digestion was good ; little by little 
the nasal voice became less marked, and the deglutition of liquids 
easier. But in spite of a tonic regimen, and of assiduous attention, 
and though for fifteen days the throat was cured, yet the child 
became more and more feeble in the legs, falling frequently and 
walking with an unsteady and tottering step. This feebleness 
increased daily; soon the child could walk but a few steps, and 
only by holding on to the furniture ; there was pallor and emaciation. 
“ September 7th.—The feebleness was so marked, that he could 
not stand upright, and if left without support, he would sink down 
in a mass ; sitting, or reclining, it was with difficulty that he could 84 
DIPHTHERIA. 
move his legs. The skin was flaccid ; anaesthesia was so complete, 
in the lower limbs, that they could be tickled and pricked, without 
the patient being conscious of it; upon every other part, sensation 
wras normal. 
“ Later : Child easily moves the arms ; no strabismus ; face pale 
and a little bloated ; appetite diminished, deglutition easy, and only 
at rare intervals do liquids return by the nose; soft palate contracts 
wTell; obstinate constipation ; pulse sixty, feeble and compressible ; 
no bruits in the vessels of the neck ; urine does not contain albumen. 
(Iron, quinine; frictions with flannel, impregnated with vapour of 
benzoin ; sulphur bath every two days.) 
“September 16th—One month from the commencement of the 
paralysis.—In the lower limbs, the troubles of sensation and motion 
the same as stated, but the hands and arms seem to participate in 
the feebleness of the legs; there is some tremulousness ; sensibility 
diminished ; continue same treatment. 
“ September 22d.—Same weakness in the legs, but feebleness of 
the arms much increased; it is only with great difficulty that the 
patient can raise his arms to his head, using his hands with reluc- 
tance ; he does not desire to play, and if he takes his play things, 
they immediately fall from his hands; he cannot feed himself.— 
The head reclines upon the chest; can be lifted, but immediately 
falls again. There is the most profound insensibility in the arms, 
back and chesttickling and pricking cause no effect. Face is not 
affected; no strabismus; sight seemingly not affected; but little 
appetite ; same obstinate constipation. 
“ October 2nd.—One month and a half. The state of the patient 
is a little better ; the legs are less feeble ; can stand upright and 
take a few steps ; uses his hands somewhat easier, but no sensibility. 
“ October 10th.—Strength returning ; can remain a longtime upon 
his legs, *but his walk is difficult, dragging his feet along the ground; 
the arms have recovered their action ; the head is held up quite 
well, but insensibility persists. From this period, the troubles 
gradually diminished in intensity; in order to hasten recovery, 
electricity was used, but on account of the great alarm produced, 
it was renounced ; sensibility obtuse, but contractility normal.— 
Convalescence continued ; strength returning ; walking better ; 85 
DIPHTHERIA. 
emaciation continues and appetite poor; pulse fifty and feeble ; no 
bruit in cervical vessels. 
“November 24th—Over three months. Sensibility still obtuse in 
feet and hands ; child can take long walks. 
“ Patient seen for the last time in the month of March, seven 
months from the commencement of the paralysis; pallor persists ; 
embonpoint not yet returned; appetite capricious ; easily fatigued ; 
no symptom of paralysis ; recovers.” 
We have avoided giving cases, on account of the space occupied 
by them, but this is so suggestive and graphic, that, with a few 
abbreviations and omissions, we have presented it. Of course it is 
not a type of the majority of convalescents, but only of those who 
suffered severely from paralysis; even then, the anaesthesia in 
this case is more than usual. Sometimes, the paralysis is 
more extended, and we have strabismus, distortions of the face, 
etc., and frequently the period of convalescence extended over a 
longer period of time. Dribbling of saliva, constipation, involuntary 
discharge of urine and faeces are sometimes manifested. The intes- 
tines sometimes suffer, and it is difficult to overcome the resulting 
constipation. Maingault records a case where no action of the 
bowels could be procured for twenty-three days. The genital 
organs and the power of virility are frequently affected most 
seriously, and this condition exists, long after all symptoms of 
paralysis have disappeared. The muscles of respiration are seldom 
affected, and those of the heart very rarely. Sometimes, there is 
hypersesthesia in one part of the body, whilst anaesthesia exists in 
another. Again, we find neither entire hemiplegia, nor entire 
paraplegia, but partial examples of each, in the same patient; a 
right arm, and a left leg, or vice versa, being simultaneously 
affected. Trousseau states that the paralysis is often erratic ; mov- 
ing from one part of the body to another. In diphtheritic paralysis, 
the prognosis is always favourable. In seventy-seven cases, 
examined by Dr. Reynolds, of New York City, there were only 
nine deaths. “ Two by masses of meat entering the trachea ; one 
from convulsions ; one with kidney disease ; one from starvation ; 
one from apparent syncope, the result of depression.” Albuminu- 
ria is often present in these cases ; there are no peculiar symptoms 86 
DIPHTHERIA. 
or invariable results which characterize its presence, or mark its 
absence ; when in large quantity in the acute stage of the disease, 
it is a grave symptom; in the convalescent condition, it more gen- 
erally coincides in its presence with severe results; but not always. 
It does not always, as is claimed by many, coexist with amaurosis. 
Anaesthesia has been so complete, that sparks of electricity have 
been drawn unconsciously, from the soles of the feet. M. Trous- 
seau was for a long time under the impression, that the loss of power 
was dependent on inflammation of the coats of the nerves supplying 
the parts affected, and was led to this conclusion from the fact, that 
the palate and pharynx are more affected, than the system generally; 
this view has been abandoned, and he now attributes the results 
observed, to the effect of the diphtheritic poison on the system, 
through the blood.” A somewhat similar view has been advanced 
by Dr. Gull, of England. Finding, in one case, that the mem- 
branes of the brain and cord were in a state of suppurative inflam- 
mation, he suggested that the original seat of the disease being near 
the cervical portion of the spinal cord, the paralytic symptoms 
may arise, from an extension of the disease from the fauces to the 
cord. This view is not here advocated, yet it would be well to 
examine the cervical portion of the cord, in all cases, where death 
supervenes, after the occurrence of paralysis from diphtheria. The 
phenomena manifested are undoubtedly due, to the action of the 
diphtheritic poison upon the nervous system through the blood; 
were the positions advocated by Trousseau and Gull in the least 
tenable, we should have paralysis occurring during, or immediately 
after, the acute stage of the disease ; or after cases, in which the 
throat had severely suffered. It is known that the facts in this con- 
nection are frequently the reverse of this; paralysis occurring 
many weeks, and sometimes months after the acute stage of disease ; 
often, where the throat has scarcely suffered in any respect; and not 
at all, where the throat has suffered severely. 
Dr. Whitney, of California, states that in the sequels of diphthe- 
ria, he has found the urine not only albuminous, “ but containing 
blood corpuscles, fibrinous and epithelial casts and cells, and crys- 
tals of lithic acid.” 
Dr. Faure, of Paris, writes, “the legs can no longer carry the body; DIPHTHERIA. 
87 
the arms lose their power ; the soft palate dangles like a dead cur- 
tain ; swallowing and even breathing become almost impossible; 
the pupils are dilated; vision much impaired ; sensation dimin- 
ished, sometimes lost, or replaced by formication; in some, parts of 
the body become cedematous, in others gangrenous; others are 
subjected to repeated faintings. Reason flashes through the dull 
stupidity and a wandering smile lights up now and then the vacant 
countenance. ” This continues until the health is slowly and 
gradually regained. Dr. Faure is the first, of the French Phy- 
sicians who turned their attention to the sequelae of diphtheria.— 
Dr. S. D. Gross, of Philadelphia, in an autograph letter, writes that 
he saw a case of diphtheritic paralysis which involved the motor 
nerves of the right side of the face and also of the lower and upper 
extremities, which were all in a state of anaesthesia. ” Dr. Kersey, 
in the Indiana epidemic, saw cases of 44 partial idiocy, ” as the 
result of diphtheria; this condition is sometimes seen, but, almost 
universally, mental torpor (which passes away, when convalescence 
is established) is mistaken for idiocy. Dr. Meranda, in the Ohio 
epidemic, saw cases of presbyopia. Cases have been seen in England, 
where, as a result, from diphtheria, the fingers and arms have been 
covered with blebs of serum. Graefe, in Germany, and Jobert, in 
France, have described epidemics of diphtheria, where the chief 
sequel was ophthalmia. Greenhow has seen, as sequels, gastrodynia, 
dysentery, diarrhoea, general squinting, otalgia, deafness and abscess, 
with the varied and general manifestations of diphtheritic paralysis. 
Herrera, who described the Spanish epidemics of the seventeenth 
century, mentions that paralysis of the muscles of the throat was a 
frequent sequel. Sloughing of the tonsils and loss of the uvula and 
portions of the soft palate have been seen, but very rarely. Dr. 
Morris, of Spaulding, England, saw one such case. Dr. Greenhow 
states, that he has never seen albuminuria as a sequel, but very 
commonly as a complication of diphtheria. Uraemia, he states, has 
never been observed, in connection with the albuminuria of diph- 
theria. It has never been seen in diphtheria, so far as our imme- 
diate experience extends. In all of the epidemics in England, 
anasarca has never been seen as a sequel of diphtheria, uncomplicated 
with scarlet fever. Aphonia is often seen. Dr. Gull has published, 88 
DIPHTHERIA. 
in the London Lancet, a case where there was total loss of power in 
the phrenic nerves and where the diaphragm was, consequently, 
unmoved in respiration ; the breathing was entirely thoracic ; there 
was blueness of the lips and tracheal rales; case ended fatally.— 
Trousseau mentions an instance, where a woman, immediately after 
parturition, was seized with diphtheria; on the tenth day she com- 
menced convalescing ; albumen was now seen in the urine ; on the 
twenty-fifth day, liquids could not be taken, and the woman nearly 
strangled, in her efforts to swallow solids ; about the fortieth day, 
improvement took place ; on the fiftieth day, delirium and convul- 
sions, as a sequel, ensued ; under the use of musk this condition 
passed off’; paralysis now complete, involving bladder and rectum ; 
complete anaesthesia; under the use of electricity and syrup of sul- 
phate of strychnia, improvement was again manifested ; large quan- 
tity of albumen present, but no disturbance of vision; erratic 
paralysis, showing no important lesion of nervous centres; final 
recovery. Mr. Dixon, of the Ophthalmic Hospital, London, states 
that the impairment of vision is due to the loss of adjusting power 
or to paralysis of the ciliary muscles; in presbyopia, resulting from 
diphtheria, the difficulty will be removed by using low convex 
glasses ; in myopia, thus resulting, concave glasses are to be used. 
(Mr. Dixon states, that presbyopia in the aged, when not the result 
of disease, is more frequently due to a loss of adjusting power, than 
to any change in the lens.) In diphtheritic presbyopia and myopia, 
the impairment of vision is due solely, or at least chiefly, to this 
loss of adjusting power, and can easily be corrected, by the use of 
the proper kind of glasses. These are the most common of the 
sequelm of diphtheria, and indeed all, that we have been able to 
learn. 
PROGNOSIS. 
Hippocrates tells us, “ that the best Physician seems to 
he, he who knows how to know in advance ,” and the testi- 
mony of ages has proved both the truth and wisdom of the 
remark. The advice of the father of medicine, on this important 
subject, will never lose its value. “ Examine the countenance of 
the patient, to see if the physiognomy is like that of a person in DIPHTHERIA. 
89 
health, and especially, if it preserves its natural expression. This 
is its most favourable state, and the more it departs from it, the 
greater is the danger.” In the simple form of diphtheria, where 
the constitutional disturbance is slight; the exudation circum- 
scribed ; where there is no headache and no croupal complication; 
where the patient is healthy and not recently the subject of some 
exanthematous disease; where there is a fair hygienic condition, 
both public and domestic; where the exudation is light-coloured, 
thin and clears off early and easily; where there is not much dis- 
charge from the nostrils, and not much foetor of breath; where 
there is no bronchial, or pneumonic complication ; where there is 
no albuminuria, or if present slight; where there is, particularly, 
an absence of haemorrhage from the mucous surfaces, an absence of 
vomiting or diarrhoea; where there is not much swelling of the 
salivary glands ; where there is but little dysphagia, no dyspnoea 
and no orthopnoea, the prognosis is usually good. 
When the larynx escapes, the case should be closely watched, for 
under this condition, the patient’s calmness and quietness may 
deceive the most experienced and vigilant. Trousseau, Bretton- 
neau, Lemoine and others attach much importance to an escape of 
the nostrils from the exudation ; in their experience, where the 
contrary is the case, the result is always doubtful. There is a 
form of dyspnoea which specially deserves mention here, for it may 
occur, when the danger is not as great, as might be supposed. 
Dyspnoea sometimes occurs in diphtheria, when the lungs, bronchiae, 
trachea and larynx are totally uninjured. The nostrils in such 
cases, are plugged with a viscid matter, whilst the tonsils and uvula 
are much swollen, and while dyspnoea is manifested there is cer- 
tainly nothing of the kind of danger, that ensues when the respira- 
tory passages below the rima glottidis are implicated. When dysp- 
noea occurs, without the symptoms of croup, or the signs of bron- 
chitis, or pneumonia, and where it is not evidently the result of a 
fatal prostration, it will be found almost invariably resulting from 
this condition of the nostrils, tonsils and uvula. Dr. Stephen 
Monckton, of England, has found that “ a lax pupil and feeble 
pulse ” betoken a state of great danger. The report of the Lan- 
cet Commission is, “ that in simple diphtheria, the prognosis is 90 
DIPHTHERIA. 
favourable ; in diphtheria with croupal symptoms, it is very un- 
favourable, and in malignant diphtheria it is most unfavourable.” 
The prognosis, in diphtheria, should be guarded and only given 
with great care and reflection. The disease is so treacherous and 
danger so often lurks, where it is unseen and even unsuspected, 
that the Physician can not be too guarded in expressing an opinion 
as to the result. Such reservation, or reticence, in this disease, 
betokens Avisdom and efficiency and not ignorance, or indecision. 
Patients frequently die, when to all appearances they are doing 
perfectly well. A child is playing listlessly about the room, com- 
plains of fatigue, lies down, and without any symptoms foreshadow- 
ing the result, passes calmly into the sleep of death. Dr. Barbour, 
in describing an epidemic at Falmouth, Ky., relates a case, “Avhere 
a little boy of ten years of age, sat up and Avhittled a stick the 
most of the day and, in the evening, put on his coat and drew on 
his boots, a feAV moments before he died.” Dr. Minot reports the 
case of Mr. Gardner, of Boston, who after an attack of diphtheria, 
during which he was not confined to bed, walked out with his 
attending Physician; “on returning to the house, he expressed a 
wish to lie down, and Dr. Adams accompanied him to his chamber; 
he had hardly thrown himself upon the bed, when he started up, in 
a paroxysm of suffocation, and fell back dead.” Such cases, and a 
long list that might be given, should teach the Physician that, in 
diphtheria, reticence is the part of true wisdom. 
Where in the sequel, paralysis ensues, the prognosis is favourable ; 
in seventy-seven cases, reported by Dr. Reynolds, of New York 
City, only nine proved fatal; two of these died from masses of meat 
entering the larynx and one from starvation ; so that six in sev- 
enty-seven is more properly the indication of the result. A.ge is a 
very material consideration, in determining the prognosis; the 
greatest number of deaths occur in children, and between the ages 
of one and six; next, between six and ten; after ten, the mortality 
is singularly and strikingly lessened. 
Anaemic and scrofulous children are very liable to the disease, 
and it is, with them, particularly fatal. A strumous taint is very 
unfavourable. Dr. Jacobi states, in regard to the fatality of the 
disease, that in “ five hundred cases, we have not lost more than DIPHTHERIA. 
91 
thirty; ” he mentions the case of a girl, of three years of age, 
recovering after the appearance of blood, pus and albumen in the 
urine ; there were tubercles in the lungs. Dr. Jacobi states, that the 
pieces of membranous exudation which are at times discharged, and 
which cause a grave prognosis, when, to the surprise of the Physi- 
cian, the patient recovers, will frequently be found to come from 
the posterior nares ; his attention was called to this, by a Physician, 
who, during an attack of diphtheria, 44 brought up these cylindrical 
tubes,” but found that they came from the nares. Dr. Greenhow 
states, that when the membranous exudation becomes thick, brown, 
or black, he has usually found the result unfavourable. (Mr. Cole- 
man, of Wolverhampton, has found pain in the cardiac extremity 
of the stomach a fatal symptom) In regard to albuminuria, it may 
be definitely stated that, although a grave symptom, at all times, it 
is not necessarily fatal. It is wanting, frequently, in severe cases ; 
and largely manifested in many that recover. The condition marked 
by the supervention of purpura is always unfavourable. Delirium 
is exceedingly rare, but always an indication of great danger. Mr. 
West furnishes an interesting case, showing the treacherous char- 
acter of convalescence, and the extreme liability of the Physician 
to give an incorrect and premature prognosis; and, most especially, 
where this is favourable. The case is that of a woman, who declined 
entering the hospital at Birmingham, but continued to attend, as an 
out-door patient, walking a mile daily, for this purpose. “ The 
throat improved in appearance each day; but, notwithstanding this 
amendment, she became weaker, and returning home, tired, on the 
third day, she took some food and went to bed. She appeared very 
drowsy during the remainder of the day, was disinclined for exer- 
tion ; refused nourishment and continued in a dozing condition, 
until morning, when she asked for breakfast. Whilst being lilted 
up to receive it, she fell back fainting and died.” Dr. Greenhow, 
after giving the particulars of a case of diphtheria, shows, at its 
conclusion, how very suddenly and unexpectedly death sometimes 
makes its appearance: “22d; continues better in all respects; 
appetite returning. Notwithstanding my earnest recommendation 
yesterday, she was sitting on a sofa downstairs, at the time of my 
visit, and her friends could scarcely believe that danger was immi- 92 
DIPHTHERIA. 
nent. She died suddenly the same night.” This was a case of a 
young girl, who, on the 15th of that month, seven days after her 
being attacked with diphtheria, had walked a distance of 61 nearly a 
mile ” to see her Physician. From the fact that when paralysis 
ensues, it is usually erratic, the inference is, that the nervous cen- 
tres have suffered no serious lesions. 
The unfavorable symptoms, in diphtheria, are severe chill, fol- 
lowed by high fever, headache and vomiting ; where the swelling of 
the salivary glands and the discharges from the nostrils are exces- 
sive ; where the exudation is thick and dark coloured, attended with 
extreme foetor of breath, and showing a disposition to extend; where 
croup, bronchitis, or pneumonia supervene; haemorrhage from the 
mucous surfaces; purpura; excessive albuminuria; great swelling 
of the cervical glands ; coolness of surface, with complaints of 
heat; obstinate diarrhoea; dyspnoea, depending on trouble below 
the rima glottidis; extensive membranous exudation, about the 
nostrils; petechiae; extreme frequency of pulse; laxity of pupil; 
scarlatinal complication ; where the exudation is tenacious and shows 
no disposition to exfoliate; where orthopncea is manifested, with 
restlessness and many of the usual symptoms, preceding death. 
Where the patient is under ten years of age; of scrofulous habit; 
the subject of an attact of scarlet fever, or of any of the exanthe- 
mata ; where the hygienic condition, public, or domestic, is bad, 
etc., the prospect of recovery, with any of the conditions just spec- 
ified, is still farther impaired. Of course, the reverse of these 
symptoms, or their absence, will induce a favourable prognosis. 
Mortality.—The mortality, in this disease, is very varied; 
depending much on the character of the disease, whether malignant 
or non-malignant, and in a very great measure, upon the treatment 
adopted. If the disease is non-malignant, the mortality is slight 
under the worst circumstances, and if it is malignant, the mortality 
is very great, under circumstances the most favourable. Treatment 
in this disease, influences the mortality to a great degree, whether 
the disease be malignant or otherwise. Thus, an unfortunate Physi 
cian, at Chapelle Vbpoux, lost exactly sixty patients, in sixty cases, 
and another at Tunbridge Wells, in four hundred cases, did not 
lose one. Of course there may have been much difference in the DIPHTHERIA. 
93 
type of the disease prevailing, but it is not reasonable to suppose, 
that the difference could have been indicated, in these results. 
There is one instance recorded, of the mortality in a Physician’s 
practice, during the same epidemic, having been diminished cne- 
half, by a change of treatment. This single fact is more expres- 
sive, than all the arguments that could be advanced. Where the 
sixty cases were all lost, the treatment was the same in all; bleeding, 
blisters, leeches, with the use of calomel, and purgatives. Where 
the cases were all saved, the treatment was exactly the opposite.— 
Three-fourths of the deaths are caused by the supervention of 
diphtheritic croup. The difference in the reported mortality is due, 
chiefly, to two causes : difference in type and difference in treatment. 
A true anti-phlogistic treatment will often bring, to a atal termina- 
tion, the mildest case of genuine diphtheria. In North Adams, 
Mass., there were eighty-five cases and no deaths ; in West Stock- 
bridge eighty-one cases and eight deaths in Menomenee, Wis., 
one hundred and thirty-three cases and four deaths ; in Orange, 
Conn., fourteen deaths in the first fifteen cases. In Albany, N. Y., 
there were two thousand cases and one hundred and eighty-eight 
deaths ; in Edinboro, Dr. Creighton treated forty -five cases and lost 
five; in Providence, R. I., there were five deaths in eight cases ; 
in Pittsfield, Mass., three deaths in six cases ; in Petersfield, Eng., 
one death in every ten cases; in Lima, Peru, one in six; at 
Chateau Chinan, forty-five deaths in one hundred and fifty cases ; 
at La ten deaths, in one hundred and twenty 
cases ; Tunbridge Wells, no deaths in four hundred cases ; at Cache- 
Creek, sixteen cases and no deaths ; Chapelle-Vdroux, sixty deaths 
in sixty cases ; Hopewell, Ohio, five in one hundred and twenty 
cases; New York City, thirty deaths in five hundred cases; * 
Milton, Ind., five deaths in eighty-four cases ; New Carlisle, Ohio, 
seven deaths in one hundred cases ; in South-Onandaga, ten deaths 
in eighty cases—with many other places, where the number of 
deaths has been given, but the proportion of recoveries omitted.— 
Of course these figures do not express the number of cases of 
diphtheria that have existed, at the places named, but the propor- 
tion of deaths occurring in the practice of respectable Physicians, 
*Dr. Jacobi. 94 
DIPHTHERIA 
in regard to this disease. It will be found, on examination, that no 
deductions whatever can be made from the statistics furnished ; as 
the mortality in this disease varies interminably; depending on the 
type of the disease, its treatment and locality, etc.* 
IMMEDIATE CAUSE OF DEATH. 
The immediate cause of death, in diphtheria, in three-fourths 
of the cases, is attributed to the supervention of croup. Mcst of 
the statistics show, that this is about the proportion of cases 
destroyed, by the supervention of this disease. 
Dr. Peacock, in an autograph letter, thus writes : “ I believe the 
cause of death to be generally the constitutional and not the local 
condition.” This is of course excellent authority, but the facts and 
statistics in this disease show, that this is an error ; the patients in 
diphtheria do not often (that is proportionally,) die from the con- 
stitutional complications. 
Dr. Cain, of Charleston, S. C., who has seen much of this dis- 
ease, writes that “ the immediate cause of death, in all the cases 
which have fallen under my observation, is asphyxia, from occlu- 
sion of the larger, or smaller air tubes.” There can be no doubt, 
but that many deaths, that have been attributed to croup, were 
caused by this condition. 
Gangrene of the throat has been at times, though rarely, a cause 
of death. Dr. Kersey, of Milton, Ind., Dr. Odriozala, of Lima, 
Peru, and a few others, record such cases. 
Pneumonia, bronchitis and croup, are the most frequent compli- 
cations of diphtheria, and consequently produce death, in a large 
number of cases; next to croup, these diseases should rank, as the 
proximate causes of death. (Edema of the lungs is mentioned, by 
Dr. Jacobi, as one of the causes of death in his cases. Asphyxia, 
from the exfoliation of the membranous exudation, about the rima 
glottidis, is another cause. 
Where tonsillitis, attended with the formation of abscess, super- 
venes, death is sometimes caused, by the sudden rupture of the 
abscess, and asphyxia produced, by the entrance of pus through the 
rima glottidis. Dr. Minot, of Boston, relates a case (Mr. Gard- 
♦Mortality, 410 in 4,109 cases—being an average in all of these cases of 10 per cent. DIPHTHERIA. 
95 
ner’s) of this kind. Dr. L. N. Beardsley, of Millford, Conn., and 
Dr. Reynolds, of New York City, give cases where death was caused 
by starvation, from implication of the oesophagus. Syncope, from 
nervous depression, convulsions, diseases of the kidney, have each 
been the immediate cause of death, in diphtheria. Dr. M. L. Lin- 
ton, of St. Louis, Mo , writes, “ most of the cases that I have seen 
terminated fatally, by throat symptoms.” In the forty-five cases 
related by Dr. R. W. Crighton, of Chapel-en-le-Prith, nine died: 
six from asphyxia; three from asthenia. Asthenia is the most 
common cause of death, after the acute stage of the disease has 
passed: being the result of intense anaemia, or hydraemia; or from 
irrecoverable prostration of nervous influence, whether occurring 
primarily, or secondarily. Pyaemia has been mentioned as a cause 
of death in diphtheria. Blake, of California, states that “ the 
most common, anatomical, cause of death is the enlargement of the 
cervical glands ; this is also the opinion of Dr. Waster, of that 
State. The intemperate use of food, when in a weak and exhausted 
condition, seems to have been the cause of several deaths ; the 
shock, here, on one of the chief nervous centres, may explain such 
a result. It may possibly be only a coincidence, but many deaths 
are recorded as having taken place, just after the indiscreet use of 
food. Undue exertion (when prostrated) has been a proximate 
cause of death. Patients cannot be too carefully warned against 
the indiscreet use of food, or against undue exercise. 
The depression from obstinate vomiting, from diarrhoea, fro.a 
haemorrhage, have all been the proximate cause .of death. We 
would thus classify the causes which have, proximately, induced 
death—croup; pneumonia; bronchitis; membranous exudation 
extending into the trachea and bronchiae ; asphyxia from various 
causes, as exfoliation of membrane, or rupture of abscess, or impli- 
cation of the nares and tonsils ; asthenia; gangrene; pyaemia; 
haemorrhage ; heart-clot; convulsions ; syncope ; Bright’s disease; 
pericarditis ; intemperate use of food, under prostration; undue 
exercise; diarrhoea, etc. 
This disease has claimed many illustrious and prominent persons 
as its victims. Brettonneau regards the death of Josephine as due 
to diphtheria, and that of Washington has been attributed to the 96 
DIPHTHERIA 
same cause ; in recent years, it has caused the death of Senora 
Stephanie, Queen of Portugal; MM. Gillette and Yalleix, distin- 
guished Physicians in France; Drs. Frick, of Baltimore; Cooke, 
of Brooklyn ; Adams, of Boston, and others. The disease has been 
quite fatal, during the last few years, in Philadelphia, Cleveland, 
and many parts of Kentucky and Virginia. 
TREATMENT. 
The treatment of this disease is simple and is easily described ; 
the indications being few and prominent. It may be divided 
into two forms: the constitutional and the local treatment.— 
In the constitutional, we first endeavour to arrest the zymotic and 
septic changes, rapidly taking place in the blood, and then to keep 
the patient alive, Dy the most rigorous sustaining treatment possible, 
whilst the effects of the disease are either being developed, or are 
passing away. In the local treatment, the object is to destroy and 
circumscribe the membranous exudation; to prevent its extension ; . 
and to remove, in every way possible, the physical and sensible 
evils, resulting from its presence. In no disease is judicious treat- 
ment more important, in none is injudicious treatment more fatal 
and reprehensible. Let the anti-phlogistic treatment, in its early 
signification, be adopted, and the Physician who lost sixty patients 
in sixty cases, would not long be mentioned as the singular example 
of professional consistency and misfortune. The old lines, that 
were wont to bring the smile of approbation and satisfaction to the 
disciples of Galen, Sydenham, Gregory, and others, would, if 
adopted in diphtheria, be soon regarded as the death warrant, con- 
veniently arranged in metre— 
• He soon returned—his skill 
From the vein, flowed the crimson tide ; 
And as the folk behind him stand, 
He thus declared his stern command : 
At nine, these powders let him take; 
At ten, this draught; the phial shake ; 
And you’ll remember, at eleven, 
Three of these pills, must then be given; 
This course you’ll carefully pursue, 
And give, at twelve, the bolus, too; 
If he should wander, or consciousness lack, DIPHTHERIA 
97 
Clap this broad blister on his back ; 
And after he has had the blister, 
Within an hour apply the clyster. 
I must be gone—at three, or four, 
I shall return, with something more. ” 
Such treatment may appear astonishing and impossible, yet the 
history of the mortuary list, in diphtheria, shows that it is far from 
being unknown and unfamiliar. 
LOCAL TREATMENT 
The local treatment of diphtheria is very simple; some 
prefer an escharotic, as nitrate of silver in solution, or in 
stick; the mineral acids either alone, or as used by Brettonneau, 
one part of hydrochloric acid to three parts of honey; others again 
use milder means, as insufflations of alum (reduced to an impalpable 
powder,) either simple or previously roasted; some again, exhaust the 
catalogue of stimulants, capsicum, turpentine, etc.; others find good 
results from the mild, or strong astringents, as vinegar, or tannin, 
or tincture of iodine, while a few use a simple disinfecting lotion, 
as the chloride of soda, lime or zinc; the chlorate of potassa in 
solution, or the mechanical mixture of levigated charcoal and water. 
We will, in this connection, insert a communication of practical 
interest, from Professor John T. Metcalfe, of New York City. 
“ In the treatment of diphtheria, I believe that all sound prac- 
titioners are agreed, that it is of prime importance to do every 
thing, calculated to nourish and sustain the patient, whilst admin- 
istering such medicines, as tend to correct the spanaemia, so fre- 
quently, if not universally recognized, as one of its most striking 
features. In common with many others, I have relied mainly on 
the tincture of the sesquichoride of iron, for internal administra- 
tion. Nor has my experience failed to convince me of its excellence. 
It has the superiority over the chlorate of potash, in not disagreeing 
with the stomach, when properly diluted, and of not producing the 
exhausting diarrhoea, which I have known to occasionally follow the 
use of the salt. My object, in addressing you this note, is not to 
speak of the general medication in diphtheria, so much as to call 
attention to the fact, that, in five cases, I have found great benefit, 98 
DIPHTHERIA 
from a topical application, of which I have seen no published 
recommendation. In the Winter of 1859-’60, a Student, of the 
University College, suffered from an exceedingly severe attack of 
the disease. There were all the well marked constitutional symp- 
toms, with swelling of the lateral cervical glands and abundant 
patches of exudation on the tonsils, uvula, roof of the mouth and 
posterior pharyngeal wall. This gentleman was a son of Dr. Webb, 
of Hempstead, Long Island. As a probably fatal prognosis had 
been made in the case, the young man’s father had come to New 
York, bringing with him, a vial containing a mixture of the bro- 
mide of iodine, in mucilage, or syrup of gum arabic ; two drops of 
the former to a fluid once of the vehicle. This he said, he had 
heard, was a good antiseptic, and might prove useful in his son’s 
case, as there was the usual foetid character of the breath. Drachm 
doses of the medicine were taken internally, at intervals of several 
hours, and with a camel’s hair pencil, it was applied frequently to 
the patches of exudation. It certainly acted as a disinfectant ; but 
it was followed by a remarkable change, in the appearance of the 
membranes. Within twenty-four hours, they had entirely broken 
down ; disappearing in spots entirely, and leaving the mucous mem- 
brane red and smooth, where the white exudation had formerly 
existed. Within the next eighteen hours, the fauces and palate 
were entirely freed from all pellicular matter, and the patient sub- 
sequently recovered. 
The next case, in which I used it, occurred in a lad, of thirteen, 
who had, two years previously, suffered severely from scarlet fever. 
The diphtherial exudation was extensive, the constitutional symptoms 
very grave, and the angina of the most marked type. To test the 
the remedy, in question, I applied it to the left tonsil, which was 
hypertrophied very considerably, and completely covered with exuda- 
tion, having very much the appearance of white chamois skin 
soaked in water. In twelve hours, the edges commenced to loosen 
and, in twelve more, the whole mass was coughed out; leaving a 
very red and a bleeding surface, under its former place. This patch 
measured a line and a half in thickness and was an inch in length, 
by three quarters of an inch in breadth. Exudation had com- 
menced to form on the uvula, when the application was made to the DIPHTHERIA. 
99 
tonsil. It soon ceased to spread, and was but ephemeral. In the 
last case under my care, a girl of thirteen, whom I had attended 
seven years before, with well marked scarlatina, the exudation 
involved the tonsils, and spread to the uvula, after the third day.— 
The bromide of iodine at once checked the foetor of breath, and, in 
twenty-four hours, caused a complete disappearance of membrane, 
both from the tonsils and uvula. I omit the details of the other 
cases, as they are not of such a character, as to make a different 
description necessary. The topical application consisted of four or 
five drops of the bromide of iodine, to the fluid ounce of gum 
syrup, well applied to the diphtherial patch every two hours.— 
There is nothing unpleasant to the taste, or in the smell of the 
tincture thus prepared, notwithstanding the very disagreeable nature, 
in both these respects of the pure liquid. It is well to continue its 
use, until the mucous membrane shall have resumed its normal 
appearance. ” As the bromide of iodine is not officinal, we subjoin 
the mode of its preparation, for those who are not able to procure 
it conveniently. Saturate an ethereal solution of bromine, with 
metallic iodine. The different works on chemistry and the ordinary 
pharmacopseas do not contain any notices of the bromide of iodine. 
Griffin, in his “ Chemical Recreations,” states that “ bromides of 
the other metals may be procured, by the addition of hydrobromic 
acid to a solution of their salts. ” The method given will be found 
simple and practicable. Lugol’s iodine caustic is as convenient and 
perhaps as efficient, as the bromide of iodine. It is an excellent 
disinfectant and produces an exfoliation of the membrane, just as 
readily. It may be used of full strength, or diluted, according to 
the judgment of the Physician. It is made, by adding to two ounces 
of water, an ounce each of metallic iodine and iodide of potassuim. 
It is not unpleasant to the patient; does not produce the ash-col- 
oured marks, caused by the nitrate of silver; is very stringent 
and is an excellent disinfectant. The chloride of zinc will be 
found an excellent application, either to the fauces or the nostrils; 
it has not the disagreeable smell of some of the cholorides and is 
very efficient, as a disinfectant. For destroying the foetor of 
breath, we know nothing more excellent, than the use of an 
ordinary charcoal troche. They can be constantly used, with none 100 
DIPHTHERIA. 
of the intervals, during which the patient and nurses are made to 
suffer from the absence of a disinfectant; they are always far more 
acceptable to the patient than gargles, lotions or injections ; com- 
pounded with some favourite spice, they correct the existing foetor 
and afford, in exchange, a pleasant aroma; and they are acce sible 
to every one. We do not wish to give a detailed statement of the 
endless remedies, that have been used, either in the local, or consti- 
tutional treatment of diphtheria; such a course would be useless 
and, when completed, w’ould be more of a curiosity, than an assis- 
tant to the reader. “ The favourite prescriptions of favourite Phy- 
sicians ” may serve to give a useful hint, but fixed formulas are both 
unnecessary and injudicious ; and each practioner had far better 
adjust the proportions, of prescribed remedies, to meet the 
exigencies, or peculiarities of each particular case. 
The application of blisters to the throat, is not advisable in this dis- 
ease ; they rarely do good and frequently produce diphtheritic 
exudation on the skin, with painful and dangerous sloughing. This 
will be found true, in the use of blisters, on any part of the per- 
son, in this disease. Leeches are also unsafe ; the haemorrhage is 
difficult at times to control; is very prejudicial and injurious to the 
patient; and the leech bites, after being covered with diphtheritic 
exudation, frequently become foul and painful sores. The different 
poultices, and fomentations, and sinapisms and fumigations had 
best be avoided; they are “ more honoured in the breach than the 
observance,” and the patient will be just as safe and far more com- 
fortable without them. Where the cervical glands are much swollen 
and the integuments hot, tense and painful, these applications do 
very little good; they generally dampen the bed or body-clothes 
of the patient, distract the attention of the attendants aud annoy 
the patient. Where this swelling does not become absolutely pain- 
ful, nothing is required. Where there is much tension, pain and 
heat, however, a mixture of equal parts of glycerin, tincture of 
opium and chloroform will be found useful—a little cologne, or 
some favourite perfume may be added, if desired. The lubricating 
and softening effect of the glycerin, with the anesthetic effect of 
the laudanum and chloroform, will be found very acceptable to the 
patient. If heat is agreeable, by covering the application, a slight DIPHTHERIA 
101 
rubefacient effect will be produced ; if cold is preferred, remove the 
covering from the part and the evaporation of the chloroform will 
sufficiently produce this effect. Unlimited use of ice may also be 
allowed; this will often be grateful to the patient, and is a valuable 
adjuvant in the treatment of the disease. l)r. A. Snead, of Rich- 
mond, Va., has used this remedy with much satisfaction and suc- 
cess. In regard to the membranous exudation on the fauces, there 
are many modes of treatment. If the lunar caustic be used, in 
stick, care should be taken that this does not break and a portion 
of it escape into the pharynx, and thus into the stomach. Fatal 
results have ensued, from carelessness in this respect. If the caustic 
in solution, is used, it is always painful and distressing to the 
patient; portions sometimes enter the glottis, or the nares, producing 
very unpleasant results. If this application were specially or specifi- 
cally demanded, let it be applied of course, regardless of the pain or the 
consequences ; but is it so demanded ? Will not many other appli- 
cations answer equally well, if not better? Again, the nitrate of 
silver produces, on the tissues affected, a characteristic effect, or 
deposit, which it is almost impossible to distinguish from the mem- 
branous exudation, and which renders it almost impracticable, to 
determine the comparative increase, or decrease of this exudation— 
a result which it is desirable to reach, at every inspection of the 
faifces. The prognosis and treatment are often influenced, by the 
conclusion which this inspection produces. Dr. Alonzo Clark, Dr. 
J. S. Wellford, of Richmond, Va., and others, think it unnecessary 
to apply the eseharotic to the exudation, already formed, but only 
to circumscribe it, by drawing, with the eseharotic, a circle around 
the diseased locality. Many of the French, English and American 
Physicians, however, think differently, and attach a direct impor- 
tance to the destruction of the membrane itself. Dr. F. B. Wat- 
kins, of Richmond, Va., who has treated this disease, with the most 
gratifying results, has usually adopted this course. If there is any 
truth whatever, in the views taken, by MM. Bouehut, Jodin and 
others, in regard to this being a parasitic formation or in the 
declarations of Laycock, of Edinboro, that it is a fungus growth (the 
oidium albicans); or that it is, in part, an accumulation of micro- 
scopic algse, etc., it is evident, that it can not be too completely DIl’HTHERt A. 
destroyed. We do not so regard it, however, but consider the exu- 
dation a .fibrinous mass. As it is certainly possible and conceivable, 
that sporules, algae, fungi, etc., may occasionally be present, as 
there is no real harm in destroying the exudation and no impor- 
tant reason for not doing so but the avoidance of the silver deposit 
on the tissues, the annoyance, alarm, etc., the destruction of the 
whole membrane if attempted, should be rare, but complete. Rodet 
has discovered a mixture, which will always neutralize the syphili- 
tic virus, when brought in contact with it, and yet not produce 
cauterization. It is usefully applied to the membranous exudation 
of diphtheria, and is thus made— 
1^.—Aquae Fluv., grs. xxxij. 
Fern Perclilorid., 
Acid Citric, 
Acid Hydrochlo., 
a. a. grs. iv. 
This may be applied, with a camel’s hair pencil. The tearing 
away of the exudation, from the mucous tissue, is entirely useless, 
and frequently causes tedious and painful ulceration. There can 
be only one advantage gained by this removal, and that is, to lessen 
the chief cause of foetor of breath and the unpleasant sensation, 
produced by the dangling of this mass about the fauces. The 
dragging away of the entire membrane, with forceps, leaving a sore, 
tender and bleeding surface, certainly, seems a most inexplicable 
proceeding. This only removes the chief manifestation of a certain 
pathological condition, and does not tend, in any way, to alter, 
ameliorate, or remove it. Where the membrane is evidently 
loose, it may be gently removed, but otherwise it is best to leave 
nature to produce the exfoliation. It should be recollected that a 
chief characteristic of this membrane is its repeated renewal and 
reformation. 
When the nitrate of silver is used, in solution, the strength may 
vary from twenty to sixty grains of the salt, to an ounce of distilled 
water. When the case is seen early, before exudation has taken 
place, or, if so, to only a limited extent, it may be useful to 
the caustic; but, even then, iodine caustic, bromide of iodine, tincture 
of the sesquichloride of iron, or the perchloride of iron, may be as 
well used. The grey deposit of silver will often be found objec- 103 
DIPHTHERIA. 
tionable, and calculated to mislead. Whatever is used had best be 
so diluted, or weakened, as not to cause much pain to the patient. 
The medicines just named, when sufficiently diluted and sweetened 
with a little honey, or syrup, will be found to make useful and 
efficient gargles. In making these gargles, we may select from a 
long list of efficient agents : tannin, capsicum, myrrh, alum, borax, 
tincture of sesquichloride iron, the mineral acids, acetic acid, etc.; 
these may be variously mixed and changed and proportioned to meet 
the desire, or fancies of the practitioner. It will be found conve- 
nient, in applying different preparations to the fauces, with a pencil 
or brush, always to use an ordinary tongue depresser. When the 
swelling of the cervical glands and general tumefaction render this 
impracticable, the same agents may be applied, in a diluted form, by 
means of a syringe. When the membrane has entirely disappeared, 
it will be best to use some astringent application, or gargle for the 
fauces, as these parts are usually left in a lax and weak condition. 
The inhalations of the vapour of water, as this is poured upon 
“ quick lime, ” have been used with much apparent benefit. If 
this vapour were “ atomized ” by some of the apparatus recently 
contrived for this purpose, good results might reasonably be antici- 
pated. Lime juice has recently been used very happily, being given 
in large quantity, and still more recently fumigations with sulphur 
have been extravagantly eulogised. 
Constitutional Treatment.—When called to see a case, if the dis- 
ease has existed but a short time, if no purgative medicines have been 
taken, and if, above all, there is a clear and undeniable indication for it, 
a single dose of calomel, followed by some mild aperient may be judi- 
ciously given. If possible, it is best to avoid all depressing agents and 
agencies, for the chief feature of this disease is a tendency, under 
the best management, to prostration. Unless the use of mercury 
be clearly indicated, it had best be avoided rigidly; when it is used 
once, it is most advisable to abandon it, during the course of the 
disease. General and local depletion, vesiccatories, sinapisms, etc., 
should all be avoided. After the use of a single dose of calomel 
and an aperient, the patient’s strength had best be husbanded in 
every possible way. As soon as the fever has disappeared, or 
begins to disappear, he had better be placed on one, or both of two DIPHTHERIA. 
agents which are peculiarly demanded, for his welfare; these are 
the tincture of the sesquichloride of iron and the chlorate of 
potassa. The scientific reason for giving chlorate of potassa in this 
disease, is that being a highly oxygenised salt, it tends to highly 
arterialize the blood, and thus to counteract the tendency to capillary 
stasis, with all the physical and physiological evils, resulting from a 
blood not sufficiently oxygenised and not sufficiently stimulating to 
ensure functional health and activity. Nitric acid would, in 
a measure, have the same effect, as this acid carries a large amount 
of oxygen, imperfectly held together. Both the salt and acid are 
good carriers of oxygen to the blood and tissues. The first rem- 
edy, originally proposed in this disease, by Dr. Heslop, of Bir- 
mingham, has by general consent been selected, as the chief and 
most reliable agent, in the treatment of this disease. In the pre- 
vention of spanaemia, anaemia, muscular and nervous weakness and 
depression, albuminuria and prostration, the salt seems to be 
especially applicable and efficient; when these conditions are mani- 
fested, it is equally reliable and valuable, for removing them.— 
When the chlorate of potash and the tincture of the sesquichlo- 
ride of iron are used, the following will be found a very convenient 
formula, although any formula will answer— 
Ij<s.—Potassae Chlorat., 5j- 
Acid Hydroch. dil., 5ij. 
Ferri Sequiehl. Tinct., 5iij. 
Aquae Fluv., §xij. 
S.—To take two tablespoonsfui every hour. 
Where the chlorate of potash causes diarrhoea, it had better be 
omitted. If, with good nourishment, the patient seems to be still 
losing strength, the iron may be doubled, in the prescription just 
given. Where, on the contrary, there is headache, fever, and 
restlessness, the iron had better be omitted, or diminished for a short 
time. In preparing the formula mentioned, add the acid to the salt; 
as soon as this assumes a yellow colour, and fumes of chlorine 
arise, add the water ; by this means, the decomposition is arrested 
and the free chlorine held in solution. 
Sometimes, either at the first visit, or afterwards, symptoms of 
croup are seen, and there is a universal disposition to give, for the DIPHTHERIA. 
105 
relief of these, a prompt emetic. It would seem to be a wide-spread 
impression, that, during the act of vomiting, exudations, or mem- 
branes, are expelled from the larynx, or trachea ; the truth in regard 
to this is, that such a result is a physical impossibility. During 
the act of vomiting, the rima glottidis is firmly closed, and if this 
were not the case, vomiting would be impracticable. The mechanism 
of vomiting, when made the subject of reflection, demonstrates that 
the giving of emetics, for the expulsion of membranous exudations 
from the larynx, is not in accordance with the teachings of physi- 
ology. The mechanism of vomiting is as follows : a full inspiration 
is taken, the diaphragm is depressed, and the rima glottidis closed; 
the abdominal muscles now contract and the stomach is compressed 
between these muscles and the depressed and firmly contracted dia- 
phragm ; the rima glottidis is rigidly and firmly contracted, to 
maintain the diaphragm in this position, and the contents of the 
stomach are fully and thoroughly ejected. When the diaphragm 
descends, after a full inspiration, and the abdominal muscles are 
then contracted, it is manifest, that if the rima glottidis is not 
firmly closed, we shall have expiration simply, and not emesis. In 
addition to this, it is a well-known anatomical fact, that the lips of 
the glottis are covered by an exquisitely sensitive mucous mem- 
brane ; that the least irritation of this is immediately reflected and 
that the constrictor muscles (the arytenoid muscles) of the glottis, 
firmly contract, closing fully and firmly this aperture. 
If the preceding mechanism of vomiting is incomplete, it is 
evident, as soon as the least portion of the contents of the stomach 
arc brought into contact with this mucous membrane about the 
glottis, that the constrictor muscles, of this aperture, fully and effi- 
ciently close it. It will thus be seen, that it is impossible for emetics 
to cause, directly, the discharge of membranous exudations, from 
the larynx and trachea. The effects of these medicines may and do 
produce that condition of the system, where, from the resulting 
relaxed state of the tissues, this exudation may be loosened and after- 
wards expelled, by another act—that of coughing; but if we have 
to rely upon coughing for the removal of these membranes, 
(as they cannot possibly be expelled by vomiting) is it not the best 
and proper course, tc cause this lax and relaxed condition of the 106 
MPHTHF.RIA. 
tissues, by a less violent and painful process ; can it not be better, 
more constantly and persistently accomplished, by the use of 
expectorants ? We leave the answer of this question to every one 
disposed to reason in regard to it. * If croupal symptoms supervene 
early, then it will be proper to treat them promptly; to commence 
the administration of mild and judicious expectorants, avoiding 
those, that are harsh and prostrating ; to produce a derivative effect 
by a simple aperient; to make immediate use of the warm bath, and 
to institute inhalations, of the medicated vapour of lime-water, etc. 
If the patient continues to become worse, and the symptoms are 
threatening, the question of tracheotomy (promptly, if in any wray 
used) must be immediately considered and solved. Without going 
into the laboured details of statistics, on this subject here, it will be 
proper to say, that the general testimony and result in France, 
England and America is prejudicial to its use. Success is very 
rare, and the fatality attending it very great. Trousseau, who has 
had a very large experience in this, his favourite operation, now 
declares, that there is one indication which entirely forbids its use 
and that is, where diphtheria is present, or there is even a diphthe- 
ritic tendency manifested. No one has had so large an experience 
in this operation, with special reference to this particular disease, and 
his testimony should certainly receive earnest consideration. Even 
where performed very early (as early as would be justifiable) the 
condition of the system, in diphtheria, is such, as to make trache- 
otomy almost certainly fatal. There is a total loss of constitutional 
elasticity and resiliency in this disease and under the most favoura- 
ble circumstances, it is often difficult to resist, or prevent the con- 
stant tendency to a serious and persistent asthenia. It is a question 
which after all had best be determined, by the circumstances attend- 
ing each particular case. It should be borne constantly in mind, 
that few cases where tracheotomy has been practised, under the 
most promising circumstances, have recovered. It has its enthu- 
siastic advocates, chiefly in the French school, where, however sci- 
entific, progressive and energetic its members, history teaches that 
conservatism is a forgotten word, and that the disposition to start- 
* It is not denied, that the succnssion of vomiting may detach membranous exudations ; this is 
possible, but whenever exudations i.re thus detached, they can only be removed by coughing or 
Violent expiration. DIPHTHERIA 
ling display and attractive innovation are frequent and paramount. 
Still tracheotomy is the final chance of rescue from death ; it can 
scarcely, under many circumstances, lessen the chances of recovery, 
and may rescue the patient from an inevitable death.* Testimony 
and the record are against the operation, on the other hand; and it 
certainly adds to the patient’s trials and suffering. These are the 
facts—each Practitioner must decide. 
When this croupal condition exists, it has frequently been 
treated by catheterism of the larynx ; this operation has been per- 
formed, to a great extent, in France, by M. Loiseau; even to the 
superseding of all other treatment. In addition to American expe- 
rience with this subject, it will only be necessary to say, that the 
committee (MM. Behier, Monneret, Roger, Se6 and Barthez) 
appointed by the French Academy, reported very unfavorably, in 
regard to it. 
Where the tonsils are enormously hypertrophied, and the uvula 
so enlarged, as to jointly produce dangerous dyspnoea, partial abla- 
tion may be adopted. Dr. Orton, of Binghampton, N. Y., who 
has seen a very large number of cases of diphtheria, writes, that 
the bi-chromate of potash has been very beneficially used by him, 
as an emetic, expectorant, and alterative ; he writes very enthusias- 
tically of this remedy, and seems to regard it, almost, as a specific. 
Whether calomel should be used when croupal symptoms super- 
venes, must be left to the judgment and experience of the 
Physician. It of course has its advocates : Brettonneau, bluersant, 
Billiet, Barthez, and others, in France ; Watson, Brown, Evanson, 
Maunsell, Tweedie, Connolly, in other sections of Europe ; Wood, 
Condie, Meigs, and many in this country, are in favour of its use. 
It is proper to say here, that many prominent Physicians, of great 
experience, and deservedly held in high esteem, rely chiefly upon 
the use of calomel, not only when croup supervenes, but through- 
out the course of this disease. Dr. F. Deane, of Richmond, Va., 
and others, offer testimony in this connection, which all who are 
prudent, conscientious and just in practice, should impartially 
receive and accord to it the respect which a long experience 
eminently justifies. It should be carefully recollected, that though 
croup may supervene in diphtheria, it is not, in the least, (so far as 108 
DIPHTHERIA. 
the constitutional condition is concerned,) similar to idiopathic croup. 
In idiopathic croup, the blood has not been affected and poisoned ; 
the disease is sthenic, the exudation is that of true croup, and the 
prostration is always secondary, or succeeding the dyspnoea and 
caused by it. In the croup, supervening in diphtheria, the blood 
has been poisoned ; the disease is asthenic, the exudation is not 
that of idiopathic croup, and the prostration is primary ; preceding 
the dyspnoea and, though increased, yet not caused by it. It seems 
strange that the same remedy should be applicable, under opposite 
circumstances. We should certainly use mercury, if at all, very 
guardedly in croup supervening after diphtheria has existed suffi- 
ciently long to induce its characteristic depression and prostration. 
It is proper to see that constipation is never allowed to exist, in 
diphtheria; either in the acute stage, or in convalescence; the 
tendency of the disease is to produce this condition, and it should 
always be prevented. Where the disease is slowly producing pros- 
tration and the fever is disappearing, (as will always be the case in 
uncomplicated diphtheria,) the most vigorous measures should be 
instituted, for sustaining the strength of the patient. The iron 
should be increased in quantity, and, where no tendency to diar- 
rhoea exists, the chlorate of potash, also. Quinine alone, or in 
combination with iron, should be freely given. Animal broths, 
beef juice, eggs, alcoholic stimulants, as far as can possibly be borne, 
porter or ale, etc., should be plentifully administered. Where 
diarrhoea exists, port wine (with some vegetable astringent, kino, 
krameria, catechu, etc., if necessary,) should be substituted, for 
wine, brandy, or ale. All stimulants should be liberally used, and 
nutriment administered constantly. This is an important part of 
the treatment, and every precaution should be adopted, to see that 
it is faithfully and energetically carried out. The patient will, most 
commonly, manifest a disposition to avoid this part of the treat- 
ment—being without any appetite and indisposed, even, to the 
exertion of eating. Nutriment may be administered in small quan- 
tities, at short intervals, if the digestion is weak and much impaired ; 
if not, the intervals may be longer and the quantity greater. Where 
tumefaction of the jaws, throat obstruction, etc., exist, the nutri- 
ment may be administered by injection; in part, if possible, or DIPHTHERIA. 
109 
entirely, if necessary. It is well to recollect, that nutrition under 
such circumstances is very slight; that absorption is feeble and 
unreliable; and, if forced to have recourse to such an alternative, 
that the material should be freely and often used. 
We come now to speak of albuminuria. This, when manifested, 
usually occurs in the early stages of the disease. It is necessary to 
recollect, that the tests for albumen, in urine, should be severally 
applied ; or, that at least, two of the tests should be used. Heat alone, 
or nitric acid alone, will not be sufficient. When the urine has its 
normal acidity, it will not coagulate on the application of heat. In 
diphtheria the urine is frequently neutral, and has been so alkaline 
in character, as to change, to blue, a piece of litmus paper, that 
has been reddened by contact with an acid. When neutral or alkaline, 
heat may cause a cloudy precipitate; when there is no albumen 
present, this precipitate is composed of phosphates. Again, nitric 
acid may cause a precipitate of lithic acid, when there is no albu- 
men present, and error again be the result. The better way will 
be to add the nitric acid to the urine, and then to apply heat; if 
albumen be present, it will be coagulated by the acid, but will not 
be dissolved by the heat; if albumen be not present, the cloudy 
precipitate of lithic acid, caused by the nitric acid, will be dissolved 
up, on the application of heat, and the urine will become again 
clear. M. Solon’s work may be conveniently and profitably con- 
sulted in regard to the different causes, producing albuminous urine ; 
it would be inappropriate, here, to go into an examination of these 
causes. 
When albuminuria exists, the tincture of the sesquichloride of 
iron will be found to be the best remedy for removing, or controlling 
it; it will be found highly useful, also, where there is purpura; or 
a tendency to haemorrhage. M. Aubrun claims to have cured 
thirty-five out of thirty-nine cases of diphtheria, by the internal 
use of the percbloride of iron. He gives two minims of the iron, 
in two drachms of water, every five minutes during the day, and 
every fifteen minutes through the night, with milk (and nothing 
else for nourishment) at libitum. “ On the third day the mem- 
branes begin to soften and become detached.” The sesquichloride, 
as ordinarily used, will accomplish all that preparations of iron can DIPHTHERIA. 
effect. A solution of the chlorate of potash, with a minim of 
hydrochloric acid, for every grain of the salt, may be used during 
the fever, or when the iron produces headache and restlessness.— 
Dr. James Bolton, of Richmond, Va., has used the muriate of 
ammonia with success and satisfaction. When symptoms of paral- 
ysis supervene, the different preparations of strychnia are used; 
these may be injected hypodermically ; electricity should be locally 
applied, and tonic treatment generally should be immediately and 
persistently adopted. With this, may be instituted passive motion, 
and a daily routine of artificial exercise. 
Time, and above all other things, change of air, must be relied 
upon for the removal of the nervous sequelae of diphtheria. The most 
obstinate, and apparently hopeless cases recover promptly, under a 
change of climate and surrounding circumstances. When the acute 
stage iias passed, there is every prospect of recovery ; for the mor- 
tality, from the sequels of the disease, is quite limited. The result- 
ing asthenia and anaemia are very conspicuous and persistent; last- 
ing sometimes for more than a year. Let it be carefully recollected, 
that the slightest imprudence in exercise is frequently fatal; the 
recumbent position should be observed, until convalescence is fairly 
established and then slowdy and gradually abandoned. Natural 
exercise should be cautiously resumed and fatigue rigidly avoided. 
Hyposulphite of soda, in five grain doses every three hours, is now 
a favourite treatment in Europe. 
The chief peculiarity, attending the autopsies in diphtheria, 
is the membranous deposit, found lining the air passages] 
Sometimes it is seen only in the larynx, but it is often found, 
extending from the rima glottidis, to the minute ramifications of the 
bronchise. Its appearance is quite varied ; from a soft, thin, pul- 
taceous mass, to a dense, thick and coriaceous membrane. It has 
been seen (in Charleston, S. C., such a specimen was presented to 
the Medical Society) plugging up the entire larynx and trachea. 
AUTOPSIES. 
The brain, heart, lungs and abdominal viscera are usually found 
healthy. The blood, thin, dark and liquid. Sometimes, the lungs 
exhibit the condition manifested in pneumonia ; they have been seen DIPHTHERIA. 
to exhibit the changes, peculiar to each of the three stages. Evidences 
of bronchitis are also seen. These results are of course only seen 
■where the disease has been complicated with some of the inflamma- 
tory affections of the lungs. Cases are examined, where no 
changes have taken place; death being the result of asthenia; 
the blood, however, even in such cases, is liquid and dark. 
Contrary to the declarations of M. Empis and others, that 
the exudation is not found, where there is no exposure to the 
air, M. Guersant states that the membranes have been found, by 
himself, in “the oesophagus, stomach and intestines.” It will be 
recollected, that Dr. Goldsmith, of Oakland College, Mississippi, 
states that, in the epidemic of diphtheria, described by himself, the 
exudation had been found in the intestinal canal. 
In the New Jersey epidemic, and in England, the subject was fre- 
quently covered with purple spots. Sometimes the kidneys are 
found deeply congested and again with the changes peculiar to 
Bright’s disease. Dr. Oliver, of Boston, Mass., records a case, 
where “ the left cavity of the pleura contained about two ounces of 
serum.” The exudation is found in all of the mucous passages and 
tissues ; the vulva; vagina ; internal coat of the bladder ; the oeso- 
phagus and intestines ; the stomach ; the entire auditory canal; * the 
fauces; nasal and respiratory passages; on the conjunctiva; the 
buccal cavity ; on wounds, etc. In death from convulsions, the 
blood vessels of the brain have been found ruptured. In the fifty- 
two post mortem examinations, of Brettonneau, the exudation was 
found in the larynx and trachea, in fifty-one cases. Abscesses 
have been found in the tonsils, and also between the pharynx and 
vertebrae. Post-pharyngeal abscess, however, is rare. The mem- 
branous exudation is frequently found on the vocal cords, and this 
is unquestionably the most common cause, for the aphonia so 
often manifested, and for the croupal sounds frequently heard. Dr. 
Greenhow reports a few cases, where the kidneys, though apparently 
healthy, were deeply diseased, both in their cortical and medullary 
structures. The chief peculiarity, however, revealed in the autop- 
sies of diphtheria is the varied manifestation, of its characteristic 
membrane. 
* Dr. Remington, Philadelphia, Penn. 112 
DIPHTHERIA. 
SUMMARY. 
\ 
We have thus seen— 
That diphtheria is a zymotic disease ; peculiar, separate and 
specific. 
That its pathology proves it to be a distinct disease. 
That its anatomical and physiological relations appertain to no 
other disease. 
That it is both epidemic and sporadic, in its prevalence. 
That its etiology is obscure and in no respect understood. 
That its symptoms and course render its diagnosis and differen- 
tial diagnosis simple. 
That it is often contagious ; hut not so always. 
That its duration, in the acute stage, is from three days to three 
■weeks, and when its peculiar sequelae ensue, that the disease may 
persist for many months. 
That hygienic influences seem not to affect the cause of the dis- 
ease ; but that they do affect its course and result. 
That its relation to age is marked and direct; that children are its 
most frequent subjects and its most frequent victims. 
That its complications are numerous and most of them dangerous. 
That there is no direct relation, between the throat lesions and 
the result. 
That it is peculiarly apt to recur ; and that convalescence from 
its attacks, is slow, tedious, treacherous, relapsing and interrupted. 
That there seem to be diseases, coincidently occurring in the 
lower animals, during its prevalence. That its sequelae are peculiar 
and such as are not seen after any other disease. 
That its mortality, when uncomplicated, is not serious ; but that its 
frequent complications render the mortality severe. 
That the chief cause of death is laryngeal implication, and 
next to this asthenia. 
That the prognosis can seldom be satisfactorily made. 
That, in no disease, does treatment more generally influence the 
result. 
That the autopsies prove (what is indicated by the pathology, the 113 
DIPHTHERIA. 
anatomical peculiarities, the symptoms and the sequelae) that diph- 
theria is a zymotic, distinct and specific disease. 
After a careful analysis and patient tillage of this field; after 
freely consulting all familiar with its cultivation, we now offer, to 
our fellow-labourers, the results of the harvest: “ Corn from the 
sheaves of science,” with the stubble, produced to sustain it. 
BIBLIOGRAPHY. 
In an Essay of this kind, it would have been impracticable to give a 
<£ footnote ” for each fact stated, or each authority cited. 
We have preferred, in this manner, to acknowledge our obligation 
to those writers and gentlemen, whose labours and courtesies have af 
forded us valuable and constant assistance. 
We are indebted, for such aid, to— 
The Files of the London Lancet. 
The Medical Times and Gazette. 
Braithwaite’s Retrospect. 
Banking’s Abstract. 
Watson’s Practice of Medicine. 
Huxham’s Dissertation on Sore Throat. 
Report of the Lancet Commission. 
Essay of Dr. Greenhow. 
Paper of Mr. Ernest Hart. 
Papers of Mr. Sanderson. 
De La Paralysie—Par—Dr. V. P. A. Maingault. 
Report of M. Trousseau. 
Works of West, Copeman, and Copland. 
British Medical Journal. 
Laycock’s Leeture. 
Wood’s Practice of Medicine. 
Dunglison’s Practice of Medicine. 
Bateman’s Synopsis. 
American Journal of Medical Sciences. 
New York Journal of Medicine. 
American Medical Monthly. 
American Medical Times. 
Medical and Surgical Reporter. 
North Amer. Med. Chirurgical Review. 
New Orleans Medical and Surgical Journal. 
Boston Medical and Surgical Journal. 
Medical News and Library. 
The Pacific Medical and Surgical Journal. DIPHTHERIA. 
The Berkshire Medical Journal. 
Essay of Dr. Slade, Boston. 
Essay of Dr. Hartshorne, Philadelphia. 
Essay of Dr. Wooster, San Francisco. 
Essay of Dr. Fourgeaud, San Francisco. 
Essay of Dr. Blake, San Francisco. 
Essay of Dr. Thayer, Keene, N. H. 
Cleveland Medical Gazette. 
Cincinnati Lancet and Observer. 
Chicago Medical Examiner. 
Cincinnati Medical and Surgical News. 
The Virginia and Maryland Medical Journal. 
American Medical Gazette. 
St. Louis Medical Journal. 
Charleston Medical Journal. 
Nashville Journal of Medicine and Surgery. 
St. Joseph Medical and Surgical Journal. 
Essay of Dr. Wade, of Birmingham. 
Over one hundred autograph letters, from gentlemen in Europe and 
America. 
Mortuary Lists of Cities, etc. 
INDEX 
Page 
Preface 1 
History 2 
Xame 15 
Pathology " 17 
Anatomical Relations 36 
Diagnosis • 43 
Symptoms 45 
Etiology 54 
Sporadic Prevalence 60 \ 
Epidemic Prevalence f 60 
Endemic Prevalence 61 
Contagiousness 61 
Incubation 69 
Duration 70 
flotation of Throat Lesions to Result 71 
Relation of Hygienic Conditions to Result 73 
City and Country Atmospheres 73 
Effect of Age and Sex 73 
Coincident Diseases in Brutes ..7." 77.7.7 75 
Complications -78 
Convalescence 7.7. 7. . .. .7.77.7.7.77.777 77 7 -79 
Recurrence and Sequelae 79 
Prognosis ..77.7.7.7.7.7.7 77 7 7 77 7.7.7.77 7.7777 7. .ss 
Mortality * .7.7.7.777 77 77 77. .7.7. .7 7......92 
Immediate cause of Death 7.7..7.7.7.7.7.7.7.77.777."." *.".'.'.', 7 77777..94 
Treatment [ .7.7.7 7.' ! ' .96 
Autopsy 7.7. .7.7.7.7.7.7.7.7......... 7.7.7. .7.77. .7.7. .7.7. .7.......7no 
Summary jjg 
Bibliography ........7.7.7............. 7.. .7.7.7..7. .7.7.7.77.77ll3 Ilf Ipcittwtil §§ielia! 
E. S. Gaillard, M. D., and W. S. McGhf.sney, M. D,, 
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