z^ gj^ l^avi^B^ wihI p^^^^^^^^^^^^H jia 1 H 1 K^^^^^^H ^^kH m3§ ■ 1 1 IViiSS^^^^^^n ■IR v^:^^^ ON" DIPHTHERIA. 7991 ON DIPHTHERIA. BY EDWAED HEADLAMj&EEENHOW, M.D., FELLOW OF THE EOTAL COLLEGE OF PHTSICIAKS, PHTSICrAK TO THE WBSTEBIf GENERAL DISPEXSABT, AND LECTUEEE ON PUBLIC HEALTH AT ST. THOMAS'S HOSPITAL. LONDON: JOHN W. PAEKER AND SON, WEST STRAND. MDCCCLX. [The Author reserves the right of Translation.] SAVIIL AND E1;WABDS, PKINTEES, CHANDOS STBEET, COTENT GARDEN, Wd TO EDWARD GREENHOW, M.D., OF HUMSHAUGH HOUSE, NORTHUMBERLAND, IN GRATEFUL ACKNOWLEDGMENT OF MUCH VALUABLE INSTRUCTION DERIVED FROM HIM DURING THE EARLIER PART OF MY PROFESSIONAL LIFE, AND IN TOKEN OP THE WARMEST FILIAL RESPECT AND AFFECTION. PREFACE. The following treatise is founded partly upon the study of diphtheria in public and private practice, partly upon information obtained in the course of an inquiry into the causes, symptoms, and treatment of the disease, made for the Privy Council, in the spring of 1859.* In the progress of this investigation I visited several districts in which diphtheria then pre- vailed, both for the purpose of observing the disease and also of ascertaining the result of the experience of those provincial practitioners who had been most extensively engaged in its treatment. From these gentlemen I received the most efficient aid in the pro- secution of my inquiry, and I gladly take this oppor- tunity to express my sense of their kindness, and of the great value of the information with which they supplied me. The materials then collected having been published in an official form, I have felt myself * The minute containing the heads of this inquiry, and the report of its results, have been printed in the Second Report of the Medical Officer of the Privy Council, pp. 167 — 237. London, i860. VI 11 PREFACE. at liberty to make use of them for my present purpose. Being desirous that my book should contain as complete an account as possible of the present state of professional knowledge on the subject of diphtheria, I have not scrupled, especially in the chapters devoted to the history of the disease, to quote freely from other authors whatever facts were suitable for my purpose, in every instance stating my authority for information not resulting from my own experience. The facts recorded in the following pages, in my opinion, clearly prove that the recent epidemic of diphtheria has been occasioned by some wide- spreading influence, deriving intensity of action from local conditions either of population or of place. It is only on such a supposition that we can account for the wide extension of the epidemic; its mildness in some districts, its excessively malignant character in others; its occasional limitation within very narrow bounds; and its tendency to linger in particular dis- tricts, or to return again and again to the same spot. These conditions being as yet undiscovered, and our acquaintance with the disease being of so recent a date as to render it doubtful whether we have as yet witnessed all its phases, I have for the most part confined myself to the statement of facts, and in a great measure avoided the expression of theoretical PEEFACE. ix opinions, which could at best be founded on but im- perfect data. I am well aware that the work which I now ven- ture to submit to the judgment of my professional brethren cannot claim to be reojarded as containins: a perfect elucidation of its subject. Perhaps the time has not yet arrived when such a work could possibly be written. My object will, however, have been at- tained, if my inquiries should be found to have supplied information which may lead to a more en- larged and perfect acquaintance with so formidable a disease. London, November i, i860. CONTENTS. I CHAPTER I. PUEHMINA-UT OBSERVATIONS — DEFINITION" OF THE DISEASE 1 -^ CHAPTER II. DIPHTHEHIA IN THE SIXTEENTH, SEYENTEENTH, AND EIGHTEENTH CENTURIES 10 W CHAPTER III. DIPHTHEKIA IN THE NINETEENTH CENTURY ... 58 CHAPTER TV. DIPHTHERIA AS A SPORADIC AND ENDEMIC DISEASE . 85 CHAPTER V. 'y NON-IDENTITT OE DIPHTHERIA AND SCARLET FEVER . 102 CHAPTER VI. HUMAN AND BRUTAL DISEASES COINCIDENT WITH DIPH- THERIA — RELATION OP PLACE, AGE, SEX, AND SOCIAL POSITION TO THE EPIDEMIC ..... 115 CHAPTER VII. COMMUNICABILITT OP DIPHTHERIA . . . . 136 CHAPTER VIII. SYMPTOMS — DESCRIPTION OP THE SEVEKA.L GRADES AND VARIETIES OF DIPHTHERIA 149 1^' XII CONTENTS. CHAPTEK IX. STMPTOMS— DIPHTHEEIA ON THE CUTANEOUS SUKEACE AND WOUNDS — OCCASIONAL CONCOMITANTS OE THE DISEASE — MANNER OF DEATH . . . .188 CHAPTER X. SYMPTOMS — SEQUELS OP DIPHTHEEIA . , . .221 CHAPTER XI, y MOEBID ANATOMY OF DIPHTHEEIA .... 235 CHAPTER XII. ^\/ TEEATMENT . " 2G1 ON DIPHTHERIA. CHAPTER I. PRELIMINARY OBSERVATIONS DEFINITION OP THE DISEASE. rpHE history of epidemic diseases forms at once -*- one of the most interesting and important subjects of medical inquiry. For the most part, prevailing siijiultaneously over a wide extent of country, and attacking large numbers of the inha- bitants, these diseases are yet sometimes remarkable for the singular immunity enjoyed by particular places or persons at times when all around are subject to their influence. Thus the disease which forms the subject of this memoir has been repeatedly observed, whilst very prevalent in certain districts, to pass over others in their immediate vicinity, of precisely the same character with respect to soil, climate, aspect, and inhabitants. A remarkable illustration of this fact came under my own observa- tion in the summer of 1859. Diphtheria had pre- vailed for many months, and had proved most fatal in a certain district of the Union of Christchurch, in Hampshire ; the remaining portion of the Union having been almost, if not entirely, exempt from the epi- B 2 ON DIPHTHERIA. (lemic. The two districts are divided by the River Stour, and the disease prevailed in all the hamlets on the western side of the river, while scarcely any cases occurred on the eastern, although both are similar in character, an,d appeared to be exposed to the same influences. The sweating sickness of the fifteenth and sixteenth centuries is said, by Caius, to have attacked almost exclusively the upper and wealthier classes of the community, and in some of its visitations the English race so exclusively, that no alien was affected by it in this country, and none but the English suffered from it abroad. Diphtheria is said to have exhibited a manifest preference for the English at Boulogne during its late severe visitation of that town. The medical history of the present century is remarkable for the reappearance in this country of two very definite forms of epidemic disease, described by the physicians of former centuries, but unknown to our immediate predecessors. I have elsewhere shown that the disease which, in our day, is called Asiatic or epidemic cholera, is identical with a disease named Dysenteria incruenta by Willis, and Diarrhoea coliquativa by Morton, which prevailed during many years of the middle and latter part of the seventeenth century.* The kind of epidemic # Willis's Fharmacetitice RationaUs. Translated by S. Bordage. Pai't I„ pp. 51-6, London: fol. 1684. Pyreiologia seu Exercitationes de Morhis TJniversalibus Acutis. Londiui : 1692, pp. 420-1. On the Study of Epidemic Disease, as illustrated by the Pestilences of London. By E. Headlara Greenhow, M.D., 8vo. Also, The British and Foreign Medico- Chirurgical Review, vol. xvii. p. 293. REAPPEARANCE OF FORMER EPIDEMICS. 3 sore-throat, now called diphtheria, which has pre- vailed so extensively during the last four years, though unknown to the last two or three generations of physicians, was familiar to the medical practitioners of this country about the middle of the eighteenth century, under the names of malignant sore-throat, epidemic croup, and morbus strangidatorius. Both cholera and diphtheria have, it is true, been observed from time to time in a sporadic form; and small outbreaks of each of these diseases have sometimes occurred ; but in an epidemic form they had been long unknown when they reappeared in our own time. The terms cholera and diphtheria are, generally speaking, and perhaps properly, only applied to the malignant forms of these epidemic diseases, to the exclusion of the milder and commonly more numerous cases of illness induced by the epidemic influence. These milder cases, although characterized by an affection of the same mucous surfaces, lack the more striking features usually understood to be asso- ciated with the terms cholera and diphtheria. The mucous membrane of the alimentary canal is alike the seat of the principal phenomena, both in cholera and the diarrhoea which commonly pre- vails so extensively during a visitation of cholera. The mucous membrane of the throat, especially of tlie tonsils and immediately adjacent parts, is not only the seat of the simpler form of sore-throat which has prevailed so extensively during the last three or four years, but is likewise, almost invariably, the situation in which the first S3^mptoms of the more b2 4 ON DIPHTHERIA. severe cases, properly tenned diphtheria, manifest themselves. The diarrhcea of cholera times does not present the excessive prostration, the blue, cold, clammy surface, the pulseless extremities, or the whispering voice of fully developed cholera; the simpler sore-throats which have usually prevailed simultaneously with diphtheria have been often un- attended by the characteristic exudation of false membrane, or by the prostration of strength, and have rarely, if ever, been followed by the raucous nasal voice, the paralysis of the muscles of deglutition or of locomotion, and the impaired vision which so fre- quently follow in the train of diphtheria; but the diarrhoea and sore-throat are respectively congeners of cholera and diphtheria, from which their diffe- rence is less one of character than of degree. I will not pause to inquire whether the term diphtheria should be applied to sore-throat epidemics, of which cases, characterized by diphtheritic exuda- tion sometimes form but a small section. It would, perhaps, have been better to have retained the English name, 'epidemic sore-throat,' or the older term ' a.ngina,' as the generic name of such epi- demics ; but as the word diphtheria is now in ordinary use for one form of the disease, I shall employ it as the generic term for the entire epidemic. The fol- lowing description will, I trust, be found sufficiently comprehensive to include every variety of the disease from that of mild epidemic sore-throat to the severest form of malignant diphtheria. Diphtheria, cojnparatively rare as a sporadic dis- DESCRIPTION OF DIPHTHERIA. 5 ease, more frequently prevails as an epidemic, in which form it often exists contemporaneously over con- siderable tracts of country, or it may occur in smaller groups, limited to particular hamlets, or even to par- ticular houses. Sometimes it has prevailed so ex- tensively, that distant countries, including portions both of the Old and New World, have been simul- taneously or successively visited by it. Diphtheria is sometimes preceded, and usually accompanied, by fever, which, in certain epidemics and in severe cases, is only transient, speedily giving place to depression. There is often a stiffness of the neck at the commencement of an attack, and usually more or less swelling and tenderness of the glands at the angles of the lower jaw. The tonsils are com- monly swollen, and, together with the immediately contiguous parts of the mucous surface, more or less inflamed. Sometimes the swelling and inflammation subside without further local mischief; at others, the inflamed surface presents, from an early stage of the disease, whitish specks, or patches, or a continuous covering of a membraniform aspect, which may ap- pear as a mere thin, almost transparent pellicle, but usually soon becomes opaque, and in some cases assumes the appearance of wet parchment or chamois leather. This membranous concretion varies in colour from being slightly opaque to white, ash- colour, bufl^, or brownish, and in rarer instances, to a blackish tint. This false membrane is a true exudation which has coagulated upon the mucous surface, from which 6 ON DIPHTHERIA. it may often be readily separated, leaving the subja- cent membrane mostly unbroken or merely exco- riated, usually reddened, vascular, tender, and dotted with small bloody specks or points, but sometimes superficially ulcerated, and more rarely in a sloughing condition. When the false membrane has been arti- ficially removed, it is apt to be renewed; and when not meddled with, to become thicker by continued exudation from the mucous surface. The severity of the disease is commonly in proportion to the con- tinuity and density of the exudation ; but cases some- times occur in which the membranous exudation is inconsiderable, and yet the general symptoms are of a very alarming kind. If the patches are small and remain distinct, the case ordinarily runs a favourable course; if they rapidly spread and coalesce, if the membrane becomes thick, and especially if it assumes a brownish or blackish colour, danger is imminent. In proportion as the membrane increases in thickness and density, does its attachment to the subjacent surface generally become firmer. The surface of the mucous membrane around the exudation is red and vascular, and so tender that in severe cases it bleeds on the slightest touch. The throat is in general the primary seat of the disease; but the inflammation is apt to spread along continuous mucous surfaces, and thus to extend up- wards into the nares and to the conjunctiva; down the pharjmx into the oesophagus ; through the glottis into the larynx, trachea, and downwards into the bronchial tubes; or forwards on to the buccal mucous DESCRIPTION OF DIPHTHERIA. 7 membrane, the gums, and lips. Wounds and exco- riations of the skin, and the mucous membrane of the nymphs and vagina when tender or irritated, especially in persons already suffering from diphtheria of the throat, are during an epidemic liable to undergo the same process of exudation, which, coagulating, forms a false membrane analogous to that on the tonsils and throat. Albuminuria, commencing early in the disease, usually within a few hours, and gradually disap- pearing with the local aifection, sometimes, but by no means invariably, accompanies diphtheria. If the urine be much loaded with albumen, the complication is a serious one; but cases have done well in which a considerable cloud of albumen was deposited from the urine by the proper tests, and very severe and even fatal cases of diphtheria have been unattended by albuminuria. After a time the false membrane is thrown off, either entire, so as to represent a mould of the parts it covered, or, which is more usual, comes away in shreds or flakes intermingled with mucus. Some- times it undergoes decomposition prior to separation, giving rise to a very offensive smell. When the mem- braniform exudation has come away spontaneously, it is sometimes repeatedly renewed, each successive false membrane becoming less and less dense, having less and less of the character of exudation, and more and more that of mucous secretion, until at length the affected surface is merely covered with a thick mucus, which gradually disappears as the mucous membrane 8 ON DIPHTHERIA. recovers its healthy condition. In other cases the exudation is not renewed when it has once been thro"\vn oiF, but the subjacent membrane is observed to be either redder or paler than natural, has a rough, ragged appearance, or is depressed below the adja- cent surface on the parts where dense false membrane has existed. Occasionally sloughing takes place beneath the exudation, or even more deeply, as in the centre of a tonsil, and may implicate the tonsils, uvula, and soft palate. More rarely the tonsils sup- purate. Haemorrhage from the nose and throat, independently of the co-existence of purpura, often occurs in the course of diphtheria, and is sometimes very profuse. The local affection may pass into a chronic form, in which relapses or exacerbations are readily produced by vicissitudes of weather or by ex- posure to damp or cold. Even perfect recovery from an attack affords no immunity from the disease in future. A peculiar character of the voice, resembling that produced by affections of the throat in secondary syphilis, is a common result of diphtheria, and often continues for many weeks after recovery. The power of swallowing is sometimes so impaired that there has been difficulty in sustaining life during convalescence ; and liquids especially are. apt, even after a compara- tively slight attack of the disease, to be regurgitated through the nostrils. Extreme anaemia, impairment of vision, a peculiar form of paraplegia, weakness of the hands and arms, numbness, tenderness of the limbs, tingling, wandering pains, and, more rarely, DESCRIPTION OF DIPHTHERIA. 9 nervous sequela3 of a hemiplegic character, are, in the order here written, ulterior consequences of diph- theria. Gastrodynia, and sometimes dysenteric diarrhoea, occasionally follow diphtheria. Pain of the ear, deafness, and abscess, are occasional but rare results of the disease. 10 CHAPTER II. DIPHTHERIA IN THE SIXTEENTH, SEVENTEENTH, AND EIGHTEENTH CENTURIES. A LTHOUGH diphtheria as an epidemic disease is •^^ new to the present generation of medical prac- titioners, it was well known, and has been very ac- curately described, under other names, by several of the older physicians. Like cholera and influenza, it has prevailed in so many countries and in so great a variety of climates, as may well entitle it to be called pandemic. It prevailed in Spain, Italy, Sicily, and other European countries in the sixteenth and seven- teenth centuries. It visited England, France, Italy, Sweden, Holland, Germany, and North America about the middle of the last century, and, then disappearing, seems to have remained almost unnoticed till towards the close of the first quarter of the present century. Within the last three or four years it has prevailed in an epidemic form on the Continent, in this country, in North America, and in Australia. It would occupy more space than is compatible with my present purpose were I to endeavour to trace fully either the local or the literary history of diph- theria ; but it seems desirable to adduce such evidence DESCRIPTION OF DIPHTHERIA BY ARETiEUS. 11 as may suffice to show the disease is not of recent origin, its tendency to prevail epidemically at uncer- tain periods, and its very wide distribution at such times as regards region and climate. The following extracts from his description of ulcerations about the tonsils, quoted from the English version of his works published by the first Sydenham Society, evidently show that Aretagus was well ac- quainted with diphtheria.* ' Ulcers occur on the tonsils ; some, indeed, of an ordinary nature, mild, and innocuous; but others of an unusual kind, pestilential and fatal. Such as are clean, small, superficial, without inflammation and without pain, are mild; but such as are broad, hol- low, foul, and covered with a white, livid, or black concretion, are pestilential. If the concretion has depth, it is an eschar, and is so called; but around the eschar there is formed a great redness, inflamma- tion, and pain of the veins, as in carbuncle;! and small pustules form, at first few in number, but others coming out, they coalesce and a broad ulcer is produced.' Aretasus then goes on to describe the extension of the disease to the tongue and gums, and sometimes to the windpipe, when it rapidly proves fatal by sufl'oca- * The extant works of Aretceus the Capjoadocian. Book i. chap. ix. pp. 253-255. London, 1856. t ' Quod si concreta ilia sordes altius descenderit, affectus ille eschar est, atque ita Greece vocatur, Latine crusta; crustara vero circumveniunt rubor excellens et inflammatio, et exiguse rarseque pustulse orientes, his- que alise supervenientes in unum coalescunt, atque iudd latum ulcus efficitur.' — Aretceus, quoted hy Bretonneau. 12 ON DIPHTHERIA. tion. Children under the age of puberty are, he sa3'S, especially subject to the disease. Egypt, Syria, and more particularly Coelo-Syria, engender the complaint, which has hence derived the name of Egyptian and Syrian ulcers. In describing the mode of death, Areta3us speaks of the foetor as so loathsome that even the patients themselves cannot endure it (a fact which has also come under my own observation), of the regurgitation of liquids through the nostrils, and of hoarseness and loss of speech. Three Spanish physicians, Villa Real,* Fontecha,t and Herrera,J who wrote early in the seventeenth centur}^, have described with great accuracy the garro- tillo, or morbus suffocans^ then prevailing in Spain, which was evidently identical with the diphtheria of our own time. Fontecha, whose work was published in 1611, says he had seen the disease as far back as 158 1, and adds that it prevailed in an epidemic form in 1599 and 1600. Villa Real mentions its appear- ance in Andalusia and other parts of Spain in 1590 and 1591. Dr. de Fontecha says garrotillo sometimes began * Joannis de Villa Heal, de Sifftiis, Causis, Essentia, Prognostico, et Curatione Morhi Suffbcantis, Compluti, 1611. t Disjautationes Medicce super ea quae Hippocrates, Galenus, Avi- cenas, necnon et alii Crrceci, Arahes, et Latini, de Anginarum naturis, speciebus, causis et curationibus scripsere diversis in locis ; et circa affectionem hisce temporihus vocatam Gaebotillo. Opus Doctoris Johannis Alphonsi de Foutecha, &c. Compluti, 161 1. X De Esseiitia, Causis, Notis, Prasagio, Curatione, et Prcecautione Faucium et Gutturis Anginosorum Ulcerum Morhi Suffocantis, Gaebo- tillo Sispane appellati, Sfc. Autiaoie Doctore Christophero Perez de Herrera, &c. Matriti, 1615. SPANISH EPIDEMIC OF THE SEVENTEENTH CENTURY. 13 with little, at others with much pain. There was always more or less swelling of the throat, both external and internal. At one time large whitish scabby ulcers appeared, at other times, only a white colour. He had also seen at thebeo:inninof, a blackish crust, inclining to a blueish or greenish hue. Some- times these signs were not discoverable. Fever often accompanied the disease, but was also frequently absent, particularly in certain epidemics. He adds that the disease was unquestionably present when, although there was little pain, a colour like flour ap- peared in the throat and fauces, accompanied by some difficulty in swallowing, by fever, and a small, weak, irregular pulse. And these signs denoted not only the presence of this throat affection, but likewise its intensity.* * ' AHquando incipit cum parvo dolore, aliquando cum magno, aliquando cum pai'vo tumore super ligulam, aut ad latera, aliquando altiori, quau- doque vero cum ampula, aliquando minime, quandoque cum vescicula, mul- toties vero deficit. Ssepe tumor magnus ostenditur ad partes externas ita, ut descendat usque ad os juguli, redendo vero quasi planum spacium, quod interest inter mandibulara et jugulum; millies vex'o non videtur, nunc per initia majora ulcera apparent albicantia, et fere scamosa ; nunc vero solus qui- dam color albicans,aut inter libidum, et passeum. Per initiaet vidimus scarum nigricantem, aut in livorem, ceu colorem chloron tendentem ; aliquando hrec omnia ab oculis effugiunt ; febris concomitata frequenter banc affectio- nem : ssepe vero anno isto 1597, vidi ipsam deficere, veluti etiam contin- git in epidemica ilia affectione anni 1599 et 1600 in hoc regno. Sit ergo certum, quotiescumque apparet quidam color veluti farinaceus in gutture aut faucibus (etiam si non reperiatur magnus dolor) cum aliquali deglutiendi difficultate : et febris, pulsusque parvus, debilis, et inaequalis ; adest et anginosa lues dicta ; reliqua enim uti ulcera supra dicta, et reliqua signa jam non solum afFectionera banc conotant, verum, et illam jam valde confirmatam ssevitiem causarum, et illarura extensionem, et intensionem. Ita ut nullus fere fuit visus ex his, qui habent ilium tumorem, non remit- tenti febre, qui non fuerit et mortuus.' — Fontecha, loc. cit., p. 28. 14 ON DIPHTHERIA. In describing the diagnostic signs of worhus siiffocansy Villa Real says the disease did not always begin in the same manner ; for the mouth being opened and the tongue held down, at one time he saw the apex altogether white; at another, a certain mem- branous crust, not perfectly white, but of a blueish colour, covering the fauces, throat, and gullet. The tongue, from the root upwards, was also either wholly or partially white, a symptom, which, taken in con- junction -svith difficulty in swallowing during the pre- valence of an epidemic, was a sure proof of the commencement of this disease even before the white false membrane became a])parent to the eye. For although whiteness of the tongue is not uncommon in other acute diseases, yet if the morbus suffocans be prevailing at the time, and there be difficulty in swallowing, it certainly indicates the existence of the white crust in the unseen adjacent parts, and also that it will presently appear in the oesopliagus and throat. The certainty is much increased if tumefarc- tion be observed in the neck behind and below the « ears, such swelling being always present in this disease, but especially in cases where the crust tends to a livid hue, and resembles a membrane.* * ' Circa signa propria, quae in hoc inorbo conspiciuntur, non semper eodem motlo apparent ; nam ore adaperto, et depressa lingua, modo con- spiciebam apicem oranino album, exeuntem ab imo gulae, et impedientem deglutionem, modo quandam crustram, veluti membranam, cingentem fauces, guttur, et gulam, non perfecte albam, sed declinantem ad lividam : quae diversitas nascitur ex caus£B diversitate : et simul cum hoc apparebat lingua alba, a radice ejus usque ad medietatem, aut fere totam, per quod SPANISH EPIDEMIC OF THE SEVENTEENTH CENTURY. 15 Although the diseased parts in morbus suffocans were swollen, the material which caused the swellinof was not eiFused into the pores, but external to the part, as if it had flowed over the surface, which it covered like a solid membrane. The false membrane is said by Villa Real to have been so consistent and elastic that it could be handled and stretched like moist leather or wet parchment, without injury to its texture and shape.* These statements, he says, were founded upon experience, for he had often ob- served the excretion of white or blueish fragments of membrane, flexible as wet leather, in patients who recovered; and in the post-mortem examination of those who had died, had found the fauces covered signum simul cum difficultate deglutiendi et grassante tali epydemia, potest cognosci morbus hie incipiens, anteaquam appareat frustrum illud album ; albedo euim linguse indicat esse in parte subjecta, et inferiori, crus- tram albam, quag jam jam per oesophagura, aut guttur, se manifestat : nam licet possit reperiri lingua alba, in febre alia acuta, aut secus, et sic uon sit proprium et pathonomonicum hujusmorbi; tamen sensata simul difficul- tate deglutiendi, et grassante tali epydemia, sis certus morbum esse suffia- cantem. Auget certitudinem, si in cello, et retro aures declivius, tumores conspicias ; nam tales tumores in omnibus reperiuntur, et magis in illis, quorum crustra ad lividum declinat, et est velut membrana, hie enim tumores simul cum aliis signis, syndromen eonstituunt signorum morbi suiFoeantis, nondum apparente crustra; aut si jam appareat, sit tamen puer renitens oris apertioni: in gradioribus enim crustra jam manifesta, ore adaperto, et depressa lingua, evidenter cognoscitur.' — Villa Real, loc. cit. PP-90. 91- * ' Tumen nullus scripsit vidisse in Itiucibus, gula, et gutture, quasdara velut membranas (como pergamiuo) cingentes fauces, &c., et tali con- stantes modo substantiae, ut si propriis manibus tendas, videas ejus partes cedere, quas si desinas, videas refluere, propriumque adquirere locum : non secus ac si corium madidum aut membranam madidam tendas et sinas. Hsec experientia didici, turn in viventibus excreta causa per os, tum in morientibus facta anatomia.' — Villa Real, loc. cit., pp. 34, 35. 16 ON DIPHTHERIA. with a similar membrane, which he could raise with an instrument, leaving the subjacent parts apparently sound.* As has been sometimes observed in this country during the recent epidemic, the white false membrane often existed in the throat at the very commencement of the illness, without any previous indisposition.! Ha3morrhage from the nose or mouth, always a serious symptom in diphtheria, was, ac- cording to the experience of Villa Real, invariably fatal. J Herrera describes eight varieties or stages of this destructive disease, which tally very nearly with what has been observed in this country during our own time. Indeed, it is evident that these Spanish phy- sicians studied the complaint very carefully, and de- scribed what they saw with great fidelity; their descriptions, as far as they extend, being quite ap- * * Partes vero, quae in hoc morbo apparent affici, tument supra naturam, non tamen vero tumore : nam materia morbi sufFocantis non est in partis poris, eandem in tumorem attoUens, sed per modum irrigationis partis super- ficiem afficit, et velut membrana qusedam solida cingit fauces, guttur, et gulam ; neque enim propter maximam ejus crassitiem, et soliditatem, potest recipi in poris. Quae ratio desumitur ab experimento : nam ssepe vidi, in his qui fuerunt liberati, excerni frustra qugedam alba, aut ad livorera declinantia, membranosa quidem, et velut corium madidura flexibilia, et in his qui interierunt, facta anatome, inveni dictam membranam cingentem partes dictas, quam instrumento ferreo levavi, parte subjecta integra ap- parente ; est ergo causa hujus morbi per modum adhserentis, et irrigantis corporis, non per modum tumoris prseter naturam.' — Villa Heal, loc. cit., pp. 102-3. t ' Ego vero, qui millies vidi hos segrotantes, statim in primo insulto morbi, conspexi jam adesse frustrum album in faucibus, gula, aut gutture, nulla prius (dicente segro), sensata Isesione.' — Villa Real, loc. cit., p. 34. J ' Observavi ssepissime, sanguinis narium aut oris fluxum, in hoc morbo esse lethalem ; nullum enim vidi liberatum ex his, qui sanguinem e naribus, aut ore rejecei'unt.' — Villa Seal, loc. cit., p. 136. SPANISH EPIDEMIC OF THE SEVENTEENTH CENTURY. 17 plicable to the disease which, after an interval of two centuries, has so lately appeared among ourselves. The first two varieties closely resembled common sore-throat, and were characterized by inflammation of the throat and surrounding parts, unaccompanied either by exudation or ulceration, and, whilst differ- ing from each other in intensity, were very mild in comparison with the others. Although perhaps less properly called morbus suffocans^ yet Herrera places them in the same categorj^, seeing that they may pass into it ; a circumstance which, as will hereafter be seen, has also been observed during the recent epi- demic. Indeed, there can be no doubt that Herrera was perfectly justified in considering these milder kinds of sore-throat as caused by the same epidemic influence, and identical with the more malignant dis- ease, from which they differed only in intensity, as is acknowledged to be the case with simple and malignant scarlet fever, discrete and confluent small-pox, or cho- leraic diarrhoea and cholera. The third variety had advanced a stage farther, there was excoriation, at- tended by slight soreness. In the fourth, there was ul- ceration, with purulent secretion and severer pain. In the fifth, a spreading sanious ulcer, with still intenser pain and an offensive smell, but without the crust. In the sixth variety, the characteristic crust, from which the disease derives its modern name, diphtheria, was plainly observable upon the ulcer. In this variety, which was more dangerous than any of the preceding, the crust was of a white colour. In the seventh variety the crust was livid ; and in the eighth, C 18 ON DIPHTHERIA. which is the worst variety of all, the crust was black.* Herrera mentions the peculiar character of the voice in this disease, resembling that of persons suffering from secondary syphilis. This, he says, disappeared altogether in the course of time, after the patient had recovered; a circumstance which scarcely happens in the venereal disease. It is hardly necessary to ob- serve that this symptom affords additional confirma- tion of the identity of the morbus suffocans of the * 'Cujus perniciosi morbi octo sunt species seu gradus. Primus, quando capacitas ipsius gutturis et ambitus, et partes vicinae, ut aspera arteria, epiglottis, larynx, aut cesopliagus, musculi interni et extemi, fauces et aliaj rubescere incipiunt. Secundus, quando partes prsedictse insigniter rubescunt, et inflammantur, discratiaque afficiuntur, et jam quodammodo dolorem aliquem sentiunt : qui gradus respectn reliquorum benigni nuncu- pari possunt. Et bse duse species primae absque ulcere non ita proprise hujus morbi suffocantis species sunt ; sed communis cum angina, qui gradus, etsi verse anginae sint ex permutatione ejusdem anginse in morbum suffo- cantem quandoque transeunt : et quousque excoriari, aut exulcerari partes illae incipiant, nomen suffocantis affectus non meretur, cum hi duo gradus ad alterutrum, anginam scilicet, et morbum suffocantem vise existant. Et quoniam hujus morbi principia sunt, ad majorem intelligentiam et ad indicationem curativam principii hujus morbi merito inter speci«s retu- limus. Tertius gradus est, quando ulcera apparent, et est saevior. Quorum ulcerum tres etiam sunt species, seu differentise. Prima scilicet, quando sola excoriatio cum aliquo dolore ulceroso perspicitur, quae tertia est in ordiue graduum. Secunda, quando ulcus cum suo pure, majorique cum dolore apparet, et est quarta, Tertia, cum cancrosum instar carbunculi et cum sanie percipitur, pessimique odoris et figurse ; attamen sine crusta, cum dolore tamen vehementiori, qui usque ad octavum et ultimum graduni incremeritura accipit, qute quinta in gradu existit. Sextus est gradus, cum crusta supra ulcus jam clare conspicitur, et serpit, corrodendo, et putre- faciendo partem ; et tunc vere et proprie crustosum ulcus, et carbuncuiosum, cancrosumque appellari potest : et est omnibus pi-aedictis gradibus pericu- losior. In triplici etiam differentia tale ulcus versatur, album scilicet, quod in sexto etiam est gradu ; lividum in septimo, et nigrum in octavo, et omniani graduum pessimo.' — Herrera, loo. cit., pp. 6, 7. ITALIAN EPIDEMIC OF THE SEVENTEENTH CENTURY. 1 9 seventeenth with the diphtheria of the nineteenth century; or that it shows partial paralysis of the muscles of the throat to have been a common sequel of the disease when Herrera practised as well as now. Lastly, he mentions the occurrence of diar- rhoea as an unfavourable sign, at whatever stage of the illness it appeared.* Some years after its appearance in Spain, but yet early in the seventeenth century, the morbus suf- focans showed itself in the kingdom of Naples, and afterwards in Sicily, where it raged with much severity, proving very fatal among children, and overspread the whole island. I have not had an opportunity of consulting the writings of the Neapo- litan physicians who described the epidemic in Italy, but I have read the account of the disease in Sicily written by Alaymus and Cortesius. The latter, in his introductory observations, asserts that the several Neapolitan physicians held very different and often quite opposite opinions respecting the nature of the disease, which they called by various names, in accord- ance with the diversity of their views. f In Sicily it was called simply the throat disease — ' gulcB morbus,'' * ' Depressa lingua, in imo guise nota qusedam alba solet conspici, quae in causa est, ut segri non bene loquantur, ut accidit in his, qui morbo Gallico corripiuntur . . , . et aegroti ad sanitatem redacti decursu temporis eque ut antea loquuntur ; quod in morbo Gallico secus accidit' .... Serrera, loc. cit., p. 19. ' Ex alvi fluxu symptomatico, continue et immoderato, sine ope et auxilio raedicamenti purgantis, malum etiam potest desumi prgesagium, sive in principio, sive post accidat.' — Herrera, loc. cit., p. 20. t ' Morbus hie, cujus naturam scire optas, respirationem, sed maxime de- glutitionem Isedit, nullumque aliud nomen in hac Urbe adeptus est, nisi c 2 20 ON DIPHTHERIA. As in the present day, the disease differed greatly in malignity, in the extent of the local affection, in its tendency to spread over the adjoining parts, and in depth; being sometimes wholly superficial, at others, attended by much swelling and inflammation, both of the external and internal parts of the neck.* Sometimes there were redness and inflammation of the surface of the palate and uvula, the tonsils remaining unaffected ; but at others, and more frequently, these glands were swollen, and sometimes so much so, that they touched each other, thereby interfering with deglutition and respiration. In the beginning there were usually swelling, heat, and redness; afterwards, guise moibum, eb quod appareat partes spectantes ad gulam ita Isesas esse, ut etiam deglutiendi actio plane Isedatur. De eo varie quidem niulti authores Parthenopsei hactenus scripserunt, sed inter se parum constantes sunt, sive nomen, sive essentiam consideremus ; alii enim affectum strangu- latorium, alii phlegmonem anginosam, alii pestilentem faucium affectum, nonnuUi epidemiam gutturis luem, et aliqui tandem variis nominibus pro varia ipsorum opinione designarunt : et hsec quo ad nomen. ' Quod spectat ad essentiam, alii scribunt eum esse aphtas malignas, alii arbitrati sunt reponendum esse in genere carbunculorum, alii intrepide pro- nuntiarunt esse anginam, qui inter se tamen divisi sunt; nam horum aliqui existimarunt esse anginam proprie dictam, alii e contra anginam lato modo, et improprie acceptam, alii determinarunt esse erysipelas, seu ignem sacrum faucium, alii denique putarunt esse inflammationem proprie dictam, quam phlegmonem Grseci appellant.' — Joannis Baptistce Cortesii, Miscellaneo- rum Medicinalium Decades Dence, p. 696. Messanse, 1625. * ' Et propterea ulcerura alia sunt maligniora, alia minus maligna, alia magis, alia minus serpentia, alia profundiora, alia minus descendentia, alia sordidiora, alia minus, alia escbaram profuudiorem, alia superficialem babent, alia Gangrenosa, et alia sphacelata, alia crustam, et sorditiem albam, alia nigrara admittunt, alia maxima cum inflammatione, et tumore, turn inter- uarum, tum externarum gulae partium conjunguntur, alia verb minus, alia, et ut plurimum, in tonsillis, alia in columella, alia in faucibus, alia aliquando in laringe, et in musculis gutturis, alia, et rarb in palato, alia in naribus nascuntur.' — Marci Antonii Alaymi, Co7isuUatio, pro Ulceris Syriaci nunc Vagantis Curatlotie, p. 54. Panhoruii, 1632. SICILIAN EPIDEMIC OF THE SEVENTEENTH CENTURY. 21 pain and difficulty of swallowing. When there was only inflammation of the parts about the throat, the sick easily recovered ; but sometimes a certain pitui- tous substance (exudation), descending from the head so speedily and unexpectedly followed the inflamma- tion, that the patient was suddenly suffocated. Very often a white substance, which presently became livid, and afterwards black, unaccompanied by pain, appeared on the inflamed surface. This material could be readily torn away from the subjacent parts, either by the finger or an instrument; but, although the operation caused no pain, the patient invariably died a short time afterwards, as happened, amongst others, to the son-in-law and grandchild of Cortesius. Sometimes mortification, accompanied by foetor, quickly invaded some part of the throat; and when this occurred, whether foetor were present or not, remedies proved unavailing, and the patient died about the fourth day, or even earlier; rarely so late as the seventh day.* Cortesius notices the frequent occurrence of se- * * Hsec aifectio Isedit pharynga. . . . Modus erat diversus ; nam aliquando pars extima palati rubicunda, et inflammata simul cum ipsa uvea appai'ebat intactis glandulis, nonnunquara et seepius glandulse prsedictse intumescebant, cum calore, et rubore primum, deinceps cum dolore, et magna deglutiendi difficultate, nonnunquam adeo tumidsB erant, ut ad in- vicem se contingerent, viam ad deglutiendum, et respirandum intercluden- tes, igitur omnes istie partes aliquando sola inflammatione, nonnunquam solo erysipelate,interdum omnes simul corripiebantur uno, vel altero affectu' Veriim si ad hunc remansissent moduni, hoc est vel inflammatione, vel erysipelate afTectse, facile segrotantes liberati fuissent, sed ad praedictarum partium inflammationem subsequebatur interdum materia qugedam pitui- tosa a capite tarn repente, et inopinatb descendens, ut miseri gegrotantes subito sutfocarentur, Non raro apparebat materia qusdam alba in super- ficie, quae paulo post ad livorem, delude ad nigredinem absque dolore muta- batur, quod gangrsense signum est manifestissimum, verum in sola supev 22 ON DIPHTHERIA. veral fatal attacks in the same family; a circumstance which has also added largely to the distress and alarm which diphtheria has lately caused in England. According to Alaymus, the disease generally com- menced in the tonsils, the uvula, or the fauces ; some- times in the larynx; at others, but rarely, in the palate, and occasionally in the nostrils.* There was reason for supposing the disease to be contagious, and a case reported by Cortesius strengthens the opinion. A monk being attacked by the disease, constantly complained that he observed a foul odour proceeding, as he supposed, from his mouth; and, to assure himself of the truth, requested a friend to verify the fact by smelling. Xot many hours after ficie esse sensus judicabat, et quod magis est, videbatur a subjectis partibus facile divelli posse. * Si quis tamen vel digitis, vel aliquo instrumento levi ipsam auferre tentasset, quamvis operatic haec fieret absque dolore, ea tamen ablata brevis- simo tempore peribant segrotantes, quod prse cseteris in Petro Soprano genero meo observatum est, cui cvim bujusmodi mortificatio apparuisset in suprema superficie dictarum glandularum faucium, et palati, ita ut videretur esse maximo respirationi, et deglutioni impedimento, Chirurgus existimans posse facillimo negotio a subjectis partibus earn separari solis digitis, levis- sime quidem earn abstulit, qua ablata tantum abest ut juverit deglutitionem, aut respirationem, ut potius utraque actio Isesa magis fuerit, unde brevis- simo tempore miser meo cum maximo dolore mortem oppetiit, id quod etiam in aliis quamplurimis, pueris ssepiiis observavi, et prtesertim in ejusdem Petri filiolo nepoti ex filia quinque annorum mihi carissimo, qui postpaucos dies eodem modo, quo pater vitam cum morte mutavit. * Aliquando, ut dixi, harum partium unam tantum, vel duas, vel etiam omnes simul bujusmodi mortificatio celeriter invadebat cum fcetore, et ubi tale symptoma apparebat, sive cum fcetore, sive sine foetore casus omnino erat deploratus ; omnia enim medicamenta tarn intus, quam extra frustra admovebantur, quia ajgrotantes celeriter moriebantur, uonnunquam in quarta die, et citius etiam, raro septimara diem attingentes, et quod miser- abile admodum erat, observabatur in una, et eadem domo plures pericli- tari et absque auxilio interire.' — Cortesius, loc. cit., p. 697. * Loc. cit., p. 54. SICILIAN EPIDEMIC OF THE SEVENTEENTH CENTURY. 23 doing so, in the presence of Cortesius and others, the friend was laid up with inflammation of the fauces and tonsils, and, remedies proving useless, died on the fourth day of his illness.* Although the description of the disease given by these Sicilian physicians is in some respects less minute and graphic than that of the Spanish authors already quoted, it is impossible to study their writings carefully without coming to the conviction that the disease recorded by them was identical with the garrotillo of the Spanish authors, and also with the disease termed diphtheria described by Bretonneau and other Avriters of the present century. The se- veral varieties of the disease mentioned by Cortesius and Alaymus closely correspond with those described by Herrera, and also with those recorded by later observers. The simple inflamed sore-throat, yielding readily to remedies ; the sloughing of the tonsils and * ' An modo contagiosus fuerit hujusmodi morbus, non vacat suspicione ; nam multi medici observantes tot iutei'ire, et praesertim in una et eadem domo, et tain frequenter cogitabant otnuino morbura esse contagiosum. . . . Anno prseterito contigit res digna auditu. Divi Francisci Gustos vir doc- trina et moribus insignis hac lue obsessus, tonsillas solummodo, et garga- reonem inflammatione laesa habebat, et continuo querebatur se percipere in ore foetorem quendam, et ut hac de re certior redderetur, ad se vocavit Baccalaureum quendam sibi amicissimura, qui maximo aflPectu assistebat, rogavitque, ut vellet olfacere, percipereque naribus, an verum esset talem foitorera emittere, an ab iraaginatione ejus prodiret : olfecit Baccalaureus me prsesente, et multis aliis, at statim non multis elapsis horis decubuit sola faucium, et glandularum inflammatione vexatus absque aliqua manit'esta corruptione partiura, omnibusque prajsidiis ex arte frusti'a iactis quarto die Buffocatus periit, et tamen Custodem non tetigerat, sed solo olfactu aerem ab ore prodeunte naribus traxerat, quai-e ab hujusmodi exeniplo veni in sententiam hunc morbum non esse absque aliqua contagione.' — Cortesius, loc. cit., p. 698. 24 ON DIPHTHERIA. adjacent parts of the pharynx; the foul fcEtor of the throat, in certain cases ; the exudation of a white, livid, or blackish crust on the inflamed surface, from which it was often readily removed without pain ; the rapid and sometimes unexpected death from suffoca- tion ; the peculiar nasal voice ; the probable commu- nicability of the disease, and its dire ravages in households attacked by it, are unmistakeable fea- tures identifying the fatal Sicilian disease w^ith the recent epidemic of diphtheria. Thus, then, undoubtedly diphtheria, although under other and various names, prevailed for many years as an epidemic in the south of Europe about the close of the sixteenth and commencement of the seventeenth centuries. Whether it then disappeared altogether as an epidemic or not I have been unable to discover; but it certainly prevailed again epide- mically in many parts of the continent of Europe, in Great Britain, and in Xorth America, about the middle of the following century. The earliest notice of the disease in this country is that contained in Dr. Fothergill's Account of the Sore Throat attended with Ulcers^ published in 1748. A disease, supposed to be the morbus strangulatorius had been observed in London or the neighbourhood in the year 1739, and cases were now and then met with by most medical men in extensive practice, espe- cially in the City, during the subsequent years, until 1746, when it broke out in a more alarming manner at Bromley in Middlesex, and at Greenwich. It afterwards appeared more generally in the metropolis ENGLISH EPIDEMICS OF THE EIGHTEENTH CENTURY. 25 and the surrounding villages. Children and young people were more liable to it than adults, girls than boys, women than men, the delicate than the robust. The illness usually began with giddiness, chilliness or shivering followed by fever, acute pain in the head, stiffness of the neck, soreness of the throat, and sometimes vomiting and diarrhoea. The pain, heat, and restlessness increased towards night, and were often mitigated by the breaking out of a sweat towards morning. ' If the mouth and throat,' says Dr. Fothergill, ' be examined soon after the first attack,, the uvula and tonsils appear swelled ; and these parts, together with the velum pendulum palati, the cheeks on each side near the entrance into the fauces, and as much of them and the pharynx behind as can be seen, ap- pear of a florid red colour. This colour is com- monly most observable on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this redness, a broad spot or patch of an irregular figure, and of a pale white colour, is sometimes to be seen, surrounded with a florid red, which whiteness commonly appears, like that of the gums, immediately after having been pressed with the finger, or as if matter ready to be discharged was contained underneath. ' Generally on the second day of the disease, the face, neck, breast, and hands to the fingers' ends, are become of a deep erysipelatous colour, with a sensible tumefaction ; the fingers are frequently tinged in so remarkable a manner, that, from seeing 26 ON DIPHTHERIA. them onl}', it has not been difficult to guess at the disease. * A great number of small pimples, of a colour dis- tinguishably more intense than that which surrounds them, appear on the arms and other parts. They are larger, and more prominent in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and lower extremities.'* These white places presently became more of an ash colour, ' when it was discernible that what at first might have been taken for the superficial covering of a suppurated tumour, was really a slough concealing an ulcer of the same dimensions.' All parts of the fauces were liable to be affected ; but the disease in general first appeared in the angles above the tonsils, or on the tonsils themselves, on one of the arches formed by the uvula and tonsils, on the posterior w^all of the pharynx, on the inside of the cheeks, or on the base of the tongue. In the milder form of the disease, an irregular superficial ulcer, scarcely to be distinguished from the sound parts but by the roughness of surface it occa- sioned, appeared on one or more of the above-men- tioned parts. ' A thin, pale, white slough seems to accompany the next degree ; a thick, opaque, or ash- coloured one is a further advance; and if the parts have a livid or black aspect, the case is still worse. These sloughs are not formed of any * An Account of the Putrid Sore Throat, by John FoTHEEGlLL, M.D., pp. 32-34. Filth edition, London, 1 769. ENGLISH EPIDEMICS OF THE EIGHTEENTH CENTURY. 27 foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the sub- stance; since, whenever they come off, or are sepa- rated from the parts they cover, they leave an ulcer of a greater or less depth, as the sloughs were super- ficial or penetrating.'* In one case these sloughs were separated by a sur- geon's probe without much difiiculty ; but the same parts were covered the following day with thick, dark, ash-coloured sloughs penetrating deep into the sub- stance. f The eruption was not always present, and especially in the winter of 1754, it either did not ap- pear at all, or its appearance was retarded. There was commonly much swelling of the parotid glands and neighbouring parts, and the tonsils and uvula were sometimes so much swelled as to leave but a narrow entrance to the gullet, which was also fre- quently surrounded with ulcers and sloughs. Yet, althou Tinct. ferri sesquiclil. . ^^s. Mellis 5J. Aquae ad. 3VJ. M. Ft. gargarism. ssepe utend. 9> Infus. serpentariae . . 5^"J' Ammon. sesquicarb. . . 3ij. Sp. ammon. aromat. . 5U- M. Cap.^ochl. ij. magn. 6ta q. hora. June 2. — Throat somewhat less congested, but the surface of the tonsils continues very tender. The 168 ON DIPHTHERIA. patches of exudation have a ragged appearance, as if separating. Surface cool; pulse 60, feeble. To have two glasses of wine during the day, and any nourishment that can be taken. Patient reco- vered. The following is another case of the same class, which I saw only once, and am therefore unable to report in detail. It terminated favourably : — M. B., aged three years, Jz//y, 1859. — Has been ailing for three days. Throat inflamed, and of a bright-red colour; tonsils much enlarged. On the right tonsil there is a patch of exudation the size of a sixpence ; on the left a smaller patch of the size of a grain of wheat; there are also three small patches on the posterior wall of the pharynx. These patches are of an ash-colour, and firmly adherent to the na- tural surface. The pulse is quiet; tongue creamy; there is no remarkable depression, no heat of skin, and apparently no difficulty of swallowing. The glands at the angles of the lower jaw are slightly swollen, but the child is playful, and does not present the appearance of serious illness. These varieties of diphtheria, in which the exuda- tion exhibits the appearance of a filmy glazing of the l^osterior fauces and tonsils, or of small circumscribed patches which do not coalesce, are comparatively mild, and rarely, if ever, prove fatal. In most epi- demics they have formed a majority of the cases, but, although so mild, since they exhibit the characteristic local test of the disease, they must be regarded as genuine cases of diphtheria. From their usualK'- DIPHTHERIA WITH MEMBRANOUS EXUDATION. 169 favourable termination, they have probably given rise to mistakes as to the efficacy of treatment, parti- cularly of local treatment. They, for the most part, recover readily under the use of simple remedies, and, though more tardily, under the application of caustics and other powerful irritants to the throat; and such recoveries have j^erhaps been sometimes erroneously attributed rather to the efficacy of the treatment than to the mild fiature of the ailment. The class of cases to which attention must now be directed is of a much more serious kind than any of those hitherto described. The exudation may, as in the former varieties, commence in the form of a thin translucent pellicle, or in detached patches; but it ra- pidly becomes thicker, and the separate patches coa- lescing, soon cover the inflamed surface, which often continues to widen in extent, until the disease has crept into the nose, the oesophagus, or the larynx. This variety of diphtheria is, in truth, one of the most formidable of diseases, and very often indeed baffles the best-directed efforts of the practitioner. The exudation may appear either as a granular deposit, possessing little cohesion, and of various de- grees of dryness or humidity, or as a more or less dense, elastic, and coherent false membrane. Doubt- less the two forms pass by insensible gradations into each other; and, as in the subjoined case, may coexist on different mucous surfaces of the same subject. The patient, a little girl aged eight years, had been ill for several days when she came under my care in December, 1857, and died within a few hours after 170 ON DIPHTHERIA. being visited. Had been suffering from slight catarrh and sore-throat for four or five days, but was up and about until within five or six hours of death. There was slight cough, and the breathing was rather stri- dulous, but not distressingly so. The tonsils ap- peared swollen, and both they, the arches of the palate, and the posterior fauces, were closely covered with a greyish or ash-coloured deposit. Dyspnoea came on suddenly in the course of the night, and the patient expired before medical aid could be procured. A post-mortem examination of the throat only was permitted. The ash-coloured deposit which loosely covered the pharynx, tonsils, and velum was found to be dry, granular, and friable. The subjacent mucous membrane was pale, rough, and excoriated. The oesophagus was perfectly healthy, the exudation ceasing a little below the level of the epiglottis. The uj)per surface of the epiglottis was partially covered with granular deposit similar to that on the tonsils and pharynx. This deposit gave place at the rima glottidis to a white croupy membrane, which extend- ing through the larynx, and downwards as far as the third or fourth ring of the trachea, formed a perfect tubular cast of the parts it covered. It was thick and tough above, but became gradually thinner as it descended into the windpipe, and terminated in an exceedingly thin, semi-pellucid, soft, and easily lace- rable margin. It was loose, merely adhering by a few points, and was readily lifted away by forceps, leav- ing the mucous membrane slightly reddened, conti- nuous, but with a few yery small bloody points where DIPHTHERIA WITH MEMBRANOUS EXUDATION. 17 1 the membrane had been still attached. There was a loose portion of membranous exudation in the larynx, and also a pellet of granular material similar to that in the pharynx, from which it had possibly passed in the progress of the hasty post-mortem exa- mination. The variety of diphtheria attended by granular deposit has been less common during the recent epidemic than the other, from which, in the cases I have seen, it has differed but little as regards severity or danger, but has been more frequently accompanied by excoriation or superficial ulceration of the mucous membrane. The most usual appearance of diphtheritic exuda- tion is that of a false membrane possessing more or less cohesion, and frequently very firm and elastic. Doubtless liquid when first effused, it speedily coa- gulates, and, as it grows in thickness, becomes denser, firmer, and tougher. It usually makes its appearance in the form of detached spots, very fre- quently upon one or both tonsils ; these sj)ots becom- ing thicker by successive additions from below, at the same time extend in circumference, and coalesce, so as to form a single plate of deposit. When first seen they are usually white or ash-coloured; and when these have united so as to form a uniform layer, they very closely resemble wet parchment; thus agreeing very accurately with the description given by Villa Real of the false membrane observed by him in the Spanish epidemics of the sixteenth and seventeenth centuries. By and bye they become dis- 172 ON DIPHTHERIA. coloured from the effects of decomposition or expo- sure, or stained of a blackish hue, probably in con- sequence of slight haemorrhage. In other cases, the membrane assumes a buff or brownish colour, very much resembling damp wash leather, and then usually adheres very firmly to the subjacent surface. In either case, the breath is apt to smell offensively, partly no doubt from the decomposition of the exu- dation; but likewise, and especially as the smell sometimes exists at a very early stage of the disease, from the depraved secretion of the tonsils. Which- ever of these appearances the exudation may present, the disease is very apt, as has already been said, to spread along continuous mucous surfaces, and thus to invade the nares, and sometimes, but rarely, the eye, to extend to the lower part of the pharynx, to the larynx and trachea, more rarely to the oeso- phagus, and sometimes forwards on to the cheeks and gums. The invasion of the nares by diphtheritic inflamma- tion, is generally manifested by redness of the margin of the nostrils, and a discharge of sanious ichor, resembling that common in scarlet fever, and also, like it, sometimes excoriating the upper lip. Epis- taxis is not an infrequent consequence of nasal diph- theria. Haemorrhage from the throat also occurs in pha- ryngeal diphtheria, but, unless in connexion with purpura, less frequently, I think, than that from the nose. In either case, the loss of blood, by exhausting the already enfeebled powers of life, has sometimes DIPHTHERITIC OPHTHALMIA. 173 appeared to determine a fatal result, and must always be regarded as an unfavourable symptom. I have not myself seen diphtheria of the conjunc- tiva. Dr. May, of Maldon, informs me that he saw one case in which the disease spread upwards, through the nasal duct to the right eye. The eye was much swollen; and the palpebral conjunctiva covered with false membrane, which came away in shreds before death. Mr. Thompson, of Launceston, who has seen a great deal of this disease, says, only one case of diph- theritic ophthalmia occurred in his neighbourhood; the deposit extended over the lower half of the con- junctiva.* Mr. Jonathan Hutchinson has published a case of diphtheria of the eye, treated at the Royal London Ophthalmic Hospital, of which I here quote the main facts : — ' Herbert P., an infant at the breast, aged six months, was brought to the Ophthalmic Hospital, June 6, 1859. He was a stout, well-grown child. The eyelids of both eyes were extremely swollen ; the skin being tense and glazed. There was a cer- tain amount of unhealthy secretion flowing from them. On opening the lids of one of the eyes, the conjunctiva in every part, palpebral as well as ocular, was concealed from sight by a thick layer of coherent lymph. This layer ended abruptly at the circum- ference of the cornea, and the latter structure was * British Medical Journal (June 5, 1858) p. 450. 174 ON DIPHTHERIA. throughout dimly opaque, though still preserving its perfect form, and free from any appearance either of ulceration or sloughing. There was no true purulent secretion ; what of fluid was present consisting of a thin ichor. The pellicle was examined microscopi- cally by Dr. Bader, immediately after removal, and was found to consist of exudation cells entangled in the meshes of a loosely fibrillating matrix. The diphtheritic pellicle might be peeled off with forceps in fragments of considerable size, and the raucous membrane beneath it was swollen, intensely congested, and readily bled. The two eyes were in an exactly similar condition. The little patient was pale, with a hot dry skin and an oppressed aspect. His tongue was a perfect type of what is known as the strawberry tongue of scarlet fever, from which disease his two brothers were then suffering. One of these, a child aged three years, had sickened with scarlet fever four days before the ophthalmia commenced in the infant. "With regard to the latter it appeared that the eyes had been attacked simultaneously four days before application at the hospital. There had been consider- able discharge from the nostrils, and the diphtheritic inflammation evidently extended in a slight degree to the nasal passages. ' Treatment. — Having separated the lids by means of a speculum, I carefully peeled away, partly by scraping with a scoop and partly by forceps, the whole of the false membrane, and then brushed the conjunctiva in every part with an almost saturated solution of nitrate of silver. A saturated solution of DIPHTHERITIC OPHTHALMIA. 175 chlorate of potash was prescribed to be used as an injection into the eye — internally the administration of chlorate of potash with liquor cinchon£e was pre- scribed.' ^Subsequent Progress. — On the following day I repeated the application of the nitrate of silver. The diphtheritic exudation had been partially repro- duced, but not very extensively. On the third day the condition of the eyes seemed much improved, the swelling of the lids had greatly diminished, and there was very little false membrane. The corner, how- ever, were still quite opaque. There was now a rash upon the child's chest; it consisted of scattered, minute, red points, but more resembled certain forms of lichen than the rash of scarlet fever ; the skin was still harsh and dry, but the tongue was improving, and its papillae less prominent. There had been throughout no sore-throat whatever, nor any inflam- mation of the mouth. On the fourth day the rash had disappeared. There were now central sloughs on both corneae. On the seventh day the sloughs were separating, and it was evident that both eyes were lost. The diphtheritic exudation had now wholly passed off. The child was still more feeble and looked very ill; ammonia in combination with bark was ordered. On the tenth day a large abscess had formed over the right shoulder. It fluctuated freely, and having very little induration of the surrounding cel- lular tissue, much more closely resembled a pysemic deposit of pus than an ordinary abscess. ' After the date of the last note the child was not ] 76 ON DIPHTHERIA. brought to the hospital for several months. On October J5, both globes were collapsed, their entire corneas having been destroyed. The abscess over the shoulder had been opened by another surgeon, a few days subsequent to the last attendance at the hospital. It had healed, and no other had formed. The child still remained pale and cachectic, and its constitution had evidently received a most severe shock from the illness through which it had passed.'* Mr. Hutchinson remarks that ' the case was one of a class entirely new to him, and that so extensive and well developed was the pellicular exudation which covered the ocular mucous membrane that there could be no hesitation in considering it as a true diphtheria. It may be remarked that the remedies used were rapidly efficient in attaining their immediate object, that of preventing the re-formation of the false mem- brane. Had the case been seen earlier, they might, in all probability, have saved the corneje.' The above case can scarcely be considered as one of pure uncomplicated diphtheria, seeing that the child had been in relation with the poison of scarlet fever, which was present in the house at the time of its illness, and that although unaccompanied by the specific rash or sore-throat of that complaint, its tongue exhibited the character of the tongue in scarlet fever. But there is no doubt the character of the ophthalmia was determined by the epidemic influence, and that the case belongs, therefore, to the same * Ojahthalmic Sosjaital Reports (October, 1859), pp. 130-2. DIPHTIIERITIC CROUP. 177 category with the diphtheritic affections associated with external injuries and with other diseases already recorded. The rarity of diphtheritic ophthalmia may be inferred from the circumstance mentioned to me by Mr. Dixon, that out of the thousands of cases which annually come under the notice of the surgeons to the Royal Ophthalmic Hospital, this is the only genuine case of diphtheritic ophthalmia he had ever seen. This fact is the more remarkable, as it appears from the statements of French, and especially of German writers,' that this particular form of the disease is by no means uncommon abroad. The extension of diphtheria to the larynx and trachea is a common occurrence m some epidemics and in particular localities, but rare in others. It was very common in at least the earlier epidemics seen by Bretonneau; and in some of the older epi- demics, which, on this account, obtained for the disease the name of morbus stra7igulatorius^ or garrotillo. Of fifty- two post-mortem examinations made by Bre- tonneau in two years, the larynx or trachea was only free from exudation in one instance, that Of a child, who appeared to die from exhaustion on the fifteenth day of the disease.* The recent epidemics in the North of France, and the English epidemics of the last four years, have less uniformly manifested this character. In a few places the disease is said to have manifested no disposition to attack the larynx or trachea; in others most of the cases ending fatally * Memoirs on BipUJieria, Selected and Translated by Dr. Sample, p. i6, N 178 ON DIPHTHERIA. have terminated in croup consequent upon the extension of the disease tlirough the glottis. But in a large proportion of the districts where the disease has prevailed, its character has, in this respect, been mixed, many cases ending in recovery or death with- out affection of the larynx, others being complicated with the symptoms of croup. Dr. Hcslop, of Bir- mino;]jam, informs me that he does not think the disease has reached the larynx in more than five per cent, of the cases he has seen in that neighbourhood. Of thirteen fatal cases in the practice of Mr. Schofield, of Higligate, near Birmingham, with the particulars of which he has favoured me, only three were accom- panied with symptoms of croup. Diphtheria had been the sequel of scarlet fever in all three. Of nine fatal cases seen by Dr. Capron, of Guilford, only three died with laryngeal symptoms. Of twerit}''- six fatal cases reported by correspondents of the British Medical Journal^ only nine, including one from bronchitis, appear to have proved fatal from laryngeal complication.* Mr. Thompson, in an ac- count of the disease in the neighbourhood of Launces- ton, says, that of 485 cases that came under his observation, the air-passages were involved in fifteen, eleven of which died, generally within a few hours after the commencement of croupy breathing.f The case of the child already related (page 170) well illus- trates that form of diphtheria in which extension of * British Medical Journal (June 25, 1859), p. 489. ■j- Loc. cit. (June 5, 1858), p. 449. P DIPHTHERITIC CROUP. 179 the inflammation into the larynx or trachea leads to a fatal result. For the following well-reported case, which I have somewhat shortened, I am indebted to Mr. Jauncey, of Birmingham : — Samuel, aged six years, a delicate, scrofulous-look- ing child, was seen for the first time on May 28, 1858. He had just been brought home from the country, and had been ailing slightly for the previous four or five days. Typhoid fever was prevalent in the village where he was staying, but of diphtheria nothing was heard. May 28. — Tongue thickly covered with white fur. Tonsils enlarged, and of a deep-red colour, without exudation ; skin moist ; pulse 90 ; bowels open ; appe- tite impaired. To be kept in bed. Beef-tea diet ; poultices to be applied round the throat; to gargle with barm and water. 9^ Infus. rosge co. ^^s. ■ 4tis hor. sum. 29th. — Thick exudation over tonsils and uvula, showing fibrinous structure under the microscope, and also a specimen of ' oidium albicans.' Urine sp. gr. 1016; clouded by heat and partially cleared by nitric acid. The throat was brushed with equal quantities of dilute muriatic acid and water. To take four drops each of tr. ferri mur. and dil. muriatic acid every third hour ; port wine and jelly. 30th. — Exudation less. 31st. — False membrane still covers the throat ; n2 180 ON DIPHTHERIA. breathing easy; patient does not seem depressed; continue treatment; ol. ricini. June I. — A croupy cough came on in the night, and is well marked this morning. Urine free from albumen. Seen in consultation by Dr. Heslop. To have an acid gargle and a mustard emetic. Vesjjere. — The breathing is accompanied by marked stridor, which was easier after an application of the acid. 2nd. — ' Croupous' symptoms very marked. A blis- ter on the throat, and emetic of sulphate of zinc and ipecacuan . Vespere. — Countenance dusky ; stridor great ; voice suppressed. Mustard emetic to be repeated. 3rd. — Died at four o'clock a.m. P.-m. Examination. — No pleuritic effusion; lungs emphysematous in front, patches collapsed poste- riorly. Deposit of tubercle in two bronchial glands, and also of the size of a horsebean in the right lung. A patch of false membrane at the bifurcation of the trachea. Trachea reddened, but free from exudcition. Larynx and epiglottis covered with lymph, as were also the pharynx, tonsils, and uvula. Between the pharynx and vertebrae was an abscess about the size of a walnut Liver, kidneys, and spleen healthy; the kidneys were examined microscopically. Comparatively few persons recover when diphtheria extends downwards into the air-passages; but some- times moulds of the larynx, trachea, and bronchial tubes, to their third or fourth division, and in a case DIPHTHERITIC CROUP. 181 seen by Mr. Thompson, of Launceston, to the fifth division, are expectorated with immediate, though too often only temporary, relief to the patient, who frequently succumbs from a renewal of the exudation. Sometimes casts of the smaller bronchial tubes are brought up piecemeal in a glairy expectoration. Occasionally the relief afforded by the expectoration of casts of the larynx and trachea is permanent. A case of this kind, in which the patient was, as it were, snatched from the jaws of death by the separation of a membrane which had threatened speedy suffocation, has been already mentioned (page 83); and I have in my possession an almost entire cast of the larynx expectorated by another patient, who appeared to be dying. The excretion of the membrane was, in this case, also followed by speedy and permanent relief. A case related by Dr. Starr, which came under his care in 1749, is so well told, so well exemplifies the tendency to a renewal of the exudation, and so well shows the identity of the disease in the present with that which prevailed in the last centur}^, that I am induced to quote the more important parts of his description.* ' December ii, 1749. — I was called to the son of Mr. Kitto, a farmer in the parish of St. Eve, a lad aged ten and a half years. This was the seventh day of his illness. His first complaints were a pain in swallowing, not great; a cough, hoarse, vexatious, like an incipient catarrh; a pain on coughing shot * FJdl. Trans, a.d. 1756. Vol. xlvi. pp. 442-3. 182 ON DIPHTHERIA. into his ears. This was still felt at times. A thin ichor ran from his mouth in great plenty, supposed to be a quart or three pints daily. ' His pain in swallowing was now so trifling that I saw him drink a considerable draught without re- moving the vessel. He was now so hoarse that he could scarcely be heard. His cough was rough, low, short, and ineffectual ; he breathed with much strait- ness and noise, especially in inspiration ; the wheezing or rattling might be heard at a great distance. Was always worse during a coughing fit, or for a short time after. When he spit by the cough it was glairy, but glutinous ; a whitish, rotten sort of stuff would sometimes accompany it, its quantity never great. Examining his mouth, he could move his tongue every way without the least pain; forward it was clean, but behind a little furred. Depressing it with a spatula, a white body was seen on the velum pen- dulum palatinum and tonsils. I desired Mr. Scotch- burn, a surgeon present, to examine with his forceps if this body adhered firmly to the velum, or was loose; on trial he found it strongly adhered. The lad complained of no pain on his taking hold of it. The circumambient parts were of a somewhat deeper red than natural;, his breath stinking, and highly offensive In a violent fit of coughing with a deal of slimy, filthy stuff from the pipe of the lungs, the membrane separated from the velum palatinum. It was not rotten like a slough, but retained, though dead, its membranous structure; was strong; would bear handling and stretching I DIFIITHERITIC CROUP. 183 without breaking.* .... The lad imme- diately, as I was told, breathed better, without that wheezing and noise heard before, and was less hoarse. . But, as usual, this relief did not prove lasting. In an hour and half the noisy respiration began anew ; his hoarseness increased, and his cough, though short and low, was busy and vexatious ; now he appeared as if quite strangled, and in the agonies of death ; now he would again revive At length, his father perceiving somewhat in his mouth, drew it out. It was a hollow bag. . . I found the supposed bag was the mucous coat of part of the larynx, the whole aspera arieria, with the grand division of the bronchial ramifications. ' There was something bloody visible about its middle. It was more rotten and tender than the former He now complained of sore- ness in the pipe, and pointed to the first and second costa as the place of its termination. Examining his mouth, no ulcer or wound was discernible in that part of the velum, &c., to which the slough adhered. It was smooth, clean, and looked only like a new skin not quite hardened He died in the end somewhat suddenly, though in his perfect senses.' The extension of diphtheria to the oesophagus is * A figure of the membrane is published with Dr. Starr's paper in tlie Phil. Trans. It very closely resembles one sent from the same county by Mr. Thompson, of Launceston, and exhibited by Dr. Murchison at a meeting of the Epidemiological Society in 1858. See also Trans, of Path. Society of London. Vol. x. p. 320. 184 ON DIPHTHERIA. rather to be inferred from symptoms, than proved by examination. From Dr. Gull's observations, it seems probable that diphtheria may commence in the lower part of the pharynx, out of reach of vision, and thence extend into the opsophagus.* The symptoms are ex- treme difficulty of deglutition, amounting sometimes to total inability to swallow even fluids, followed in some instances by vomiting, as if the disease had extended to the stomach. In one of Dr. Gull's cases the fauces were injected, but free from exuda- tion ; the finger passed into the lower part of the pharynx discovered a thickened and obstructed state of the part. Any attempt to swallow, even a small quantity of fluid, was followed by its ejection through the nostrils. In a second case, the fauces were not noticeably affected. Mr. Stiles, of Pinchbeck, informs me that he has met with cases in which there was difficulty of ' swallowing, without any evident throat affection. He attributed this to the existence of diphtheritic exudation in the lower part of the pharynx, or the oesophagus, beyond the reach of vision. In one in- stance, a patient thought from a sensation of choking that some substance was sticking in his throat, and on passing a probang, shreds of false membrane were brought up on the sponge. Diphtheria existed in the patient's house at the time. Probably oesophageal diphtheria is most frequently caused by the extension of the disease from its usual seat in the fauces, and * Loc. cii., pp. 300, 305. DIPHTHERIA OF THE CESOPHAGUS. 185 thus sometimes occurs after the disease wouhl seem to have disappeared. It is attended by extreme difficulty of deglutition, often followed within a day or two by pain either during the passage of food through the oesophagus, or after it has arrived in the stomach. Indeed, severe gastrodynia is not of in- frequent occurrence during convalescence from diph- theria; but has not, under my observation, led to any worse result than delaying recovery by pre- venting the patient from eating. In one instance, in the practice of Mr. Balls, of Spalding, diphtheria was followed, after apparent recovery, by intense pain at the epigastrium, vomiting, and collapse, which proved fatal in thirty hours. The patient had been impru- dent in diet the day previous to the attack of pain ; but this Avould scarcely have determined so serious an affection. Unfortunately, as no post-mortem exa- mination was made, it is impossible to decide whether the cause of death was, as supposed, perfo- ration of the stomach, or not. Mr. Coleman, of Wolverhampton, also had a case of diphtheria, that of a female, aged twenty-two years, in which severe pain of the cardiac extremity of the stomach, much aggravated by taking food or wine, came on after the exudation had disappeared from the throat, and the patient was supposed to be going on favourably. The case proved fatal. Mons. Espagne, of Montpellier, relates a case of oesophageal diphtheria in a patient, aged ten and a half years, suffering from typhoid fever. The diphtheria came on about the twenty-third day of the illness; 186 ox DIPHTHERIA. and the patient died three days afterwards. On examination after death, the arch of the palate, the uvula, and tonsils were covered with shreds of firm, grey-coloured false membrane. The entire posterior wall of the pharynx was coated with a thick false membrane, which extended, without breach of con- tinuity, down to the cardiac orifice of the stomach. This false membrane was exactly moulded upon the oesophagus, and about the thickness of a line almost throughout its entire length. It became notably thinner towards the stomach, ceasing abruptly at the lesser curvature, but ending by some very thin portions prolonged in the direction of the greater curvature. The diphtheritic concretion formed a complete tube, flattened from before backwards, and plaited longitudinally. It was easily detached from the oesophagus, the mucous membrane below it being injected, and of a violet colour, without any trace of ulceration. The larynx and trachea presented no appearance of false membrane.* The extension of diphtheria forwards into the mouth has been less common in this country than it would appear, from the French writers, to have been in France. The exudation has occasionally appeared on the gums, has sometimes extended on to the buccal mucous membrane, and has more rarely formed a complete covering to the palate and inside of the cheeks, from the fauces to the teeth. One * De la Diphtlierite, de sa Pafhogenie de ses Caracteres et de son Traiteinent. Par le Docteur Adolphe Espagne, p. 107. Montpellier, i860. DIPHTHERIA OF THE MOUTH. 187 such case proved fatal in the practice of Mr. Rush, of Southminster; and in a second, the patient nearly died of starvation from inability to swallow after the membrane had come away. The first case seen by me was one of pellicular diphtheria of the inside of the cheeks and gums; and I have observed exuda- tion in the same locality in several other instances; but the danger in such cases has always arisen from the condition of the fauces, and not from that of the mouth. 18S CHAPTER IX. SYMPTOMS. — DIPHTHERIA ON THE CUTANEOUS SURFACE AND WOUNDS OCCASIONAL CONCOMITANTS OF THE DISEASE MANNER OF DEATH. ALTHOUGH the presence of fibrinous exudation upon the surface of the mouth and throat and the several tracts of mucous membrane continuous with it, is the essential local sign of diphtheria, similar exudations sometimes occur on other parts of the body, where, from abrasions or other causes, the skin approximates to the condition of a mucous sur- face. The pudenda and vaginal mucous membrane are, perhaps, after the throat, the most common situa- tions of diphtheritic deposit. As in the following case from my own notes, pudendal diphtheria is gene- rally an accompaniment of diphtheritic disease of the throat, but sometimes occurs without the latter. E. P., aged one year and a half, has been ill five days. March 20, 1859. — Is sitting up; pulse under 80; skin cool. The tonsils and uvula are covered with a thick, white false membrane, which appears to be sej)arating at the edges. The injected mucous mem- brane surrounding the exudation bled freely on being accidentally touched with the tongue depressor. There is an ichorous discharge from the nostrils. DirHTHERIA OF THE PUDENDA. 189 which look sore and red. The pudenda are swollen, and covered with a white membranous deposit, ex- tending over both labiiB, and surrounded by a blush of inflammatory redness. There is also an excoriated surface on the buttock, which is partially coated with a less perfect membrane. The exudation on the mucous membrane of the pudenda could be detached in flakes; and, on lifting up its edge with a pair of forceps, the surface below was seen to be red and tender, but not ulcerated. There is no swelling of the lymphatic glands, either at the angles of the lower jaw or in the groins. The breathing is slightly stridulous. Symptoms of croup became more fully developed subsequent to my visit, and the little patient died from the extension of the disease into the larynx. The late Mr. Edwardes, of Wolverhamptom, saw two cases of vaginal diphtheria, both of which proved fatal from exhaustion. The disease accompanied diphtheria of the fauces, and both children were inmates of the same cottage where there had already been two fatal cases. Mr. Cooper, of Cromer, had in one instance seen the pudenda of a little girl covered with exudation unattended by diphtheria of the throat. Dr. Nichol- son, of Redditch, also writes me word that he has met with one case of pudendal diphtheria in a patient whose throat remained unaffected; and several prac- titioners in the fenny parts of Lincolnshire, Cam- bridgeshire, and Norfolk inform me that they have, from time to time, met with cases of pudendal dijph- 190 ON DIPHTHERIA. tlieria, unaccompanied by throat affection, anterior to the recent outbreak. In Dr. Nicholson's patient the parts were abraded by acrid discharge, there was great depression, requiring the free use of stimulants, and recovery was very tardy. Wounds and abrasions of the skin often become covered with diphtheritic deposit, analogous to that on the throat. This sometimes occurs during the prevalence of diphtheria without the corresponding affection of the fauces, but more frequently in per- sons who are already suffering from the ordinary form of the disease. Dr. Nicholson, to whose notes I have already been indebted for valuable facts, mentions the occurrence of diphtheria on wounds in two cases without throat affection. One of these, a man aged thirty-two years, had been operated on for fistula in ano. On the fifth day diphtheritic exudation ap- peared upon the wound, which eventually sloughed under the use of caustics. The patient died. The other case was that of a female, aged fifty-three years, who was suffering from caries of the metacarpal bones of the second and third fingers. On the third day, after an abscess connected with the diseased bones had been opened, the wound became covered with diph- theritic exudation. The parts were subsequently amputated, but diphtheria reappeared on the new wound, haemorrhage from the bowels supervened, and the patient sank fourteen days after the operation. More frequently diphtheritic exudation has ap- peared on Avounds simultaneously -svitli the occurrence of diphtheria in the fauces. I have already related DIPHTHERIA ON WOUNDS. 191 (page 82) a case in which diphtheria attacked a punc- tured wound on the foot of a boy. The following case occurred in the practice of Mr. Stephens, of Christchurch : — A. B., aged thirty-two, wife of a labourer, came under treatment in February, 1859, She had an infant ten months old, and had been suffering for several weeks from an abscess in the left breast, previously to which time her health had been good. February 10. — Complains of stiffness in the throat, difficulty in swallowing, and pains in the ears. The tonsils, soft palate, and uvula are of a deep claret colour, but free from both ulceration and fibrinous deposit. Pulse 140, small and weak; skin warm and perspiring; tongue moist and covered with a creamy fur; bowels confined; entire loss of appe- tite. There is no rash on the skin, and no thirst. On the side of the left nipple is a sore the size of a shilling, from which issues a thin watery discharge. Poultices to be applied to the breast. Jl Pulv. rhsei gr. viij. Hyd. c. creta gr. v. M. Statim sum. 51 Ammon. sesquicarb. . . 5J' Decoct, cinchonse . , . §vj. M. Cap. cochl. ij. magn. 4! a q. hora. February 12. — Feels worse; has had no sleep; great pain in the ears ; bowels have been twice freely opened; tongue much as before; pulse 138, very weak; urine neutral, scanty, high coloured, contains no albumen. Skin perspiring ; there is a diphtheritic patch, the size of a bean, on the left tonsil. 192 ox DIPHTHERIA. Beef-tea and port wine. February 13. — Has not slept, feels much worse; bowels not opened; tongue dry and brown; pulse 160; skin dry; urine scanty. The patch on the left tonsil is much increased in size, and there is now also one on the right tonsil. Complains of stiffness in the left breast, the sore upon which is covered with a yellow diphtheritic deposit. Applied hydrochloric acid, mixed with honey, to the tonsils. Omit the steel mixture, and resume the ammonia and bark. 14th. — Much better. Has slept some hours; felt no pain from the application of the acid ; bowels not opened; pulse 140, softer; skin perspiring copiously; tongue moist, and cleaner at the edges; deposit on the tonsils of a darker colour; velum of a less deep red ; no pain in the ears ; urine more plentiful ; has taken nourishment more freely. Continue the medi- cine, and repeat the aperient with rhubarb and grey powder. 15th. — Decidedly better; has slept well; pulse no, softer and fuller; tongue cleaning; skin warm and moist; aperient has acted once; urine is depositing lithates. There is no exudation on the right tonsil, and that on the left is much smaller. No ulceration. The deposit on the sore has come away on the poultice. Continue medicine and nourishment. The patient went on favourably from this time, the deposit on the tonsils having entirely disappeared by the 19th, and convalescence being established on the 26th of Februar}^ Diphtheritic membranes frequently form on the DIPHTHERIA ON BLISTERED SURFACES. 193 excoriations caused by blisters, but although perhaps then most common, their occurrence is probably not restricted to times when diphtheria of the throat is epidemic. M. Becquerel mentions the occurrence of eighteen cases of gangrene of blistered surfaces during an epi- demic of diphtheria at the Hospital for Sick Children in Paris, in 1841. The gangrene was always preceded by the development of false membrane upon the raw surface. This false membrane did not separate, but became confounded with the slough which very fre- quently sjDread so as to occupy a gradually widening surface. The aifection sometimes occurred simul- taneously with diphtheria of the throat, but, in several cases, independently of any other diphtheritic dis- ease.* Quite irrespective of the presence of diphtheria, blistered surfaces in cachectic persons, especially in children suffering from measles, are apt to become coated with a white membranous substance which is commonly considered as a slough, but, in reality, appears very analogous to diphtheritic exudation. Like the latter, it is surrounded by an inflamed border, which sometimes, acquiring a tendency to spread, ex- tends be37ond the margin of the original sore. Around this, small vesicles occasionally form, which, on break- ing, show the denuded cutis covered with a dirty white pellicle similar to that on the blistered surface. After a time true sloughing takes place, and the patient * Gazette Mddicale de Paris, 1843, p. 692. O 194 ON DIPHTHEEIA. either dies, or the skin-like exudation is thrown off, leaving a healthy suppurating surface. More rarely the false membrane dries up, and peels off in shreds, leaving the subjacent skin unbroken, and merely red and tender. The formation of false membranes on blistered sur- faces may thus, perhaps, be regarded as at least an occasional result of the epispastic action of cantha- rides ; and M. Bretonneau has shown that pellicular exudation is the normal consequence of the application of oil of cantharides to the mucous membrane of the mouth. ' In less than twenty minutes ' after the ap- plication ' the epidermis shrivels and becomes raised and detached. It is soon replaced by a concrete pel- licle, at first thin and semi-transparent, which speedily becomes more opaque and thicker. This membrane, which is at first slightly adherent, is detached and reproduced with great readiness. Within a period of six or seven days it may be several times renewed.'* Diphtheritic exudation often forms on other abra- sions of the skin, and on the denuded cutis of vesicular eruptions, as well as on blistered surfaces. In his account of the epidemic of the last century, Dr. Starr has well described the occurrence of diphtheria in connexion with cutaneous eruptions. The following case affords a good illustration of diphtheria of the cutis : — Jane Smith, aged fourteen years, admitted under "* Traiie de DiplitMrite, p. 356. Also British and Foreign Medico- ^hirurgical Review, vol. xxv. p. 4. Also Memoirs on Diphtheria, pub- lished by the New Sydenham Society, pp. 185-189. DIPHTHERIA ON ABRASIONS OF THE SKIN. 195 my care as a patient of the Western General Dispen- sary, April i4tli, 1859. Has been suffering from sore-tliroat since Friday, the 8th instant. There is great difficulty in swallow- ing, and the glands at the angles of the lower jaw are swollen and tender. The rio-ht tonsil is much enlara'ed, and was covered with a dense, buff-coloured, leathery membrane, which came off readily on being laid hold of with forceps, leaving the surface of the mucous membrane rough and bloody, but not ulcerated. There is also an extensive false membrane on the posterior wall of the pharynx. Voice raucous ; breath very offensive; bowels confined; tongue creamy; pulse about loo, exceedingly small and feeble; is lio;ht-headed at nio'ht. The catamenia have come on since her illness, being a fortnight before the proper period; urine highly albuminous. On inquiry I find there are four cases of slight sore-throat in the pa- tient's house. Garg. cum clilor. sodse .... ^xij. Saepe utend. ]^ Tinct. ferri sesqulclil 5y- Aquas cinnam 5^j- M. Cap. cochl. ij. magn. 3tia. q. liora. Jpril 1^. — Walked a distance of nearly a mile to see me this morning. Is better ; there is less false membrane, and the place on the right tonsil, from which the leathery exudation was removed yesterday, is to-day much less red and inflamed. There are several patches of false membrane on the right tonsil, and a consider- able-sized piece is hanging partially attached to the right side of the pharynx. Tongue cleaner ; papilla3 at o2 196 ON DIPHTHERIA. its tip slightly enlarged, giving it a strawberry-looking appearance ; pulse 1 20, but of better volume ; tlie cata- menia continue ; the bowels are confined ; the nose is sore, and the edp:es of the nostrils much excoriated by an acrid discharge. The offensive smell from the throat is much diminished. There is no kind of erup- tion on the skin. On the dorsal aspect of the meta- carpal part of the left thumb is an irregular-shaped vesicle of about the area of a half-crown, Avhich origi- nated in a scratch received about six days ago. On lifting up the loose cuticle, no moisture was found in the vesicle, but the cutis was covered with a dense membranous exudation of a pinkish colour, insen- sible to touch, separated from the cuticle which lay loosely over it, but firmly adherent to the cutis. The lymphatics of the arm and hand are inflamed. A por- tion of the false membrane being peeled off without causing pain to the patient, was found, on examina- tion under the microscope, to consist of corpuscular and fibrinous exudation, analogous to that from the throat. 18th. — Throat less inflamed, but there is now a tendency to ulceration, and the offensive smell from it continues. There is still a considerable quantity of membranous-looking exudation on the posterior fauces, and when the patient attempts to swallow liquids, they arc regurgitated through the nostrils. Voice improved; tongue slightly furred; pulse 74, feeble; catamenia continue. The exudation on the thumb has separated under the use of white-bread poultices, leaving a red surface, from which there is DIPHTHERIA ON ABRASIONS OP THE SKIN. 197 scarcely any discharge. There is a slight watery haemorrhage from the nose, which has excoriated the edges of the nostril and the ujDper lip. There are several claret-coloured, purpurous-looking patches, varying in size from a pea to a horse-bean, on the thumb, fore-arm, and inner aspect of the left elbow. 2oth. — Appears better in several respects, but the throat is now evidently sloughing. There is great difficulty in swallowing, and the patient takes but little sustenance. Is delirious at night; bowels act daily ; pulse 84, exceedingly feeble ; urine highly albuminous. The wound on the left thumb is less sore and irritable. The claret-coloured patches on the thumb, fore-arm, and left elbow, are paler : complains of numbness in the right hand and arm. 2 1 St. — Appears to-be improving. To contiiuie the wine, beef-tea, and the steel mixture, and to remain in bed, which she was very unwilling to submit to, and which her friends did not enforce. 22nd. — Continues better in all respects. Appetite returning. Notwithstanding my urgent recommenda- tion yesterday, she was sitting on a sofa downstairs at the time of my visit, and her friends could scarcely believe that danger was still imminent. She died very suddenly the same night. A post-mortem ex- amination was refused. The following cases of cutaneous diphtheria, from Mr. Simon's Second Annual Report^ are given on the authority of Dr. Sanderson :* — * Loc. cit., p. 273. IDS ON DIPHTHERIA. ' At Ash, in a family consisting of an infant, a3t. nine months, and two older children, the latter con- tracted faucial diphtheria, which assumed its ordinary characters. Daring their illness the infant was suf- fering from extensive excoriation of the skin of the chest, produced by the constant dribbling of an acrid discharge from the moutli. When first seen, the whole of the inflamed surface was covered by a mem- branous concretion of firm consistence. The infant died in the course of the following day. No affection of the fauces could be discovered. ' A little girl, £et. eleven, one of a family in which two fatal cases of faucial diphtheria had recently oc- curred, was, on March 4th, under treatment for a scald of the foot. On that day she contracted the disease. About a week after the* concretion had ap- peared on the fauces, the scalded surface became covered with a pellicle, which soon acquired sufficient thickness and firmness to be detached in flakes. This separated spontaneousl}^, leaving a healthy sore. There was no sloughing at any time, and the patient did Avell. In another example a similar concretion was formed on the reddened and partly blistered sur- face produced by the application to the skin of the linimentum ammonite.' Sometimes exudation forms on the surface of the cutis when denuded by natural vesication. This hap- pened both in the Cornish and American epidemics of the last century, and has sometimes, though not frequently, occurred during the recent visitation. The ULCERATION AND SLOUGHING OF THE THROAT. 199> following good example is taken from the information, collected by Dr. Sanderson :* — ' W. G., £et. eight, became ill June 7th, on which day a bulla of rupia simplex appeared on his right index knuckle, and another on the forehead at the root of the nose. On the third day after their appearance, it was found that the surface of the corium, beneath the now flaccid and ruptured epi- dermis, was covered by a firm white pellicle. Each eye was surrounded by a zone of erysipelas, with vesication here and there on the red and swollen sur- face. There was intense swelling and redness of the velum, uvula, and right tonsil, and the last was covered with diphtheritic concretion. The skin was cool and pallid; there was extreme muscular weak- ness and prostration. Pulse 84. He died the fol- lowing day.' Cases of ulcerated sore-throat are said to have been sometimes intermixed in the same epidemic with others exhibiting the characteristic exudation of diphtheria, and sloughing occasionally takes place at an advanced stage of the latter. Of this class of cases,, I have seen several examples ; but although careful observers have mentioned their occurrence, I have not myself seen any cases of simple ulcerated or gan- grenous sore-throat coincident with an epidemic of diphtheria. Mr. Thompson describes the sore-throat prevalent about Launceston as having been of two * Second Beport of the Medical Officer of the Privy Council, p. 273, Loudon, i860. 200 ON DIPHTHERIA. kinds, both presenting the same general symptoms, but differing locally in this respect, that whilst in the one the tonsils, and sometimes the pharynx, nares, and soft palate, were covered with diphtheritic de- posit, in the other the tonsil was scooped out into an ulcer with raised violet-coloured edges; the bottom of the ulcer exhibiting a dark ash-coloured slough. In another class of cases there was at first neither deposit nor ulceration, the tonsil being simply swollen and painful. Such cases generally terminated in ulceration, which, beginning in several distinct spots, gradually involved the whole tonsil. Sometimes the tonsil sloughed very extensively, leaving a consider- able cavity after recovery.* Dr. Capron also men- tions having seen cases, during the epidemic at Spal- ding, in which swelling and oedema of the soft palate, uvula, and tonsils was rapidly followed by sloughing or gangrene, attended by severe constitutional s^miptoms. Slou2;hino; and ulceration are occasional concomi- tants of diphtheria, occurring generally at a com- paratively advanced stage of the local affection. Sometimes, when cases presenting the brown leathery exudation recover, tlie diphtheritic deposit on sepa- rating leaves a slowly-heahng ulcer of the subjacent parts. In other cases, sloughing commences in the centre of the tonsil, and extending to the mucous membrane, causes considerable loss of substance, and sometimes destruction of a portion of the velum, uvula, or other soft parts. One such case, shown to * British Medical Journal (June 5, 1858), p. 449. ULCERATION AND SLOUGHING OF THE THROAT. 201 me by Dr. Morris, of Spalding, had quite recovered, with the loss of the uvula and the greater portion of the soft palate; and I. have seen several in which l^erforation of the telum, or shght destruction of substance, such as a portion of the uvula, had occurred. Probably sloughing would be more fre- quently seen, were it not for the rapid progress of severe cases to a fatal termination; for in two instances I have observed slouo-hino; in the centre of the tonsils after death, the mucous membrane being still apparently continuous, and covered with mem- branous exudation. The following case of ulceration occurring after the exudation, is taken from a paper on Diphtheritic Sore- Throaty by Dr. Sanderson.* ' M. F., aged nineteen, previously in good health, first complained of sore-throat on the 24th of August. I saw her August 25, when her condition Avas as follows : — ' No complaint (' feels better'), except of weakness. Skin natural; pulse regular, but weak; breathing natural; no cough; no headache; urine loaded with albumen ; voice weak and nasal ; intense swelling of the tonsils and adjacent parts on the left side. A dirty white, apparently thin coating covered the ton- sils, velum, and arches, as far back as could be seen, and extended forwards, on the left side, over the soft palate. '■August 27. — Pulse 88, weak; urine still albu- British and Foreign Ifedico- C/th-urgical Revieiv, vol. 25, p. 191. 202 ON DIPHTHERIA. minoiis ; the membranous concretion partly detached from soft palate; swelling diminished; other symp- toms as before. ' After this she gradually improved ; and, in the course of a few days, the concretion had, for the most part, become detached, when it was found that an ulcer existed of the left half of the soft palate, which had completely divided the anterior faucial arch on that side, and occasioned a hiatus, which was ren- dered apparently larger by the retraction of its margin by muscular action. The cavity of the ulcer was covered with an adherent pultaceous fibrin, and its edges were surrounded by a border of crimson mucous membrane. When last seen (Sept. 14), the cavity had diminished, but was still considerable; the voice was much improved, but was still nasal ; there was no regurgitation of liquids by the nose.' M. Becquerel has described an epidemic of diph- theria, complicated with gangrene of the fauces, which came under his observation at the Hospital for Sick Children at Paris, in 184 1. It comprised cases of laryngeal diphtheria, of pharyngeal diphtheria complicated with gangrene, and also cases in which the raw surface of blisters became gangrenous. The laryngeal cases presented nothing unusual; but the pharyngeal bear immediately upon the sub- ject now under consideration. Of seventeen cases of gangrenous angina, fifteen proved fatal, and two only were cured. In thirteen of these cases the gangrenous affection followed, or was coincident with, false mem- brane. In two only gangrenous ulceration, which ULCERATION AND SLOUGHING OF THE THROAT. 203 had evidently been left by the separation of a slough, was found at a post-mortem examination; but it could not be determined whether the gangrene had been preceded by false membrane or not. In two other cases gangrene had unquestionably taken place without being preceded by exudation. The gangrene was altogether in the centre of the tonsils, and sur- rounded by a tissue of increased density, friable, and manifestly infiltrated with blood.* Suppuration of the swollen tonsils sometimes, but rarely, occurs in diphtheria; and still more rarely suppuration of the external glands. More or less swelling of the glands at the angle of the lower jaw may be said to exist in every case. Sometimes it is very slight; at others very considerable. It is in the latter class of cases that suppuration sometimes occurs. In one such case I was present when the tumour was punctured. Previously to the operation, the tumour conveyed to the touch rather the boggy sensation caused by an infiltration of pus, than the fluctuation of a defined abscess; but the skin was tense, red, extremely tender, and there was distinct pointing. These circumstances appeared to justify the making of an incision, which was followed by a discharge of bloody sanies, mixed with streaks of pus. Dr. Gull mentions having seen in a child suppura- tion of the inguinal glands simultaneously with slight diphtheria of the fauces.f And it will be recollected * Gazette Medicale de Paris, 1843, pp. 690-1. t Seccnd Report of the Medical Officer of the Privy Council, p. 3or, 204 ON DIPHTHERIA. that the formation of an abscess followed diphtheritic ophthalmia, in the case already quoted from the Ophthalmic Hospital Reports. Albuminuria is a frequent, but not a consttint, attendant upon diphtheria. Its occurrence was first observed by Dr. Wade, of Birmingham, who, in ex- amining the body of a person who had died of diph- theria, found such changes in the kidney as induced him to examine the state of the urine during life more carefully than he had previously done.* He thus discovered that albumen is frequently present in the urine of patients sufiering from diphtheria — a fact which has been confirmed by subsequent ob- servers, both abroad and at home. When albuminuria occurs in diphtheria, it usually does so at an early period of the illness, generally within a few hours after its commencement. In this respect diphtheria differs essentially from scarlet fever, in wliich albumen is rarely found in the urine till a much later period of the illness. Very often a cloud, probably of phosphates, which re-dissolves on the addition of nitric acid, is thrown down by heat, a few hours before the detection of albuminuria; and in several instances a similar cloud has been thrown down for a day or two after the dis- appearance of albumen. The albuminous urine of diphtheritic patients rarely, if ever, presents the smoky appearance so com- mon in those sufi*ering from scarlet fever. On mi- * Midland Q^uarterly Journal of the Medical Sciences, vol. ii., p. 398. I ALBUMINURIA. 205 croscoiDic examination, casts of the urinary tubes are generally found ; but both Dr. Heslop, of Birming- ham, and Mr. Houghton, of Dudley, have met with cases of profuse albuminuria in which no tube casts could be discovered. The presence of albumen in the urine must always be regarded as a serious cir- cumstance in diphtheria; and, of course, more so if the albumen be in large quantity. But neither is its presence an absolutely fatal symptom, nor does it always coincide with great severity in the other symptoms: and it has sometimes been wanting in cases which were, in other respects, severe, and even proved fatal. Albumen was found in the urine of the following patient, the other symptoms being of a mild character. Richard Galway, aged twenty years, labourer, a strong, healthy-looking man, was admitted under my care as a patient of the Western General Dispensary, April 9th, 1859. Dates his illness from Saturday, the 7th instant. His first feeling of discomfort was that of ' a lump in the throat,' soon followed by soreness and difficulty of swallowing. On inquiry, it appeared that he had felt indisposed during the pre^dous week, having suffered from ' pains in the bones' and drowsi- ness. Voice thick, tonsils much enlarged, and toge- ther with the velum congested and of a dusky-red colour. On the right tonsil was a patch of firmly- adherent, white exudation, which resisted an effort to remove it with the forceps. There was also a smaller patch on the left tonsil, another patch on the uvula, and two patches of the same white membranous exu- 206 ON DIPHTHERIA. elation on the posterior wall of the pharynx. There was swelling of the lymphatic glands at the angles of the lower jaw. Pulse 84, small and feeble; skin sweaty; bowels regular. Entire loss of appetite. Urine slightly albuminous. There had been neither scarlet fever nor sore-throat in the house in which he lives, nor, so fiir as could be discovered, had he been in contact with persons suffering from either of these complaints. I^ Tincfc. ferri, sesquiclil. . . . ^''J- Aqua) Bviij. M. Cap. cochl. ij. niagn. 4ta q. hora. ]^ Tinct. ferrl. sesquiclil. . . . 5^'j- Acid, hydrochl. dil 5"j- Aqua} 5vj. M. Fiat gargar. sispe utend. Ajyril n. — Pulse 80, extremely feeble. The left tonsil is almost free from exudation, but there is still a piece of tough membrane adherent to the right, and another upon the posterior fauces. That portion of the velum which was only inflamed when first seen, is to-day coated with filmy, semi-opaque membranous- looking exudation. Glands at the angle of the lower jaw remain swollen ; urine still albuminous. — Pergat. 12th. — Decidedly better; pulse 73, thready and exceedingly feeble. The throat is for the most part free from exudation, and less congested, but there remains a patch of false membrane on the right tonsil near the velum, and another of smaller size on the left side of the posterior fauces. Tongue clean; bowels regular ; urine very pale and abundant, is free from albumen. ALBUMINURIA. 207 From this time he gradually but slowly recovered. No change of treatment was adopted, and the illness terminated in none of the sequelae common after diph- theria. In a much severer case, under the care of Dr. Bristowe, in St. Thomas's Hospital, which I had the opportunity of watching from day to day, albumen was found in the urine in small quantity, about the sixth or seventh day of the illness ; continued to occur about five days longer, and then disappeared as con- valescence approached. The frequency of the occurrence of albumen in the urine of patients suffering from diphtheria, and the precise circumstances under which it happens, still require much investigation. It has evidently been more common in some districts than in others. Dr. Sanderson says it was found at Hertingfordbury in all the cases, except one, in which it was sought for. At Wirksworth, Dr. Webb found it in every case in which he examined the urine. At Crowle, albumen was frequently found in the urine ; but in some severe and fatal cases it could not be discovered. Mr. Carr, of Blackheath, met with it frequently, but not always.* It was often found in the urine by the Birmingham medical practitioners, but by no means always, even in severe cases. I have myself several times been unable to detect albuminuria by the proper tests in very malignant cases of diphtheria. As patients recover from the disease, all traces of * Second Report of the Medical Officer of the Privy Council, p. 309. 208 ON DIPHTHERIA. i albuminuria disappear. I have omitted few opportu- nities of examining the state of the urine during con- valescence, and in no instance have found albumen in that of persons suffering from the sequela of the dis- ease, after what may perhaps be called the acute stage had gone by. Urasmia has not, so far as I know, been observed in connexion with the albuminuria of diph- theria. Dr. Sanderson, who analysed the urine of a diphtheritic patient in St. Mary's Hospital, ascertained that at the acme of the disease, when there was total loss of appetite, the quantity of urea excreted in a period of twenty-four hours, was about twice as great as during a similar period when convalescence had become established, and the patient was able to take extras as well as ordinary diet.* In other respects the urine does not present any constant or remark- able character in diphtheria. It varies much, but very frequently contains an excess of phosphates, and sometimes, especially during convalescence, an excess of lithates, and the specific gravity is often high. In no instance has anasarca occurred in conjunction with diphtheria in cases under my own observation, and most other observers agree in the same statement. I saw a case in Lincolnshire, in which the patient, an adult male, said there had been swelling of the feet and legs at night, and puffiness of the face in the morning, shortly after the attack, but he was exces- sively ana^miated, and anasarca certainly did not exist when I saw him. A few practitioners inform * BritisJi and Foreign Medico- Chirurgical Sevieto, vol. xxv., p. 196. HiEMORUHAGE AND PURPURA. 209 me tliey have known anasarca to follow diphtheria; but its occurrence, if it ever happen, in cases unconi- IDlicated with scarlet fever, is at least very rare. Besides haemorrhage from the nose, throat, or bronchial membrane, diphtheria is sometimes at- tended by purpura. Profuse oozing of bloody sanies from the throat, mouth, or nose sometimes takes place concurrently with the appearance of purpurous spots on the body or limbs. What may perhaps be termed local purpura is also sometimes observed, as in the case of Jane Smith (page 195), upon whose left hand and arm were claret-coloured blotches of a purpurous nature. Dr. Gull has met with purpura about the skin of the neck and upper part of the chest.* Mr. Williams, of Dursley, had a fatal case at Elmcote, in which the patient died, apparently from tlie profuse discharge of bloody sanies, resemblino- claret, from the throat, amounting to two pints per day ; and Mr. Clo^ves, of Stalham, another, a woman, aged thirty-two years, in whom purpura made its appearance ten days from the beginning of the illness, and after the membranous exudation had altogether disappeared from the fauces; there Avas ha'morrhao-c from the gums, fauces, nose, vagina, and anus, ac- companied by sloughing of the nates, under which the patient sank. Other eruptions besides purpura sometimes ac- company or follow diphtheria. An irregular, measly * Loc cit., p. 304. P 210 ON DIPHTHERIA. I mottling of the skin is not uncommon at an early stage ; and at a somewhat more advanced stage of the disease, I have, in two instances, seen an eruption very closely resembling the rose rash of typhoid fever.* A similar eruption was observed by Dr. Nicholson, of Redditch, in a case attended by alarming depres- sion, but which ultimately recovered. I have also observed erythema nodosum in the course of diph- theria. And Dr. Gull mentions having met withj erythema papulatum, and also urticaria, differing from the rash which occasionally occurs during recovery from cholera, only in the greater distinctness of the wheals. Similar eruptions have been noticed by other practitioners. In two instances under my observation, sudamina have appeared at a rather latej period of the complaint ; and Dr. Nicholson mentions; their occurrence in nine cases at Redditch as early as the second or third day from the commencement of the exudation. The patients were young, and of ages intermediate between four and nineteen years. The temperature of the skin, never perhaps much raised above the natural standard even in the earb stage of diphtheria, usuall}'- falls somewhat below if as the disease advances ; and, in severe cases, especially towards their close, the surface becomes cold. De- * Mr. Ray, of Dulwicli, says lie has only seen rash in one case of dipb theria. It occurred on the eighth, and disappeared b^' the eleventh da}^ of'' the illness. It was very like the roseoloid rash of typhoid. There were no petechite, and the eruption was confined to the thorax, abdomen, and back. — Second Report of the Medical Officer to the Privy Council, p. 327, STATE OF THE PULSE AND TONGUE. 211 lirium, or rather wandering of the mmd, from which the patient is at once recalled when his attention is attracted, is also an occasional, but not a freqnent concomitant of the disease. In ni}^ experience, this has always been a serious symptom. The pulse varies much in frequency, sometimes differing but little from the standard of health; at others, and oftener, being quick and becoming more accelerated as the case advances to a fatal termination ; in a few cases it has been below the natural frequency. Dr. Heslop informs me he has found it as low as 40 in a child only five years of age. Whatever may be the state of the pulse as regards frequency, it rarely fails to become remarkably feeble at an earl}^ period of the illness; and this circumstance, added to the remarkable ano?mia, and pallid, worn aspect of the patient, has more than once led me to suspect the existence of diphtheria in cases where, the pain and difficulty in swallowing being slight, no reference was made to the throat by the patient in describing his ailment. The tongue exhibits no uniform character in diph- theria, being sometimes coated with a white creamy fur ; at others clean, excepting perhaps at the pos- terior part. The appetite almost invariably fails at an early period of the illness ; and, at a later stage, partly from dislike to food, partly perhaps from the difficulty in taking it, but probably also from extreme debility rendering patients averse to exertion, there is often much difficulty in inducing them to take sufficient nourishment to sustain the failing strength. p2 212 ON DIPHTHERIA. Many cases, I am persuaded, terminate fatally from this cause, which might perhaps be saved by the freer use of wine and food. The proportion of deaths is high in the malignant form of diphtheria ; but whilst, on the one hand, very unpromising cases sometimes do well; on the other, patients whose symptoms have not been particularly alarming to the unskilled observer, very often die. Death occurs in several modes. In one class of cases, this event is preceded by certain constitutional symptoms attendant on gangrene. The latter has been rare in this country, but has been well described by Becquerel, in his account of the epidemic already referred to. Towards the end of the case the sur- face of the body becomes cold, the pulse extremely quick, and finally, intermittent; the countenance becomes shrunken, and assumes the hippocratic aspect; vomiting and diarrhoea supervene, the latter soon becoming involuntary, and occasionally delirium, coma, or nervous agitation precede death. Sometimes, in gangrenous coses, death is caused by haemorrhage before the development of the con- stitutional symptoms. In one of M. Becquerel's cases, death was the result of violent haemorrhage from the inferior pharyngeal artery, and probably some of the cases of ftxtal haemorrhage on record in this country have really arisen from gangrenous ulceration. This is the more probable, as when gangrene occurs sub- sequent to the formation of false membrane, it is most difficult to distinguish, and was not dis- MANNER OF DEATH. 213 covered until after death in two of M. Becquerel's cases. More commonly, when diphtheria proves fatal, this event arises, either from the extension of the disease to the larynx and trachea, and the mechanical obstruction to respiration produced by the false membrane; from exhaustion of the powers of life; or probably, on account of its sudden occurrence, from syncope. It was from its so often terminating in asphyxia, that the disease acquired the name of morbus sfrangula forms, by which it was formerly known. As has already been said, the frequency with which the larynx and trachea are implicated, and, of course, of this termination of the disease, varies much in different epidemics, and probably in different localities. In this class of cases death is preceded by stridulous breathing, and the other symptoms of croup. It is just possible that death by asphyxia may occur independently of any affection of the larynx or trachea. The following case, for the particulars of which I am indebted to Mr. West, of Birmingham, appears to have been of the latter kind. A little girl, aged six years, was said to have been choked while eating her dinner. Her mother had previously remarked that she was ailing and had lost her appetite, but she had not had recourse to medical advice. On Mr. West's arrival the child was dead. The body was emaciated, and the fauces completely stuffed with a greyish white fibrinous deposit, which appeared to extend some distance down the pharynx. 214 ON DIPHTHERIA. Layer after layer was removed in succession before the tonsils and palate could be reached. There was no evidence of deposit nor any sign of inflammation about the larynx ; but about the upper surface of the epiglottis were several large plates of fibrine, which probably assisted in producing the dyspnoea first ob- served by her mother a few minutes before death. A post-mortem examination on the following day showed the fauces and pharynx to be the seat of superficial ulceration, with here and there small patches of semi- detached fibrine. The larynx and trachea were healthy, and no disease existed in the abdominal or thoracic viscera. When exhaustion is the cause of death, its approach is gradual. The pulse becomes quicker and quicker, and, at length, imperceptible. The patient's aspect becomes more and more dejected; food and wine are refused, or administered with much difficulty, and, unless disturbed, the patient lies quiet, apparently somnolent, and takes no notice of surrounding objects. There is none of the agony noticeable in cases where the larynx participates in the disease, but the end is usually quiet, and the mental faculties are preserved till the last. Sudden death in patients the aspect of whose case is not alarming, or who appear out of danger, is a peculiar characteristic of diphtheria, and this circum- stance has added greatly to the fear with which this disease has been regarded by the relatives of the sick and the pubhc at large. One case of sudden death when the patient appeared to be improving has MANNER OF DEATH. 215^ already been related (page 197), and many others have fallen under the notice of my medical friends and cor- respondents. Mr. West has sent me the history of a young woman, aged twenty, who presented herself as an out-patient of the Queen's Hospital, at Birmingham,, suffering from diphtheria. She declined to enter the hospital, but continued to attend among the out- patients for three successive days, on each of which she walked a distance of a mile from her home for this purpose. The throat improved in appearance daily; but, notwithstanding this amendment, she be- came 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 exertion, refused nourishmenty and continued in a dozing condition till the following morning, when she asked for breakfast. Whilst being lifted up to receive it she fell back fainting, and died before assistance could be obtained. Mr. Carr, of Blackheath, also mentions extreme suddenness of death as one of the most marked characteristics of true diphtheria, and adds that it occurs in an instant when the patient has the power of sitting up in bed, of speaking, and of swallowing.* Mr. Eitchie, of Leek, had such a case in which he had discontinued his attendance, the throat being well and the sick person apparently convalescent. The patient suddenly be- came worse; there was vomiting, the surface of the body Was cold, and there was great depression with- * Second Report of the Medical Officer of the Privy Council, p. 309. 216 ON DiniTHERIA. out haemorrhage or other ostensible cause. When ' visited the patient sat up in bed and answered ques- tions, but then, having laid himself back and stretched out his arms, he died before the medical attendant left the room. Another case of Avhich I have notes "svas that of a child who died in its chair immediately after being examined by the surgeon. Sometimes sudden death has occurred after patients were able to resume active habits, and may perhaps have been induced, by over-exertion, whilst in the very depressed an Herniated condition produced by the dis- ease. A boy, aged ten years, who had been suffering from diphtlieria for five days, although well enough on the previous evening to hold the surgeon's horse, died on the sixth day of his illness. A carpenter's apprentice, convalescent from diphtheria, went home to visit his parents, who lived at a distance of three miles from his master's house. On his arrival he took a basin of bread and milk, went to bed, and died suddenly three hours afterwards. A man-servant, aged sixteen years, who had been ten or twelve days under treatment for diphtheria, seeming to be con- valescent, obtained leave to go home and see his friends before returning to his occupation, and there died suddenlv. Dr. Bellvse mentions a case of this kind, that of a boy, aged ten years, who, having been ill nearlj' three weeks, had so far recovered as to be able to go out ; and, on the day of his death, walked to a farm-house at a considerable distance from his home. About ten o'clock the same evenino- Di-. Bellvse, on beino- sum- MANNER OF DEATH. 217 moned to see his patient, who had been suddely seized with violent pain in the bowels about an hour before, found him sinking from exhaustion. Although re- lieved by fomentations and other remedies, he died very soon after the visit. A post-mortem examina- tion was refused. Indeed death, either from S3aicope or the accession of collapse, fatal in a few hours after exertion, has so often happened wdien patients have appeared to be recovering satisfactorily, that convalescents from diphtheria cannot be considered out of danger until some time after the thi'oat is well, and the very marked anaemia produced b}'' the disease has disap- peared. It is true that death, whether sudden or otherwise, usually occurs within a few days; but sometimes as late as the sixteenth or seventeenth day of the illness, or perhaps even later. In the following case, reported b}^ Mr. Adams, of Harrington-square, death took place from secondary exhaustion as late as the nineteenth day of the illness. It is a rather unusual case in other respects, and especially as regards the late period at which albumen first appeared in the urine. The case is that of a schoolboy, who dwelt at Camden Town.* ' The disease set in with a febrile attack which lasted forty-eight hours, with hot skin and rapid pulse — 120; soreness of throat, and stiffness of neck; but no diphtheritic effusion was observed until the day following, when the left tonsil was seen to have * Second Report of the Medical Officer of the Privy Council, p. 327. 218 ON DIPHTHERIA. several white sj)ots upon it, which by the next day- had spread into one uniform patch over that body. The right tonsil now presented a few small spots, and more j^ain was complained of in swallowing, although no real difficulty was experienced. By the evening of the second day the fever liad subsided, and the pulse fallen to its normal standing. On the 5th day the pulse began to fail in power, and therefore wine was allowed him, ^Yith citrate of iron and ammonia. On the 7th, there was no increase of mischief in the throat, but the nostrils began to discharge a serous matter, respiration became snoring, and sleep veryrest- less ; but while awake he breathed quietly, and with no difficulty. Glands on left side of neck enlarged ; pulse 92; no fever. On the 9th, much the same, but albumen had appeared in the urine, nth day: nos- trils discharged less; sleep much less troubled. 13th day: diphtheritic patches were becoming detached; urine contained only a trace of albumen; pulse 92. He was cheerful, and amused himself, as he had done for several days, in reading and being read to; but his appetite now began to fail, and there was reluc- tance to take the quantity of wine ordered for him (8 oz. daily). 14th day: the false membrane had entirely disappeared, as also the albumen in the urine* The voice now became nasal, and more pain was ex- perienced in deglutition; fluids occasionally passed through the nostrils ; pulse fell to 80 ; slept well and composedly. 15th : voice more deeply nasal. Com- plained that swallowing gave him pain in the ears MANNER OF DEATH. 219 and head, and of being sick. Beef-tea and wine have returned several times; brandy was therefore sub- stituted for wine ; pulse 72. 16th: passed a comfort- able night, but there was difficulty in getting him to take anything; was thirsty, and craved for water, which very generally returned immediately after it was taken; as did food, brandy, and the medicines prescribed with the hope of allaying the irritable stomach; pulse 60; no fever; no pain. 17th day: everything is rejected by the stomach immediately, and alarming attacks of vertigo, or swimming of the head, were complained of, accompanied by temporary loss of consciousness; pulse 40, . . . By the 18th day, the action of the heart had declined to 33 beats in the minute. On the morning of the 19th day, it had fallen to 24; but, on being disturbed to take food or brandy, would suddenly rise to 70 or 80 per minute. He still maintained a cheerful manner; but now and then, perhaps two or three times in an hour, the eyes would turn up, and he would lose consciousness for a moment, and recover in a state of alarm. In the afternoon he died.' Tlie fatal result is sometimes preceded by convul- sions. I have not myself witnessed this termination of the disease ; but several cases have been reported to me. Dr. Gull mentions a case in which convul- sions were coincident with suppression of urine. The patient, a child of two years and a half old, had been ill of the disease nine days. ' The urine was scanty for several days, and intensely albuminous ; it 220 ON DIPHTHERIA. then became suppressed ; there was constant vomiting for two days, then convulsions, and screaming, and death.'* The signs which indicate great danger in diph- theria are, croupy symptoms consequent upon the extension of the disease to the larynx or trachea; the occurrence of pneumonia; a brown or blackish ap- pearance of the false membrane; haemorrhage from the nose, throat, bronchial tubes, or intestines; pur- pura; coj^ious discharge from the nostrils; intense albuminuria; great swelling of the cervical glands; marked diminution of temperature, and sickness or diarrhoea, especially at an advanced period of the ill- ness. Any one of these symptoms denotes that the case is severe; but when — as sometimes happens — two or three are combined, the patient must be regarded as in imminent danger. * Second Report of the Medical Officer of the Privy Council, p. 304. 221 CHAPTER X. SYMPTOMS. — SEQUELiE OF DIPHTHERIA. TTNDER the most favourable circumstances, per- ^ sons who have suiFered from fully-developed diphtheria often remain feeble, ailing, and anasmic for many weeks ; and the throat sometimes continues to present traces of the disease long afterwards, or is very susceptible to the influence of cold or raw weather. Occasionally, many months elapse before perfect recovery; and I have known one instance in which the patient did not regain his strength for nearly a year. Besides the extreme anaemia which is so marked a result of diphtheria, this disease is very apt to be followed by certain nervous affections of a peculiar kind. These consist of paralysis, and anaes- thesia of particular muscles, tenderness and tingling of the skin, gastrodynia, impairment of vision, and deafness. Few persons recover without impaired voice or power of deglutition, arising from paralysis of the muscles of the throat; and sometimes, though rarely, there is complete aphonia, or absolute in- ability to swallow. The husky, nasal voice which 222 ON DIPHTHERIA. follows diphtheria is very striking, and closely ana- logous in character to that of persons suffering from syphilitic affection of the throat. It is remarkable that this affection, in common with the other nervous sequela3 not yet described, very often does not mani- fest itself until the patient is in other respects conva- lescent. The impaired power of deglutition consists sometimes of a difficulty in swallowing liquids, some- times solids; but the former is the more common. Patients are sometimes able to eat a hearty meal without difficulty; but when they attempt to drink, a large portion of the liquid is regurgitated through the nostrils. The difficulty in swallowing liquids and the nasal tone of voice are usually found in the same person ; and, although the voice is sometimes slightly affected without impaired power of deglutition, the latter is very rare without the former. Difficulty in swallow- ing solids, when the power of swallowing liquids is comparatively perfect, occurs but seldom. Dr. Monckton, of Brenchley, relates a case in which the difficulty of swallowing was so great fourteen days after apparent convalescence, that he was compelled to feed the patient by the aid of the stomach-pump. The case, that of a strong young woman, proved fatal.* Paralysis of the muscles of the neck, producing inability to carry the head erect, is an occasional, but rare, sequel of the disease. Among a great many convalescents from diphtheria that I have seen, not * Second Report of the Ifedical Officer to tlie Triry Cotincil, p. 296. PARALYSIS OF THE MUSCLES OF THE NECK. 223 one has suffered from this affection. I quote the following very remarkable case from a short paper by Dr. Gull, published in the Lancet. ' About a fortnight ago, I was called to see a boy, of whom I received the following history : — Age eleven. Had had an affection of the throat, from which he convalesced, and was sent into the country for change of air. About five weeks from the time of his being taken ill, it was noticed that he did not carry the head erect — it drooped to one side or the other. There was occasional difficulty in deglutition ; loss of voice, and attacks of dyspnoea threatening asphyxia. In a day or two from the beginning of these symptoms, the breathing became entirely tho- racic. The diaphragm was unmoved in inspiration and depressed in expiration, indicating a loss of power in the phrenic nerves. Deglutition was next to impossible. The child could utter no sound. There were fearful attacks of stransrulation when the head was moved in particular positions ; and, even when the breathing was at the best, there was blueness of the lips and tracheal rales. The intelligence re- fnained unaffected. The legs could be moved only feebly; the movement of the arms was not impaired; the muscles of the neck were wasted and flaccid; there was no swelling of the fauces; over the trans- verse processes of the cervical vertebra?, on the right side, there was tenderness, and the adjacent deep- seated absorbent glands were slightly enlarged ; no febrile excitement. Pulse feeble, 90. A paroxysm of suffocation suddenly ended the case a few hours 224 ON DIPHTHERIA. after my visit. No post-mortem examination could be obtained.'* The above case is very interesting on accomit of the length of time that ela2:)sed between the affection of the throat and the development of the secondary disease, and also of its great severity and fatal termination. Mr. Graveley, of Newick, mentions the case of his own son, aged two years, in whom singular paratysis of the muscles of the neck occurred after diphtheria. The head rolled about by its own weight backwards, forwards, and sidewards, exciting fear of dislocation ; and when it settled, the child was apparently unable to move it, and looked about him with a curiously slow turning of the eyeball. f Paraplegia is by no means an uncommon sequel of diphtheria, and, though more rarely, paralysis of the arms. Sometimes the paralytic affection is of a hemi- plegic character. The following case, which I had the opportunity of seeing with Dr. Morris, of Spalding, well illustrates several of tlie points just mentioned, though the paralysis was less complete than in some other cases which I have seen : — ■ R. A., cet. twenty-eight years, resides in a small but clean and wholesome house at Pinchbeck. His case was the worst that Dr. Morris had seen to re- cover. On Friday, January 28th, 1859, ^^^ felt a ' nasty taste' in the mouth. On the following day he * Lancet, 1858. Vol. ii. p. 5. I Second Be^iort of the Medical Officer to the Frivy Council, p. 279. PARALYTIC AFFECTIONS AFTER DIPHTHERIA. 225 complained of sore-throat, and on examination by Dr. Morris, it was found to be congested and inflamed. On the 30th, the tonsils, soft palate, and posterior fauces -were covered with false membrane, and the case subsequently became one of malignant diph- theria. March 20. — Yery pallid and anaemic ; voice thick, snuffling, and nasal; there is a white filmy patch on either side of the arch of the palate, that on the right side being the largest ; the uvula has nearly sloughed away, and he says that at the time of its occurrence the stench was so bad that he could scarcely bear it. On the right side of the posterior fauces is a patch of opaque white false membrane, the size of a split pea; the rest of the posterior fauces are covered with a semi-transparent secretion. Skin sweaty; pulse 72, feeble. Sight a little dim; complains of numbness in the belly, and in the legs, arms, and hands, but especially in the left arm and leg. Is unable to dress himself, from weakness of the arms ; has lately felt pricking as of pins and needles in the fingers; is rather giddy when out of doors, and still has slight difficulty in swallowing. Three weeks since his face was puffed in the morning, and there was slight oedema of the feet and legs, particularly at night; urine pale coloured, clear, and free from al- bumen. The following case of paralysis after diphtheria, which formed the subject of a clinical lecture by Pro- fessor Trousseau, well shows the serious nature of the Q 226 ON DIPHTHERIA. nervous affections which sometimes follow an attack of diphtheria :* — A woman, ha\^ngbeen recently confined, contracted diphtheria from a patient in a neighbouring bed. Alum insufflations and applications of hydrochloric acid were resorted to, with the effect of removing all diphtheritic exudation. On the tenth day she spoke with a nasal voice, and deglutition was very diffi- cult, and accompanied by nasal regurgitation. A notable proportion of albumen was also found in the urine. The paralytic affection of the pharynx kept increasing, so that by the twenty-fifth or thirtieth day the woman could no longer swallow, and was like to have died while trying to take some solids. About the fortieth day some improvement in this respect took place, but now numbness of the hands and feet was observed, as well as defective pronunciation from imperfect movement of the tongue. By the fiftieth day, progression had become uncertain, and general nervous symptoms, chiefly consisting in delirium and convulsions, set in. The worst apprehensions were now entertained ; but musk having been administered, some improvement took place. So considerable, how- ever, was the paralysis, that the patient could not raise herself without the assistance of two nurses. The bladder was also affected during two or three days, but not the rectum. With this paralytic condition anaesthesia coexisted, the patient remaining absolutely * Medical Times and Gazette, vol. ii. 1860, p. 90, quoted from the Gazette des Hopitaux. PARALYTIC AFFECTIONS AFTER DIPHTHERIA. 227 insensible to pricking with needles. On the hundred and fiftieth day the symptoms were so much amelio- rated under the use of the syrup of sulphate of strychnia, that the patient could get in and out of bed easily, could knit a little, and was able to distin- guish between wool and cotton by the touch. No disturbance of visual power took place, although during six Aveeks enormous quantities of albumen were found in the urine. ' One circumstance worthy of note is the remarkable alternations which were observed: sometimes one limb, and sometimes an- other, being aifected to-day, and well to-morrow, to become suddenly bad again; and so on. And,' says M. Trousseau, ' as this is of common occurrence in diphtheritic paralysis, we may justly conclude that the lesion of the nervous centres is not of a very grave character.' Impaired vision is another common sequel of diph- theria, which, like those already described, only comes on subsequently to recovery from the primary local disorder. The patient is usually able to see distant objects with sufficient distinctness, but is unable to see things close at hand. Indeed, several of the most striking cases that have come under my notice were those of children who appeared to be quite well until, on returning to their studies, it was found that they could not see to read. The defective vision comes on gradually ; first of all, the patient is unable to read small print, and can only read large print when held at a distance from the eye, a power which is also lost at a later period. The restoration of sight is equally q2 228 ON DIPHTHERIA. gradual. The following case, reported by Mr. West, of Birmingham, illustrates the impaired vision, and also some of the other sequelae of diphtheria. H. D., a boy aged twelve years, when first seen, Dec. 1 2th, 1857, appeared to be suffering from great prostration, both of mind and body, occasioned, as his mother thought, by the great exertions he had made to prepare for a school examination. He also com- plained of pain in the throat and of difficulty in swallowing. On examination, some dirty white specks were visible on the right tonsil. These specks of exudation very greatly increased in the course of the three or four following days; and many shreds of false membrane and much viscous secretion were brought away in gargling. On the 19th he was much better as regards the throat, but suffered greatly from weakness. Towards the end of the year deglutition became difficult, his food returning through the nose. The voice, which had been previously clear and harmonious, now be- came thick and snuffling, and at length the power of articulation was almost gone, so that he could only make himself understood by the most painful effort. The throat, upon examination, appeared healthy, ex- cepting that the right tonsil was smaller than the left, and that the velum was relaxed and almost without motion. After these S3anptoms had continued a few days, his sight also began to fail. At first he could only see to read when the book was held at a great distance, but this power gradually diminished, until he was unable to distinguish even the lines, and was IMPAIRED VISION AFTER DIPHTHERIA. 229 compelled to give up reading altogether. There was also strabismus. His gait became uncertain and feeble, so that he moved about with much difficulty. Wine and nourishment were freely administered, but no sign of amendment appeared till January 19th, when he went into the country, where, in the course of three months, his recovery was completed, and he has since enjoyed perfect health. Impaired vision often occurs as a sequel to diph- theria, unaccompanied by any other nervous affection, and sometimes it follows cases which, during their j)rimary stage, were not thought to be diphtheria. A youth at school had sore-throat at the same time with a companion who slept in an adjoining bed. The ill- ness in both cases was so slight that I believe no medical man was called in. Just after their indispo- sition, the boys returned home for the holidays, when one of them was shortly seized with paraplegia, and the other Avith partial blindness. It was only in con- sequence of my inquiries that I was informed of the pre-existence of sore-throat, a circumstance which, taken in conjunction with the present attack, enabled me with confidence to pronounce the opinion that both boys had suffered from diphtheria, although in a very mild form. Mr. Dixon, who has seen several cases of impaired vision after diphtheria, in a note wdth which he has favoured me, says, that the impairment of sight was due to loss of adjusting power. The sight was as good as ever for distant objects, but the patients either could not read at all, or very imperfectly. He 230 ON DIPHTHERIA. adds, that a low convex glass remedies the want of adjustment, exactly as it does that defect in elderly persons. The correctness of Mr. Dixon's view is con- firmed by a fact mentioned by Mr. Gravely, of Ne wick, who says that a patient of his, a girl aged fifteen years, who could not see without them, was able to do needle- work with the aid of her grandmother's spectacles.* The several nervous sequelae of diphtheria may occur separately, but, as in the following cases, two or more of them are often observed in the same sub- ject. The first was mentioned to me by Dr. Belly se, of Nantwich, and is also reported in the Lancet ;f — M. B., aged fifteen years, was attacked on June 9, 1858, with severe diphtheria. She complained of great pain and stifi'ness of the neck. There was no external swelling, but the uvula and tonsils were much in- flamed, SAVollen, and agglutinated by a large thick * slough,' extending to the posterior fauces and ante- riorly on to the palate. There was great depression, quick, irritable pulse, and the surface of the body was covered with a cold, clammy perspiration. The slough separated about the eighth day, leaving a healthy, granulating ulcer of the subjacent surface. There was, about the same time, a considerable accession of pain and stifi'ness of the neck, attended with complete .aphonia, a constant flow of saliva, and great fa3tor of the breath. These symptoms were followed in a day or two by violent pain at the epigastrium and conti- nual sickness. Diarrhcea now also set in, and lasted * Loc. cit., p. 279. t Lancet, 1858. Vol. ii. p. 513. PARALYTIC AFFECTIONS AFTER DIPHTHERIA. 231 ten days, leaving the patient in a state of great debi- lity. Under the use of tonics and generous diet she improved so much as to be able to walk out of doors, but the improvement was not permanent. Pain and tinglmg of the limbs, with soreness of the soles of the feet, came on, and increased until the slightest move- ment was most painful. This state gradually passed into entire loss of power and impaired sensation of the lower extremities, which lasted for three months. She regained her voice and the use of her limbs by slow degrees, and was after a time restored to health. The next case is the more interesting because it is that of a medical man, Mr. Moyce, of Rotherfield, who records his own sensations : — On Nov. 8th, Mr. M. felt a sensation of pricking, which soon became burning, in the right tonsil. In the night there was much pain, with a sense of swell- ing. The next morning there was, on the right tonsil, a patch of exudation about the size of a farthing, which gradually extended forwards almost to the teeth; the left side was very slightly affected. There Avas much external swelling. After four or five days the exudation began to clear away, and then difficulty and pain in swallowing, amounting to agony, super- vened. In the course of three or four weeks he got about, and attended to his practice for a fortnight. During the latter half of December the tone of his voice became altered, and he began to have regurgi- tation of solid food, which would accumulate in the posterior nares until it caused spasmodic cough. He was able to swallow fluids, if taken very slowly. He 232 ON DIPHTHERIA. now lost the use of his tongue, could not move it in eating, and his speech became unintelligible ; he also began to see double, and indistinctly, but could see with spectacles. Next followed tingling and tender- ness of the palmar surface of the hands and fingers, accompanied by a peculiar hardness and roughness of the integument. Presently the soles of the feet and toes were similarly affected, and then there was loss of power in the limbs, especially the legs. The arms were so weak that he was unable to feed himself. These symptoms remained unabated for eight or nine weeks, and then gradually diminished in the same order in which they had begun. Even now, after a lapse of two years and a half, he is not strong, and can neither walk nor swallow as well as before his illness.* The following case of hemiplegia following diph- theria is related by Dr. Gull : — A boy, of rather delicate temperament, when re- covering from diphtheria, was suddenly seized with intense neuralgia in the left leg, which passed off after a day. It appeared to be connected with the femoral vein, which was rather hard and very painful to the touch. After two days he became very restless, and, in a few hours, completely hemiplegic, on the right side, including the face, and speechless. The action of the heart was most tumultuous, and »the sounds muffled. The child rallied under the free use of wine and ammonia; but the hemiplegia remained for * Second Iiej)oi't ofihe Medical Officer of the Privy Cutiucil,\). 282. DIPHTHERIA WITH BRONCHITIS OR PNEUMONIA. 233 many months, after which there was slow improve- ment.* The majority of cases which are protracted until the development of the nervous sequelae, recover, but death occasionally takes place even at a remote period. Mr. Moyce mentions the death of a boy, aged eleven or twelve years, from exhaustion during the paralytic stage, two months after he had been quite free from throat affection. f The nervous sequelae of diphtheria are not always in proportion to the severity of the previous illness, and do not occur exclusively after the severest cases, but sometimes follow comparatively mild attacks. Their duration is uncertain, varying from two to three or four months, but the slighter affections may perhaps sometimes pass off in a shorter period than two months, and, in all probability, severe cases are occasionally prolonged beyond the fourth month. Diphtheria is apt to be complicated or followed by bronchitis or pneumonia. The presence of the former is denoted by the expectoration of casts of the smaller bronchial tubes, intermingled with frothy or glairy secretion, and by the stethoscopic signs of bronchitis. Mr Thompson says, in many instances he saw casts of the smaller tubes expectorated, whilst a stetho- scopic examination gave all the symptoms of capillary bronchitis. -^ A gentleman, aged forty- six, died from this condition of the lungs. His throat was first affected. After a few days the breathing became im- * Loc. cit., p. 303. f Loc. cit., p. 282. 234 ON DIPHTHEKIA. peded, with all the ordinary symptoms of capillary bronchitis in the first stage, the throat continuing to improve. He gradually sank, constantly expectorat- ing casts of the small tubes, precisely similar to the deposits in the trachea.'* Mr. Clowes, of Stalham, informs me that recovery has, in cases under his care, been sometimes protracted for months in consequence of the accession of bronchitis. The occurrence of pneumonia as a complication of diphtheria has only come under my observation in post- mortem examinations. I have met with it twice, and both Mr. Simon and Dr. Bristowe note its occurrence in their communications to the Pathological Society on the morbid anatomy of diphtheria. f Mr. Rush, of Southminster, has seen two cases of diphtheria in which fatal pneumonia intervened after the exudation had disappeared from the throat and the patients were sup- posed to be doing well. And although I have received no detailed cases, other practitioners who have favoured me with the results of their experience of this disease, have likewise mentioned the existence of pneumonia in conjunction with diphtheria. * British Medical Journal (June 5, 1858), p. 449. f Transaciions of the Pathological Society of London. Vol. x., pp. 316 and 321. 235 CHAPTER XI. MORBID ANATOMY OF DIPHTHERIA. XAIPHTHERIA is essentially an inflammation ■^-^ of the fauces, ■which sometimes only causes disordered secretion from the mucous membrane; at others produces ulceration, and even gangrene; but, more frequently, an exudation which, coagu- lating on the surface, forms the false membrane from which the disease obtains its name. The exudation varies in consistency, from a pultaceous or almost liquid exudation, to a firm, consistent, and more or less elastic membrane. In the latter case, its outer surface is often uneven, usually less dense than the deeper portion, and sometimes flocculent or fissured. It varies from a quarter of a line to a line or more, and, in one instance I have seen, was nearly two lines in thickness. The elastic form of false mem- brane is not unlike the exudation poured out from an inflamed serous membrane. Sometimes the exu- dation is not membranous, but dry and granular. Low forms of cryptogamic plants are occasionally found on the exudation, a circumstance which gave rise to the belief that the disease is of parasitic origin. This opinion is disproved by the facts that, on the one 23G ON DIPHTHERIA. hand, the supposed parasite is not invariably present in diphtheria; and, on the other, that it is frequently found on unhealthy mucous surfaces which are not oi a diphtheritic nature. Examined under the micro- scope, the exudation is found to consist of coagulated fibrine and epithelium ; the latter being usually more abundant in the outer portion, or layer of membrane; whilst the deeper portion is more purely fibrinous. But in this respect there are numerous variations. Exudation cells are often intermixed with the fibril- lated texture. The exudation is sometimes already undergoing decomposition, or other change, before it leaves the throat, and is at others more or less stained with blood. At first only opaque, the exuda- tion soon becomes white or ash-coloured; if thick and adherent, brownish or buff-coloured; and i£ stained by slight haemorrhage, blackish. The exuda- tion is sometimes very loosely, at others very firmly, adherent to the subjacent surface; and occasionally, especially when of the friable, granular variety, is merely superimposed upon the natural surface. The mucous membrane underneath the exudation, or from which the exudation has recently exfoliated, is often intact, and generally much congested and swollen; sometimes it is white, opaque, or unnatu- rally pale ; at others it looks raw, the epithelium having been shed with the false membrane. It often presents an excoriated and roughened appearance; is sometimes ulcerated, and, more rarely, gangrenous. When false membrane, still adherent to the mucous surface, is lifted up, it is often seen to be attached to MORBID ANATOMY. 237 the subjacent surface by numerous small thready adhesions, as though processes of exudation passed into the mucous follicles; and, on removing it, the mucous membrane is more or less abundantly dotted with bloody points. The submucous tissue is often oedematous, infil- trated with blood, and sometimes the seat of inter- stitial exudation. The tonsils are usually swollen, and, on being cut into, are often infiltrated with blood, so as to impart to them an ecchymosed appear- ance ; sometimes their tissue is softened ; and in two instances I have found the centre of a tonsil in a state bordering on gangrene. There is generally more or less of inflammatory efi'usion into the struc- ture of the tonsils ; and in one instance, on the tonsil being laid open, there was an oozing from it of a creamy fluid resembling pus. In some instances, the oesophagus and the muscular and other tissues around the fauces are congested or infiltrated with blood; the parotid and submaxillary regions are much swollen, and the integuments studded with livid purpurous spots. In a case mentioned to me by Mr. Jauncy, of Birmingham, an abscess was found between the pharynx and vertebra?. The case was that of a child, aged six years, which died after an illness of nine or ten days, croupy symptoms having set in three days previous to death : — ' The lungs were emphysajmatous in front, col- lapsed in patches posteriorly. A portion of false membrane was found at the bifurcation of the trachea, which was elsewhere free from exudation, 238 ON DIPHTHERIA. but reddened. The larynx, epiglottis, pharynx, ton- sils, and uvula, were covered with lymph. An abscess about the size of a walnut was found between the pharynx and vertebrte. Liver, kidneys, and spleen healthy. The kidneys were examined micro- scopically.' When the disease extends to the larynx and tra- chea, the false membrane generally becomes thinner and less consistent as it descends in the tube, until it disappears gradually in the form either of a very thin pellicle, or of a creamy fluid. The mucous membrane of the affected portion of the larynx and trachea is generally more or less congested, and often thickened, so as to diminish the calibre of the pas- sage, even after the false membrane has been re- moved, or has come away. The subjacent membrane is here, for the most part, intact; but sometimes, being denuded of its epithelium, exhibits, on the removal of the exudation, a red excoriated appear- ance, somewhat like the raw surface produced by a blister. It also, under the same circumstances, pre- sents small bloody points similar to those observed on the mucous membrane of the pharynx. The epiglottis, besides being covered above or below, or on both sides, with exudation, is likewise often swollen so as to contract the entrance to the wind- pipe. The bronchial tubes are sometimes lined with false membrane down to the third or fourth bifurca- tion, and even lower; and the lungs, sometimes partly emphysiematous, are also liable to be affected with pneumonia, which is most commonly of the lobular MORBID ANATOMY. 239 form. In tlie latter case, the little bits of splenified lung are sometimes surrounded by crepitating and comparatively healthy lung, sometimes by portions of emphysasmatous lung. The kidneys have sometimes been found quite healthy after death from diphtheria; in other cases they have been congested, and, on being sliced, have exhibited under the microscope transparent fibrinous casts of the tubes. The urine, in such cases, is gene- rally albuminous, and also presents under the micro- scope fibrinous casts of the tubes, which occasionally contain blood corpuscles, or granules of hcematine, or a few altered epithelial cells. In a case briefly referred to by Dr. Gull, in his communication to the medical officer of the Privy Council,* the membranes of the brain and. cord were in a state of suppurative inflammation, the sub- arachnoid space being full of soft, purulent lymph ; and the same physician, although he gives no 2^ost~ mortem facts in support of the opinion, suggests, that the original seat of the disease being near the cervical portion of the spinal cord, the paralytic symptoms so common in a late stage of diphtheria may arise from the disease having extended by continuity from the fauces to the upper part of the cord.f At present, this opinion can only be received as suggesting a careful examination of the cord in future post-mortem examinations ; for thus only can it be deter- mined whether the paralytic affection has a con- * Loc. cit., p. 299. t Lcc. cit., p. 303. 240 ON DIPHTHERIA. stitutional origin, or arises from the supposed local disease. In a case related by Dr. Bristowe, and exhibited by him at the Pathological Society, the muscular tissue of the heart was coloured with extravasated blood. And in a more recent case treated by the same physician in St. Thomas's Hospital, in which I had the opportu- nity of examining the organs after death, the heart was studded with petechial spots on its outer surface. The following cases are adduced in illustration of some of the points mentioned in the preceding ac- count of the morbid anatomy of diphtheria. The first has been selected because it well shows the ten- dency of the disease to become engrafted, so to speak, on other disorders, especially the eruptive fevers ; the others, mainly on account of the detailed description of the microscopical appearances noted by such com- petent observers as Mr. Simon and Dr. Bristowe. S. Beard, aged four years, was admitted a patient of the Western General Dispensary, under the care of my colleague Dr. Sanderson, on June 29, 1859. She had been taken ill on the previous day with the pre- monitory symptoms of measles, and was visited by the house surgeon, Mr. Plaskitt. It was not until the 4th of July that she complained of her throat; and she first came under the observation of Dr. San- derson on the 6th of that month. The skin was then of a not unnatural warmth; the countenance was pale, and its expression rather distressed. The child was somewhat drowsy, and difficult to rouse; there was a slight discharge from the nostrils, which were CASES ILLUSTRATING THE MORBID ANATOMY. 241 lined with coagulated blood arising from an epistaxis on the previous day. Respiration natural in fre- quency ; pulse 1 20 ; the mucous membrane covering the tonsils was of a deep-red colour, but less bright than is usual in ordinary tonsillitis. The anterior surface of the uvula was bare, but the posterior sur- face and sides were covered with a soft concretion, capable of being detached, and evidently of slight consistence. All the parts were smeared with a tenacious mucus, which was constantly being dis- charged from the mouth ; and flakes of concretion, which had been excreted during the preceding night, were exhibited by the mother. There was very little external swelling or tenderness about the neck, and the breathing was not at all croupy, although said to have been so. Urine intensely albuminous. July 7. — A tubular cast, of soft consistence, dis- tinctly marked by the laryngeal rings, was discharged during the night. July 8. — Much worse; feet and hands warm; belly hot. Pulse 160, feeble, and very difficult to count; respirations about 30. Prolonged, somewhat musical expiration sound, varying in tone from minute to minute ; inspiration sound, short, less noisy, and not musical. Countenance pale, but not livid. Voice resembled a shrill whisper heard through a long tube. The cough, which occurred occasionally, was very short, and precisely similar in tone to the voice, A few small shreds of concretion were still attached to the uvula and velum; but none elsewhere. There were excoriations at the corners of the mouth, not t 242 ON DIPHTHERIA. covered with concretion. Miicons surface of u deep- crimson hue. Vespey^e. — Respiration increased in frequency to 40 in the minute ; countenance more indicative of dis- tress. She died at seven a.m., of the 9th. Post-mortem Examination (made June ic, twenty- seven hours after death). — Slight mottling on the arms, probably the remains of the eruption of measles. The upper surface of the tongue was healthy as far backwards as the base of the epiglottis, excepting that there was a small patch of exudation, not much larger than a grain of wheat, adherent to one of the large papillae. The subjacent surface was healthy ; both tonsils, especially the right^ were vascular, and pre- sented a pitted, roughened aj)pearance. The mucous membrane covering the margin of the epiglottis, ej^iglottidean folds, and arytenoid cartilages, was white and opaque. The anterior portion and edges of the upper surface of the epiglottis were of a brownish white colour. The mucous membrane of a cavity behind the left tonsil and between it and the posterior pillar of the fauces contained a creamy- looking exudation. The corresj^onding hollow on the right side was free from exudation. The sub- stance of the tonsils, particularly of the right, was decidedly softened. On being incised, they exhibited patches of extravasation and of pigmentary discolor- ation ; but in other respects the section presented a natural aspect. The mucous membrane of the larynx and trachea was unnaturally white and opaque, as though covered with exudation; but nothing could CASES ILLUSTRATING THE MORBID ANATOMY. 243- be stripped off it. This condition of the membrane became less and less obvious in a downward direction^ Here and there were seen punctuated patches of red- ness, which sometimes followed the intervals between the rino's of the trachea. Several loose frao-ments of exudation, some of which, although readily detached^ were still adherent to the natural surface, were found in the upper part of the trachea. The subjacent mucous membrane was unbroken, and closely resem- bled the surroundino' mucous surface. The apex and upper portion of the left lung, as far as a line extending upwards and backwards from the notch, was emphysaBmatous, and along the free mar- gin were emphystematous lobules, surrounded by portions of splenified lung. The lingua and margin of notch Avere completely splenified. The secondary division of the bronchus leading to the apex of the left lung contained cylindrical casts, of about the consistence of boiled macaroni, at their proximate extremity ; but diminishing in consistency until they disappeared in the third or fourth division of the bronchus, in the form of creamy-looking fluid. The division of the bronchus leading to the lower lobe contained no casts, excepting in one of the tertiary divisions leading towards its posterior aspect. It was not ascertained whether or not this portion of exudation was continuous with that in the bronchus, leading to the apex. The mucous membrane was for the most part remarkably pale, but otherwise healthy.. There was bronchitis in a few of the smaller tubes, as • shown by the frothy secretion which they contained,. R 2 244 ON DIPHTHERIA. and by slight vascularity. The parenchyma was firmly splenified throughout the lower lobe, with here and there scattered portions of emphysajmatous lung. The two upper lobes of the right lung were em- physa?miatous ; the loAver lobe was also emphyssematous at the upper portion, and partially so below. The bronchus leading to the apex contained here and there adherent, but also partly detached, patches or frag- ments of soft exudation, which ceased rather abruptly in the third bifurcation, and less decidedly terminated in creamy fluid than those on the left side. A consi- derable-sized tube leading towards the base of the upper lobe was choked with a cylindrical mass of semi-diffluent white and opaque secretion, which, under the microscope, exhibited cells without fibri- nated matrix. The bronchial branches leading to the middle and lower lobes were free from exudation. The mucous membrane of the tubes in the upper lobe, like that on the left side, was perfectly white. That of the tubes leading to the middle and lower lobes on the right side markedly injected. The folio win o; case, communicated to the Patholoo^i- cal Society by Mr. Simon, is quoted from the Trans- actions of that Society for last year :* ' A. H., set. thirteen, had been suffering from diph- theria for nineteen days before his death, and during the last eleven had been under treatment in St. Thomas's * Transactions of the Pathological Society of London. Vol. x., pp. 316-19. CASES ILLUSTKATING THE MORBID ANATOMY. 245 Hospital. On the eighth day of the disease a large mass of thick, dense, very fibrinous false membrane detached itself from the fauces, leaving the surface of the tonsils and soft palate raw (like that of skin from which the cuticle has been removed after blistering) but not ulcerated or sloughing. On part of this sur- face, a second thinner false membrane soon formed, and subsequently came away in shreds. There was irritating discharge from the nose, and during the last days of life some of the patient's drink escaped this way. Early in the disease there had been swelling below tlie jaw, but this had subsided many days before death. On the seventeenth day of the disease super- ficial ulceration began at the left tonsil, and on the eighteenth day had extended to the size of a shilling. On each of the last eleven days of life the urine was examined ; it always gave abundant precipitate with nitric acid, and latterly also with heat; but in the earlier days it precipitated imperfectly with heat, and largely with acetic acid. Microscopically it showed fibrinous tubule-casts, containing traces of hasmor- rhage, but scarcely any renal epithelium. Through- out the progress of the disease the patient was pale, feeble, and disposed to be chilly, so that wine and much external warmth had from the first been neces- sary. The tongue was always moist. No eruption appeared upon the skin. There was no delirium or stupor, and neither cough nor any sign of laryngeal obstruction was observed. The respiration was na- tural till within a few hours of death, when it became short and hurried. 246 ON DIPHTHERIA. ' The following were tlie post-mortem appearances : — With exception of an occasional very delicate film, there was no false membrane about the fauces. In the situation of the left tonsil was a sloughy ulcer, somewhat larger than a shilling. The posterior sur- face of the soft palate was congested, and there adhered to its somewhat swollen mucous membrane small patches of false membrane. In the recess of mucous membrane beside the epiglottis was an irre- gular depression, evidently the remains of an almost cicatrized ulcer. About an inch below the aperture of the glottis, the pharynx presented on its right side a small circular ulcer, about two lines in diameter, with somewhat raised margins, and on the left side .another similar ulcer, about the size of a pin's head. In other respects the pharynx and oesophagus were iiealthy. On washing out the nares, a strip of false membrane an inch in leno;tli was removed. The mucous membrane covering the septum showed patches of congestion, was thickened, and had shreds of false membrane adherent to it. ' Both lungs, except in their- upper and anterior parts, were greatly congested with blood, and less crepitant than is natural, especialty the lower lobes, whose posterior parts were in many places nearly or quite Avithout air; and the most solidified portions broke down on firm pressure with the finger. At one section the exuding fluid was obviously purulent, and microscopical examination showed pus exten- sively in other parts of the hepatized structure. The bronchial mucous membrane was a little injected; the CASES ILLUSTRATING THE MORBID ANATOMY. 247 tubes contained thin frotliy fluid tinged with blood, or more tenacious reddened mucus. ' The kidneys were large, and intensely congested. Sections of the cortex, microscopically examined, showed frequently the presence of large, transparent, colourless rods of apparently iibrinous material, soluble in acetic acid and liquor potassas. These rods were sometimes floating free, sometimes partly or wliolly held within urinary tubules, of which evi- dently they were casts. They were generally struc- tureless, but (no doubt from the manner of their formation) had a disposition to transverse fracture, and sometimes presented lines curving almost concen- trically across them, or had this direction given to little clusters of granular matter, probably altered epi- thelium, which they occasionally contained. Apart from the presence of these casts, the tubular struc- tui'c of the kidoc}^ was not very obviously diseased; but, after prolonged and careful observation, it could confidently be said, that, at least in many parts, the cell-growth within it was redundant, so that the tubules were more opaque than natural, and had their interior canal encroached upon, or even quite occluded by an increased amount of epithelium. The Malpighian tufts within their capsules showed a little indistinctly. 'The venous system was everywhere remarkably full of blood; the liver was greatly congested; the heart was healthy, with a firm coagulum in each of its four cavities.' The next case, also taken from the Transactions of 248 ON DIPHTHERIA. the Pathological Society^ is from a communication by Dr. Bristowe.* ' T. N., £et. ten, the son of a farm labourer, was admitted into St. Thomas's Hospital, under Mr. Solly's care, on the i2t.h of November, 1^58, with contraction of the left wrist and elbow-joints, after a burn. On the 18th he was operated upon, and con- tinued under mechanical treatment up to the com- mencement of the malady of which he died. He appeared perfectly well on the 20th of March, 1859, but on that day partook of some gin and other im- proper articles of diet. The following morning he had a slio;ht attack of shiverino^, and seemed other- wise a little indisposed. On the 22nd he complained of slight soreness of the throat. This increased, and on the 24th the following notes were taken by the surgical registrar : — ' " Throat much swollen externally, particularly on the right side. On looking into it the right tonsil is seen filling up the fauces, and has upon it a pulta- ceous material. Pulse small and weak, 130; tongue furred; skin cool." ' On the 25th he was placed under my care. He has slept a little in the night, and is said to be now rather better than he has been. He is extremely feeble, however, not at all feverish, and perfectly rational. The skin is cool, and gives no indication of rash. Pulse small, weak, slightly irregular, and about 100. There is great tumefaction, hardness. Loc. cit., pp. 326-31. CASES ILLUSTRATING THE MORBID ANATOMY. 249 and tenderness in the upper part of tlie throat, chiefly in the parotid and submaxillary regions, and more on the right side than on the left. The anterior half of the tongue is clean, and its papillae are healthy; the posterior half is somewhat furred. The right tonsil is much swollen, and covered by a thick wash-leather-like false membrane, which is prolonged from it on to the pillars of the fauces, over the right half of the soft palate, and to the edges of the poste- rior teeth. The nose bled this morning, and a little thin sanious fluid has continued to ooze from it. Has no pain anywhere except in the throat; experiences pain and difliculty in swallowing, but can manage to take fluids. No cough or difliculty of breathing. Bowels opened yesterday. ' March 26, two r.M. — Slept pretty well, but is much worse than he was. Skin cold, without trace of rash. Pulse quite imperceptible. Throat more swollen, hard, painful on pressure, and studded on the right side with small congested points. Tongue dryish, but not much furred. The breath has a faint, gangrenous odour. There is no appreciable change in the condition of the interior of the throat. Is quite sensible, but very rest- less. No cough, or embarrassment in breathing. He continued to sink, and died at half-past five p.m., re- maining sensible to the last.' The following were the post-mortem appearances : — * The front and sides of the throat were thick and brawny ; and the parotid and submaxillary regions were much swollen and hardened, especially on the right side, where also the integuments were studded 250 ON DIPHTHERIA. with congested and livid spots. On cutting into the neck, its muscular and cellular tissues, from the in- teguments to the vertebrae, and from the ears and root of the tongue to the upper opening of the tliorax, ■were found indurated and brawny, and so infiltrated with blood as to be everywhere almost black. There were no circumscribed fluid or clotted collections, but the blood was uniformly diffused throughout the tissues. There was no appearance of pus, and no visible indication of inflammatory deposit. ' The soft palate and uvula, the tonsils and pillars of the fauces, the oesophagus aad larynx, were all in- tensely and deeply congested, tumid, brawny, and covered in many places by toughish, adherent, ashy, false membrane, or by pultaceous puriform exudation. The soft palate was quite half an inch thick, infil- trated with blood, and studded with shreds of false membrane. The tonsils were swelled, but at the same time presented deep fissures and excavations, and were covered pretty completely by greyish-yellow false membrane. This was in parts thick, tough, and pretty firmly adherent; but over the convexity of the tonsils became changed into a soft, pultaceous deposit, which seemed partly pus, and partly super- ficial slough. On incising the left tonsil it was found softened, deeply congested, partly infiltrated with blood, and studded with distinct pus-holding cavities; and the surfaces of the fissures passing into it from the surface were soft, greenish, and slightly gan- grenous. The right tonsil was generally in the same condition as the leftj but presented several deep, dis- I CASES ILLUSTRATING THE MORBID ANATOMY. 251 tinctly gangrenous, foetid excavations. The mucous surface of the base of the tongue and back of the pharynx was congested, and presented here and there shreds of adherent membrane. The mucous invest- ment of the epiglottis, and indeed that of the whole larynx, were thickened, indurated, and deeply con- gested. The epiglottis was covered pretty exten- sively by a toughish adherent membrane, about half a line thick; and a similar formation, in less abun- dance, was studded over the rest of the laryngeal surface, and accumulated along the vocal cords. The trachea was congested, but other\vise healthy; the oesophagus also was healthy; but the tissues inrnie- diately surrounding them, like those of the rest of the neck, were infiltrated with blood. Several por- tions of the hard palate, and septum nasi, were re- moved, and their mucous covering was found con- gested, and lined by adherent false membrane. ' Pericardium healthy. Heart small, firmly con- tracted, and nearly empty, its auricle and right ventricle containing a little fibrinous clot only. The valves were healthy. The nauscular tissue was gene- rally pale ; but almost all the musculi papillares and carnea3 columnce of the left ventricle, and the walls of the apical half in nearly their whole area, and to a depth varying irregularly from a quarter of an inch downwards, were almost black from sanguineous in- filtration. The same condition was observed in the right ventricle, but to a less extent, the papillary muscles and the parietes being studded irregularly and thickly with black, blood-infiltrated patches of 252 ON DIPIITIIEinA. various sizes; some so thick as to reacli tlie external surface of the organ, and some dotted with white spots and patches, which looked at first sight like suppurating points. ' Pleural healthy. Lungs crepitant throughout, and not materially congested. Tliey presented, how- ever, on their external surface, a few dark-red, almost black spots, about a quarter of an inch in diameter, which were found to correspond to small subjacent patches of solid, dark-coloured, granular lung tissue. The bronchial tubes contained much secretion. ' Peritoneum healthy. Liver of usual size, gene- rally of normal colour and consistence; its surface and substance, however, were thinly studded with petechial spots. Spleen of usual size, pale, and of moderate consistence. There was a little effusion of blood in the sub-mucous and cellular tissues around the pancreas and supra-renal capsules; and the latter organs presented patches of extravasated blood in the interior, though apparently in other respects healthy. The cellular tissue of tlie mesentery was studded pretty thickly with small, and not very intensely coloured patches of congestion and extravasation. The stomach and intestines were healthy, but the ilium contained two lumbrici. The kidneys were of the usual size, pale and apparently perfectly healthy. Aorta and vena cava healthy. ' The fldse membrane about the fauces and neigh- bouring parts was made up chiefly of a network of fibrillated lymph. The fibrillar were very irregular in outline and dimensions, but generally comparatively CASES ILLUSTRATING THE MORBID ANATOMY. 253 thick; and they coalesced with one another in all directions, so as to leave irregular spaces between them, Avliich were small, and often not larger in diameter than the fibrillas themselves. When seen in thickness, the tissue above described presented a pebbly character, like that afforded by an accumula- tion of nuclei; but the fallacious nature of this ap- pearance was recognised on 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 network of well and sharply defined, occasionally bulging, fibres, which appeared to be, so to speak, the skeleton of the original network. In some places the false membrane consisted of an apparently 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. ' The pus-like fluid in the tonsils consisted of well- marked pus-cells, characteristically aff'ected by acetic acid. Some of the muscular tissue from the small muscles of the larynx and from those of the neck was examined, and found to be striated and healthy- looking; but the spaces between the fibres were loaded with blood-corpuscles. The cellular tissue in front of the epiglottis presented a net-work of fibril- lated tissue like that constituting the false membrane I 254 ON DIPHTHERIA. itself"; but the meslies were larger and more distinct. The muscular tissue of the heart was found to be gene- rally in an early stage of fatty degeneration, the trans- verse markings being nearly absent, and the fibres studded with minute molecules. But in the portions infiltrated with blood the degeneration was more ad- vanced than elsewhere, the stride were wholly deficient, the fibres crowded, and in some cases opaque, with beads of oil, many of which Avere of considerable size. The white pus-like spots in the right ventricle consisted simply of muscular fibres extremely degenerated. ' The kidneys, though looking healtliy to the naked eye, were really much diseased. The IMal- pighian bodies were generally health}^, but a few pre- sented accumulations of oily granules between the capsule, and contained tufts of vessels. The epithe- lium of the tubes was generally opaque and granular. In many instances the peripheral surface of the cylinder of cells presented numerous oily globules; and not infrequently the tubes appeared filled with separated and irregularly clustered epithelial cells, loaded with oil so as to be almost opaque. In a few cases, tubes were filled with recently extravasated blood; and occasionally transparent casts Avcre seen floating about the field of the microscope. The con- tents of the medullary tubules were more generally un- healthy even than those of the cortical ones. ]\Iany contained transparent fibrinous casts, and the majority presented oily, breaking-down, epithelial contents.' I am indebted to Dr. Bristowe for the foUowinof report of a case, which recently proved fatal in St. CASES ILLUSTRATING THE MORBID ANATOMY. 255 Thomas's Hospital. I had not the opportunity of seeing the patient during life, but carefully examined the affected organs after death. E. T., a girl, aged eleven years, suffering from club-foot, had been in St. Thomas's Hospital, under Mr. Solly's treatment, since May 22, i860. On the evening of June 23, she first complained of sore- throat. This increased in severity during the next few days ; pain and difficulty of swallowing came on, and on the afternoon of the 27tli she was placed under the care of Dr. Bristowe. There had been no marked febrile symptoms, no shivering, head-ache, or pains in the limbs. Neither in the ward nor among the child's friends had there been -any cases of scarlet fever or diphtheria; but a little girl in an adjoining bed had been attacked, much about the same time, with a sore-throat, which had disappeared in a day or two, and presented no unusual character. 'June 27. — Is perfectly sensible and composed, having by no means the aspect of a person seriously ill. Has no head-ache, or pains about the limbs; complains of a little thirst and loss of appetite, but no sickness, cough, or difficulty of breathing. Pulse 124. The pupils are natural. The skin is warm, but not dry, and without trace of rash. The external fauces on the right side are much swollen, very tense and tender, but not discoloured. On looking into the throat the right tonsil is seen to be so much en- larged as to appear almost to close the passage, and is covered in nearly its whole extent by a thick, greyish, false membrane. The uvula is pushed over to the 256 ON DIPHTHERIA. left side, and almost concealed; is somewhat thick- ened, and a little false membrane adheres to it. The left tonsil is hidden, and apparently not enlarged. The tongue is covered with a whitey-brown fur, and its papilla3 are not prominent. Hirudines ij. faucibus externis. Catapl. lini postea. 51 Chlorat. potass. gr. iv. Acid, hydrochl. V\i- Aqufc dist. 5SS. 4tis horis. Milk diet. Strong beef tea. Two eggs. Wine three glasses. ' 38th. — Passed a comfortable night, and has taken all her wine and nourishment. The leeches have given her great relief. There is little appreciable change in either her general health, or in the condition of the throat, except that the right side is less tense and tender than it "was. The bowels are confined. Wine 4 glasses. Pulv. rhtei c. hydrarg. 3j. statim. ' 29th. — Was very restless during the night. The bowels have been relieved, and she has been very sick. The skin is hot, and rather dry. No rash. Pulse 128. No pains anywhere, excepting in the throat; no cough or difficulty of breathing. Great pain and difficulty of swallowing. There is copious discharge from the nostrils. Tongue clean. The right side of the throat is in the same condition as vester- day; but the left side also is noAV distinctly swelled and painful. The right tonsil is about as large as it was; but the membrane, which is thick and tough, is detached and curled up at the margins. The left CASES ILLUSTRATING THE MORBID ANATOMY. 257 tonsil is somewhat increased in size, and also presents a distinct false membrane. The uvula is seen with difficulty, but has a few patches on its surface. The lungs are resonant in front; but the respiratory sounds are masked by the noise produced in the throat. Urine albuminous. Sp. gv. 1015. Wine twelve glasses. ' Towards the evening she grew considerably worse, and became very restless. The pulse rose to 152; a troublesome cough, at times a little croupy in cha- racter, came on ; the breathing became rapid (40 in the minute), and more noisy than it had been. She continued perfectly sensible. ' 30th, nine a.m. — Has been very restless all night, and has taken very little wine and nourishment in consequence of inability and disinclination to swallow. Is now manifestly sinking; is scarcely sensible, but can be roused; breathing rapid, accompanied by loud rattle and frequent moans; pulse imperceptible ; lips dry. Died at 10 a.m. ' Autopsy. — The body was in fair condition. There were no traces of eruption or of desquamation. The right submaxillary region was much swelled and in- durated ; the left also, and the intervening parts, were swelled, though in a less degree. ' Chest. — Pericardium healthy. Heart of natural size, and for the most part healthy. Its external surface presented numerous petechial spots, and its cavities contained partly decolorized coagula. The pleura? were free from adhesions, but the upper lobe of the left lung was covered by a very thin film of S 258 ON DIPHTHERIA. recent granular lymph. The lungs were rather large, heavier than natural, and presented, when handled, the uTegularly solidified character distinctive of lobular pneumonia. On section, the upper lobes of both lungs were found to furnish well-marked speci- mens of the condition just named. They were studded thickly with smallish solid masses, running to some extent into one another, and separated by an imper- fect network of still crepitant, though congested, lung tissue. The solid masses varied in character; in some instances were distinctly apoplectic, in others had the appearance of being due to simple carnifica- tion, and in others presented various degrees of the brick-red tint and granular condition belonging to red hsepatization. The lower lobes were, in many respects, in the same condition as the upper ; but they presented a greater degree of simple collapse, and, consequent!}^, a less amount of crepitant tissue; the hsepatized and apoplectic patches, too, were larger, and presented less of the lobular arrangement. The bronchial tubes were congested, and contained much frothy mucus. ' The larynx, trachea, and adjacent parts, were now removed and examined. The right tonsil was found to be very large, though scarcely so large as during life; the left also was enlarged, but in a less degree than its fellow; and the uvula and soft palate were somewhat thickened. The tonsils, soft palate, uvula, base of tongue, and posterior and lateral part of pharynx were covered, more or less completely, with tough, somewhat elastic, whitish false membrane. CASES ILLUSTRATING THE MORBID ANATOJ^IY. 259 On the base of the tongue and uvula it formed merely thin, scattered patches. But over the tonsils, pillars of the fauces, and rest of the pharynx, it formed layers of considerable extent, and often more than half a line thick. The membrane had become generally more or less detached at the edges ; and that portion connected with the right tonsil had sepa- rated in nearly its whole extent, and hung as a loose, discoloured mass, backwards into the pharynx. On peeling the membrane off, it was found pretty firmly attached, and accurately moulded to the inequalities of the subjacent mucous surface, which was con- gested, but not ulcerated. On section, the tonsils were seen to be deeply congested throughout, some- what softened, and studded thickly with small patches of yellov/ish (but not distinctly purulent) inflamma- tory deposit. The tissue of the soft palate and uvula was a little brawny. ' The mucous membrane of the upper part of the larynx was congested, and somewhat thickened ; and a thin false membrane covered the epiglottis, extended into the aryteno-epiglottidean folds, and down to the superior vocal cords. False membrane also extended into the sacculi laryngis, and was scattered in small patches over the mucous membrane for about an inch below. The greater part of the trachea was healthy. ^Abdomen. — Peritoneum healthy. Liver healthy, but studded with a few pallid patches. Spleen, pancreas, and supra-renal capsules healthy. The mucous membrane of the stomach presented nume- rous petechial spots; and Peyer's patches in the s 2 260 ON DIPHTHERIA. lower three feet of the ileum were remarkably dis- tinct and prominent; in other respects the alimen- tary canal displayed nothing unusual. The kidneys did not look unhealthy ; but exhibited, in their cor- tical substances, alternate pallid and congested vertical streaks. Uterus and ovaries healthy. Larger blood- vessels natural. ^Microscopic Examination. — The ftxlse membrane was identical in its intimate structure with those which I had formerly examined and described.* The only unnatural character exhibited by the kidneys was, general great granularity of the epithelium, and consequent opacity of the undenuded tubules. It seemed, too, as though the individual cells Avere ab- normally large. There was no trace of effused blood, and no casts. The Malpighian bodies were normal.' * Transactions of the Pathological Society of London. Vol. x. Medical Times and Gazette. 1859. 261 CHAPTER XII. SUGGESTIONS TOR TREATMENT. TN the management of a disease so rarely attended -L by febrile excitement, and so rapidly producing marked depression as diphtheria, it is not surprising that there should have been great unanimity among medical practitioners as to the necessity for the adoption of a supporting plan of treatment, and the avoidance of blood-letting and other antiphlogistic measures. And it is well worthy of note that this unanimity has not been confined to our own time, the physicians who treated the earlier epidemics having agreed very nearly with ourselves on this point; and, however they might differ in details, followed a mode of treatment similar in principle to that which has been almost universally adopted during recent epidemics. Diphtheria is, indeed, in this respect in exact accordance with other severe epidemic diseases ; patients suffering from influenza, for example, rarely, if ever, bear depletion, and almost always require a liberal amount of support. Seeing that scarcely any two cases are precisely similar, it would be impossible to define rules of treatment applicable to every variety of diphtheria, or even to each of its principal complications and sequelae. No 262 ON DIPHTHERIA. specific remedy has been discovered suitable to a majority of cases, as quinine is to the treatment of ague; therefore each case requires to be carefully studied, and the treatment modified to suit its pecu- liar features. The varying intensity of the disease has also tended much to prevent a just estimate of the usefulness of remedies the dissimilar value of which, in difi'erent hands, has probably often arisen from the different nature of the cases with which they have had to deal. Hence there has, perhaps, sometimes appeared a tendency, on the part of their proposers, to over-estimate the usefulness of remedies which have proved less valuable when employed by other and equally competent practitioners. I do not propose to recapitulate the numerous remedies which have been suggested for the treat- ment of diphtheria; much less do I intend to offer suggestions which could be supposed to supersede the exercise of the practitioner's independent judg- ment. The method of treatment which I have found most useful, and which has received the largest share of professional approbation, may probably be, in a great measure, gathered from the cases detailed in the preceding pages. I shall, therefore, in the few observations which I think it desirable to offer on this branch of my subject, restrict myself to a very brief sketch of the system of management which I have found most useful in the treatment of this disease; again premising that it will probably re- quire to be greatly modified in order to suit the requirements of different cases. LOCAL TREATMENT. 263 With regard to external local treatment, it may be well to say that I have in no instance deemed it advisable to apply leeches to the swollen throat — a proceeding which has been sometimes recommended ; but the inutility, not to sa}^ danger of which may, perhaps, be estimated by the unfavourable result which so often follows their application in severe cases of scarlet fever. Neither have I, generally, directed the application of hot poultices or fomentations to the neck, such applications having seemed to me to afford little or no relief, and their frequent renewal being troublesome to the patient. Blisters to the throat appeared to be perfectly useless in the few cases in which I saw them tried ; and are, more- over, objectionable from the probability of the abraded surface assuming a diphtheritic character, and thus adding to the depression which forms so dangerous a feature of this disease. In fact, after trying both plans, and seeing them extensively tried by other practitioners, I arrived at the conclusion, that appli- cations externally to the throat are entirely useless to the patient. Slight cases do very well without them; and in severe cases they prove valueless, and do but serve to distract the attention of the nurse from really important duties. Local treatment applied to the throat internally has been almost universally adopted in the treatment of diphtheria; and — though I by no means deny its value when judiciously employed — I am sure much mischief has been produced by its indiscriminate use, especially by the frequent tearing away of the exu- 264 ON DIPHTHERIA. dation by probangs, or similar contrivances for the application of nitrate of silver, or of strong caustic solutions. Observing that removal of the exudation, and the application of remedies to the subjacent surface, neither shortened the duration, nor sensibly modified the progress of the complaint, but that the false membrane rarely failed to be renewed in a few hours, I very soon discontinued this rough local me- dication to the tender and already enfeebled mucous membrane. The propriety of this course became evident at the very first post-mortem examination I had the opportunity of witnessing, and has been con- firmed by all my subsequent experience. In the first place, the application can but rarel}^ extend to the entire diseased surface; and, in the next, the subjacent tissues are so deeply involved in cases of really malignant diphtheria, that any application to the surface of the mucous membrane could appa- rently exercise no beneficial influence upon the dis- ease. The same observation applies with even greater force to the indiscriminate use of strong solutions of chloride of zinc, or of Beaufoy's solution of chloride of soda. The only instance in which much benefit can be expected to arise from the local application of escharotics, is when the patient is seen at a very early stage of the illness, while the throat is simply in- flamed, or the exudation, if it be already present, is circumscribed, fully in view, and surrounded by healthy tissue. In the former of these cases I have seen much benefit derived from pencilling the throat LOCAL TREATMENT. 265 gently, two or three times within the first twenty-four hours, with slightly diluted tincture of the sesqui- chloride of iron. This application, softly laid on with a camel's-hair pencil, appears to have checked the local affection, and the patient has sometimes rapidly recovered under its use. In a still more diluted form, as in the proportion of a drachm of the tinc- ture to seven drachms of water sweetened with honey, the same medicine forms a most useful gargle in the milder kinds of sore-throat which so commonly occur during the existence of an epidemic of diph- theria. When, even though there be exudation, the diseased part is entirely in view and surrounded by healthy tissue, it would certainly be proper to pencil the affected part thoroughly with solid lunar caustic, or probably, in preference, with hydrochloric or nitric acid. It is just possible that this treatment might in such cases check the progress of the complaint, and lead to a rapid recovery ; but, unfortunately, the dis- ease is rarely seen under such peculiarly favourable circumstances, and the opportunity of trying this experiment has not occurred to me in any but the mildest cases, in which so severe a form of treatment appeared unadvisable. Whilst, however, the severer kinds of local treat- ment should thus be very cautiously employed, much benefit will generally be derived from the use of milder and soothing detergent applications. Simple gargles of borax or alum dissolved in Avater, or of solution of chloride of soda, in the proportion of half a drachm of the solution to the ounce of water, in 266 ON DIPHTHERIA. either case sweetened with honey, bring away the foul secretions and loose flakes of exudation, and thus both by cleansing the mouth, and lessening the obstruction about the fauces, very materially facilitate the administration of remedies and nutri- ment. Such gargles may be used either cold or tepid, as is most agreeable to the patient, and in very young children, or whenever patients are unable to gargle, they may be injected into the throat with a syringe, the patient's face being held over a basin immediately afterwards, so as to facilitate the return of the liquid together with the secretions and debris of the exudation vvdiich it may have detached. Pro- bably in many cases, a simple injection of tepid water might answer the purpose equally well; and I have seen little benefit derived from the use of the chlori- nated gargle, except where the breath was foetid from the decomposition of the exudation within the fauces. When the concretion has cleared away, and the throat is free from ulceration or excoriation, it is well to discontinue all local treatment, time being usually the best remedy. Sometimes the throat re- mains slightly congested or relaxed, or very sensitive to changes of weather for long after an attack of diphtheria. In the former of these cases the gargle, with the tincture of sesquichloride of iron already mentioned, has been the most useful application in my experience. In the latter I am accustomed to trust to constitutional treatment, gargling the throat with cold water, and — especially when the advice can be followed — to recommend change of air. CONSTITUTIONAL TREATMENT. 267 It rarely happens that the practitioner is consulted sufficiently early to undertake the treatment at the very outset ; but when the patient is seen before de- pression has commenced, provided the pulse be firm, and the patient tolerably vigorous, an emetic of sul- phate of zinc and ipecacuanha is a useful prelude to other treatment. It is difficult to estimate accurately the probable severity of an attack of diphtheria at this early stage; but it has appeared to me that the use of an emetic at the beginning has sometimes mitigated the subsequent illness. After the operation of the emetic, the folio win 2; have been found the most efficient remedies : — The mist, chlorinei, prepared after the form given by Dr. Watson in his classical work on the Principles and Practice of Physic; a simple solution of chlorate of potass in syrup and water, with a minim of diluted hydrochloric acid for each grain of the salt; and the tincture of sesqui- chloride of iron ; the dose in each case being propor- tioned to the age and condition of the patient. The tincture of sesquichloride of iron, first recommended in the treatment of diphtheria by Dr. Heslop, of Birmingham, has been so generally adopted by the profession, as to afford a guarantee that it has in the main been equally useful in the hands of others as it proved in his own. There are, nevertheless, cases in which I have found chlorate of potass more useful, and there are others in which the combination of the latter mth the tincture of iron is a better remedy than either of them separately. In cases unattended by immediately urgent symp- 2G8 ON DIPHTHERIA. toms, where the concretion is firm, and there is ap- parently no tendency to haemorrhage or purpura, I prefer the above-mentioned mixture with the chlorate of potass given at intervals of three, four, or six hours. When the exudation is surrounded by deeply injected, softened membrane, Avhich abrades and bleeds on the slightest touch, or whenever there is albuminuria, then the tincture of sesquichloride of iron in full and frequent doses is the proper remedy. If, in such cases, there be a tendency to purpura, from five to ten or twelve minims of diluted hydrochloric acid may be advantageously combined Avith the iron. When the htemorrhagic tendency co-exists with great foetor of breath, the tincture of sesquichloride of iron will be best administered in conjunction "with mist, chlorinei. Whatever medicines be prescribed, it is essential to their success that they should be administered regu- larly at stated intervals, and that the necessary sus- tenance be systematically given with equal regularity intermediately between the doses of medicine. To insure this it is well to require the nurse to note upon paper the exact time when each dose of medicine or article of diet has been given, together with the quantity of each taken by the patient. Of course, the same system is applicable to the administration of wine when this is found necessary. A glance at this record at each visit shows the practitioner at once how far his instructions have been carried out, and secures a degree of accuracy scarcely otherwise attainable. It very often hajDpens that patients suffering from diph- CONSTITUTIONAL TREATMENT. 269 tlieria are said to be unable to swallow food, and it is quite possible that lives have been sacrificed to this belief, which is, nevertheless, frequently erroneous, the power of swallowing often remaining undiminished, even in the severest cases, to the last moments of life. In such cases it is well for the medical man to test the correctness of the assertion by causing food to be administered in his presence. It will then sometimes be found that patients who, being disinclined to be disturbed, have refused food or wine, can yet swallow without difficulty, tlius showing that the real obstacle lay rather in the want of method and perseverance on the part of the attendant than in the inability of the patient to swallow. "When diphtheria is attended by much depression from the beginning of the illness, the sesquicarbonate of ammonia given in decoction of cinchona is some- times very useful, but is subordinate to alcoholic stimulants, such as wine or egg and brandy, which are indispensable, the chance of recovery in such cases depending much more upon the alcoholic stimu- lant than the medicine. But although this be true, it is by no means advisable to employ stimulants in- discriminately in diphtheria, many of the milder cases doing quite as well without. Neither when they are required, is it necessary to give the very large quantity of wine that is sometimes sup- posed, especially in children, proper nutriment often answering a better purpose. In order to insure sti- mulants being given only at the proper time and in the right quantity, the state of the pulse should be 270 ON DIPHTHEEIA. carefully watched, and wine administered as soon as it begins to flag, the quantity being regulated by its efl'ect on the circulation. On this account it is best to begin with small doses, repeated at regular inter- vals of four or six hours, and to increase either the quantity or the frequency of its administration as occasion may require, remembering that whenever wine is absolutely necessary, its regular exhibition is equally essential by night as by day. The chief danger in one form of diphtheria arises from the extension of the disease into the larynx and trachea, producing croup. Such cases are often very unmanageable, and are best treated on similar princi- ples to idiopathic croup, but modified on account of their diphtheritic character. If the patient's strength will admit, it is well to administer an emetic of sul- phate of zinc and ipecacuanha, as soon as croupy symptoms manifest themselves, and this, provided there be no special reason to the contrary, should be at once followed up by small but frequent doses of calomel or hydrarg. c. creta, with the object of modifying the quality of the exudation. At the same time, nutriment, and stimulants if necessary, should be freely and regularly given so as to sustain- the patient's strength. Failing the success of other treatment in diphthe- ritic croup, the question will very properly arise whether, when dyspnoea is very urgent, the operation of tracheotomy should be performed. Upon this subject I have no personal experience, but the opera- tion has, in this country, been almost always un- TRACHEOTOMY DIET. 271 successful. On the other hand, I have had the opportunity, in two instances, of observing, in post- mortem examinations, that the false membrane ex- tended a very short distance down the trachea, and, in one of these, death appeared to have been caused by the partially separated membrane acting as an obstruction to the admission of air. Perhaps, in this instance, the performance of tracheotomy might have saved the patient; and, when the case appears to be otherwise hopeless, it would probably be right to give the patient the chance afforded by the opera- tion, provided there should be no evidence of the extension of the disease to the bronchial tubes, or of the existence of pneumonia, either of which would manifestly contra-indicate the performance of an operation, which must, under such circumstances, prove unavailing. The best nutriment, during what may be termed the acute stage of the complaint, consists of good beef- tea or chicken-broth, arrow-root, new milk (of which patients may advantageously take a quart or more during the day), cream, and eggs either lightly boiled or beaten up with milk, or with wine or brandy when the latter are requisite. As convalescence becomes established, fish, chicken, or other solid food should be given as early as possible, the patient's strength meanwhile being maintained by the liquid nutriment just mentioned. However the strictly medical treatment may be modified in order to suit particular cases, it is of paramount importance in the management of diph- 272 ON DIPHTHERIA. theria to husband tlie patient's strength, to avoid every depressing influence, and especially to caution the patient against over-exertion, the disease as it advances being attended by such extreme anaemia, that a very slight effort has sometimes appeared suf- ficient to cause death. As has already been stated, this danger continues, even when the more urgent symptoms have disappeared, and convalescence would seem to have set in; patients having sometimes expired suddenly under such circumstances, after trifling muscular exertion. In order to guard against this, it is proper to confine the patient to bed from the beginning of his illness, and to keep him in a recumbent position until convalescence be con- firmed. It is also prudent for some time after re- covery to give a little light nutriment or wine before allowing convalescents to exert themselves. It would perhaps be too much to assert that patients have been saved by attention to these apparently trifling matters ; but it may at least be safely affirmed, that many have been sacrificed to the neglect of them. The same general principles are applicable to the treatment of the complications and sequelae of diph- theria. When this disease is complicated with bron- chitis or pneumonia, these affections must be treated in the ordinary manner, save that the patients will probably require a liberal allowance of wine and nourishment. Bismuth and hyoscyamus with bland nourishment, especially new milk, eggs, cream, and farinaceous articles of food, are the treatment best suited to cases in which the disease, creeping down- TREATMENT OF SEQUELiE. 273 wards along the oesophagus, has caused gastrodynia or vomiting. Small doses of calomel or hydrarg. c. creta with opium or Dover's powder, followed by castor oil, afford the best prospect of success in the treatment of diphtheritic as of ordinary dysentery. Time is the most important agent towards re- covery from the several forms of nervous affection which follow diphtheria; but the cure is often acce- lerated by judicious change of air and scene, by good nourishment and tonic medicines. In the selection of the latter, regard should be had to the age and con- dition of the patient. Sometimes diluted nitro- muriatic acid in combination with a light bitter, such as the infusion of gentian orcalumba, has been found to suit patients better than more potent medicines. Citrate of iron and quinine is often very useful ; and when there has been albuminuria or purpura, or there is extreme anaemia, the tincture of sesquichloride of iron, with or without a few minims of diluted hydro- chloric acid, or a grain or two of quinine to each dose, according to circumstances, is oftentimes serviceable. Occasionally sulphate of quinine in combination with diluted sulphuric acid, administered in any proper vehicle, will be found the best tonic. Minute doses of strychnia are said to have been sometimes useful in cases where diphtheria has been followed by para- plegia; but I have no personal experience of their value. On the whole, though convalescence is usually much protracted, patients for the most part recover perfectly from the antemia and purely nervous sequela3 of diphtheria, provided they survive the six- T 274 -ON DIPHTHERIA. teenth or seventeenth day of their illness ; and though tonics should certainly be persevered in, if they ap- pear useful, there can be no doubt that they ought to be discontinued, if they do not agree with the patient nor appear to accelerate his recovery, seeing that time and good nursing will, in all probability, restore him to his pristine health. THE END. In Octavo, the First Volume of A SYSTEM OF SURGERY, THEOEETICAL AND PRACTICAL, WBITTEN BY VAEIOTJS AUTHOES, AND EDITED BY T. HOLMES, M.A. Cantab. ASSISTANT-SURGEON TO THE HOSPITAL FOR SICK CHILDREN. It is generally admitted that a comprehensive work, which should embrace the whole science and practice of Surgery, as it is understood in the present day in England, and which should in all its parts be the product of indi- vidual research and experience, and not a mere compilation from the labours of other men, has long been wanting in the English schools. With a view of supplying this deficiency, it has been proposed by the projectors of the present undertakiug to form into a complete and systematic treatise a collection of essays on the principal topics of surgery, written for the most part by gentlemen connected with the hospitals of the metropolis, who are specially qualified from predilection and previous research to treat of the subjects which they have undertaken, and many of whom are favourably known by former works on these subjects. The principal causes which have interfered with the success of such undertakings hitherto, have been the diflBculty of obtaining qualified contributors, and the length of time over which the pub- lication has been allowed to extend. It is hoped that the subjoined list will show that the former difficulty has been surmounted — the latter will be avoided by producing the book in volumes instead of numbers, as has hitherto been customary, at as short intervals as possible, and by not com- mencing the publication until all the matter for the complete work is almost ready for the press. When finished, if it succeeds in its object, it will present a complete and impartial view of British Surgery, free from the bias of any school, or the prejudices of any individual ; while the special attention of the authors having been drawn to their several subjects, any advance which the rapid improvement of surgical knowledge may introduce into them, will be registered and kept in readiness for future editions. Illustrations will not form a prominent feature in the work, but they will be provided where they are absolutely necessary for the fuU understanding of* any subject. Where subjects are treated of which are common to Surgery and Medi- cine, the assistance of pliysicians who have paid peculiar attention to those subjects has been gladly accepted. The following is a List of the Contributors. Db. Barclay, Assistant-Physician to St. George's Hospital. John Bikkett, Surgeon to Guy's Hospital. George Busk, F.R.S., Surgeon to the Seamen's Hospital-ship 'Dreadnought.' George TV. C^vllendek, Demonstrator of Anatomy at St. Bartholomew's Hospital. Holmes Coote, Assistant-Surgeon to St. Bartholomew's Hospital. Campbell de Moegan, Surgeon to the Middlesex Hospital. James Dixon, Surgeon to the Eoyal Ophthalmic Hospital, Moorfields. William H. Flower, Assistant-Surgeon to the Middlesex Hospital. Henry Gray, F.R.S., Lecturer on Anatomy at St. George's Hospital. Charles Hawkins, Inspector of Anatomy, Consulting Surgeon to Queen Charlotte's Hospital. Pkescott G. Hewett, Assistant-Surgeon to St. George's Hospital. James Hinton. Timothy Holmes, Assistant-Surgeon to the Hospital for Sick Children. Carsten Holthouse, Surgeon to the Westminster Hospital. Thomas King Hornidge, late Demonstrator of Anatomy at St. George's and St. Mary's Hospitals. Jonathan Hutchinson, Assistant-Surgeon to the London Hospital. T. H. Huxley, F.R.S., Lecturer on Natural History at the School of Mines. De. Jenner, Physician to University College Hospital. Athol Johnson, Surgeon to the Hospital for Sick Children. Sydney Jones, Assistant- Surgeon to St. Thomas's Hospital. Henry Lee, Surgeon to the Lock and King's College Hospitals. Joseph Lister, F.R.S. , Professor of Surgei-y in the University of Glasgow. Dr. Little, Physician to the London Hospital. Thomas Longmore, Deputy Inspector- General of Hospitals. Sir James Ranald Martin, F.R.S., Examining Surgeon to the India Board. Charles Hewitt Moore, Surgeon to the Middlesex Hospital. James Paget, F.R.S., Assistant-Surgeon to St. Bartholomew's Hospital. Alfred Poland, Assistant-Surgeon to Guy's Hospital. Geoege David Pollock, Assistant-Surgeon to St. George's Hospital. Samuel James A. Salter, Surgeon Dentist to Guy's Hospital. William Scovell Savory, F.R.S.,Professorof Comparative Anatomy at the Royal College of Surgeons. Alexander Shaw, Surgeon to the Middlesex Hospital. Dr. Sibson, F.R.S., Physician to St. Maiy's Hospital. John Simon, F.R.S., Surgeon to St. Thomas's Hospital, Medical Officer to the Privy Council. Heney Smith, Surgeon to the Westminster General Dispensary. Thomas Smith, Demonstrator of Anatomy at St. Bartholomew's Hospital. Thomas Tatum, Surgeon to St. George's Hospital. Heney Thompson, Assistant- Surgeon to University College Hospital. Alexander Uee, Surgeon to St. Mary's Hospital. LONDON : JOHN W. PARKER AND SON, WEST STRAND, W.C. gw .Bl UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. MAY 1 5 1363 BIOMED LIB JUN 7 RECD BIOMFD LIR V MAY 2019^9 OJC 131985 BTOMED. LIB. REC'D 610MED LIB 1 1986 RECB •"#>**^^^ED DEC 09 -87 ^^■^ I Form L9-52m-7,'61(Cl437s4 °%0 ««j(P> m& '87