Part 108

If these light articles of diet are well borne, they are to be gradually and watchfully exchanged for beef-essences, the blood of a rare beefsteak, and the more substantial broths. Solid articles of food should not be allowed during the first ten days after an attack, and for still longer periods patients should be admonished against excesses in eating, and especially in respect to indigestible articles. Those lesions of the blood and of the stomach, and those grave disorders of nerve-function which occasion hæmatemesis in yellow fever, are slowly repaired. Instances are reported in which black vomit and death have followed excessive eating and drinking ten or twenty days after dismissal from treatment.

There are, however, certain conditions which are liable to complicate yellow fever which demand a course of dietetic procedure different from that which I have recommended. Thus, children cannot bear privation of food until the paroxysm is over if its duration is long. In like manner, a more supporting course is required in most of those cases in which yellow fever occurs as an intercurrent affection, in all those cases which are termed typhoid or adynamic per se, and, more emphatically still, in every case in which hemorrhages are occurring. A failing pulse should in all instances admonish us to resort to nourishment and stimulants.

It is a fortunate circumstance that in yellow fever the lower bowel is generally in a state favorable for the retention of nutritious enemas. In the most trying and critical hours of desperate cases I have seen patients tided through by the use of skilfully prepared and skilfully administered injections of some suitable meat-essence. When insomnia exists, chloral hydrate or bromide of potassium may be conveniently given in these vehicles.

It is evident that the discussion of the vastly important sanitary questions pertaining to the prevention of yellow fever cannot be appropriately discussed in the present article.

{656}

DIPHTHERIA.

BY A. JACOBI, M.D.

DEFINITION; SYNONYMS; HISTORY.--Diphtheria is a specific, infectious, and contagious disease, characterized principally by epithelial changes in, and the exudation of fibrin on and into mucous membranes, the surface of wounds, and the rete Malpighii, thereby constituting the so-called pseudo-membrane. Under the names ulcus syriacum, ulcus ægyptiacum, garotillo, morbus suffocans, morbus suffocatorius, affectus suffocatorius, pestilentis gutturis affectio, pedancho maligna, angina maligna, angina passio, mal de gorge gangréneux, ulcère gangréneux, angina polyposa, angine couenneuse, cynanche, croup, diphtheritis, and diphtheria, the disease has been known and described at different periods by the writers of different nations. The Hippocratic writings and some remarks in the Talmud allow of some doubt in regard to their explanation. Whether their authors observed or recognized diphtheria cannot be proven. There is less doubt in regard to Archigenes, quoted by Oribasius. Aretæus of Cappadocia is notably the first, if we except Asclepiades only, who is said to have performed laryngotomy. The description of the pharyngeal and laryngeal manifestations furnished by the former, however, can leave no doubt in our minds that he knew diphtheria and recognized it. Galen, in his remarks on the Chironian ulcer, tells us that the pseudo-membrane was gotten rid of by coughing when the respiratory passages were affected by the disease, and by hawking when the disease was in the pharynx. Cælius Aurelianus recognized diphtheria of the pharynx and larynx, as well as the diphtheritic paralysis of the soft palate; it is to him we are indebted for the information that Asclepiades resorted to scarification of the tonsils, and even to laryngotomy. Aëtius in the fifth century distinguished white and grayish patches and gangrenous degeneration, observed paralysis of the soft palate, and advised against energetic local treatment and the forcible removal of the deposits before they were in a condition to fall off spontaneously. The Arabs and Arabists contain no allusions to the subject, but early chronicles tell of an epidemic raging in St. Denis in 580, subsequent to a great inundation. There appear to have been memorable epidemics in Rome in 856 and 1005, in Byzantium in 1004. The former are mentioned by Baronius, the latter by Cedrenus.

According to Morejon, Gutierrez wrote his Tradado del enfermedad del garrotillo in the second half of the fifteenth century. A malignant form of angina raged in 1517 in Switzerland, along the Rhine, and in the Netherlands; in 1544 and 1545 in Northern Germany and on the Rhine; {657} in 1557 in France, Germany, and Holland; to the latter refer the reports of Tetrus Fosterus. Antonio Soglia, quoted by Chomel, describes an epidemic in Naples and Sicily (1563), which spread in the following year as far as Constantinople; Joannes Wierus, epidemics in Dantzic, Cologne, and Augsburg (1565); Ballonius (Baillon), in Paris (1576). At the same time this disease was frequent in Denmark. From Spain there are reports on severe epidemics between the years 1583 and 1618; the year 1613 was long known as the year of diphtheria (anno de los garrotillos).

Mercado (1608) speaks of a child that had communicated the disease to his father by biting his finger. Casealez advised gargles containing alum and sulphate of copper. Herrera described diphtheria of the skin and of wounds, and looked upon the pseudo-membrane as the essential characteristic of the disease. Heredia, in 1690, recognized the suffocative and asthenic forms, as well as the paralysis of the soft palate, the pharynx, and the limbs; he also called attention to the occurrence of relapses, which he attributed to the absorption of the morbid products, and endeavored to prevent by cauterization.

Naples had diphtheria 1610-45, in its worse form 1618-20, together with erysipelas, and diphtheritic affection amongst cattle. About those times tracheotomy was often performed by Severino, the same who found pseudo-membrane in the larynx at a post-mortem examination made in 1642. In 1620 the disease was in Portugal, Sicily, and Malta; in 1630 in Spain, according to Fontechu, Villa Real, and Herrera. It was remarked that in some instances no membranes were perceived in the throat, but the cases were liable to terminate fatally with large glandular swellings round the neck and general symptoms of adynamia. Sicily was again invaded in 1632, Rome in 1634, Italy from 1642 to 1650, Spain in 1666. The Italian reports emphasize the marked contagiousness of the disease and its tendency to depress the vital powers, also the weakness of the mental faculties left behind. In Germany the disease was described by Wedel in 1718. The epidemics observed by him were not very instructive, yet they sufficed to teach the importance of isolating the sick.

In the New England States diphtheria appeared in the seventeenth century. Samuel Danforth lost the four youngest of his twelve children by the "malady of bladders in the windpipe" within a fortnight in December, 1659, in Roxbury, Mass. John Josselyn mentions an epidemic in New England, mainly in Maine, which lasted at least until the year 1671. Mr. Douglass reports another, which commenced on the 20th of March, 1735, in Kingston township, about fifty miles east of Boston, and extended all over, and also to Boston, where it was mild at first. But in 1738 it was very severe, and remained so for some time. Indeed, it did not abate for a long time, to judge from a letter of Cadwalader Colden written in 1753 to Dr. Fothergill, and the two letters of Dr. Jacob Ogden, written in 1769 and 1774 to Mr. Hugh Gaine of New York; as also from John Archer's "Inaugural Dissertation on Cynanche Trachealis, commonly called Croup or Hives," published in 1798. In 1809 there was a severe epidemic in Philadelphia; in 1816 in Crete.

{658} The reports of Le Cât concerning epidemics in Rouen in 1736 and 1737 being doubtful, the first great epidemic must be set down, in France, for 1745. It commenced in Paris, and invaded the provinces afterward. Chomel gave an accurate description of the diphtheritic paralysis of the soft palate, and reports a case of strabismus. Epidemics are reported from the Netherlands in 1745, 1746, 1769, 1770, 1778-86; from Spain in 1764-71; from England in 1744-48 (by Starr), from Plymouth, England, in 1751-53 (Thurham) and 1776. Dropsy and glandular swellings were frequent; emetics and pure air were the sheet-anchors of treatment. The Netherlands, France, and the West Indies were invaded from 1770-80 by the disease, which was found often complicated with scarlatina; Portugal in 1786 and 1787; France again in 1787 and 1788; Northern Germany in 1790. At that time, particularly in France, the main reliance was had on the internal administration of cinchona and the insufflation into the throat of alum.

Epidemics have been described since from different localities in different years: in Glasgow, 1812 and 1819; Switzerland, 1823-26; Norway and St. Helena, 1824; New York and Kentucky, 1826 and 1828; French provinces, 1834; Paris, 1841; several parts of Europe and North America, 1845-56; Paris, 1853-55; England, 1854 and 1859, when 95 per cent. of all the cases of nasal diphtheria proved fatal; Netherlands and Sweden, 1855; all Western Europe, 1855-65, up to the present time, and all Europe since; California, 1856 and 1857; Portugal and France, 1856; Eastern Prussia, 1850, 1852, 1856, 1857; and all the countries with a cold or moderate climate to this very day.

During the second half of the eighteenth century but two writers are worthy of especial notice--Home, a Scotchman, 1765, and Samuel Bard, an American, 1771.

Home deserves credit for having distinctly drawn the line between the pseudo-membranous and the gangrenous affections. He also endeavored to prove that croup and angina maligna were two distinct diseases, notwithstanding all that had been said since the time of Aretæus in favor of their identity. The false membrane of croup he looked upon as an aggregation of mucus. He sought for it exclusively in the respiratory tract, and disregarded any connection between it and the false membrane found in the pharynx.

Bard's experience was very extensive; he saw membranous pharyngitis, laryngitis, and pharyngo-laryngitis; he speaks of the membrane as met upon the skin, of paralysis of the muscles of deglutition and of the larynx, and likewise of paralysis of the lower extremities, as sequelæ. He looked upon the morbific process as the same whichever were the mucous membranes attacked, and made a distinction only according to the localization of the disease. The influence which he might have exercised in shaping the professional opinion on the nature of the disease did not make itself felt, partly because of his classical modesty, and partly because of his remoteness from the centres of European learning. Not before 1810 was his book translated into French (by Ruette). While his style is classical in its simplicity, his observation is astonishingly correct, and his conclusions as to the actual identity of all the diphtheritic processes in the most various clinical symptoms unimpeachable this very day. His description of the various forms of pharyngeal diphtheria is painfully {659} good, his observations on cutaneous diphtheria very accurate, his few dissections well recorded, particularly when he speaks of tracheal and tracheo-laryngeal diphtheria, and his historical reviews very judicious indeed. "Upon the whole, I am led to conclude that the morbus strangulatorius of the Italians, the croup of Home, the malignant ulcerous sore throat of Huxham and Fothergill, and the disease I have described and that first described by Douglas of Boston, however they may differ in symptoms, do all bear an essential affinity and relation to each other, or are apt to run into each other, and, in fact, arise from the same leaven. The disease I have described appeared evidently to be of an infectious nature, and, being drawn in by the breath of a healthy child, irritated the glands of the throat and windpipe. The infection did not seem to depend so much on any prevailing disposition of the air as upon effluvia received from the breath of infected persons. This will account why the disorder sometimes went through a whole family, and yet did not affect the next-door neighbors. Here we learn a useful lesson--viz. to remove young children as soon as any one of them is taken with the disease, by which many lives have been saved and may again be preserved."

Jurine, in his prize essay of 1807, denies the gangrenous nature of angina maligna and emphasizes the frequent complication of membranous croup with membranous pharyngitis. It was reserved for Bretonneau to enforce attention to the ideas of Bard by asserting (though he did not mention either his monograph or its French translation of 1810) the identity of angina maligna, or by whatever other title it may be known, with membranous laryngitis, and by inaugurating his theory with a new name for the disease to perpetuate the views expressed therein. First and foremost, he called attention to the continuity of the membrane (according to him, composed of coagulated mucus and fibrin) of the nose, pharynx, and respiratory tract, its identity with certain morbid conditions of the skin, and promulgated the theory that "diphtherite"--the name dates from that time--is a specific disease, an affection sui generis, and differs both from a catarrhal and a scarlatinous inflammation.

The modern history of diphtheria may be dated from June 26, 1821, when Bretonneau read his first essay on that subject before the French Academy of Medicine, and gave to the disease the name it now bears. His second and third (Nov. 25th) papers belong to the same year; his fourth was read in March, 1826; his fifth appeared in the Archives gén. of January and September, 1855. It was only in 1826 that the material, previously gathered, was summed up in his celebrated monograph. Before this time, however, the separate essays had received prominence from the reports and commentaries of Guersant, who laid particular stress on the statement that diphtheria was a non-gangrenous affection, identical, and even synchronous, with croup in the majority of epidemics. Since that epoch the literature on the subject has assumed enormous proportions. It is a matter of regret that the limited space allotted to this subject should exclude much historical detail of the etiology, pathology, and therapeutics of diphtheria. If the history of any disease is interesting, and the neglect of its study has ever punished itself, it is diphtheria. {660} Particularly would the treatment have been more successful if the knowledge of former times had been available and more heeded. As long ago as in the seventeenth century depletion in diphtheria was condemned, and in the seventeenth and eighteenth centuries the local treatment with muriatic acid and the internal administration of cinchona, camphor, and roborant diet were held to be the only admissible ones. Bretonneau urged the same principles, and still in our own times, for want of historical knowledge, we had to learn the old lesson over again.

The following is a brief review of the main points of discussion upon subjects connected with the symptomatology and pathology of diphtheria since Bretonneau's first paper:

Bourquoise and Brunet express their belief (1823) in the contagious character of this disease. Desruelles (1824) sees a diagnostic difference between the sporadic and the epidemic forms in the participation of the brain in the latter. Louis referred a number of cases of croup in adults to pharyngeal diphtheria as their source. Mackenzie considers that croup has its origin in the fauces, and urges the employment of lunar caustic. Billard (1826) denies the specific character of diphtheritic inflammation. Hamilton describes cases that terminated in suppuration, and which he therefore distinguishes from Bretonneau's cases. He describes two modes of termination of the disease--one in croup, the other in a state of debility arising from the effect of the absorbed secretion on the respiratory nerves. Pretty looks upon those cases of croup that have their original seat in the tonsils as contagious. Bland (1827) explains the difference between croup and diphtheria. Deslandes declares them to be identical. Bretonneau publishes a work in which he compares diphtheria with scarlatina anginosa, and recommends the use of alum. Emmangard is the first one of the physiological school who, likening diphtheria to typhoid and claiming its origin in a malarial infection, calls it angina gastro-enterica. Abercrombie is in favor of distinguishing diphtheria from croup, but reports a number of cases of diphtheria of the pharynx that terminated fatally by stenosis of the larynx. Ribes, who encountered the disease in nine members of a single family, asserts that croup rarely occurred without a preceding diphtheria in his experience; he advises an examination of the throats of apparently healthy individuals. Fuchs relates the history of epidemics of angina maligna, and declares croup to be a genuine angina maligna trachealis, which only does not run through all the stages. Broussais opposes the identity of croup and diphtheria (1829), and gives a report of cures by means of antiphlogistic regimen and laryngotomy. Diphtheria and gangrenous angina are synonymous with him. Gendron expresses a belief in the identity of diphtheria and gangrenous angina. Roche considers the membrane rather of hemorrhagic than of inflammatory origin, and consisting of discolored fibrin. About the same time Trousseau is endeavoring to clearly establish the diagnosis between diphtheria and scarlatinous angina. Shortly after (1830), he reports cases of diphtheria which originated in blistering wounds, and of diphtheria of the skin giving rise to throat affections, and {661} diphtheria of the throat followed by skin disease. T. F. Hoffmann cites a severe case, that ultimately recovered, with consecutive paralysis of certain cranial nerves. Cheyne (1833) makes a stand against the "confounding of croup and cynanche maligna under the name of diphtheritis." Bourgeois witnessed an epidemic succeeding mumps.

Fricout and Burley (1836) declare their belief in the contagiousness of the disease. Bouillaud attacks the theory of its specific character on the ground that abstraction of blood produced favorable results. Stokes makes a distinction between primary and secondary croup according to the original seat of the affection (1837). Kessler advocates (1841) the view of its contagious nature, and Rilliet and Barthez adduce evidence of the occurrence of ulceration and gangrene in the course of the disease. Taupin, like Ribes, enjoins a methodical examination of the throat of every patient during the prevalence of an epidemic of diphtheria, whatsoever be the disease from which the child suffers. Boudet (1842) opposes Bretonneau's hypothesis that croup is a descending diphtheria, and holds to the identity of diphtheria and gangrenous angina. In this contest Durand (1843) also takes sides against Bretonneau, and lays particular stress on the point that the diphtheritic patient succumbs rather from the severity of the constitutional symptoms than from suffocation. Rilliet and Barthez, on the other hand, rally to the support of the attacked master, asserting that the usual form of croup and that resulting from a descending diphtheritis are one and the same, while they claim that diphtheritis and gangrenous angina are distinct affections.

Meanwhile, the strife regarding the nature of the disease continued. Guersant and Blache (1844) describe the stomatite couenneuse (noma, stomacace, according to them, the rarest kind of gangrenous angina) as a form of Bretonneau's diphtheritis, and Landsberg raises the question whether a nerve-inflammation, present in a certain case, was to be looked upon as an accidental or an essential feature of the disease, and finally comes to the conclusion, with Schönlein, that it was a neurophlogosis dependent on the disease. Bouisson (1847) reports a case of diphtheritic conjunctivitis resulting in loss of the eye. Robert publishes his observations on diphtheria of the skin and of wounds, which he attributes to an atmospheric contamination in crowded wards of hospitals, and looks upon it, with Delpech and Eisenmann, as a form of hospital gangrene. Virchow, in the same year, distinguished the catarrhal, croupous, and diphtheritic varieties of the disease. Meanwhile, reports of paralysis of the soft palate after diphtheria came from Morisseau, from Trousseau and Lasegue, and lastly (1854-59) from Maingault. The subject of diphtheritic conjunctivitis was studied by A. v. Graefe (1854), who encountered the disease as a complication of diphtheria of the pharynx, nose, and skin, and hence considered it a part of the general disease rather than an independent local affection. Diphtheria, in its effects on the system, had at the same time been investigated by Trousseau, who sums up with the statement that the principal source of danger lies in the invasion of the larynx, and that the large majority of cases of croup began as a diphtheria of the pharynx, but that, even without the occurrence of a laryngeal localization, many cases terminate fatally owing to adynamia.

Outside of France, too, the subject had attracted attention. West, who had never seen the disease occur primarily, describes diphtheria as a {662} complication of measles. Bamberger (1855) divides the inflammations of the mouth and pharynx into the catarrhal and croupous forms, and considers croup and diphtheria to be subdivisions of the latter form, differing only in degree. The paralysis of the muscles of deglutition is discussed by Dehænne (1857) who had contracted the disease, and the paralysis of other muscles by Faure. A case of diphtheria of the tonsils, nipples, and vagina in a woman recently confined, followed by infection of the new-born and the death of both, is reported by Mathieux; and cases of diphtheritic conjunctivitis by Grichard, Warlomont, and Testelin. The same year Isambert published a work in which he divided the diphtheritic affections into three forms--viz. angine couenneuse, scarlatinous angina, and diphtheritic angina. The last-mentioned is further subdivided into a croupous-diphtheritic angina, in which croup of the larynx plays an important part, and into that form in which death results from adynamia; in the latter form there is a marked swelling of the lymphatic glands. Apparently, at this time the epidemic in Paris underwent a considerable change, for the croupous form does not occur by far so frequently as Bretonneau had asserted, and croup of the larynx without a preceding diphtheria of the pharynx was observed more frequently than he would lead us to believe.

The various changes in the symptoms of the epidemics of diphtheria which were observed in different places and countries, and at different times, explain many of the differences of opinions in regard to the nature of the disease. The literature of that subject is in the last twenty-five years simply stupendous, and a few more notes must suffice for the elucidation of the drift of theories and observations. Beale was the first to look for organic beings as the cause of the disease, without finding any. Laycock sees it in the bacilli and spores of oidium albicans; Wilks, however, found the same parasite in other affections. Cammack declares the diphtheritic membrane to be herpetic. Feron also calls Bretonneau's mild form of the disease a herpetic angina with pseudo-membrane; so does Gubler. Bouchut writes against the identity of diphtheria, croup, and gangrene. Condie describes the disease as occurring with scarlatina. Litchfield claims that it is a concealed scarlatina, and Hillier that it has some connection with it. Millard cites one case in the course of which gangrene occurred, and another in which skin, mouth, pharynx, respiratory passages, oesophagus, and vulva were affected at the same time. Harley vainly endeavored to inoculate the disease in animals. Stephens declares the disease to be infectious. Sanderson looks upon it as identical with the angina maligna of the aged. Farr considered the exhalations from sewers an important etiological factor. Sellerier, Kingsford, and Harley (1859) report paralyses as sequelæ. Maugin speaks of a specific eruption; Ward, of an accompanying purpura. Bouchut and Empis remarked the frequent presence of and danger from albuminuria; so did Wade. Maugin calls attention to the fact that, when present in diphtheria, it occurs early, whereas in scarlatina it is seen during the period of desquamation, and is not of frequent occurrence even then. Gull gives an account of cases in which death resulted from asthenia, and speaks of a nerve-lesion which he attributes to the severity of the local inflammation. Hildige describes diphtheritic conjunctivitis as seen in Graefe's practice, and looks upon it as contagious. Magne denies its contagious or {663} infectious character. Mackenzie, while probably having seen false membrane appear on the conjunctiva when in a state of inflammation, yet refuses to recognize diphtheritic conjunctivitis as a distinct disease.

In the same degree that observations of cases and epidemics increased in number, the nature of the disease and its cause commenced to be studied. The assumption that the latter was a chemical poison was soon doubted, and the parasitic nature of diphtheria considered by many as proven.

After Henle had (1840) expressed his belief in the existence of a contagium animatum, and morbid processes had for some time been compared with the phenomena of fermentation, Schwann demonstrated the presence of lower organisms in fermentation and putrefaction. The discovery of the cause of the silk-worm disease by Bassis, of the achorion by Schönlein, of the acarus by Simon, of bacteria in malignant pustule by Pollender, Brauell, and, above all, by Davaine, in relapsing fever by Obermeier, the teachings of Pasteur concerning the conditions under which putrefaction occurs,--all tended to explain the various infectious and contagious diseases by analogy also, and to stimulate the search for a vegetable organism in diphtheria. Buhl was the first to discover schizomycetæ in diphtheritic membrane, but expressed no opinion as to the part they played in the process. Hüter found them in the gray diphtheritic covering of wounds, in the surrounding apparently healthy tissues, and in the blood. Hüter and Tomasi found them in the diphtheritic membranes of the pharynx and larynx, inoculated them on the mucous membranes of animals, and described them as small, round or oval, dark-colored, active little bodies. The latter observers look upon these organisms as a part of the infectious element. Oertel found them in diphtheritic membrane and in inflamed mucous membranes in the lymphatic vessels, lymphatic glands, kidneys, and other organs; he considers them as the contagious element of diphtheria. Nassiloff, too, after inoculations in the cornea resulted in an enormous multiplication of the microscopic organisms and their appearance with pus-cells in the lacteals and in the lymphatics of the palate, and even in the bones and cartilages, asserts that the development of organisms is the primary step in the diphtheritic process. Eberth made successful inoculations in living tissues; the micro-organisms, introduced into the cornea, proliferated actively and caused an inflammation of irritative character in the surrounding tissue. He asserts, with the positiveness of an evangelist, that diphtheria cannot occur without bacteria. Klebs inoculated the micrococci in pigeons and dogs, and found them in the blood of the animals after death. Orth found them in the pleura, lungs, kidneys, and urinary bladder. But what their action is, whether they are directly pernicious, or deprive the body of certain elements (as of oxygen in malignant pustule, according to Bollinger), or injure mechanically by acting on the coats of the blood-vessels (either directly or by means of altering the blood), thus depriving whole territories of their blood-vessels, is a question upon which the principal advocates of the parasitic theory have not yet agreed. Even Oertel acknowledges the impossibility of explaining the manner in which bacteria act (Ziemssen, Handbuch, ii., 1, p. 581, 2d ed.). This much is positive, at any rate: that no one has yet proven that the vegetable organisms alone, and not other, free or fixed, parts of the {664} diphtheritic membrane, are the vehicles of the infecting elements (Steudener); and even now the question has not been decided whether the bacteria met with in diphtheria constitute the cause of the disease, or are a part of the process, or co-effects of the poisonous action--whether they are the carriers of the poison or entirely indifferent entities.

The most important observations made by those who deny a direct etiological connection between micro-organisms and septic diseases in general, and diphtheria in particular, are those of Hiller and Billroth. The latter has proven the morphological identity of the various kinds of bacteria, although it cannot be denied that the apparent similarity may mask a yet unknown difference. Hiller calls attention to the fact that large numbers of micrococci have been found in the cadaver where death has not been the result of septic disease, and also that septic infection is not always severest where the bacteria most abound, but where an extensive chemical decomposition or a mass of putrefying tissue is found. This would indicate that the septic process is rather dependent on chemical decomposition than on the presence of bacteria.