Diphtheria, croup, etc

Front matter

Shelf .:J0&5.r

UNITED STATES OF AMERICA.

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Chapter I. Definition 1

" II. Nomenclature 2

III. History 2

IV. Cause 14

u V. Climatic and Atmospheric Influences ... 31

" VI. Mode of Propagation 33

" VII. Predisposing Causes 39

" VIII. Period of Incubation 42

" IX. Prophylaxis 44

■" X. Symptoms 45

" XI. Diagnosis , . 64

" XII. Prognosis 66

" XIII. Pathology 69

«» XIV. General Treatment 77

" XV. Therapeutic Treatment. 81

«■ XVI. Local Treatment 84

" XVII. Constitutional Treatment 92

Chloral Treatment . Ill

<* XVIII. Nasal Diphtheria 121

" XIX. Laryngeal Diphtheria 123

" XX. Treatment of Diphtheritic Paralysis .... 126

» XXI. Medical Prophylaxis 127

" XXII. Croup , 129

" XXIII. Tracheotomy 151

" XXIV. Plastic Bronchitis 156

Foemul^: 163

v

Introduction

The treatment of different diseases by similar remedies, as advocated in the following pages, to thoughtful practitioners will appear neither strange nor unreasonable. Diseases differing widely in their essential characters, are not infrequently related by symptoms or phenomena that are common to several.

The entire system of the so-called " Rational treatment of disease," indeed, consists in the treatment of the symptoms as they arise, if we except only the few instances in which the treatment is specific. Pain in the chest for example, may be occasioned by a variety of diseases, as pneumonia, pleurisy, and neuralgia, but regardless of its cause, requires anodynes for its cure. Hemorrhage, whether from the lungs, the stomach, the uterus, or the bowels, depending on different organic or general diseases, calls alike for gallic acid, ergot, and the like. An exhausting diarrhoea occurs in quite opposite states and may be very properly controlled by opium, etc., regardless of the particular disease ; sleeplessness, occasioned by very diverse causes, calls alike for chloral, morphia, etc. ; debility, regardless of its cause, is treated properly with nutrients and restoratives ; and an exalted temperature of the body, whether inflammatory or typhoid, with antipyretics. Symptoms, and not the names of diseases, are treated by intelligent practitioners, with the exception of those treated by specifics as before stated.

In the diseases which we call Membranous, and which only are the subjects of this volume, we observe a common diagnostic symptom or manifestation. It is not pain, nor diar-

VII

VIII INTRODUCTION.

rhoea, nor hemorrhage, nor hyperpyrexia, nor debility, but a peculiar exudation from the blood, generally upon mucous surfaces, denominated false membranes. These membranes are so nearty identical in structure and materials as to render a distinction nearly or quite impossible.

As we shall have occasion hereafter to note, their appearance has been attributed to both local and general causes, which are possibly so obscure, remote, or ethereal, as forever to elude discovery. What we wish hereto observe is, simply that these diseases, having a like prominent and diagnostic symptom, may rationally be treated by the same or similar remedies without the violation of any principle entitled to professional respect.

It is but reasonable to infer, from the identity of these plastic exudates, that some similar S3 T stemic disturbance exists in each of these diseases ; and yet this is only inferential. Many regard croup and plastic bronchitis as purely of local origin from the lack of early constitutional symptoms ; while others, equally honest and intelligent, observe that common acute inflammation in the same localities is not ordinarily attended by the membranous exudation, and therefore conclude that in these, as in diphtheria, there probably exists primarily some peculiar toxaemia.

Neither of these theories is thought to be entitled to, or should be given, any particular influence by the practitioner in deciding upon his therapeutical measures at the bedside, and hence they are dismissed for the present without discussion for matters of a more practical nature.

AUTHOR.

DIPHTHERIA.

CHAPTER I.

DEFINITION.

Diphtheria is an acute, specific, contagious, febrile disease, which occurs epidemically, endemically and sporadically, in most countries of the world, and is characterized by general or constitutional symptoms like other pj^rexial diseases, with a greater or less degree of inflammation of the mucous membrane of the pharynx, larynx, air passages, or other mucous passages ; and by the formation on the surfaces of these parts, particularly upon the mucous membrane of the pharynx and upper air passages, of a lympho-fibrinous membrane, generally in patches of a whitish, yellowish, or grayish color.

It is further characterized by more or less inflammatory swelling of the glands of the throat and neck or adenitis.

During the prevalence of diphtheria, wounded, abraded, or ulcerated surfaces, upon any part of the body, frequently become covered with a membranous deposit similar to that in the more ordinary situations. The constitutional sj-mptoms usually denote a depressed state of the vital powers. Often the urine becomes albuminous from renal disturbance. The sequelae most common are lesions of the nervous system causing a greater or less degree of paralysis, impairing in proportion, phonation, deglutition, respiration, sensation, etc. Fatal cases usually terminate by gradual apnea ; less freqently by asthenia and cardiac thrombosis.

Chapter II. Nomenclature

The term diphtheria is of Greek origin, and maj^ properly be defined b} T the English term membrane. Diphtheria, diphtherite, and diphtheritis are ail used as synonyms, and have the same origin.

Diphtherite, as applied to the disease under consideration, was origin all}' emplo3 T ed by M. Bretonnau, a celebrated French physician, in his work entitled " Traite de la Diphtherite," published in Paris in 1826. Trousseau, considering the term objectionable because of the termination ite, used in medical science to imply inflammation, changed the word to diphtherie, in order to get rid of the aetiological doctrine of inflammation expressed b} r the suffix ; and, technically speaking, diphtheria is the English synonym of the French diphtherie.

Among ancient writers the disease received a varity of apellations, as ; ulcus Egyptianum vel Syriacum — the Eg}*ptian or S} T riac ulcer; angina gangrenosa — gangrenous sore throat ; morbus suffocans vel strangulatorius — suffocating or strangulating sickness ; garotillo — throat disease ; angina suffocativa — suffocating sore throat ; malum canna — throat sickness ; and many others.

Chapter III. History

(compiled from the best authors.)

It is not the purpose of the writer, nor within the scope of the present volume to enter exhaustively into the bibliography of diphtheria. This alone would fill a volume, and could not be made profitable to the laborious practitioner of medicine, for whom alone, in the interests of humanity, this treatise is designed. The following epitome of what is known on the subject is derived from a careful study of the best authorities, and may be regarded as authentic.

Diphtheria, or throat affections in some respects analagous to it, can be traced to a remote antiquity ; their identity with the modern disease is, however, often, only imaginary, or inferred from the resemblance of a few symptoms. There are no proofs of any epidemic prevalence of the disease as it is seen at the present time, until about the middle of the eighteenth century.

Among the more ancient medical records quoted by writers in proof that the ancients were acquainted with this affection are the following. Nearly twenty-five hundred years ago, or about the time of Pythagoras, an East Indian physician, named D'hanvantare, gave a description of a disease, thought by some to have been diphtheria, in which "An increase of phlegm and blood causes a swelling in the throat, characterized by panting and pain, destro3-ing the vital organs, and incurable : — a large swelling in the throat impeding food and drink, and marked by violent feverish symptoms, obstructing the passage of the breath, arising from phlegm combined with blood, is called closing of the throat."

Galen of Pergamos, about the middle of the second century, speaks of a membranous formation in the pharynx being ejected by expectoration. Aretseus of Cappadocia, a physician of renown who practiced at Rome about the time of Augustus, has left a history of the Eg}^ptian or SjTiac ulcer, considered to have more points of resemblance to the diphtheria of to-day than any other disease of antiquity. This was characterized by ulcers on the tonsils, some mild and harmless, while others were pestilential and fatal. " The former, which are common — are clean, small, and superficial, and are unaccompanied by either pain or inflammation. The latter, which are rare — are extensive, deep, putrid, and covered with white, livid, or blackish concretion. If it extends rapidly to the chest through the windpipe, the patient dies on the same day by suffocation.

Ccelius Aurelianus, writing about the close of the third century, " describes the barking sound of the voice and its occasional complete extinction, the stridulous breathing, and lividity of the face. His reference to the defective articulation sometimes present, and to the passage of fluids into the nose in swallowing, probably refer to the paralytic symptoms of the disease. It is supposed by some that the Askara frequently mentioned in the Talmud as a fatal epidemic, was, in fact, diphtheria. Rashi, the learned commentator of the Talmud and Old Testament, remarks with reference to the Askara, that sometimes it breaks out in the mouth of a man and he dies from it. 'Also that sudden death ensues from suffocation.' " (Mackenzie.)

" Macrobius speaks of a similar epidemic at Rome, A. D. 380, during which, sacrifices were offered up to a certain Goddess — ut populus Romanus, morbo, qui angina dicitur promisso voto, sit liberatus." (Slade.) "Aetius, of Amida, in the sixth century delineated the disease as presenting white and ash-gray spots in the pharynx, slowly ending in ulceration." (Mackenzie.)

Brief and unsatisfactory as are the preceding quotations, they are believed to constitute the bulk and basis of the evidence extant that the ancients were acquainted with this malady. From the sixth to the latter part of the sixteenth century, nothing further in medical history is noted as having any very probable reference, or clear analogy to this disease. Hecker's accounts of the epidemics of the fourteeth, fifteenth, and sixteenth centuries, in Holland, France, and England some of them characterized by violent anginose affections, quoted by Slade to connect the ancient and modern records of the disease, must be considered irrelevant, and wanting in any recorded appearance or symptom characteristic of genuine diphtheria. .

HISTORY.

Of modern writers, Bailou, a distinguished French physician, whose writings bear the date 1576, is believed to be the first who makes distinct mention of a false membrane. In the early part of the 17th century an. epidemic angina, denominated garrotillo prevailed in Spain. Its best description is by Villa Real, who states that he has seen "a thousand times, in patients at the first onset of the disease, a white matter in the fauces, gullet, and throat. He adds that the matter is of such nature, that if you stretch it with your hands it appears elastic, and has properties like those of wet leather — facts which he noticed, not only by observing the matter coughed up by the living, but also by the examination of it in the dead."

About the same period, accounts of the disease, less satisfactory because of the omission of the post-mortem appearances, were written by Herara and Fontecha. They, however, confirm the prevalence of garrotilla (diphtheria) in Spain between the years 1581 and 1611. The name "garrotillo" was first given the disease because those attacked by it perished as if strangled by a cord. In 1617 diphtheria was prevalent in an epidemic and fatal form at Naples and in other parts of Italy. (Sgambatus.) It was sometimes called "Male-de-canna" — disease of the trachea. It continued its ravages for a period of at least twenty years, and has been described by several other writers of authority, as, Carnevale, Zacutus Lusitanius, and Marcus Aurelius Severinus. " Carnevale in particular has given us full data of this epidemic in his treatise entitled 'de Epidemico Strangulatione Affectu.' The children were first attacked, the disease afterward spreading among the population generally, and proving very fatal, The disease commenced by mild inflammation of the throat ; soon the affected parts presented a whitish exudation ; the breath became fetid ; deglutition impossible ; the respiration embarassed, and the patient died of suffocation. This writer also gives us the different appearances which the pharynx presented in this epidemic ; he also speaks of the extension of the disease to the trachea, oesophagus, and pituitary membrane ; — of the diagnosis, prognosis, and the topical remedies, all of which are quite in accordance with modern views" (Slade). Carnevale also asserts its identity with the disease which had been prevailing in Spain under the name of garrotillo.

In 1625 the writings of Cortesius show that the same disease extended, a little later, to Sicily. He speaks of a membrane in the throat, which could readily be torn away, as being one of its characteristics. In 1632 Alaymus published a treatise upon the Syrian ulcer. He prefers this term, he says, inasmuch as it applies to all forms of the disease, which he describes in a manner similar to Carnevale. " In 1713 Dr. Patrick Blair, of London, in a letter to Dr. Mead, described a disease as ' the croops ' which, he says, was epidemic and universal at Coupar Angus, and which was no doubt diphtheria." (Mackenzie).

From 1743 until 1748 the disease prevailed in Paris, and has been described by Malouin and Chomel. About the same date G-hisi describes an epidemic of the disease in Palermo, and noticed the paralytic sequelae. Also about the same time a similar epidemic appeared both in England and at Cremona, accounts of which were given by Fothergill, Starr, and G-hisi. These epidemics were very destructive, especially in England, where it was regarded by Fothergill as scarlatina. He says, " If the mouth and throat be examined soon after the first attack, the uvula and tonsils are found swelled ; and these parts, together with the velum-palati and' pharynx, appear of a bright red color, which is most marked on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of redness, a broad spot or patch of an irregular form, and of pale white, is sometimes seen surrounded with florid red, which whiteness appears like that of the gums immediately after being pressed with the fingers, or as if matter ready to be discharged was contained beneath. G-enerally on the second day of the disease, the face, neck, hands, and breast, are of a deep erysipelatous color, with a sensible tumefaction. A great number of small pimples, of a color more intense than that which surrounds them, appear on the arms and other parts." (In a note he says, " The eruption and redness have not so regularly accompanied the disease during the latter part of this Winter, 1754, as they did last year. In some cases they did not appear at all, in others not till the third or fourth day.") " The appearances in the fauces continue the same, except that the white places become more ash-colored ; and it is now found that what might have been taken for the superficial covering of a suppurated tumor, is really a slough, concealing an ulcer. Instead of the slough, in mild cases, a superficial ulcer, of an irregular form, appears in one or more parts, scarce to be distinguished from the sound, but by the irregularity of surface which it occasions. Towards night, heat and restlessness increase, and a peculiar kind of delirium comes on, the pulse is generally very quick ; in Some hard and small ; in some soft and full. The tongue is generally moist, and not often found coated. In some it is covered with a thick white fur ; and these generally complain of soreness about the root of the tongue." (Slade.)

" In 1749 Marteau de Grandvilliers described an outbreak of the disease in Paris, and the elder Chomel, in detailing the symptoms, accurately described diphtherial paralysis. In 1750 the formation of a membraniform concretion in the throat is distinctly described by Dr. Jno. Starr, as occurring as an epidemic in Cornwall, England." (Mackenzie.)

In 1757, Dr. Huxham in a treatise denominated "A Dissertation on the Malignant Ulcerous Sore Throat," described an epidemic which had been prevalent at Plymouth, in which some of the cases were undoubtedly of the character of secondary diphtheria. "Not only," says-he, ; ' were the nos-

8 DIPHTERIA.

trils, fauces, &c, affected, but the windpipe itself was much corroded, and pieces of its internal membrane were spit up."

" Dr. Starr, of Liskeard, published a paper in the Philosophical transactions, upon the malignant ulcerous sore throat epidemic which appeared in that place in 1749. In this paper, besides other details of the epidemic, he gives the full data of a case in which the false membrane commencing in the fauces, extended to the larynx. He particularly dwells upon the physical properties of the exudation, its adherence to the subjacent surface, its frequent detachment and reproduction. In fact, he gives a complete picture of Bretonnau's diphtheria."

In 1789, Dr. Samuel Bard of Philadelphia, in a work entitled, "Researches on the Nature, Causes, and Treatment of Suffocative Angina," gave a detailed account of " an uncommon and highly dangerous distemper " which had recently proved fatal to many children in New York. He recognized the analogy between this disease and croup, as well as the manner in which it spreads from the throat to the larynx. He observed it sometimes as simple angina ; sometimes as angina complicated with laryngitis, and occasionally as laryngitis alone.

" In general the disease was limited to children under ten years of age, though some few grown persons, particularly women, had symptoms very similar to it. Most of the persons attacked were observed to droop before they were confined. Usually the first symptoms were a slightly inflamed eye, a livid countenance, and slight eruptions upon the face. At the same time, or very soon after, those who could speak complained of an uneasy sensation in the throat, but without much soreness or pain. Upon examination, the tonsils appeared swelled and highly inflamed, with a few white specks upon them, which, in some cases, increased so as to cover them all over with one general slough ; this, however, although a frequent symptom, did not invariably attend the disease. The breath was not offensive, and deglutition but very little impeded.

" These symptoms continued in some cases for five or six days without creating any alarm; in others, a difficulty of breathing came on within twenty-four hours, especially during sleep, and was often suddenly increased to such an extent as to threaten immediate suffocation. Generally it <?ame on later, increased more gradually, and was not constant.

" This stage of the disease was attended with a very great and sudden prostration of strength, a very peculiar, hollow, dry cough, and a remarkable change in the tone of the voice. In some the voice was almost entirely lost, and would continue ver}' weak and low for several weeks after recovery. These symptoms continued for one, two, or three days, and greatly increased in those who died ; purging in several cases came on, the difficulty of breathing became more marked, and the patient died apparentl} T of suffocation. This commonl} T happened before the end of the fourth or fifth day. One child, however, lived under these circumstances to the eighth day. Shortly before he died, his breath and expectoration were somewhat offensive ; but this was the only instance in which I could discover anything like a disagreeable smell, either from the breath or expectoration.

" In some cases instead of the difficulty in respiration, ver} T troublesome ulcers appeared behind the ears.

" ' These began with a few red pimples, which soon ran together, itched violently, and discharged a great deal of ver}^ sharp ichor, so as to erode the neighboring parts, and in a few days spread all over the back part of the ear, and down upon the neck.'

" In a few cases swelling of the parotid and sublingual glands was noticed. Dr. Bard says : —

" ' I met with but two instances of anything like this complaint in adult persons. Both of these were women, and one of them had assisted in laying out two of the children that had died with it. At first her symptoms resembled rather an inflammatory angina ; but, about the third day, the tonsils appeared covered in some places with sloughs : her pulse was low and feeble ; she had a moist skin, a dejection of spirits, and some degree of anxiety, though nothing like the difficult breathing of the children.

" '• The other was a soldier's wife ; who, for some time, before she perceived any complaint in her throat, labored under a low fever. Her tonsils were swelled and inflamed, and covered with sloughs resembling those of the children * but her breath was more offensive, and she had no suffocation.

u ' I have had an opportunity of examining the nature and seat of this disease from dissection in three instances. One was a child of three years old. Her first complaint was an uneasiness in her throat. Upon examining it, the tonsils appeared swelled and inflamed, with large white sloughs upon them, the edges of which were remarkably more red than the other parts of the throat. She had no great soreness in her throat, and could swallow with little or no difficult} 7 . She complained of pain under the left breast ; her pulse was quick, soft, and fluttering. The heat of the body was not very great, and her skin was moist ; her face was swelled ; she had a considerable prostration of strength, with a very great difficulty of breathing ; a very remarkable hollow cough, and a peculiar change in the tone of her voice. She was exceedingly restless ; was sensible, and when asked a question, would give a pertinent answer ; but otherways r she appeared dull and comatose. All these sj-mptoms continued or rather increased till the third night, on which she had five or six loose stools, and died early in the morning.

" l Upon examining the body — which was done on the afternoon of the day she died — I found the fauces, uvula, and root of the tongue interspersed with sloughs, which still retained their whitish color. Upon removing them, the parts underneath appeared rather pale than inflamed. I perceived no putrid smell from them, nor was the corpse in the least degree offensive. The sesophagus appeared as in a sound state. The epiglottis was a little inflamed on its external surface ; and on the inner side, together with the inside of the whole larynx, was covered with the same tough white sloughs as the glands of the fauces. The whole trachea, from the larynx down to its division in the lungs, was lined with inspissated mucus, in form of a membrane, remarkably tough and firm ; which, when it came to the first subdivisions of the trachea, seemed to grow thin and disappear. It was so tough as to require no inconsiderable force to tear it, and came out whole from the trachea, which it left with much ease ; and resembled, more than anything, both in thickness and appearance, a sheath of thin chamois leather. The inner membrane of the trachea was slightly inflamed ; the lungs, too, appeared inflamed, as in peripneumonic cases, particularly the right lobe, on which there were many large livid spots, though neither rotten nor offensive ; and the left lobe had small black spots on it, resembling those marks left under the skin by gun-powder. Upon cutting into any of the larger spots which appeared on the right lobe, a bloody sanies issued from them without frothing.' "

11 He supposed the prevalence of the epidemic to depend upon the state of the air or a peculiar miasm " which more or less, according to particular circumstances, generate an acrimony in the humors and dispose them to putrefaction ; and which have a singular tendency to attack the throat and trachea, affecting the mucous glands of these parts in such a way as to occasion them to secrete their natural mucus in greater quantities than is sufficient for the purposes of nature, and which in this particular species, when secreted, is really either of a tougher or more viscid consistence than natural, or is disposed to become so from rest and stagnation."

Dr. Bard, says Mackenzie, was a careful and painstaking observer, and his monograph contributed very considerably to the accuracy of contemporary knowledge of diphtheria ; to which we might truthfully add that it is the model after which have been constructed most of the descriptions of diphtheria which have since appeared, both in this country and in Europe.

In 1802 appeared the "First lines in the practice of Physic," by Dr. Cullen, professor of the practice of physic in the University of Edinburgh, in which, under the title "cjrcanche trachealis" is to be found a description thought to be characteristic of the diphtheria of to-day.

In 1826 appeared the works of M. Bretonneau. These owed their origin to the alarming outbreak of the disease among the soldiers in the barracks at Tours in the latter part of 1818, spreading from thence to the surrounding country. In Tours most of the victims were children, and the larynx most frequently affected, while among the soldiers the gums were the favorite seat of the diphtheritic exudation. Bretonneau describes the disease in Tours as mild at the commencement, but becoming alarmingly severe in a few days, and very fatal. From thence it spread to two small villages adjoining, and thence throughout France. In some towns, remarkable for their salubrity and good sanitary conditions, it raged violently, while others situated in low marshy regions, almost entirely escaped. Elsewhere it seemed to select ill-drained localities, and pass over those in better sanitar}^ conditions. As evidence of its virulence a case is mentioned in which out of seventeen persons in a single farmhouse, thirteen died of the disease.

In Edinburgh, in 182(5, the disease prevailed as a fatal epidemic, and was accurately described as " diphtherite " by Dr. Abercrombie, in his work on "Practical Researches on Diseases of the St6mach, ,r published two years later.

After the subsidence of the notoriety Bretonneau gave diphtheria, it attracted but little attention for several years, till in 1841 an epidemic in the Children's Hospital in Paris brought it again before the profession. This epidemic was described by M. Becquerel. The children of the institution were attacked with sore throat, often attended with membranous exudation, sloughing, and gangrene. The disease was not limited to the faucial and laryngeal surfaces, but appeared also upon abraded and blistered cutaneous surfaces. He noted also a remarkable state of the blood in its want of coagulability.

During the following fifteen years diphtheritic epidemics prevailed from time to time in various parts of Europe, especially in France, and were described by Empis, Lemoine Jobert and Lespiaen. Dr. Ernest Hart, of London, ably described the great English epidemic of 1858-1859. The first case was supposed to have been imported from Bolougne (probably a relic of the fatal epidemic there in 1855) to Folkstone in 1856. Assuming alarming malignancy in 1858, it spread widely ; was very fatal during the following } T ear, and for three years more continued prevalent. The local name was " Throat fever."

In 1856 an epidemic of this disease prevailed in San Francisco and other California towns, and was described by V. Fogeaud in an essay on diphtheria and by Dr. Jas. Blake, of Sacramento. The mortality was very great.

About the same date, Dr. Beardsly of Milford, Conn., described a fatal epidemic of diphtheria in that and adjoining towns, in which the first s} 7 mptom almost uniformly was pain in the ear a day or two in advance of any other manifestation of the disease.

In 1858-diptheria prevailed in Albany, N. Y., and in many other towns, and may be said to have been constantly prevalent from that period to the present time, not only in this county, but also in England, France, Germany, and most other countries of the globe ; and is amply discussed in the books on general practice, and in monographs, of recent date, to be found in the library of every physician.

A complete history of the medical treatment of diphtheria would constitute one of the curiosities of medical literature — more curious than instructive. The terrible fatality which has attended the disease, seemingly little abated by any treatment hitherto practiced, has led to the exhibition of almost every known remedy; but failure still incites to laudable research and trial of new remedies.

Such conditions have caused discrepancy and distrust, and have led many practitioners of eminence to ignore authorities, to discard precedents, to repudiate so-called specifics, and to treat the disease on general principles, or as the symptoms occurring in any case might seem to demand. Confusion and doubt here, as generally, precede order and confidence.

The therapeutical history of the disease, although not intended to constitute an integral part of this treatise, will of necessity, be somewhat developed when we come to speak of treatment in chapters 16 and 17.