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THE NEW SYDENHAM
SOCIETY.

 

INSTITUTED MDCCCLVIII.

 

VOLUME III.
MEMOIRS

ON

DIPHTHERIA

FROM THE WRITINGS OF

BRETONNEAU,
GUERSANT, TROUSSEAU, BOUCHUT, EMPIS
AND DAVIOT.

f
SELECTED AND TRANSLATED

BY

ROBERT HUNTER SEMPLE, M.D.

WITH
A BIBLIOGRAPHICAL APPENDIX,

BY
JOHN CHATTO,

LIBRARIAN TO THE ROYAL COLLEGE OF SURGEONS.

THE NEW SYDENHAM SOCIETY,
LONDON.

 

MDCCCLIX.

$5 4
A.u49 413

LONDON:

Printed by Jamzs WiL11am Rocug, 5, Kirby Street,
Hatton Garden.

em
CONTENTS.

BRETONNEAU ON DIPHTHERITE
Introduction
First Memoir
Second Memoir
Third Memoir .
Fourth Memoir
Fifth Memoir
GUERSANT ON Croup (Tracheal Diphthérite)
TROUSSEAU ON DIPHTHERITE F
BoucuuT on Croup (Tracheal Diphthérite)
Empis oN DIPHTHERITE
Davior oN DIPHTHERITE .
APPENDIX (Bibliography )
INDEX

Page

23
126
139
173
207
235
271
301
345
383
405
INTRODUCTION.

Tue distinguished author of the philosophical Nosography, in taking
the modifications which inflammation undergoes in the different
organic tissues as the basis of his classification of phlegmasiz, has
certainly thrown a new light upou a great number of diseases, and has
impressed a new impulse upon the spirit of observation. Still we are
compelled to admit that the diversity of the inflammatory alterations
and that of the phenomena by which they are accompanied, may not
depend upon these modifications alone. The specific nature of the in-
flammation, still more than its intensity or than the nature of the
tissue in which it is seated, influences the disturbance introduced
into the functions by every inflammatory lesion. To the specific
nature of the inflammation must be referred the duration, the severity,
and the danger of the greater number of the pyrexie. No tissue,
perhaps, exibits a single inflammatory lesion; but the different in-
flammations with which the external tegumentary layer is affected,
offer, undoubtedly, the most multiplied and the most remarkable
varieties. By paying a little attention we shall be equally convinced
that the mucous tissue, which is the internal tegumentary organ, is
also the seat of very different kinds of phlegmasiz.

The anatomical characters by which several of these phlegmasize
are distinguished, the progress of their development, their stages and
their symptoms, form the subject of this work, which has especial
reference to the description, the history, and the treatment of pelli-
cular inflammation. I have had occasion to study this affection under
all its forms, during the course of several epidemics, and I have been
able to determine that it is separated by special properties from some
other inflammations, accompanied with membranous exudations,—
affections which are very distinct, and the characters of which I have

also pointed out.
B

\
2 BRETONNEAU’S INTRODUCTION.

In another work, which will immediately follow the present, I shall
describe the different aspects under which several phlegmasie of the
gastro-intestinal mucous coat are successively exhibited ; I shall set

forth the peculiarities proper to each of them ; and I shall assume, as
the term of comparison, the affection which I have most frequently
observed, namely, the exanthematic pustular eruption which is met
with in the digestive canal of subjects who sink under putrid epidemic
fever. This pyrexia is. one of the diseases which is most commonly
observed in practice. Being independent of atmospheric conditions,
we find it prevailing, almost without interruption, in populous cities,
while it does not reappear, in other localities, until after a longer or
shorter interval.
‘The first two Memoirs, on “ Croup and Malignant Angina,” were
read at the Académie Royale de Médecine, in 1821, and perhaps, it
might have been more convenient to combine them as a monograph
on pellicular inflammation; but, being engaged in other occupations,
I have preferred to leave them unchanged, and to devote a third
section to observations which could not have found a place in the
two which precede it.

In thus going over the ground again, I have been able to deter-
mine some facts which remained doubtful, to add others which I have
since collected, and to supply some omissions. In fact, the result
has been, that the same subject has been treated in different places.
Thus, after having treated of tracheotomy, in the second and
third sections, I have devoted to it an additional and separate
article; so that the advantages and disadvantages of this operation
are discussed in three different paragraphs. This course I know to
be rather irregular; but I think that the reader, while waiting for
results which are doubtful and unknown, will also be interested in
those which he sees progressively developed, under conditions the
whole importance of which is not at first foreseen.

An additional motive determined me to this course. I at first
entertained the intention of proving the identity of Croup and Malig-
nant Angina, and in order to attain my object more rapidly, I sup-
pressed, in a reading at the Académie, many details which might
have led me astray. But the opinion which I ventured to oppose,
has prevailed so generally, that this question is still one of the most
important of those which remained for me to treat.

Since 1821, I have continued to follow the progress of the epidemic
affection which was the occasion of my researches, and I have
, BRETONNEAU’S INTRODUCTION, 3

seen it reproduced in other places. My friend, Dr. Guersent, has
been enabled to verify my observations at the Hépital des Enfans,
At whatever period I have met with Malignant Angina, I have con-
stantly found in it the identical characters which have been remarked
by the Spanish and Italian physicians of the seventeenth century,
and which have been so judiciously noticed by a French physician,
Marteau de Grandvilliers, in his Treatise on Gangrenous Affections
of the Throat, published in 1757. I do not doubt that this able
physician, if he had met with less difficulty in opening bodies, would
have ascertained that the danger of the affection which he was ob-
serving, did not at all arise from a gangrenous lesion. In fact, after
having described with care the Pellicular Angina, and the Scarlatinal
Angina, he confounds these two diseases; but it is evident, that,
he required ‘only the aid of pathological anatomy to avoid an error
into which he had been led by the authority of Huxham and
Fothergill.

It is the opinion of Professor Laennec, that diséases cannot be
more certainly distinguished than by their anatomical characters.
Deeply imbued with this opinion, I have never neglected any occasion
of multiplying my necroscopic researches during the course of the
epidemic which I have been called upon to observe. It is, in fact, only
by following the changing aspect of every morbid lesion, and by com-
paring the results of a great number of observations, made at dif-
ferent times and places, that it is possible to determine the alterations
which belong to one and the same kind of disease.

It will be readily imagined that I have had some obstacles to over-
come; but I should render myself guilty of exaggeration and ingra-
titude in hesitating to acknowledge that they have often been
removed by the civil and religious authorities, and if I did not add
that there has been a progressive diminution of the resistance which
prejudice at first opposed to my researches. With alittle perseverance
the most rooted objections are found to yield to motives which are
recommended by their disinterestedness, and which derive their
strength from the benevolence of their objects.

I have employed considerable time in returning to the point to
which the ancients, and particularly the authors of the seventeenth
century, had arrived ; they, in fact, perfectly described the symptoms
of Malignant Angina, and their attention had already been specially
directed to the signs which prove that the disease extended from the

pharynx to the air-passages.

a2
4

4 BRETONNEAU'S INTRODUCTION.

In the year 1740, the nature of the pseudo-membranous exudation
which lines the air-passages, was pointed out by Ghisi. In all countries,
physicians began to perceive that it was necessary to open dead
bodies in order to ascertain the seat of diseases: it is even probable
that after the new impulse given by Morgagni, they would not have
failed to discover that Malignant Angina consists only in a gangrene
of the mucous tissue, if Francis Home, by publishing his “ Treatise
on Croup,” had not suspended the progress of observation. It is diffi-
cult to conceive how a work which contains only a small number of
isolated and scattered facts, was capable of obliterating the traces of
the ancient traditions, and, for half a century, of preserving a great
amount of influence over the opinions of practitioners! Such is, how-
ever, the fact. Struck with the most ordinary mode of termination of
Malignant Angina, Francis Home persuaded himself that he had just
met with an affection which had hitherto escaped the attention of
his predecessors ; he thought that he ought to give it the popular
name under which he found it designated in a Scotch province:
the novelty of his discovery was widely diffused, and the new deno-
mination so fascinated all persons, that it prevented them from re-
cognizing a disease observed from the most remote antiquity, and
which, in our own days, is accompanied by all the symptoms which
it has uniformly exhibited.
TREATISE ON DIPHTHERITE,

 

FIRST MEMOIR

ON THE DIPHTHERITIC PHLEGMASIA, OR PELLICULAR INFLAMMATION
OF THE MOUTH, PHARYNX, AND AIR-PASSAGES.

Tur Memoir which I have the honour to submit to the judgment
of the Academy, is extracted from a collection of observations on the
special phlegmasiee of the mucous membranes. The result of my
labours tends to prove, that many inflammatory lesions of the mucous
tissue have been confounded together, while the gradations of the
same affection have often been mistaken for so many different diseases.

The inflammations of the mucous membranes exhibit, perhaps,
some characters no less varied than those of the cutaneous phlegmasiz,
the classification of which has exercised so fully the talent of nosogra-
phers. The exudation which accompanies them, presents, in itself,
remarkable varieties ; sometimes it is a diffluent serosity, sometimes it
is mucus variously altered ; sometimes it is a coating, which has the
whiteness and consistence of cheesy matter ; at other times it is an
intimately adherent membranous substance, or simply an adherent
membraniform pellicle. The degree of thickness, or of induration,
the force of cohesion, the colour, the amount of elevation of the
affected tissue, and the more or less limited nature of the inflam-
mation, furnish a multitude of other varieties, which I shall not
undertake even to indicate. I shall only add, that some very
frequent combinations of these different alterations co-exist too con-
stantly with the symptoms of certain diseases, to prevent us from
seeing in them the relations of cause and effect.

So far from entering into these distinctions, and insisting upon
the difference of the inflammatory conditions of the mucous tissue, I
undertake at present to prove, by the testimony of facts, that the
6 BRETONNEAU’S FIRST MEMOIR.

Scorbutic Gangrene of the gums, Croup, and Malignant Angina, are
only one and the same form of phlegmasia. These facts, which are
supported by numerous researches in pathological anatomy, have been
noticed and collected together, during the course of an epidemic
which prevailed at Tours, from 1818 till 1820; and they have been
obtained either in the town, the population of which amounts (1826)
to upwards of twenty thousand souls, or in the Hospital, where the
number of patients varies from one hundred and twenty to four
hundred. They are similar in their nature to those facts which have
been seen in our own time, or have been observed from the most
remote antiquity, and by bringing together the notions of modern
times, and those which have been transmitted to us by the ancients,
their anomaly and discordance are explained.

To prove that Croup is only the last degree of Malignant Angina,
that Malignant or Gangrenous Angina is not gangrenous, that
there is no relation between sphacelus or a supposed superficial
mortification and the alterations which this disease leaves behind
it, would be a difficult undertaking, even for a physician whose
opinion would have all the weight due to eminence attained by
useful labours. Although in a very different position, it remains
for me to accomplish a more delicate task; for I have not only
to demonstrate the nature and identity of these affections, but I
must also show that the ancients had recognized this identity, and
that, moreover, they had traced the objects presented to them with
great fidelity ; and that, in a word, they had represented them as they
might be seen without the help of pathological anatomy; so that
the illusion of distance, which must necessarily have been found in
their representations, has become for the moderns a source of ma-
terial errors, and errors the more dangerous, because they have been
solemnly ratified by the assent of many justly celebrated men.

But the truth has only to exhibit itself, in order to surmount these
obstacles. From the moment when chance presented it to me, I
thought that before publishing my conclusions, it was my duty to direct
my attention again to the observation of facts, to review them, to exa-
mine them a second time, and to consider them under all their aspects.

Sixty bodies were opened during the course of the epidemic.
Although the examination of certain viscera, which had not presented
any sign of morbid alteration during life, was sometimes neglected,
the state of the digestive canal and of the air-passages was always
studicd with the most minute exactness.

x
SCORBUTIC GANGRENE, 7

I endeavoured to prosecute my researches on the bodies of those,
who had more particularly presented, either the characteristic sym-
ptoms of Croup, or those of Malignant Angina, whether the progress
of the disease had been left to take its course without any treatment,
or had been fruitlessly opposed by the most energetic and most op-
posite remedies. _

In a great number of subjects, I was able to follow the decreasing
modifications of the disease up to its perfect cure, which was
obtained under the influence of special, general, or local treatment.

A hundred and thirty- soldiers, and twenty individuals of all
ages, presented the different gradations, acute or chronic, of scorbutic
gangrene, confined to the mouth, or extending to the pharynx, and
not differing, in the latter case, from Gangrenous Angina.

In order not to exceed the bounds which [ have thought it con-
venient to prescribe to myself, I shall, in the first part, limit my
observations to the examination of each of these affections, and to
the explanation of their general and common character.

In a second Memoir, the historical records will be succinctly
analyzed, and I shall show, that the results of their comparison do
not at all differ from those which have been furnished to me by direct
observation. I shall add what I have been able to glance at in re-
lation to the contagion of pellicular inflammation, a question, the
solution of which is no less serious than difficult. Some therapeutical
observations will terminate the second division of this Memoir, the
principal facts of which will be collected together in a general view
of the epidemic which prevailed at Tours.

1. Or Scorsutic GANGRENE.

The appearance of this affection varies very much according to its
extent, or to its greater or less duration. It generally presents itself
under the form of a greyish ulceration, occupying the undulating
border of the gums ; the tartar is deposited in greater quantity than in
the healthy state on the surface of the teeth, or rather the latter are
coated with a grey-brown dirty matter, of the colour of rust. Their
line of insertion is more particularly the seat of the disease, so that
the adhesion of the gum to the neck of the tooth being gradually
destroyed, an incurable looseness is the result; and this is one of the
ordinary and troublesome consequences of Scorbutic Gangrene.
8 BRETONNEAU'S FIRST MEMOIR.

The diseased parts allow the blood to transude with such facility,
that it is sufficient to open the lips gently, in order to let it ooze out
im little drops from all the ulcerated surfaces.

When the affection is communicated from the gums to the
mucous membrane lining the lips and cheeks, a white spot arises at
the point of contact ; it soon increases, and becomes grey, livid, and
blackish : sometimes it sinks deeply, and then the edges of this foul
ulcer are swollen, and of a livid-red colour; thick patches are detached
from its surface, and are replaced by new layers. A sanious serosity
flows from the mouth in abundance, and this flux, which continues
during sleep, soaks in and stains the linen of the patients. The
surrounding cellular tissue and the circumjacent lymphatic glands
become tumefied. The breath is rendered intolerably offensive, and
the disease then assumes the most specious resemblance to the true
gangrene of the mouth, which is a more dangerous affection, and one of
an entirely different nature. I purposely omit peculiarities, the detail
of which at present would be out of place, and which can only be
observed in following the progress, and the successive stages of scor-
butic gangrene. I shall only add, that when arrived at this stage,
the disease may be cured without leaving any cicatrix, and without
the least trace of it beg perceptible.

The disease which has just been described, has shown itself
among the soldiers of the legion of La Vendée, while they were still
in garrison at Bourbon. When they arrived at Tours, at the begin-
ning of 1818, a great number were attacked by it. The disgusting
affection broke out especially in the western barrack, which had just
before been occupied by another regiment, exhibiting no case of the
disease. The malady was thought to be of a scorbutic nature, and
was attributed to endemic causes; the well-water was especially
suspected ; it was found soft and brackish; but in fact, the water of
this establishment, like the filter-water of all the district, had
neither the taste which was attributed to it, nor any other bad
quality. ;

It was evident, that this affection had nothing in common with
scurvy, however little precision was attached to this word, and
however little it was taken in the acceptation laid down by Lind in
his Treatise on Scurvy, a work based upon a great mass of observa-
tions, and a master-piece of learning and criticism. ;

Thus the juice of sorrel, alone or combined with the juice of the
cress, and anti-scorbutics in all forms, were administered in large
SCORBUTIC GANGRENE. 9

doses, and during a considerable time without any diminution of the
disease or any arrest of its progress; yet this of itself became pretty
frequently stationary when it was limited to the gums of the incisor
teeth.

There was no circumstance in the management of the soldiers, and
there was no error in hygiene which had predisposed them to the
scorbutic cachexia. But a more direct proof that the affection of the
mouth was not induced by such a diathesis, is to be found in the
circumstance that their constitution in other respects offered no trace
of it. They were strong men, of good constitution, who, in every
other respect, enjoyed full and perfect health.

The necessity of combating a purely local affection by topical
means, having been thoroughly recognised, hydrochloric acid, so
often employed with advantage in modifying aphthous ulcerations of
the mouth, was tried with a success which surpassed all expec-
tation.

This disease was certainly the stomacace of the ancients, and the
Ségarite of the Spaniards, denominations which, with an etymology
of different origin, have only a single meaning, since they both
signify a foul ulcer of the mouth. It was, moreover, the affection
designated by the learned commentator of Boerhaave, under the name
of scorbutic gangrene of the gums, and of watery cankers (chancres
aquatiques); a disease which he subdued by means df hydrochloric
acid; in fact, he believed it to be of a scorbutic nature, but still he
did not fail to observe that it was exasperated by an anti-scorbutic
treatment.

The diagnosis of the disease, and its relations with well-known
affections being so positively established, there was nothing less sur-
prising than to see the spots in the mouth extending to the pharynx,
and at other times the tonsils presenting the first traces of the dis-
ease, which did not then differ in any respect from Malignant or Gan-
grenous Angina.

Van Swieten, who certainly saw the disease in several of its forms,
recognises the identity of these two affections, and he quotes, in
support of his opinion, a part of the description traced by Aretzeus,
a description of remarkable fidelity, in which the general features
as well as the details of the different morbid alterations which form
the subject of this Memoir, are represented with such forcible and
true touches, that it-is difficult to understand how the impression
and the remembrance of them have ever been effaced.
10 BRETONNEAU’S FIRST MEMOIR.

2. Or Marienant ANGINA.

The enumeration of the names which have been given to this for-
midable malady would be tedious. It is, however, remarkable that
many of them express the idea of choking and strangulation. When
the disease appeared at Tours, it was new to the greater part of the
practitioners, and upon its diagnosis and treatment, opinions were
divided, while the views laid down in books were very little calcu-
lated to reconcile them. During the prevalence of the disease, it
became our duty to observe it, and closely to study its nature, which
must have been very destructive if we may judge by the descriptions
which have been drawn of it, by its repulsive aspect, and by the
rapidity of its progress. Some cases collected at the beginning of
the epidemic, will serve better than any description, to give an idea
of its true characters.

Casz 1.—A child, five years old, healthy, and of good constitu-
tion. Coryza, rather severe pain of the ear, which was relieved after
the appearance of a serous discharge through the auditory canal.
For two days only there had been slight pain in the throat ; degluti-
tion was so little affected that the child supped in the evening with
its parents, and with its accustomed appetite. The third day the
throat appeared to be obstructed, and on examination of the back of
the mouth, at eleven o’clock, a.m., large grey spots were seen cover-
ing the tonsils, the bases of which were red and swollen. Light
leeches were applied to the sides of the neck, and produced an
abundant flow of blood; and kermes mineral was given in emetic
and repeated doses. , There was a hoarse cough, with alteration of
the sound of the voice; in the evening there was aphonia, extreme
fetor of the breath, a blackish-grey tint of the eschars which extended
over the whole surface of the pharynx; frequent and small pulse ;
dyspneea, lividity, and sinking, which terminated in a peaceful death
during the early part of the night. It appeared to me very evident
that death was caused by gangrene of the back of the mouth; but
I asked and obtained permission to make inquiries into the extent
and true seat of a disease, which had had so rapid and fatal a ter-
mination.

Necropsy.—External appearance. Body stout ; lividity; tume-
faction of the sides of the neck. Internal appearances, observed
eight hours after death. The velum palati was of a blackish-grey
MALIGNANT ANGINA. 11

tint, as far as the height of the palatine arch; the putrid decom-
position of the surface of the tonsils appeared still more advanced ;
the eschars extended from the guttural opening of the nasal fossz as
far as the commencement of the esophagus; they penetrated into
the glottis, where they assumed a dull-white tint. Their margin was
marked by a bright-red line. The mucous membrane of the trachea
exhibited no trace of inflammation ; a small quantity of mucus was
accumulated near the bifurcation of the bronchi. This gangrenous
alteration, which had extended with so much rapidity, had gained so
little in depth, that the velum palati divided from before backwards, :
presented a vermilion section between two grey lines, which were
quite superficial. The fetid odour exhaled by the patient had ceased
to be perceptible after death.

Tt was impossible to make a more imperfect investigation. To what
a degree may prejudice blind the judgment! The prepossession in
favour of the existence of a gangrenous affection prevailed over
evidence. Although no excuse can justify the want of attention in
so severe a case, where everything demanded the most accurate in-
vestigation, some circumstances may at least explain the hurried nature
of this autopsy, which was made in the middle of the night, in a con-
fined place, and under the eyes of parents, whose sorrow inspired me
with the fear that I had already carried my zeal for science too far.

Doubt was the first result of this case. Indeed, how could
gangrene be limited to such slender surfaces, and deviate, in this
respect, from its habitual character? A disposition which was so
peculiar to this epidemic affection, required a new and especially a
more severe investigation. There was reason to fear that the occasion
would not be long wanting, for it was observed that the number of
those who were dying of Gangrenous Angina, was daily increasing.
Children were particularly attacked by it, and at this age, the disease
_ appeared to be transmitted by contagion.

Casz 2.—A child, eight years old, was brought to the Infirmary,
of the Orphan Hospital. Tottering gait, complexion pale and leaden,
eyes sunk; aphonia, pulse feeble and frequent ; breath foul, the fetor
being perceptible at a great distance. It is stated that this child
had complained of a pain in the throat only for a few days, without
much apparent difficulty in deglutition. All the soft parts of the back
of the mouth were of a grey tint and appeared deeply sphacelated.
One of the tonsils, hanging and detached, seemed to be retained only
12 BRETONNEAU’S FIRST MEMOIR.

by loose remains of cellular tissue. Although there appeared to be
no hope of recovery, a sponge soaked in concentrated hydrochloric
acid was applied to the isthmus of the throat.

The next day all the symptoms began to mend, and membraniform
shreds were detached: the topical applications were continued, and
a cure was obtained on the eighth day of the treatment. Astonishment
was excited on a view of the existing state of the pharynx ; for the
velum palati, the uvula, the tonsils, especially the left, which was seen
ina state of putrid dissolution, separated and almost entirely detached;
in fact, all the parts, the presumed removal of which had induced the
denudation of the bones, were in a healthy state, and had preserved
the most perfect integrity.

A fortnight had elapsed and this child appeared to be completely
recovered, when he complained of a feeling of suffocation, which made
him put his hand to his neck. In the evening he had some con-
vulsive movements and vomited. In the night he uttered some
piercing cries and died, saying that a beast was devouring his inside.
In this expression there was more truth than might at first be sup-
posed, for the small intestine was distended with two balls of worms ;
one especially, exceeding in volume the child’s fist, was arrested in
the duodenum, and was formed by the interlacement of twenty
worms (ascaris lumbricoides),'the movements of which had irritated
and wounded the intestine, so that in a great part of its circum-
ference the mucous membrane was destroyed by this attrition. The
pharynx, the larynx, and the trachea were quite healthy. A slight
wrinkling of the edges of the glottis was the only alteration which
could be discovered at the back of the mouth after the most attentive
examination.

The facility with which I succeeded, by means of the application
of hydrochloric acid, in producing the removal of the eschars which
in some subjects extended from the mouth to the pharynx, and the
success of this measure when it was employed at the commencement
of Malignant Angina, tended to conceal the danger of a disease
which was about to desolate so many families.

Casr 3.—A child, seven years old. Sore-throat with slight fever ;
on the right tonsil, which was a little tumefied, there was a white spot
which disappeared after two applications of hydrochloric acid,weakened
by mixing it with two parts of honey. Four days elapsed without any
apparent alteration of the health: the child made no mention of the
MALIGNANT ANGINA. 13

return of sore-throat from the fear of another application of the acid;
but the difficulty of deglutition became so distressing, that it could no
longer be concealed. A fresh examination of the throat was therefore
made; allthe back of the mouth was of a grey-marbled tint; there
was frequent cough, with abundant expectoration. The local appli-
cations were renewed. ‘The next day the tone of the voice was
altered, and on the following day, aphonia was complete, there was
hoarse cough, dyspnoea, and sibilous inspiration, fetid breath, and
lividity of the face. In the night, the dyspnoea increased every
moment, and on the morning of the third day, counting from the
relapse, the child expired in rising to make water.

Although a part of the symptoms observed towards the end of
the disease exhibited a great analogy with those of Croup, yet it was
probable that the gradual embarrassment of the respiration originated
in a propagation of the gangrene, which had undoubtedly extended

. from thé pharynx to the air-passages; and the epidemic mortality,
already mentioned, had certainly no other cause than the extension
of the gangrenous eschars which were seen in the back of the
mouth.

Necropsy.—As in the child who forms the subject of the first case
the walls of the pharynx were in appearance covered with eschars ;
but an unexpected difference was observed in the interior of the
trachea; a tube of a membraniform substance which was white,
supple, elastic, consistent, adhering feebly to the mucous membrane,
or even merely applied to its surface, extended from the orifice of the
larynx to the last divisions of the bronchi.

It became impossible to mistake the false membrane which
characterizes Croup, or to doubt that the air-passages were the seat
of this disease. A multitude of conjectures sprang up on a more
minute examination. The inorganic tube, invaginated in the trachea,
was continuous with the eschars of the isthmus of the throat, and
these supposed eschars represented the expanded portion of a funnel
of which the tracheal tube formed the stem. That surface of the false
membrane, which, in the pharynx, was in contact with the mucous
tissue, was neither grey nor blackish, like the opposite surface ;
it had the whiteness, the consistence, and the morganic aspect of
the exudation, drawn from the trachea and the bronchi. I pass in
silence the identity in action of the different chemical re-agents on
these different portions of the false membrane. What is most worthy
of remark is, that when the exudation was removed (and in order
14 BRETONNEAU’S FIRST MEMOIR.

to remove and detach it, it was sufficient to raise it with the dis-
secting forceps) the walls of the pharynx presented not the least
trace of gangrenous alteration ; red patches, dotted with spots of a
deeper red, without erosion and without thickening of the tissue, were
the only marks of inflammation which could be observed, and the in-
flammatory redness was still less marked in the trachea.

From what affection did this child dieP Was it from Croup,
Augina Maligna, or a complication of these two diseases? Up to
this time, the symptoms of Malignant Angina had alone been ob-
served, and in several patients, the coincidence of the affection of
the throat with scorbutic gangrene of the gums, a coincidence
already often observed in the Hospital, characterized still better the
disease so often described, both under this name and under that of
gangrenous sore-throat. During the life of the child, the affection
of the throat had shown so much similarity to Malignant Angina,
that the nature of the disease had not left the least doubt. Arter
death, pathological anatomy discovered more certain and positive
relations with Croup, both in respect to the inflammatory lesion of
the mucous tissue and to the membranous exudation which was
produced by it,

What then was the nature of this dangerous disease? Could the
intensity of Croup proceed so far as to affect the pharynx and simu-
late Malignant Angina, or was the gangrenous sore-throat invested
with fallacious appearances, which went so far as to mislead ‘us as
to its most striking character, namely, that which has given to it its
denomination ? This last opinion was improbable, and yet the doubt
was strengthened by a remark that must have often been made; all
the phenomena of inflammation are inverted in Malignant Angina,
and the gangrene which is usually its last stage, here takes the
initiative; the slough is formed and renewed with an unusual
_ rapidity. Whence then arose so great an anomaly ?

Were, then, Malignant Angina, and Scorbutic Gangrene, which
sometimes become chronic, and Croup, a disease eminently acute,
only varied forms of one and the same species of phlegmasia? The
least probable of these suppositions has been found the most true ;
but let me not anticipate the explanation of the facts which will leave
no doubt in this respect.

Pathological anatomy might suffice to resolve these questions and
many others, which curiosity would have already induced me to clear
up, if more serious motives had not made it incumbent on me to
DIAGNOSIS OF DIPHTHERITE. 15

pursue my researches. Some adults, anda greater number of young
subjects, died in an almost sudden manner, and as many as five
children were carried off from a single family in the neighburhood
of the town.

The following were the circumstances which gave a new impulse
to my inquiries. A pupil of pharmacy, attached to the Hospital, was
still suffering from the effects of Malignant Angina, and, perhaps,
from those of the rather energetic local treatment which the severity
of the disease had demanded, when he went to pass a few days in
the country. During this time one of the children of the vine-dresser
in the house died of Croup ; the disease had been recognised in good
time, and the treatment most generally in use had been adopted. The
resident pupil of the Hospital (M. Velpeau) succeeded in ascertaining
after death, that the walls of the pharynx were covered with exuda-
tions. The disease was seer to extend from the tonsils to the velum
palati in another child of five years old (the brother of the former
child), who was treated in the same manner and died likewise. The
mother, aged forty-four, began, three days afterwards, to suffer from a
slight sore-throat. Alarmed by the apprehension of what she imagined
was a burning of her throat, she would not consent to any local appli-
cation until she had waited too long; and she died. During the
last two days her attendants had been struck with the alteration in
the tone of her voice. Her eldest daughter, aged twenty, and a
young woman of the neighbourhood, who had nursed the patient,
were brought to the Hospital. They were both already suffering from
severe symptoms of Malignant Angina. I succeeded in obtaining
permission to examine the trachea of the woman who had just died.
When the parts were removed, we found in the trachea a slightly
adherent membraniform tube, half-a-line thick at its lower extremity,
which, consequently, must have extended itself downwards into the
bronchi. It was evident that the exudation of the pharynx was of
the same nature as the tube invaginated in the trachea.

The two young peasant girls were treated and cured by applica-
tions of concentrated hydrochloric acid.

Twenty-two post-mortem examinations were successively made,
with the sole intention of ascertaining if the exudations, which, in
the pharynx, assumed the appearance of eschars, so as to produce an
illusion which it was always difficult to dissipate, were really composed
of an inorganic substance of the same nature as the Croupal exuda-
tions, and above all,in order to be assured if the organized tissues which
16 BRETONNEAU’S FIRST MEMOIR.

they covered, preserved their integrity. Subsequently, it appeared still
more important to ascertain if, in other cases, more suddenly fatal,
in which the breath had not presented any fetor, and in which the
Croupal cough, the alteration in the tone of the voice, and the fits of
suffocation had not been preceded by any apparent difficulty of de-
glutition ;—if, I say, in these circumstances, when the beginning,
the developed stage, and the termination of the disease, had presented
the most perfect appearance of Membranous Angina, the formation
of the exudations had always commenced upon the tonsils, at a
point, in fact, where, by the help of local treatment, we might,
prevent their extension.

Different therapeutical questions presented themselves and required
new investigations; but the greater part of these observations would
here be out of place. I shall confine myself to the indication of
their general results, and to a notice of those points which have a
particular relation to any leading subject of discussion.

In comparing together the morbid lesions, observed in fifty-five
subjects of all ages, who, in the course of two years,* had fallen
victims to epidemic Angina, I find that it once happened that the
false membrane existed in the trachea without any exudations being
found either upon the tonsils or upon any other part of the pharynx.
In no case, even when the Malignant Angina had assumed the most
repulsive aspect, was I able to discover anything which resembled a
gangrenous lesion. Ecchymoses of very limited extent, as well as
a slight erosion of the surfaces on which the disease had developed
itself, were the most serious alterations of tissue which I was able to
ascertain. Six or seven times, that is to say, in the proportion of
one to nine, the membraniform exudation reached to the extreme
ramifications of the bronchi. In a third of the whole number, it
passed beyond their great divisions ; in all the rest it terminated at
different distances from the trachea, so that’ the mechanical obstacle
offered to respiration by the development of the false membrane
always appeared to have been the immediate cause of death.

* M. Velpeau, my pupil and friend, at present Professeur Agrégé in the
Faculty of Medicine at Paris, and who was then first house-pupil at the
General Hospital of Tours, assisted me throughout in these post-mortem
researches ; his zeal for the progress of his art foretold the well-merited
success which he has since obtained.
DIAGNOSIS OF DIPHTHERITE. 17

A single exception was observed: a child who appeared to die of
exhaustion on the fifteenth day, from Malignant Angina, without
any other symptoms than a continual vomiting, had the pharynx
lined with thick pellicles, which did not pass beyond either the
commencement of the cesophagus or the entrance of the glottis.

The concrete exudation, observed on the surface of the pituitary
membrane, did not in all cases occupy the same extent of surface ;
in general, the guttural opening of the nostrils was incrusted
with it; but it was seldom found to reach as far as the orifice of the
nose. In the latter case all the anfractuosities of the nasal fosse
were covered by it. In two young children, a thick, consistent
membraniform tube, invaginated in the cesophagus, was traced as
far as the cardiac end of the stomach.

Notwithstanding the length of these details, I must add that I
saw in a woman of thirty, who was attacked by Malignant Angina
to such a degree as to resemble gangrene, a membraniform pellicle
which projected from the external auditory meatus, and extended to
a part of the concha. There was the most perfect similarity between
the affection of the pharynx and that of the skin, and they both
yielded to a few local applications of hydrochloric acid.

At the very time when this woman was most seriously affected, her
daughter, aged five, had behind her ears a slight excoriation covered
with a membranous coating; the symptoms of Croup supervened
suddenly: the intractability of the little patient scarcely allowed of the
possibility of my assuring myself that the tonsils were covered with
pellicles of a yellowish-white colour ; she died forty-eight hours after
this examination. The next day, her younger brother appeared on
the point of perishing in a fit of croupal suffocation ; but a few fumi-
gations brought about the expulsion of a membraniform tube. The
following days, other fragments of false membrane were drawn away
from the child’s mouth after efforts of coughing, produced by the same
means. The tone of the voice remained altered for some time; but
the child recovered. Subsequently the same membranous excoria-
tion was observed behind the ears of another child a few months
old, and this unusual affection was removed by two or three applica-
tions of hydrochloric acid. At first, the health of the little patient
appeared to improve; but some little time afterwards it died. It
would be difficult, by the mere narration of the symptoms of the
fatal disease, to draw any conclusion as to its nature. The post-
mortem examination proved that the child died of Croup, and that a

c
18 BRETONNEAU’S FIRST MEMOIR.

membraniform pellicle of considerable consistence, extended from the
pharynx as far as the trachéa.

I should scarcely have pointed out circumstances which appear to
have but little relation to my subject, had not a membranous affection
of the skin, quite similar to what I have just described, and some-
times even attacking blistered surfaces, exhibited itself as a serious
symptom, frequently accompanying the attacks of Angma Maligna
in two epidemics, which were observed, one by Starr, in the county
of Cornwall, and the other by Samuel Bard, in New York.

The details of three cases, presented at distant periods by sub-
jects of different ages, who died of Croup and Malignant Angina,
will prove, better than a mere assertion, the identity of the morbid
affection of which they died.

Case 4.—A very weak and small child of fifteen, who died of
Croup.—White, thick, coriaceous pellicles lined the walls of the
pharynx and of the trachea, and extended over the whole of the
pituitary membrane. The false membrane had seldom been found
so tenacious and elastic. It passed deep into the esophagus, but in

place of forming there a complete tube, it was spread out by dis- ’

tinct bands which were terminated in pomts at different distances ;
the longest reached the cardiac end of the stomach. A rather vivid
redness descended below the false membrane and circumscribed it ;
so that between each red dotted streak there remained a perfectly
healthy interval. P3

Casz 5.—A woman aged thirty-three, moderately stout, healthy,
and of good constitution, who had bestowed great care upon the child
who forms the subject of the preceding case, experienced a rather
severe pain in the throat; deglutition was especially painful. The
tonsils were tumefied and of a deep red colour; white spots were
observed upon their surface. The following day there was dyspnoea
with hoarse cough; a copious blood-letting was ordered from the
arm and twenty leeches were applied to the upper part of the chest ;
and syrup of ipecacuanha was given in repeated doses. All the
symptoms continued to increase ; and soon one of them predominated,
namely, palpitations of the heart attended with extreme pain. Death
terminated this state of suffering on the sixth day of the disease, and
the fourth of the treatment.

After death, the body presented a puffy swelling of the face, and
cedema of the neck and the upper region of the chest.
GENERAL CONSIDERATIONS. 19

Autopsy, twenty-seven hours after death—The brachio-cephalic
artery was opened by the first stroke of the scalpel; a prolonged
hissing sound was heard, manifestly caused by theair escaping from the
divided vessel; another portion of air escaped as soon as the incision
penetrated into the right thoracic cavity, but nothing similar was
observed on the left side. Both lungs exhibited superficial emphysema-
tous dilatations; the right alone was depressed. ‘The vessels of the
small curvature of the stomach were filled with air, as well as those
which ran along its surface. In the back of the mouth and in the larynx
we found pellicular exudations and all the usual alterations already
mentioned. One peculiarity alone was remarked: the tube, formed by
the false membrane, hung freely in the trachea: this tube was thick
and very firm, and was becoming very adherent to the larynx. Is
it not probable that during life it may have performed the office of
a valve allowing the air to penetrate into the lung, and opposing its
escape? May not this circumstance have brought about the rupture
of the pulmonary cells, and determined the passage of air into the
blood-vessels, an accident which appears in this case, to have been
the immediate cause of the palpitations and of death ?

Casz 6.—Examination of the body of a woman aged fifty-five,
who died after having thrown up, for several days, by the efforts of
coughing, large and tubular shreds of membraniform pellicles.
The false membrane, which extended beyond the third division of the
bronchi, presented to me only this notable peculiarity, namely, that
from the trachea to the glottis it was composed of several lamine
superposed on one another, while in the remainder of its extent it was
formed only of a single lamina.

Inflammatory Lesions and Alterations of ‘Tissue ; General
Considerations.

It is sometimes rather difficult to discover the organic alteration of
which the concrete exudation is merely the product. Generally it is
confined to a pointed redness, arranged in irregular spots, without the
least swelling; for we must not attribute to the mucous covering
(which does not participate in it at all) the tumefaction of the sur-
rounding cellular tissue. This tumefaction is nowhere more con-

siderable than under the skin, in the vicinity of the lymphatic glands
c2
4

Soe
20 BRETONNEAU’S FIRST MEMOIR.

which correspond to the region of the mucous membrane affected.
It is from these glands themselves, that the intumescence seems to
extend and diffuse itself. Their congestion is constantly observed,
and even from the beginning it is considerable, and out of propor-
tion to the slight extent and intensity of the inflammatory lesion. I
have twice seen it terminate by a suppuration analogous to that of
buboes. (See the letter of Ghisi.) This redness of the mucous
membrane without thickening of tissue, which is quite superficial, and
which, however, is accompanied with an abundant and remarkable
concrete exudation, appears to me, I admit, a very peculiar in-
flammatory condition.

I should not express my entire opinion, if I did not add that I see
in this membranous inflammation a specific phlegmasia, as different
from a catarrhal phlogosis as the malignant pustule is from Zona, a
disease more distinct from Scarlatinal Angina, than scarlatina itself
is from small-pox; in fact a morbid affection sui generis, which is
no more the last degree of a catarrh than a squamous eruption is
the last degree of erysipelas.

As it is impossible to apply to a special inflammation which is so
well-marked, any one of the improper names which have been given
to each of its varieties, let it be permitted me to designate this phleg-
masia by the name of Diphthérite, derived from SipOépa, pellis,
exuvium, vestis coriacea, whence comes diupGepow, corio obtego.

The more attention I have given to the study of the phenomena
peculiar to this inflammatory condition, the more it has appeared to
me to differ from every other by characters which are proper to it.

If we examine with the microscope the most vivid diphtheritic spots,
and those which appear to the naked eye to be pointed with red
and white, we see that they are due to very minute vascular injection,
and that the points of a brighter redness are so many little ecchy-
moses, while the white spots are only the prominent orifices of the
mucous follicles. ‘

Diphtheritic inflammation is propagated in an altogether peculiar
manner on the surface of the mucous membranes which it attacks ; it
spreads on them almost like a liquid which is effused or flows over
them.

We often see a long, narrow streak, of a dark red colour, which
extends into the pharynx, or descends into the trachea, either alone
or accompanied with other distinct strie. A band of pseudo-mem-
branous matter is formed in the middle of each stria. At this period
GENERAL CONSIDERATIONS. 21

some rounded pores, or rather some semi-transparent bulle, are still
observed in the substance of the pellicle; the sides of this growing
pellicle, irregularly crenate and attenuated, are confounded with the
mucus which surrounds them, and which, without being altered in its
appearance, is already altered in its properties, for it has no longer any
viscosity, and is coagulated, ready to be concreted. Soon the bands
are enlarged, they become more dense and homogeneous, and form, by
their union, complete tubes, of a single lamina, united to the
mucous membrane by little prolongations which penetrate into the
orifices of the muciparous follicles. If the pellicle is detached, the
redness increases in the denuded points, the false membrane is repro-
‘duced, and in proportion as the superposed laminze add to its thick-
ness, it becomes more and more adherent to the organic surface.
If it happens that such morbid processes take place in the respira-
tory canals, any chance of recovery is probably small.

I would willingly have abridged this description, if the knowledge
of the various appearances which are successively assumed by the
membranous exudation were not often useful in practice. The long,
narrow, and porous bands which are seen floating in the sputa, when
an abundant expectoration is established under the influence of a
mercurial treatment, indicate that there no longer exists any mem-
branous tube in the trachea, and that it is only very recently that
the morbid affection has penetrated there. There is more hope that
it will be modified in the trachea before the pellicles are united
into complete tubes, and have acquired so much adhesion as to render
the prognosis very unfavourable.

The characters which I have just described distinguish also the
diphtheritic phlegmasia from some other membranous inflammations
with which it is necessary not to confound it.

The whole of the phenomena of this specific inflammation are
found upon every point of the mucous membrane on which we may
observe them, and the white narrow border, which circumscribes the
so-termed scorbutic gangrene of the gums, is only the membranous
exudation reduced to small dimensions. It rarely happens, unless the
patients are very young, that in making its first appearance under this
form, the Diphtheritic Phlegmasia is transmitted to the air-passages.
It is especially when it shows itself in the first instance upon the
tonsils that this sudden and dangerous extension is to be feared.
One or several whitish spots, similar in appearance to lichen,* which

* The word lichen is here used in its botanical’seuse. (ED.)
22 BRETONNEAU’S FIRST MEMOIR.

are seen on their surface, and the tumefaction of the lymphatic glands,
situated at the angles of the jaw, are the characteristic symptoms
of a disease, which it is necessary to arrest at its onset by sub-
stituting an inflammation of another character. Long intervals in the
return of symptoms peculiar to the affection of the air-passages, often
conceal a serious amount of danger. These often quoted intervals of
intermittent Croup, belong to a numerous class of pathological
phenomena. What practitioner has not observed them ? Is it not in
an intermittent manner that scirrhous tumours, calculus, and many
other permanent causes of pain, make their fatal influence perceptible?

Putting aside for the moment the conclusions which may be drawn
from contagion (a. question which belongs exclusively to the second
part of this memoir), and only considering the epidemic character in
the Scorbutic Gangrene of the gums, Malignant Angina, and Croup,
I think that the identity of these three affections, founded upon an
identity of organic alterations, which have been demonstrated by
pathological anatomy, cannot be invalidated by a few unimportant
symptoms.

If, at the commencement of the epidemic, the death of many children
was generally attributed to Croup, because it was sudden and pre-
ceded by all the symptoms of that disease, whereas in adults, the
fetid smell of the breath, and the lividity of the complexion, caused
the ideas of gangrene and putridity to prevail, the ditference in the
development of the air-passages, at the different periods of life,
sufficiently explains this apparent anomaly.

It is scarcely necessary to point out that the fetor of the breath
and the gangrenous appearance of the pharynx depend upon the
putrid solution of the pellicular exudations. The exudation of
the blood, a common phenomenon of diphtheritic inflammation, com-
pletes the delusion. The false membrane, coloured by this fluid,
assumes successively different tints, indicative of itsdecomposition. The
contact of the air, the influence of damp heat, indeed, all the conditions
favourable to induce putrefaction, and even those which may impress
upon it the character of a gangrenous alteration, are combined. It was
difficult then for the senses not to be deceived ; but why should this
delusion still exist? The causes which produced it are easily to be
understood. It has never prevailed entirely, and it will be seen that a
multitude of well-conducted observations have often been on. the
point of dissipating it.
‘DIAGNOSIS OF DIPHTHERITE. 23

SECOND MEMOIR

ON DIPHTHERITE, OR PELLICULAR INFLAMMATION OF THE MUCOUS
TISSUE.

In the preceding Memoir, read at the Academy, and submitted to
the opinion of that learned Society on the 26th of June, I undertook
to show, that Scorbutic Gangrene of the gums, Malignant Angina, and
Croup, are only one and the same species of disease, the phenomena
of which present a great diversity of symptoms, according to the
fonctions of the organ affected, without the necessary existence of
any essential difference between the pellicular inflammation which
becomes so formidable by its propagation into the air-passages,
and that which, being limited to the gums, causes only a slight in-
disposition. I have also said, that according to the uniform
result of a great number of clinical observations and of post-mortem
examinations, it was constantly found that Malignant Angina was not
accompanied by any mortification, that only fallacious appearances
had given rise to the suspicion of a gangrenous alteration, and that in
fact the lividity and torpor which precede the death of adults arise
only from a slow asphyxia, the consequence of the mechanical obstacle
which is gradually opposed to respiration by the false membrane, in
the same way as the fetor of the breath depends upon the putre-
faction of this same albuminous production, which assumes the ap-
pearance of ‘eschars upon all the surfaces affected with pellicular
inflammation.

I have been led to propose the denomination of Diphtherite to
designate the phlegmasia which forms the particular object of this
Memoir, in order to distinguish it from several other pellicular in-
flammations, from membranous mercurial inflammation, and from a
buccal phlegmasia which is accompanied by a caseiform exudation (a
very distinct sporadic affection); but above all, this name will
distinguish it from Scarlatinal Angina, a membranous inflammation
accompanied by a cutaneous exanthem, and which has often been
confounded with Diphtheritic Phlegmasia, although it differs from it
essentially by its mode of attack, its duration, and its different ter-
minations. Before passing to the second part of this Memoir, which
will have for its object the examination of some historical details,
the discussion of facts relative to contagion, and the explanation
24 BRETONNEAU’S SECOND MEMOIR.

of the different therapeutic plans which have been opposed to the
true Diphtheritic Phlegmasia, it will be convenient to represent its
characteristic features in a tabular form drawn up from nature, and
to describe them more minutely than I have done in the first part.

Spectric CHaracters oF DIPHTHERITE.

At the beginning of the disease, a circumscribed redness is per-
ceived, covered with a coagulated semitransparent mucus. This first
layer, which is slight, supple and porous, may be still further raised up
by some portions of unaltered mucus in such a manner as to form
vesicles. Often, in afew hours, the red spots extend perceptibly from
one to another, by continuity or by contact, like a liquid which is
effused on a flat surface, or which flows by streaks in a tube. The
concretion becomes opaque, white and thick, and it assumes a mem-
branous consistence. At this period it is easily detached, and does
not adhere to the mucous membrane, except by some very slender
prolongations of concrete matter, which penetrate into the mucipa-
rous follicles. The surface which it covers is generally of a slight
red tint, with points of a deeper red; this tint is more vivid at the
periphery of the spots.*

If the false membrane in detaching itself, leaves the surface of
the mucous membrane uncovered, the redness which was obscured
by the exudation returns, and the points of a deeper red allow
blood to transude. The, concrete coating is renewed and becomes
more and more adherent upon the points which have been first
attacked ; it often acquires a thickness of several lines, and passes
from a yellowish white colour to brown, grey, or black. At the
same time the transudation of blood becomes still more free, and

* The mode of circumscription of the diphtheritic spots presents varieties
which it is necessary to notice in practice. Sometimes an intense red-
ness, accompanied by tumefaction, circumscribes these spots. Crustam
vero circumveniunt rubor et inflammatio, says Areteus. Sometimes a
thinner, half-transparent membrane spreads rapidly, and does not appear
circumscribed. Instead of forming upon the surface of the tonsils mem-
branous layers, which present the appearance of a deep ulceration, it
covers and envelopes them. In this last case, the danger of its extension
and propagation into the air-passages is still more to be feared. I have
sometimes availed myself of the epithet “ enveloping” (. enveloppantes ) to de-
note this disposition of the pellicular exudations.
SPECIFIC CHARACTERS. 25

is the source of those s¢i//icidia which have been so generally re-
marked by authors.

At this time the alteration of the organic surfaces is more ape
rent than at the beginning; portions of concrete matter are often
effused into the substance itself of the mucous tissue; a slight
erosion, and a few ecchymoses are observed in the. spots, which,
by their situation, are exposed to some friction, or from which
the avulsion of the false eschars has been attempted. It is above
all towards this period that the pellicles which are bemg decomposed
exhale a foul odour. If they are circumscribed, the cedematous
swelling of the surrounding cellular tissue makes them appear de-
pressed, and by this appearance alone, we might be tempted to believe
that we have under our eyes a foul ulcer with a considerable loss
of substance. If, on the contrary, they are extended over large
surfaces, they are partly detached, they hang in more or less putri-
fied shreds, and they put on the appearance of the last stage of
sphacelus. But when we open the bodies of those who, after some
days of disease, die of tracheal Diphtherite, there will be found in the
air-tubes all the gradations of this inflammation from its first stage
on the parts recently attacked, up to that which is the most likely
to deceive us by the aspect of a gangrenous alteration, involving
those which were first affected.

As we have sometimes seen gangrene supervene in inflammatory
affections, of which it is not generally the termination, as, for
example, in syphilitic chancre, I do not understand why, in some
circumstances, it should not succeed to diphtheritic inflammation ;
but this case must be very rare, since it was not once present in
more than fifty post-mortem examinations.

Whatever may be the structure of the membrane on which
diphtheritic inflammation is developed, the disease preserves all its
characters. The dissimilarity which so remarkably exists between the
surface of the tongue and that of the buccal cavity, and the more
striking disparity of the internal coats of the pharynx and of the
cesophagus, do not produce any notable change in the aggregate
of its phenomena.

It was seen, during the whole course of the epidemic which
prevailed at Tours, to affect a kind of predilection for the tonsils and
for the gums, a fact which is consistent with the most ancient observa-
tions. With regard to this last mode of attack, so frequently ob-
served among the soldiers of the Legion of la Vendée, it appeared
26 BRETONNEAU'S SECOND MEMOIR.

to be favoured by the contact of the vessels which the soldiers used
in common. The mucous covering of the tongue, and that of the
cesophagus are, on the contrary, the surfaces which chiefly oppose the
extension of this inflammation. I have not been able to discover
its primitive development upon the skin. The manner in which the
epidermis is altered must offer some remarkable peculiarities. Dr.
Gnuersent, Physician to the Hospital for Children, who has frequently
observed the pellicular affection of the vermilion part of the lips,
may furnish some useful information upon this point.

In an epidemic at New York, and more especially in another
epidemic of Diphtheritic Angina observed by Starr in the county
of Cornwall, it was behind the ears, upon the sores of blisters, and
generally upon all the points where the skin had assumed some
resemblance to the mucous tissue, that the pellicular inflamma-
tion, which afterwards spread very extensively, was seen to com-
mence.

The rapid progress of Diphtherite was usually retarded some
days after its invasion. This phenomenon is not peculiar to
Diphtherite; it occurs in several other diseases, and the local
symptoms of syphilis, for example, after having rather rapidly reached
their highest degree of intensity and extent, very soon lose their
activity. In the present instance, this tendency to a stationary con-
dition is of particular importance in the prognosis, since it is by
its propagation into the air-passages, that pellicular inflammation
becomes fatal. In fact, there is not the slightest relation between
the danger of a pellicular affection of the mouth, serious as it is

believed to be (provided the disease in spreading itself has already —

lost a part of its energy), and the peril to which the patient is exposed
by a small diphtheritic spot, which shows itself in the first instance
upon the surface of the tonsils, from which it may propagate itself
in a few days, sometimes even in a few hours, into the ee and
soon into the last ramifications of the bronchi.

The human organism seems to acquire by custom the peopstty of re-
sisting diseases, as it acquires the power of resisting the gradual action
of poisons and of venoms. -This power is obtained, for a more or less
durable period, by paying a first tribute to such agencies as small-pox,
vaccination, and climate, without speaking of the inaptitude of con-
tracting blennorrhagia, an inaptitude which may also be acquired and
maintained, if we are to believe the assertion of John Hunter. Perhaps
this influence of custom may contribute to the extinction of some
HISTORICAL EVIDENCE. 27

epidemic contagious affections, by wearing out the disposition to con-
tract them. Perhaps also, for the same reason, there may be no indi-
viduals less exposed to take Croup, during the course of the epidemic,
than those who have already been attacked with scorbutic gangrene
of the gums. However this may be, it is at least certain, that after
the departure of the legion of la Vendée, it was not scorbutic
gangrene which showed itself among the soldiers sent to replace it,
but Diphtheritic Angina, which placed three patients in great risk of
their lives.

It is not to explain, still less to prove, a fact so often observed,
that I have contrasted with some analogous facts this tendency of
Diphtherite to become stationary ; I have only endeavoured to give a
reason for some apparent contradictions which are observed in
practice. .

Authors have agreed in saying, with much truth, that there is the
greatest danger of the air-passages becoming attacked, if the cir-
cumscription of the white spots in the pharynx is no longer to be
perceived; but this assertion ceases to be true from the time when
the disease has lasted several days, for then it is often seen to make
no further progress. It also happens, that a pellicular inflammation
of the gums, in a few days from its commencement, surpasses by its
duration and its intensity another affection of the same nature,
which has lasted for some months, and the course of which, though
at first rapid, has afterwards become retarded.

‘Anatysis oF Historrcat EvipENce.

In deferring so long the explanation of the bibliographical history
of the affection which forms the subject of this Memoir, several
advantages have been sacrificed. I do not conceal from myself
that facts which may seem to be more in accordance with those
already related, might have inspired more confidence ; but, in order
that a great number of historical notices should be properly inter-
preted, it was necessary that, by the help of pathological anatomy,
the seat, the extent, and above all the nature of the lesions which
exist after death, should be exactly determined.

We never fail to discover a familiar object in the most in-
correct drawing ; thus, we easily perceive the principal features of the
diphtheritic affection, when we have studied them according to
28 BRETONNEAU’S SECOND MEMOIR.

nature, in the descriptions which have reached us, at whatever epoch
and under whatever denomination its ravages have been noticed.
Truth makes its way through the prejudices of the age and of the
schools, and often the testimony rendered to it has the more value
as it escapes without the consciousness and contrary to the intentions
of him who offers it.

If some passages in the works of Hippocrates relate to Diphtherite,
their brevity permits us to doubt the fact. When he says, in the book
on Dentition (if indeed this book is to be attributed to him)
“ Quibus cito in tonsillis ulcera serpentia considunt, febribris ac tussi_
permanentibus, periculum est rursus esse generanda ulcera,” it is
probable that he had in view rather an aphthous ulceration of the
back of the mouth, than a disease, all the symptoms of which would
have struck so able an observer more forcibly.

In the works of Aretzus, we find the first description of the
Diphtheritic Phlegmasia, a disease which he has depicted under all its
aspects, and which in his time, was undoubtedly not new, since
he speaks of it as of an affection which was known in Egypt and
Syria, and was so common that it had received the name of Hgyptian
or Syriac ulcer: “ Ulcera, in tonsillis fiunt, aliqua mitia, aliqua
pestifera, necantia ; pestifera autem sunt lata, cava, pinguia,
quodam concreto humore albo, livido, autnigro sordentia. Quod
si concreta illa sordes altitis descenderit, affectus ille eschara est,
atque ita Greecé vocatur, Latiné crusta ; crustam vero circumveniunt
rubor excellens et inflammatio, et exigue rareeque pustule orientes,
hisque aliz supervenientes in unum coalescunt, atque indé latum
ulcus efficitur. Id si interim in os depascendo serpit, ad
columellam usque pervenit, linguam etiam occupat et gingivas ;
dentesque indé labefactautur et denigrescunt. . . . . . In
collum etiam phlegmone erumpit. . . Atque isti haud itd multis
diebus intereunt. . . At st in pectus per arteriam td malum
invadat, illo eodem die strangulat. Pueri usque ad pubertatem
maximé hoc morbo tentantur.”

Although he mixes with this faithful description the opinions and
some of the frivolous explanations peculiar to his age, with what truth,
on the other hand, does he not describe the sufferings of the croupal suf-
focation which terminates the disease : “'Tussis spirandique difficultas
enascitur, et modus verd mortis quim miserrimus accidit. Pallida his
seu livida facies, tristantur cim tonsille comprimuntur. Cimque de-
cumbunt, surgunt ut sedeant, decubitum non ferentes; quod si
' HISTORICAL EVIDENCE.

sedent, quiete carentes itertim decumbere coguntur; plerimque recti
stantes obambulant, nam quiescere nequeunt. Inspiratio magna est,
expiratio verd parva; raucitas adest vocisque defectio. Hee signa
in pejus ruunt cim subito in terram collapsis anima deficit.”

Who would not recognize in this striking and animated picture,
some details of which I have omitted with regret, the scorbutic
Gangrene of the Mouth, Malignant Angina, and Croup,—the same
affections, indeed, which I have endeavoured to describe with a rigid
and severe exactness ?

Aetius adds to the description of Areteus, a commentary and some
particulars which leave no doubt that he had seen the same disease
two or three centuries later.

It is perhaps less from want of occasions for observation than from
want of observers, that we must pass from the fifth to the end of
the sixteenth century to find the disease again well described.

It may be inferred from some passages in the historians, that
physicians have not noticed all the epidemics of this kind, even
when they presented themselves with the most serious symptoms,
and caused the most severe calamities. Macrobius, in the year 380,
speaks, according to Julius Modestus, of sacrifices which were insti-
tuted in honour of a heathen goddess, “ ut populus Romanus morho
qui Angina dicitur, promisso voto, sit liberatus.”

The diversity in the appearance of the disease and its insidious
progress, may have often prevented its being observed. Sometimes
the epidemic terminates as soon as a small number of individuals
have been attacked. Even when its duration is prolonged in any
country, a few intervals between its attacks seem to offer a security
against its ravages, which act only in detail, and on a few subjects
at a time.

We cannot mistake tracheal Diphtherite for the orthopneeic affection
of which Baillou speaks, in the second book of his Epidemics, when
giving an account of the constitution of the winter of 1576. M. Royer-
Collard (Dict. des Sciences Médic. Art. Croup), observes with truth,
that the quotation from Baillou, given in Lieutaud, copied in a multi-
tude of modern works and even adopted by the authors of the
collections of observations and facts relative to Croup, is very inexact.
This quotation appears to him to be adapted to the idea which has
been formed of this disease in more modern times, and he thinks *
“that if Baillou has certainly had several kinds of Croup under his
notice, it is not, therefore, proved that he knew which was Croup.” It
30 BRETONNEAU’S SECOND MEMOIR.

is sufficient to read attentively the passage from Baillou and the
annotations upon it, in order to adopt the views of M. Royer-Collard :
but, at the same time, we arrive at the conviction that at the period
when Baillou wrote, Malignant Angina prevailed at Paris, and that it
was there misunderstood. It carried off children and adults; Baillou’s
father-in-law fell a victim to it. In vain does this able practitioner
persist in regarding the difficulty of respiration as a symptomatic
affection, and in vain does he support his opinion by clinical ob-
servations, for his testimony receives additional weight from his pre-
judices, and it does not permit us to doubt that the orthopneeic
affection of which he speaks was not really Malignant Angina.

Ever since the end of the sixteenth century, Diphtherite has almost
constantly shown itself in every region of the old or new continent.
At first, it continued for a long time in Spain, and during nearly
forty years it was noticed in different parts of the peninsula. Rather
later, all Italy was successively afflicted by it. It has prevailed at
Naples only for two years, and already the number of those who have
died of it has amounted to more than five thousand.

It is especially towards the middle of the last century that similar
epidemics, less general and less prolonged, but also more multiplied,
have attracted attention in England, in France, in Sweden, and in
America, particularly at New York and Philadelphia. It appears
that this disease terminated the life of the celebrated Washington.
Towards the same period, writers began to designate it under two
different denominations, or rather to view two distinct diseases in the
same affection, namely, Croup, and Malignant Angina, according to
the prominence of some or other of its symptoms.

At present, itis becoming so frequent that at very closely con-
nected periods, but at great distances in locality, I have seen it attack
three individuals of the same family; namely, the child whose death
caused the competition for the Prize Essay on Croup, next the mother,
who remained for a long time affected with scorbutic gangrene of the
gums, and then the grandmother, the ex-Empress Josephine, whose
last moments were preceded by suffocation, aphonia, and all the
other symptoms of Malignant Angina.*

It ought not to be necessary to demonstrate among the greater
part of these epidemics an identity which has never been contested ;

* Professor Béclard has permitted me to quote his testimony in this

place, and he states, that in preparing the body for embalming, he saw in
thepharynx the false membranes which characterize pellicular inflammation.
HISTORICAL EVIDENCE. 31

the question is to prove that at the different epochs when the Malig-
nant Angina has shewn itself, the occlusion of the air-tubes has
constituted the principal danger of the disease. On this point, the
most positive and unanimous testimony presented itself in abundance.

The epidemic affection receives in Spain the name of garotillo,
because those who were attacked by it perished as if they had been

strangled by acord. The Neapolitans, struck by the most formidable
' of its symptoms, call it malé in cannd, disease of the air-tube or
trachea. A great number of denominations proposed by the physi-
cians of that age, such as that of pass¢o anginosa, affectus suffocatorius,
laqueus gutturis prefocans pueros, abscessus, morbus strangulatorius,
have no other meaning than popular names. But it is superfluous
to discuss this matter, when the most express declarations leave no
doubt upon the point. “It often happens,” says Mercatus, “ that
those who are attacked with the garotillo perish in less than four
days, instar laqueo suffocatorum.” :

The disease had appeared for some years, when the learned physi-
cian of Philip II. and of Philip IIT. published his observations,
which serve as commentaries to two particular histories, which he
calls Consultations. It is in his eyes the most serious disease which
he has met with; he is astonished at the rapidity with which persons
who appeared to enjoy the most perfect health, were fatally attacked,
and at the disproportion which he remarks between the real danger
and the appearance, often very slight, of the disease. He insists on
comparing it with some greater diseases, the cure of which it is more
easy to obtain ; and he designates as very malignant a fever which
often hardly shows itself at all. “Non multum fidere oportet si
febris mox non appareat aut succrescat, nam szpe citids suffocat
affectio quam si febris succendatur.” He adduces the difficulty of
respiration, which is accompanied rather frequently with difficulty of
deglutition. “Cum pectoris et dorsi dolore,* ac veluti compressione
suffocante; . . . . cum vocis et loquele vitio . . . . Quibus etiam
accedit sublimis respiratio, et alta spirituum revulsio, cum maxima
pinnarum nasi distentione . . . . Variis ulcerum coloribus, fetore,
etc.” He recurs several times to the swelling of the lymphatic glands
(pestiferi morbi naturam redolens) and of the cellular tissue of the
sides of the neck.

* Tt is especially in adults, who resist the malignant Angina longer than
children, that I have remarked this symptom of the propagation of the
diphtheritic inflammation into the last division of the bronchi.

\
32 BRETONNEAU’S SECOND MEMOIR.

Without doubt, Fonseca, and some other Spanish physicans, whose
original works I have not been able to procure, agree with Mercatus
in the description of the symptoms, since Heredia, the physician of
Philip IV., who wrote twenty years later on this subject, makes no
mention of the diversity of opinion among his predecessors, except in
relation to the treatment. At the time when he published his Trea-
tise, de Angind Malignd, inserted in the third volume of his works,
the disease had not changed its aspect. He regarded the fever which
accompanies the Garotillo as entirely symptomatic.

Sgambati and Carnevale are distinguished among the Italian phy-
sicans, who have described the epidemic of the commencement of
the seventeenth century. Carnevale especially, in his Treatise, de
Epidemico strangulatorio affectu, in discussing the greater part of
the questions relating to the disease, relates many facts. I should
have too much to quote, even if I confined myself to those which
characterize the nature of the disease. It is in every point the same
epidemic as that which has been observed at Tours, from 1818 to
1822: and to avoid the errors into which the author has fallen, it
would have been sufficient if he had examined after death the
alterations which he describes with exactness, since he describes such
as are usually seen during life.

It was in the month of June, 1618, in a market-town of Naples,
named Chiaia, near the sea-shore, that the epidemic affection began
to be remarked; many children died, “ morbo quodam medicis incog-
nito jugulatos, sed oris internas partes tentante et apprehendente.”
The disease soon extended to the rest of the town, and the children
were no longer the only victims. The greater part of those who
were attacked, perished of the disease. The author thought that he
ought to give the name of strangulatory to this disease, because it
appeared to strangle and suffocate the patients, the passage of air
being intercepted, either by an ulcer or by inflammation. According
to him, the name of Angina could not be fairly given to an ulcerous
inflammation proper to the tonsils. He prefers, therefore, to desig-
nate it under the name of strangulatory affection, succeeding to the
ulceration of the tonsils, because, if the strangulation is not the ne-
cessary consequence of the disease, it is the mode of termination
which it generally presents. He does not acknowledge that it is an
Anginoid affection, although it suffocates like an Angina: “ If I learn,”
says he, “that it strangles the greater part of the patients, it is because
the putrilage (?) and the corruption of the parts oppose themselves
NOLA’S TREATISE. 33

to the passage of the air (viam ingredientis egredientisque aeris im-
pediunt, arctant, claudunt).”

If we persist in giving the name of Angina to the epidemic affec-
tion, because it strangles like a bowstring or a cord, he consents to
admit this denomination only in order to express one of its symptoms ;
names being of little importance, he adds, when we speak of any
striking objects which we have under our own eyes.

It is with such diffuseness, or, rather with such prolixity, that
Carnevale sustains his opinion. This author treats of the different
aspects which the disease presents in the pharynx; of its extension
to the trachea, the esophagus, or the pituitary membrane; of its
differential signs; and of the prognosis. Carnevale, like Aretaus,
places confidence especially in local treatment.

The Treatise of Nola, which appeared in 1620, does not invalidate
any of the facts announced by Carnevale; the author, who was still
young, admitted that he wrote in order to exercise his mind. Ac-
cording to him, the disease is propagated rather by infection than
contagion ; it was caused by the exhalations which escaped from the
soil after the earthquake of 1616. During the first year, these exhala-
tions occasioned an epizootic disease, affecting first the lower animals,
because they kept their muzzles nearest to the earth; in the following
years, children were attacked, and lastly, adults.

Although he supported this opinion with arguments, which are
as puerile as they are paradoxical, Nola might have enriched science
with valuable facts, if he had observed more carefully the epizootic
disease of which he writes; but he describes it more like a poet than
a physician, and it is impossible to discover in his description more
than a very doubtful analogy with the epidemic affection. However,
it is not without interest to hear a man who appears rather disposed
to put himself in opposition to received opinions, discoursing upon
the same facts, observed in the same places, and at the same period.
Tke symptoms of the epidemic disease must have possessed some very
striking characters, since the description of Nola is entirely in con-
formity with that of Carnevale, and since, besides, these authors seem
to have treated the same subject independently of each other.
Nola remarks that the white layer which appears to spread so rapidly
into the pharynx and trachea, is extremely superficial :—“Crustulis
quibus detersis, sinus cutis profunditate non altior remanebat.”

In 1622, twelve years later, Alaymus published his “Treatise on
Syriac Ulcers.” Here we find exactly the same facts reproduced in

D
34 BRETONNEAU'S SECOND MEMOIR.

different language. From several remarkable passages, which prove
that the characteristic features of the epidemic affection which prevail-
ed at Palermo, belong no less to Croup than to Angina Maligna, I
shall quote only the following: “Et ut unico prognostico multa
concludamus si difficultas spirandi ... . si egri decubitum non
ferant, sed sedere cogantur, et si sedentes' non quiescant : si Vox rauca
et interclusa eis fiat, magnam quidem viarum spirits interclusi-
onem et subitam anime exsolutionem, hee omnia significant.”
The symptoms which foretel the fatal termination of Membranous
Angina could not be more clearly described than in this enumeration,
in which the author affects to paraphrase Areteus, in order, no
doubt, to enforce more fully the truth of his description.

About the same time, Cortesius thought that he perceived some
difference between the garotillo of the Spanish physicians and the
epidemic affection which he witnessed at Messina; but what he says
on this subject is, on the contrary, calculated to demonstrate the con-
stant uniformity of symptoms under which Diphtherite was mani-
fested. It carried off his son-in-law, and a little later, his grandson.
The difficulty of breathing increased in the former immediately after
some attempts had been made to remove the eschars from the pharynx.
Morgagni is astonished that such an able anatomist should have been
opposed to the post-mortem examinations demanded by the senate of
Messina, and that he should declare them to be absolutely useless,
inasmuch as it was sufficient to make the patients open their mouths
to ascertain that they were dying of gangrene, with which all the parts
of the back of the mouth, and especially the tonsils, were affected.

Marcus Aurelius Severinus appears to him still more reprehen-
sible; for this author had seen many thousand children carried off
by this formidable disease, and yet he inserted in his Treatise only a
single post-mortem examination, and this was so vaguely described,
that scarcely two lines relate to the subject! These two lines, how-
ever, are remarkable, “Larynge investigata, contecta erat pituitd
quadam crustaced, citra ulceris speciem.”

No physician of this age mentions that a cutaneous exanthem
accompanied the other symptoms of the Malignant Angina which
they have so well described.

Since the middle of the seventeenth century until 1740, few
descriptions appeared of Malignant Angina. If, since this period,
we compare together the general descriptions, and especially
the particular histories of epidemic Croup and of gangrenous sore-
EPIDEMIC AT CREMONA. 35

throat, we shall arrive at the conviction, that the same disease
is described under these two names, and that it has always presented
_ an assemblage of the same symptoms; but we shall be able to ob-

serve that those of Malignant Angina predominate in young subjects
who perish by tracheal strangulation, and that those of Gangrenous
Angina, on the contrary, are more striking in adults, who are more
slowly suffocated.

Ghisi, after having given an exact description of the epidemic
Angina which began to show itself at Cremona in the month of May,
1747, merely says that in some subjects, “other mortal and
treacherous cases of Angina which were accompanied with scarcely
any difficulty of deglutition, killed unexpectedly and exactly in the
same manner as the cases of the first kind, thé progress of which had
been neglected ;” that is to say, that all those patients, whether they
had or had not experienced a pain in the throat which had attracted
attention, perished from suffocation. Ghisi has taken particular
pains to depict with great force and truth the dreadful sufferings
attending their death. But the absence of difficulty in deglutition,
which has been so much insisted upon, has been constantly observed
in all the epidemics of Malignant Angina; and, particularly in that of
Tours, it has too. often inspired the most dangerous security. Details
which were found in works, the recollection of which was quite recent,
were not the object of this letter of Ghisi, so often quoted in the
annals of Croup. It is evident that he wrote it only to make men-
tion of the case of a little girl who expectorated a tubular false mem-
brane, some moments before dying. It is true that on opening the
body of another child, he found in the trachea a membraniform
pellicle, which was altogether of a similar character, and he states
explicitly, that everything in the throat was healthy, “nelle fauci
tutto ci vede sano.” Whether the pellicle was really developed in the
first instance in the trachea, and whether the pharynx was examined
with sufficient attention, it is impossible to determine; but it is at
any rate certain, that these two children died of the epidemic affection
which then prevailed at Cremona, and to which Ghisi himself assigns
all the symptoms of Malignant Angina, being the same symptoms as
those which had characterized the epidemics of the preceding century,
and which at an epoch nearer to our own days, were seen to be repro-
duced in the epidemics of Croup described by Starr, Bergius, Van
Bergen, Rosen, Zobel and Keetel.

But on this point, instead of expressing my own opinion, I may
D2
36 BRETONNEAU’S SECOND MEMOIR.

adduce a testimony which cannot be suspected; namely, that of
Michaélis of Gottingen, the author of a monograph on Membranous
Angina. The case of his younger sister, carried off by this disease, is,
according to him, the type to which he refers all the examples of the
malady which he was able to collect.* He discovers that in the epi-
demic which Cullen and Crawford refer to Croup, a great number of
the cases belong to Malignant Angina. He supposes that these two
diseases prevailed at the same time and that they may have been con-
founded together. His rule for distinguishing them, is to refer to
Malignant Angina all the cases in which the fetor of the breath
has been particularly observed, especially if, at the same time, spots
have been seen in the pharynx. “But inthe cases,” he says, “in
which fragments of false membrane have been expelled by the efforts
of coughing, there is no doubt that this was not really our disease.”

Rosen, who recommends us not to confound Croup with Malignant
Angina, falls into this error himself. The affection described by him, is
said to be transmitted from one child to another ; pellicles are seen in
the pharynx from the beginning of the disease, and a long time before
it is terminated by croupal suffocation. It is true that the membra-
niform tube, which at this period particularly attracted attention,
is seen in the trachea after death; but Michaélis fears that Rosen,
who does not adduce facts observed by himself, has been ill-in-
formed. He is more embarrassed by the cases collected by Starr,
who has described, under the name of strangulatory disease, the
destructive epidemic of the county of Cornwall. He frankly con-
fesses that after having divided the cases into two parts, there re-
mains a third variety which appears to belong as much to one affection
as to the other. A particular case which he translates literally, espe-
cially offers him some insurmountable difficulties. The length to
which this analysis has already extended does not permit me to copy
more than the following few details.

Membranous shreds are seen in the pharynx of the child who
forms the subject of the case; and at the moment when it is on the
point of suffocation, its father helps it to disengage a membraniform

* The difficulty of deglutition observed during life, the enlargement of
the tonsils which was perceived and noted after death, and the character of
the affection which prevailed at this period in the surrounding countries, all
lead us to believe that the disease of which Michaélis’s sister died, presented
a much greater resemblance to Diphtheric Angina than is indicated at

first by the too succinct case which he has related in his

fon “Treatise on
Membranous Angina.” ne
DIFFERENTIAL DIAGNOSIS. 37

tube several inches long. The respiration becomes free ; the supposed
eschars of the pharynx, touched with hydrochloric acid, are detached
without leaving, on the points which they occupied, any trace of ulcera-
tion or even of erosion. Other membraniform fragments and por-
tions of tube are also expectorated, but twenty-four hours after the ex-
pulsion of the last fragment, the child dies suddenly, preserving, like
all those affected with the same disease, its presence of mind to the
last moment.

If this case should still leave any doubt upon the identity of Croup
and Malignant Angina, I know not what the most obstinate preju-
dice could object to the assertions of Samuel Bard, whose name
figures in the list of authors who have written on Croup. He
saw upon several children in the same family, thick coriaceous
pellicles formed upon the tonsils, and propagated from the pharynx
to the trachea; and at the period of this extension he observed
all the symptoms of Croup developed. He remarked in several
adults the same succession of phenomena; three post-mortem
examinations exhibited to him, as an uniform result, white, thick,
coriaceous, elastic layers of concrete matter, which lined the walls
of the pharynx. A membraniform tube of the same nature, advanced
into the trachea and became progressively thinner in proportion
as it descended into the bronchi. The tracheal mucous membrane
was slightly inflamed; that of the pharynx, after the pellicles were
removed, was found rather pale. Neither the appearance of the
surfaces, nor the smell of the bodies, allowed the least suspicion of
putrid or gangrenous alteration.

I shall conclude this historical sketch by a succinct analysis of the
works which complete the history of Diphtherite up to our own time.

The dissertation of Dr. Fothergill has no relation to this disease,
except by the learned researches which he has instituted on the subject ;
but the complaint which he observed and described is certainly a
Scarlatinal Angina, and very different from Diphtheritic Angina. The
gangrenous sore-throats, observed by Huxham, are also related, for
the most part, to Scarlatinal Angina.

In 1747 and 1748, Arnault of Orleans, makes mention of terrible
quinsies, which carried off the patients in twenty-four hours. He
says that he opened two children who died of this disease, and that
the tracheal mucous membrane was found detached like a roller of
the length of three or four fingers. It was as thick as parchment
and its colour was white.
38 BRETONNEAU’S SECOND MEMOIR.

The history of the gangrenous sore-throat, edited by Chomel, pre-
sents several special observations on Diphtheritic Angina, of which all
the symptoms were noted daily with great care.

In 1768, Marteau de Grandvilliers, a physician at Aumale, pub-
lished a description of gangrenous sore-throats which he had observed
for several years in Picardy. This is one of the most interesting
Treatises which has appeared on this subject. Being an attentive
as well as a modest observer, he has collected a great number of
facts, and arranged several special narratives with great exactness.
If, at a period when the inorganic nature of the false membrane had
already been discovered by Ghisi in Italy, the physician of Aumale
preserved, as an example of exfoliation of the trachea and bronchi,
some long membraniform tubes expectorated by a young man who
died of a gangrenous sore-throat ; and if, after having opened a body,
he persuaded himself that it was the mucous membrane of the trachea
which was detached beneath his fingers like the epidermis in a burn,
T should have less right than another to be surprised at it, since I
was not able to avoid a very similar mistake in circumstances which
rendered it less excusable. The practical facts collected by Marteau
would have contributed more certainly to clear up several thera-
peutical questions, if he had not, like Fothergill and Huxham,
confounded Scarlatinal Angina with Diphtheritic Angina.

The dissertation of Samuel Bard appeared in 1771. Since that
time, many observations on Croup, which, under this denomination,
have really reference to more than one disease, have been published
in the periodicals or in a multitude of special Treatises. Several
of these observations present the union of Malignant Angina with
Croup, as a complication. The frequency of this complication,
and the singular affinity of these two diseases, is a fresh presumption
in favour of their identity which I abstain from insisting upon.

Is Diphtherite contagious? All the authors of the seventeenth
century reply to this question in the affirmative. Alaymus, in
speaking of the danger of contagion, expresses himself with much
force : “Caveant angue pejus parentes suos filios secum gerere, ubi
puerulus hoc modo infirmatur ; et si in domo ejus continget, statim
alios pueros valetudine fruentes separent.”

Carnevale quotes, on this point, in a Latin verse, the opinion of
his contemporaries :

“Cede cité, longinquum abi, serusque reverte.”
Cortesius, indeed, says that-this disease is not contagious except
IS DIPHTHERITE CONTAGIOUS? 39

in a limited sense ; but on this point he quotes the case of a young
student who died of the disease after having approached a monk
affected with the same malady, this patient having begged the student
to ascertain if his breath was as fetid as he himself believed it to be.
Cortesius concludes by remarking that the disease is not free from
contagion.

Nola, who is a partizan of infection, does not deny that, by
very close intimacy, the disease may be communicated; but then,
according to him, it is a simple transmission.

Marcus Aurelius Severtnus says on this point :—~ Quod ad con-
tagium attinet, hoc communi omnium consensu atque experimento
evincitur.”

During the epidemic of Tours, twelve children, from six to nine
years old, who went as day-scholars to a school consisting of thirty
pupils, were attacked in the same week with Diphtheritic Angina.
There were not at this period any other examples of the disease in
the town. Five died three or four days after the symptoms of Croup
had declared themselves ; and in the families of some of the scholars,
other children were attacked.

An attendant at the Hospital, two Sisters of Charity, and two
pupils attached to the medical department, suffered from the
epidemic affection.

Still it must be admitted that it was often impossible to arrive
at the origin of the contagion, and in some circumstances it was
altogether improbable that it occasioned the disease. It cannot be
denied that the same difficulties might be raised relatively to the
transmission of the small-pox, if the contagion of that disease were
not established on the most solid foundation. Every time that it has
been brought from without into the General Hospital, and that it
has propagated itself, it has been easy to ascertain at the beginning,
the exact period when it was communicated. But as soon as a
certain number of individuals were attacked by it, it became im-
possible to follow the traces of the contagion through a multitude
of indirect and doubtful modes of communication.

If it were still more positively demonstrated, that Diphtherite is
contagious, it would not be less certain that it is so in a degree
very inferior to that of other diseases. But on this point, and on
the mode and the conditions of contagion, much remains to be
learned. I have made ineffectual attempts to communicate Diphtherite
to the lower animals.
40 BRETONNEAU’'S SECOND MEMOIR.

TREATMENT OF DIPHTHERITE.

Diphtheritic inflammation of the mucous membrane of the mouth,
when arrived at the degree which has received the name of “ watery
canker,” (chanere aquatique) is to be regarded as a serious affection,
against which various modes of treatment have been employed with
more or less success. It is chiefly to the means of contending
against pellicular inflammation of the air-passages that the attention
of practitioners has been directed, but the frightful rapidity of the
disease has suggested modes of treatment which are rash and ill-
advised, more violent than energetic, and better adapted to precon-
ceived ideas of its pathology than appropriate to its nature.

It is not its violence which renders it formidable, and it is not by
an energetic violent determination of blood, nor by its destructive
activity, that it takes away life; but the inert product of a superficial
inflammation is accumulated in the respiratory tubes, and all the
phenomena of Croup in its last stage, are the necessary consequences
of the increasing embarrassment of a function so important to life
as respiration.

I do not conceal from myself that I am approaching a difficult
question ; and one which from the seventeenth century has been the
subject of discussions, “in which,” says Fothergill, “bitterness
and acrimony were not spared.”

Even the multitude of the measures to which we havehad recourse,
only proves too fully the insufficiency of the greater number of them.
The difficulty of choice among so many modes of treatment which
are equally lauded, and equally disapproved, is increased by the
application which has been made of them to very distinct diseases.
A simple tracheitis or even a very mild sporadic affection, which is,
perhaps, the same as that designated by Millar as his acute asthma
in the first stage, has made the reputation of the most accredited
methods. This sporadic affection which simulates Croup is not at all
rare. It commences as it terminates ; that is to say, from the begin-
ning, the alteration of the tone of the voice, the peculiar sound
of the cough (resembling the barking of a young dog heard at
a distance), and the spasmodic difficulty of respiration, would cause
the most fearful apprehensions, if our fears were not counter-
acted by the rhythm of the circulation, which is not so much
disturbed as it is accustomed to be at this stage of true Croup; and
TREATMENT OF DIPHTHERITE. 41

if we had not an additional reason for security in the natural state of
the pharynx, and in the absence of swelling of the lymphatic glands,
which in epidemic Croup, are constantly tumefied in the regions
corresponding to the affected membranes.

It is after crying, and a prolonged exposure to cold air, that we
often see, especially in young patients, an indisposition which has
appeared to me to depend upon a simple catarrhal annoyance, or a
kind of obstruction of the glottis.

‘With regard to epidemic Croup, I am compelled to declare, con-
trary to the generally received principle, that abstraction of blood
has appeared to me to be hurtful, and to accelerate the propagation
of Diphtheritic inflammation. Emetics and blisters have been used
without relief, and I can assert that these means had not been
omitted in the greater number of patients who died.

At one period when I had already recognized the inefficiency of
blood-letting in extinguishing an inflammation which yielded only
to local applications, I still believed that it would be useful in
moderating its rapidity. I persisted especially in looking upon it
in this light, after having ascertained that the idea of a putrid and
gangrenous alteration was supported only upon a misapprehension,
and I persisted the more willingly, because this course appeared to me
to reconcile the opposing views of the ancients and moderns. In fact,
in the seventeenth century, the local application of caustic prevailed,
and bleeding had fallen into great disrepute, especially if the disease
had already made some progress. It was then condemned, I said to
myself, upon the preconceived opinion of the septic character of the
disease, while at the same time, it was simply without efficacy against
the mechanical lesion, which causes the principal danger of Malignant
Angina. But modern physicians have hastened to resort to it only
in order to prevent the formation of the false membrane. This view
has, I admit, something of so specious a character, that I have not
abandoned it without much hesitation; I have been compelled,
nevertheless, to yield to evidence, seeing too frequently the occur-
rence of the opposite to that which I had hoped. I am certain that
the symptoms of Croup, so far from having been retarded, have
several times manifested themselves immediately after the appli-
cation of leeches, applied with the intention of preventing this
fatal disease, the fear of which had been excited by a very slight
sore-throat. I am now astonished that I did not sooner understand
that sinapisms, pediluvia, purgatives, and irritant injections were
42 BRETONNEAU'S SECOND MEMOIR.

measures which were not appropriate to the nature of the disease, and
were without proportion to its severity.

From the commencement of the epidemic observed at Tours, the
tendency which Diphtheritic inflammation of the mouth had to per-
petuate itself by the removal and the renewal of the pellicles (so long as
we had no recourse to local applications) made known to us the
value and the advantage of topical remedies; and I can declare with
Van Swieten, who says, in speaking of spirit of salt (hydrochloric
acid), “Neque fefellit unquam me, huic consilio unicé confidentem
nisi, etc.,” that I have always found local applications efficacious
when I have been able to carry them over the whole extent of the dis-
eased surface. The favourable results from hydrochloric acid very
soon assigned to it an extensive preference. I regretted afterwards
that I did not make a comparative trial of the efficacy of many
other substances which have been much praised as specifics in Croup.

Sulphuret of potassium, continued for some time as a local applica-
tion, was found to have no effect against the pellicular inflammation
of the gums, and it was the same with powdered cayenne (capsicum
annuum), the decoction of which is employed, it is said, as a specific
in the gangrenous sore-throats of the Caribbee Islanders.

The effects of sulphuric acid and of ammonia, have been doubtful.
Powdered alum has had some success ;* and a complete cure has been
obtained by the use of calomel, although the method of application
was defective, since this insoluble body, mixed with honey, was only
applied, like hydrochloric acid, once in twenty-four hours. These
attempts were not continued for a sufficient length of time nor were
they sufficiently multiplied to allow much confidence to be placed in
the results. The substances which possess a certain degree of
causticity induce a membranous inflammation, often difficult to be
distinguished from the morbid affection. Hydrochloric acid, in the de-
gree of concentration in which it is sufficient to employ it (one part to
three of honey),t was free from this inconvenience, especially if the

* Areteus recommends the use of alum. In later times, the same sub-
stance has been extolled under the name of anticroupal powder, and the
insufflation of this powder into the back part of the mouth, has been re-

-commended as a very good specific in this disease. ° But the evidence
which Dr. P—— gives of the efficacy of this local treatment, no doubt pre-
ferable to many accredited plans, has been quoted in several Medical
Journals only in order to make it a subject of bitter derision.

+ Since this memoir was read at the Academy, I have ascertained that
it is preferable to employ hydrochloric acid pure and concentrated.
USE OF HYDROCHLORIC ACID. 48

applications of it were made at distant intervals ; and it always appear-
ed more advantageous to employ the strong acid at long intervals
(twenty-four or thirty hours) than to return more frequently to less
energetic applications. It appears sufficient to substitute another
inflammation in order to arrest the progress of that which is
specific. Ihave obtamed an analogous effect upon the pustules of
small-pox,* from the second to the fifth day of the eruption, by
pricking the heads with the point of a gold or silver needle, wetted
with a solution of nitrate of silver. The variolous inflammation is
extinguished almost instantaneously. Such a very slight touch
is sufficient upon pustules of the second day, that all traces of
it disappear before the period of suppuration. The same deduc-
tion may be drawn from many other practical observations, but it is
by the very fact of the constant efficacy of the local treatment, that
its advantages ought to be appreciated. In general, it is less by reason
of its serious character, than by its prolonged duration, that
Diphtheritic inflammation has made itself important. Unfortunately,
local treatment is no longer applicable when the membraniform
pellicles have reached the larynx.

Nevertheless, five individuals have been preserved from the danger
of imminent suffocation by fumigations of hydrochloric acid, but
these fumigations are dangerous and difficult to manage. Hven in a
case where local treatment is no longer applicable, an energetic mer-
curial course still offers some valuable resources. It was only near
the end of the epidemic, that an unhoped for example of cure, ob-
tained by an English surgeon, Mr. Conoly, became the occasion of
new efforts, rewarded by a success which surpassed all expectation.
I have collected the detailed history of seven patients very rapidly
cured of Croup; and in the stage to which the affection of the air-
passages had already reached, I cannot doubt that they were rescued
from approaching death by the agency of mercury. The inutility
of the most accredited plans, and the abuse which English physicians
seem to have made of calomel, had at first prepossessed me against
a remedy, the whole worth of which I had failed to recognize.

A very sensible effect was perceived a few hours after the ad-
ministration of the first doses; the point of the tongue began to clean,
and, what is a still more favourable sign, the cough began to be

* A memoir on this subject was read at the Royal Academy of Medicine,
in 1821, but before that time I had already performed these experi-
ments (Arch. Gén. de Méd. Cahier de Juillet, 1825).
44 BRETONNEAU’S SECOND MEMOIR.

moist. Is it by substituting another irritation, namely, a mer-
curial irritation for a morbid one, that calomel produces an exfolia-
tion of the pellicles, and opposes itself to a reproduction of the
false membrane? ‘Tracheotomy has been advised as a last resource
in imminent cases of suffocation. The tendency which the inflamed
surfaces have to be covered with new pellicles was the strongest
objection against this operation. But was there no reason to hope
that it might have been performed under more favourable auspices, if
we had had recourse to it after the acid fumigations had modified the
phlegmasia, and reduced the disease to the inconvenience occasioned
by the presence of the false membrane ? and would it not be sufficient
to obtain the expulsion of the foreign body by the aid of this operation
in order to finish the cure? I have been twice induced by these
motives to practise it, and I am convinced, that it would have
succeeded in the case which I subjoin, if calomel had been employed,
instead of fumigations.

Casz 7.—N. D., aged six years; stout, of rosy complexion;*
slight coryza, rather painful tonsillitis, without much fever. (Leeches
and anemetic.) The third day, a swelling which showed itself behind
the angle of the jaw, was the cause of my apprehending Croup. A white
membranous spot was seen on the right tonsil; but the child was
better, and it was only six days after the appearance of the first sym-
ptoms, that he was taken to the ordinary family physician. At that
time it was impossible to overcome his resistance, and to determine the
state of the back part of the mouth. (Anemetic.) On the seventh day,
in the morning, the pharynx was found lined with thick pellicles
descending beyond the reach of the sight, the sound of the voice was
altered, and the hoarse cough which the little patient could cause to be
heard at will, indicated undoubtedly, that some false membranes were
alreadyformed in the larynx. The respiration was only slightly impeded
and the fever was scarcely marked. (Topical treatment and fumiga-
tions.) The following day the symptoms were aggravated. Some
shreds of membrane were expelled by the efforts of the cough; there
was somnolence. In the evening, there was comatose insensibility, with
lividity of the lips, and coldness of the extremities. The rapid beatings
of the pulse could not be counted; the head was thrown backwards; the
dyspnea became extreme; the expiration was rattling (rdJewse), and

* This child was an out-door pupil in a school, where several of his
schoolfellows had already been attacked with epidemic Croup.
A TRACHEOTOMY CASE. 45

each inspiration was accompanied with an acute hissing sound. At one
o’clock in the morning, the imminence of the suffocation, and the
wishes of the parents induced me to perform tracheotomy. Asphyxia
was making rapid progress; the preparations for the operation were
hastily made; but.as the opening of the trachea was retarded by the
effusion of the blood, which poured out so copiously from a thyroid
vein that it was indispensable to tie it, the child remained for some
time in a state of apparent death. In the place of a canula, which
we were not able to procure immediately, a large quill facilitated the
access of the air. Then there was deep and noisy respiration, which
stopped all at once for some seconds, and death appeared certain.
There was sudden convulsive cough; ejection of bloody mucus by
the wound and bythe quill. At this moment a gum-elastic catheter,
reduced to a proper length, was substituted for the quill. The
respiration ceased to be noisy, and it became quiet and regular;
the face again acquired a rosy colour. The catheter was fixed to the
neck by a bandage; but the child pulled it away at the moment
when the dressing had just been finished, and notwithstanding the
promptitude with which we hastened to replace it (the inspiration
taking place only through the wound), the little patient, who was
already standing up, ready to return to bed, fell back in less than
three seconds, completely asphyxiated. Precautions were then taken to
prevent another similar accident ; the catheter was firmly retained by
means of a twisted thread, fixed to a bandage with a hole in it, bound
round the neck, and calmness was restored. At two o’clock .in the
morning, the respiration was slow and regular, and the child drank
without difficulty ; he expressed his wants by the motion of his lips,
in such a manner as to make himself easily understood. He promised,
by signs, not to make any effort to draw away the tube. During the
remainder of the night the respiration was alternately noisy and
tranquil ; it became very difficult about two o’clock in the morning.
A portion of the false membrane was entangled in the tube, which
was immediately taken out. The edges of the wound were kept apart by
means of a pair of forceps with their branches curved outwards. A
long membranous cast was entangled in the opening of the trachea,
and was felt by the fingers, but it slipped away several times before
it could be seized.

From the moment of the extraction of the foreign body, respiration
was performed without difficulty by means of the tube which was
then replaced. Occasionally, however, by means of a small sponge
46 BRETONNEAU’S SECOND MEMOIR.

attached to the end of a piece of whalebone, we used the precaution
of wiping away the mucus, which, in accumulating at the orifice
of the instrument, sometimes rendered the passage of the air noisy
and difficult. Some broth was allowed the little patient, according
to his own wish, and he played on his bed during a part of the day ;
the night was passed in tranquillity.

The second day after the operation the pellicles on the tonsils,
and the velum palati were detached; the local treatment had been
continued. During the day, the respiration became more painful
without being noisy. At this period the oppression appeared to
depend upon a more deeply-seated obstacle, namely, the extension
of the disease into the bronchial tubes; and the slow and gradual
progress of the dyspnoea confirmed this opinion. The occlusion of
these tubes, compared with that of the trachea, seemed still more
and more distinguishable; but a rather considerable portion of
false membrane, which had been entangled in the opening of the
catheter, having been drawn out with it, the respiration became quite
free, and hunger began to be ‘felt. The inflammation of the lips
of the wound kept them gaping. The catheter was replaced by a small
silver spring, which kept the rings of the trachea separate. A slight
depression of the ale nasi, at the time of inspiration, showed that
a small quantity of air was beginning to penetrate through the
larynx.

I was now venturing to entertain hopes in which I feared to
allow the parents to participate ; but I was about to be sadly disap-
pointed. The pulse was accelerated during the night: to the fever were
jomed prostration and oppression, and the dyspnoea was augmented
every moment. A sudden dilatation of the pupil, comparable to the
flying open of a spring, marked the moment of the cessation of life.

This unfortunate child preserved up his death to a kind of exalta-
tion of his intellectual faculties. With a movement of the eye,
he asked, thanked, or refused expressively and with inconceivable °
rapidity. All his movements were sudden and vehement. In drink-
ing greedily, he bit the edges of the vessel, and clasped everything
presented to him as if he wished to fix himself to it.

Tt had been thought necessary to oppose the extension of the
Diphtheritic Phlegmasia by means of fumigations of chlorine and
hydrochloric acid. This plan had been adopted at the period
when suffocation appeared imminent, in the hope of putting an end
to the cough and provoking the expulsion of the false membranes.
ACCOUNT OF THE AUTOPSY. 47

After tracheotomy, it was again adopted, and, although it was
managed with extreme caution, it may possibly have done mischief.

Autopsy, twelve hours after death.—All the abdominal viscera
were free from morbid alteration; two rather circumscribed and
partial spots of hepatization, which were observed towards the centre
of the right lung, made us suspect that the inhalation of the hydro-
chloric vapour might have caused inflammation of the pulmonary
parenchyma. ‘This lesion, however, differed much from those which
I have observed in animals exposed to the prolonged inspiration of
this vapour.*

The air-tubes, which we had alternately believed to be free or affected
below the aperture made in the trachea, were examined with much
attention. The mucous membrane, in the vicinity of the wound,
was found a little reddened and tumefied; that of the bronchi was
not at all different from its healthy state. No false membrane
was discovered along the whole extent of the air-passages, as high
as the ventricles of the larynx; but a fibrinous mass of seven lines
in length, of a cylindrical form, without any hollow, and which
adhered to the glottis only by one of its sides, closed incompletely
the entrance of this cavity. A slender pellicle still covered the
base of each ventricle, and adhered to it very slightly. No trace
of Diphtheritic inflammation existed anywhere else, and everything
proved that the object for which the operation had been performed
was on the point of accomplishment, if the patient had not sunk, I
will not say from the peripneumonic lesions (for they were not
serious enough to enable us to attribute death with certainty to their

/ existence), but without doubt from the general and prolonged dis-
turbance of the most important vital functions.

This disproportion between the morbid alterations and their fatal
result presents nothing surprising. It cannot be concealed that here
is the weak side of pathological anatomy. Although at the time when
appreciable lesions exist, it discovers pretty accurately their special
character, it does not so constantly show us a due relation between
the symptoms which are manifested and the alterations which exist
after death, and it is especially rare that it offers a sufficient explana-
tion for the cessation of life.

It is clear that I intend to speak here only of acute diseases, for

* M. Bretonneau here describes in a note some results of his experi-

ments and post-mortem examinations on dogs, which were made to inhale
the fumes of hydrochloric acid. (Ep.)
48 BRETONNEAU’S SECOND MEMOIR.

precisely the contrary happens in chronic affections, as I have else-
where explained. Lesions which supervene slowly often attain a
degree which seems to have long been incompatible with the
exercise of a function essential to life.

In order not to augment the length of this Memoir, I shall add
only a single example of success by the mercurial treatment, and a
detailed history, chosen from a great number of those which have
demonstrated to me the inefficacy of blood-letting and emetics em-
ployed at the commencement of the disease.

Case 8.—F.P., aged seven, of slender stature. For five days
there was sore-throat, with tumefaction of the lymphatic glands of
the neck and sub-maxillary region, with fever. On the sixth day,
there was diminution of the sore-throat and of the general symptoms.
On the seventh day, there was frequent cough. In the evening there
was cough and croupal voice, with abundant, glairy, frothy expec-
toration. Fragments of false membrane, evidently proceeding from
the larynx, were seen floating in the midst of the expectorated matter.
There was orthopnea with sibilant inspiration, and an alteration of the
tone of the voice, the change of which became less sensible when the
child spoke very low. On exploring the throat, it was found lined,
in all its extent, with membranous pellicles of a yellowish-white
colour; the tongue was covered with a thick, slimy, greyish coating.
(Four aeaiue of calomel were ordered every hour). After the fourth
dose, the expectoration was easier and more abundant ; a membranous
tube, three inches long, was thrown up; the respiration was more
easy ; there were two stools. On the eighth day, the respiration
again became more painful and more frequent ; there was somnolence,
a livid tint of the face, and commencement of asphyxia. (Frictions on
the arm and on the lateral parts of the body with mercurial ointment ;
these frictions were renewed every three hours.) There was agitation,
and convulsive cough, followed by the expectoration of a thick mem-
braniform pellicle, thirty lines long and thirteen broad, with its edges
irregularly torn. The tongue was remarkably modified; on its
anterior half it was clean and moist and of a rosy tint. On the
ninth day, the mouth did not present any sign of mercurial
affection ; the cough was less hoarse and the respiration more easy.
(Calomel, two grains every hour.) On the tenth day, after ten
frictions, and after the administration of two drachms (gros) of calomel
in sugared water, in jujube-paste or apricot jam, at the fiftieth
INEFFICACY OF BLOOD-LETTING. 49

hour of the treatment the gums were scarcely swollen; the respira-
tion became more and more free, and the tint of the skin was natural ;
the cough was catarrhal and loose; the voice was hoarse. Some
fragments of false membrane, reduced to small dimensions, could no
longer be distinguished from the abundant, thick, rounded, muco-
puriform expectoration, which, with a small quantity of glairy
matter, proceeded from the pharynx. However, by means of
repeated washing, and by shaking the matter ‘of the expectoration
with water, the mucus was attenuated, and it allowed the deposition
of insoluble portions of membranous matter at the bottom of the liquid.
Two or three stools of a deep green colour were passed every day.
At this date, vomiting succeeded to nausea, and became more and
more frequent. The doses of calomel were given less frequently
and the frictions were discontinued. There was dyspepsia and sudden
emaciation, which latter made rapid progress. On the eleventh day
there was loathing and nausea, with muco-puriform expectoration,
variegated with streaks of blood. (Soothing drinks.) On the twelfth
day, in the morning, there was a little appetite; in the evening there
was voracity. There was less abundant expectoration of lighter
sputa, which were still bloody. (Chicken broth, with or without the
addition of potato starch.) On the thirteenth day the voice was
gradually resuming its natural tone. The hunger was appeased
only temporarily by the administration of light food; the expectora-
tion became less frequent, and ceased to be tinged with blood. After
the tenth day, the pulse exhibited no febrile frequency ; and, from
the thirteenth day, the patient began to be convalescent. Great
precautions were taken to protect him from the effects of cold,
and his health, up to the time when I write, has undergone no
alteration.

The following case shows how little efficacy the most copious
blood-lettings possess in arresting the progress of Malignant
Angina.

Casz 9.—A. S., a little girl, five years of age, of rather a delicate
constitution. For two years this child had been frequently attacked
with coryza and bronchial catarrhs.

On the first day there was sore throat, with painful deglutition.
On the second day there was febrile excitement ; very well-marked
swelling of the cervical lymphatic glands, situated at the angle of

the jaw. After having attentively explored the state of the pharynx,
E

Lh
50 BRETONNEAU’S SECOND MEMOIR.

I found both tonsils red and tumefied; white, semi-transparent,
separated, enveloping pellicular membranes, were seen very distinctly
upon the left tonsil, and were still more apparent upon that of the
right side. The largest and most opaque was nearly three lines in
its greatest diameter.

The treatment was directed by a physician who had recognized
the existence of Croup, although the cough was not yet manifested.
Twenty-two leeches were applied at two intervals, and blood flowed
abundantly for twelve hours. Two pounds of syrup of ipecacuanha,
with tartar emetic, were administered in the space of three days.
There was repeated vomiting.

The examination of the throat had left no doubt in my mind as to
the nature of the disease, and all the facts which I had been able to
collect up to that time had so constantly shown me the inefficacy of
general remedies in the treatment of Diphtheritic Angina, that I
could scarcely hope for success by the means employed.

It was not by the use either of derivatives, however powerful they
may have been, or of blood-lettings, general or local, that the exten-
sion of diphtheritic pellicles and their propagation into the air-passages
had previously been prevented.

For three days, I could obtain only vague reports upon the state
of the little patient, which, however, were generally satisfactory.
These reports, and the results of my own observations, were entirely
opposed to each other, but I had now a favourable opportunity to
reconsider my opinion that the progress of Malignant Angina could
be suspended only by special treatment. It remained for me to
discover the modifications which the exudations on the tonsils, and
the diphtheritic phlogosis of the pharynx, had undergone under the
influence of blood-letting and emetics.

At the time when I most wished to obtain some information in
this respect, and when I was determined to ask for it, I was again
called in consultation, on account of the urgent danger. of the
child.

On the sixth day, there was considerable tumefaction of ‘the sides
of the neck, extinction of the voice, and croupal cough, which
was infrequent, short and hoarse; breath fetid. The interior of the
pharynx was grey, and mottled with brown and black; fragments of
false membrane, hanging and detached, resembled shreds of organic
tissue, which seemed likely to separate after having reached the last
stage of sphacelus.
INEFFICACY OF BLOOD-LETTING.. 51

The imminent: danger was unanimously recognized, and mercurial
treatment alone appeared to offer any hope of recovery. (English
calomel, two grains every half-hour.) Cough less frequent; som-
nolence. The embarrassment of the breathing was caused by two
different obstacles; and the hissing sound denoting the difficulty
with which the air traversed the larynx, could not be mistaken,
for the guttural rattle, caused by obstruction of the pharynx. In
the evening, the lividity of the complexion became more and more
marked, and asphyxia made rapid progress.

The calomel, together with some sugar, remained deposited on the |
lips. During the course of the night, mercurial preparations were rubbed’
in under the arms, and on the back of the neck. (Two liquid stools of
a dark-green colour.) On the seventh day, at half-past four o’clock in
the morning, the respiration became less difficult, the cough was more
frequent, more prolonged, rather soft, and more catarrhal. The
point of the tongue was red and moist. The child spoke very
low, but very distinctly, and promised to be tractable. The hopes
which such an unexpected change had raised in our minds, were
dissipated towards the middle of the day; the symptoms were again
aggravated, and after twenty hours of slow asphyxia, life was quietly
extinguished. The last portions of calomel were not swallowed, and
the skin had not sufficient warmth to dissolve the mercurial oint-
ment. During this lengthened struggle, we tried to make the child
inhale oxygen gas, with the intention of prolonging life, and of
allowing the calomel time to act. I even hoped, that if the torpor
of asphyxia were temporarily arrested, the efforts of the cough
might throw out the pellicles which were perhaps already partly
detached. In fact, where a special treatment has not modified the
Diphtheritic Phlegmasia, suffocation, suspended by the ejection of the
false membranes, generally returns, but in the present case, their
expulsion was followed by a respite which might have allowed us to
reckon more and more upon the effects of the calomel.

A jet of oxygen gas was simply directed towards the mouth, by
the aid of a bladder supplied with a close-fitting pipe; and, although
under the circumstances it was impossible to procure immediately a
sufficient quantity of gas, and although the want of proper means to
favour its inspiration did not allow us to follow out this plan for any
length of time, it had very well-marked effects. The livid tint of
the lips and of the face, for an instant changed to red, the stupor

was sensibly diminished, and perhaps under more favourable circum-
E2
52 BRETONNEAU’S SECOND MEMOIR.

stances, the treatment might not have been unavailing. Might not
blisters (applied only for a few hours) have diminished the tume-
faction of the sides of the neck, and subsequently, the difficulty
of respiration? I am only too sensible of the improbability of the
success of a mode of treatment which is out of proportion to the
disease. When this has arrived at its last stage, life cannot be
prolonged except with acceleration of the circulation, and I do not
conceal from myself that everything that quickens this, must hasten
the fatal termination of the case.

At the time when the child died, numerous researches had estab-
lished the anatomical characters of Diphtherite, and from this point
of view these researches presented no interest, but we might in other
respects derive some useful information from this case. It was not
impossible that the calomel might have produced effects capable of
being ascertained, thus allowing us to judge whether, even when the
mercurial treatment can no longer cause the disease to retrograde,
it does not limit its progress, and thus allow some favourable chances
for the success of tracheotomy.

Autopsy, eighteen hours after death. External aspect. Body
rather stout. Anzemic paleness over the whole surface of the body.
The swelling of the sides of the neck was still considerable.

Thorae.—Lungs crepitant, of a rosy white, the tint of which
became more deep towards their posterior and dependent parts. The
mucous membrane which covered the bronchial tubes was pale,
and the first traces of the disease were observed only in the trachea.
Towards its middle part we began to discover some violet-coloured
pointed spots, not very distinct, but which were found more
confluent and of a more decidedly red colour on tracing this tube
upwards. The membraniform pellicle which lined the upper third
of the trachea terminated an inch above the diphtheritic redness
by a free slender, irregular, and, as it were, worn-out edge. In
the larynx it became more adherent; it increased in thickness
and almost entirely obliterated the glottis. In this region it
was no longer possible to separate it completely from the mucous
membrane which was of a deeper red. The walls of the pharynx
presented the appearance of sphacelus which had reached its last
stage; detached filaments, and hanging membranous lamine, super-
posed upon one another, of a blackish grey, and dirty-white colour,
resembled thick eschars ready to fall off. The laceration of the
INEFFICACY OF BLOOD-LETTING. 53

tonsils especially appeared to be the consequence of the putrid solu-
tion of these organs. It is, however, undoubted, that these deceptive
appearances are only the results of the changes of colour, and of
the detachment and more or less advanced decomposition of the
pseudo-membranous layers which add successively to the thickness
of the pellicle. Although considerable strips were detached
during life from the surface of the tonsils, these glandular bodies
still preserved an investment which doubled their volume; and the
most prominent points of their surface were found reddened or
ecchymosed.

The calomel had exerted the most marked influence upon the diph-
theritic phlegmasia, at the base of the tongue, on the lateral parts of the
pharynx, and on all the points where its contact had been more imme-
diate and more prolonged. The inflammation in those regions was so
completely subdued, that doubts might have been entertained of its
existence, had there not remained fragments of false membrane which
still lined the mucous fosse, together with a slight alteration of tint,
analogous to that of an ecchymosis which is on the point of termi-
nating by resolution. This false membrane lined all the inside of the
nostrils, and had lost nothing of its primitive colour; it was of a
yellowish-white, adhered but slightly to the pituitary surface, and
had so much tenacity, that strong traction might be employed without
breaking it; still it was not possible to extract it by the guttural
aperture of the nasal cavities, except by pushing it back at the same
time from their anterior orifice; on several points it had attained
more than a line in thickness. It was moulded exactly to the
meatuses and the apertures of the nasal fosse.

That surface which corresponded to the mucous membrane was
studded with papille as apparent as those on the point of the tongue.
There were prolongations of fibrinous matter, which penetrated into
the apertures of the muciparous follicles. The pseudo-membranous
pellicle reached the anterior orifice of the nostrils, and even projected
beyond it; but, although the snuffling might have been attributed
to the propagation of the diphtheritic affection into the cavities of
the nose, none of the physicians who examined the child several
times every day, had remarked the projection which the exudation
made externally; so true it is, that the most apparent signs easily
escape our senses, unless they are kept ever on the watch, and unless
they are directed towards a definite object of investigation !
54 BRETONNEAU’S SECOND MEMOIR.

The great extent to which the disease had reached at the time when
the mercurial treatment was commenced, and that which it still
occupied at the time when tracheotomy might have been proposed,
scarcely ‘permit us’ to believe that this operation would have had
any other result than to retard the moment of death.

‘

GenzraL SKETCH OF THE EPIDEMIC WHICH PREVAILED aT Tours,
From 1818 to 1821.

Before the arrival of the Legion of la Vendée, the majority of the
physicians of Tours, had not met with a single example of Malignant
Angina ‘in the whole course of their practice, and I own that until
that time, I myself did not recollect having seen Croup more
than twice. In other cases, the very facility of the cure had made
me doubt the reality of some of those recoveries, which the tender-
ness of mothers is so much disposed to exaggerate. It was ih the
neighbourhood of the principal Barracks, that Malignant Angina first
began to show itself. Among the soldiers, pellicular inflammation
of the gums was most frequently observed ; nevertheless, Malignant
Angina was also seen to show itself in — of them, whether
the affection was propagated from the mouth to the pharynx, or
developed itself in the first instance upon the tonsils. There
was one man, of the age of twenty-three, who died in four days;
and his illness presented exactly the combination of the sym-
ptoms of Croup, which frequently shewed itself in this quarter
of the town, and especially affected children. There could not be
the slightest doubt of the nature of a disease characterized by the
most complete combination of its symptoms.

In fact, the change in the quality of the voice, the peculiar sound
of the cough, and the paroxysms of suffocation, which were more and
more frequent near the end of the illness (the whole duration of

which was from three to four days), left the less uncertainty, since
nothing extraordinary had been observed in the pharynx (which was
not explored), and since a slight difficulty of swallowing had scarcely
attracted attention.

It even happened that young patients did not complain in any
way of difficulty of deglutition, and that the most attentive persons
sometimes mistook the period, when the diphtheritic phlegmasia began
to attack the tonsils. Dr. R. observed, in his eldest son, aged ten
EPIDEMIC DIPHTHERITE AT TOURS. 55

years, the commencement of Malignant Angina. The disease yielded
so readily to two or three local applications, that he thought he had
exaggerated the danger of the disease. Some days later, another
of his children, aged eight years, seemed less cheerful, and less good-
humoured than usual. Alarmed by a swelling which he perceived
on the left side of the angle of the jaw, Dr. R. hastened to examine
the pharynx ; he found the tonsil of that side tumefied, and enveloped
‘by pellicles, which were directed behind the posterior column of
‘the velum palati, and descended beyond the reach of sight.

The child complained of no pain in the throat ; the same evening
the diseased tonsil was painted, though to a very small extent,
with a very weak mixture of acid and of honey. The next day the
sound of the voice was altered, and cough supervened ; there were
paroxysins of suffocation, fever was not perceptible, the appetite was
maintained ; the night was bad. The following day, the child was
‘better ; nevertheless, the cough assumed a more and more alarming
character, and became less frequent, short and hoarse. He con-
tinually felt hungry. He played during the day, seated upon his bed.
The relations of Dr. R. could not understand why they ought to fear
for the life of a child who was not ill. At three o’clock in the
afternoon, there was rather a severe paroxysm of suffocation, accom-
panied with rattle, which quickly proved fatal.

A long time after anatomical researches had taught us that the
‘disease almost always began in the pharynx, it often happened
(whether sufficient attention was not exercised, or the intractability
of the children prevented the exploration of the back part of the
mouth) that we were unable to discover anything there during life,
though after death the thickness and the deep colour of the pellicles,
which from the tonsils, extended to the nasal fossee and into the
air- tubes, left no doubt as to the origm of the affection,
and the course which it had traversed. But although, at the be-
ginning, the death of several children was not attributed to its true
cause, we fell afterwards into an opposite error. The'fear which
exaggerated the danger, magnified the slightest attack of sore-
throat into the epidemic affection. This circumstance contri-
buted not a little to obscure several important questions relative to
therapeutics.

In the Legion of la Vendée, the occurrence of Malignant Angina,
compared with Scorbutic Gangrene of the Gums, was in the propor-
tion of one in nine cases.
56 BRETONNEAU'S SECOND MEMOIR.

Among the inhabitants of the town, this last affection was
always very rare. I have already said that the difference was attri-
buted to the use of the vessels which the soldiers employed in
common. The ascertained number of those who died during the
course of the epidemic, cannot be estimated above one hundred and
fifty.

Although at the beginning, some cases may have been overlooked,
the omissions cannot be considerable; upon the whole, it would be
difficult to reckon twenty adults. There was a much greater number
of adults attacked than this proportion seems to indicate; but they
were treated with more success than the children; and I may assert
that more than a hundred and fifty cures were obtained by different
physicians by means of local treatment.

Notwithstanding all the care I have bestowed, I have not been
able to obtain one single example of a spontaneous termination of
Diphtherite. Nevertheless, some cases are to be found which are
quoted by authors. There would be less doubt upon the subject
if the Diphtheritic Phlegmasia had not been so often confounded with
other affections. (See Description des maux de Gorge Gangréneua,
by Chomel.) This subject presents many difficulties. Among the
numerous cases of Croup published in periodical works, there are
several in which the disease terminated by a fortunate expulsion of a
false membrane. The intensity of the fever, the pain referred to
the larynx, and the whole progress of the disease, seem to indicate
an inflammation of an entirely different character. I have met with a
remarkable example of this sporadic affection in an adult woman.
An acute pain, accompanied with fever and referred to the larynx,
was felt before, and especially after, the ejection of a false membrane,
which was found floating in the midst of abundant viscous sputa;
it was more than halfa line in thickness, and, by its semi-transparency,
it resembled less the croupal pellicles, than pleuritic false membrane.
Its shape indicated that it had lined the thyroid cartilage, as far as
the first rings of the trachea. A bloody mucous expectoration pre-
ceded, accompanied and followed the expulsion of the pellicle. The
voice remained hoarse for several weeks, although convalescence
appeared to have been established for some time.

If we pay attention to the fact that these mucous surfaces are
rarely excoriated without being covered with a membranous exuda-
tion, we shall easily understand that the existence of a pellicle in
the larynx is not a certain mdication of one and the same in-
EPIDEMIC DIPHTHERITE AT TOURS. 57

flammatory process; and that what is true with regard to the Diph-
theritic Phlegmasia, may be quite false with regard to any other kind
of inflammation.

It is from my desire to throw some light upon these questions,
which become very interesting in practice, that I have minutely noted
down all the phenomena of Diphtherite.

I believe that I have proved in the first part of this Memoir that
the pellicular inflammation, known from the remotest antiquity, is a
special inflammatory process, which preserves all the essential cha-
racters which are peculiar to it, on whatever point of the mucous
tissue it may be developed.

In the second Memoir, after having freely explained my views with
regard to the slight efficacy of the general means opposed to the
disease which I have had to treat, I endeavoured to demonstrate,
that in the first stage of the disease, local treatment, which inspired
so much .confidence in the ancients, is still in the present day the
safest method; and that in its last stage, the most powerful resources
which have been discovered in our own days are the medicines
which exert a specific action upon the affected organ.

' Finally, comparing the facts which I have now, perhaps at too
great length, detailed to the Academy, with those already known,
I have seen them gain in certainty what they have lost in
novelty, and I confess my belief that even from this circumstance,
the labour to which I have devoted myself, will not be altogether
useless.

If I am not deceived, the researches in morbid anatomy, which I
have multiplied, and which I have followed out with the most
scrupulous exactness, serve to connect the modern with the ancient
opinions; they show that Croup is not a new disease, but the
most ordinary termination of Malignant Angina. May these re-
searches be the means of establishing the views of practitioners
upon the incontestable points in the history of this disease, of calling
their attention to those which remain doubtful, and of preventing
the experience of past ages being entirely lost to us.
58 BRETONNEAU’S SECOND MEMOIR.

ADDITIONS TO THE SECOND MEMOIR (JUNE 1825).
Eprpemic DrpaTserite.

The first two parts of these researches were already printed when
I had occasion to make the following additions to them, and to
annex to them successively the Third and Fourth Memoirs.

Diphtheritic Angina has recently been observed at La Ferriére, a
little town seven leagues to the north of Tours, and nine persons
have died. The disease appeared to be transmitted from one subject
to another. Does contagion give rise to these epidemics which are
so partial and confined to such small localities? or rather does it
not often happen that Diphtheritic Angina is developed sponta-
neously, and is afterwards transmitted? These’ questions like most
of those relating to the contagion of many other epidemic diseases,
will, perhaps, remain for a long time incapable of solution.

Té was undoubtedly Diphtheritic Angina which presented itself to
the observation of M. Jurine, and of which mention is made in the
following passage of the Report of the Commission. “It is easy to
distinguish Croup from Angina Tonsillaris, Angina Pharyngea, and
even from the Gangrenous Angina of adults. But there is another
sort of Angina, generally epidemic, and perhaps contagious, which is
called Gangrenous, and sometimes Aphthous, which specially attacks
children, and which is so often complicated with Croup, that it ts
almost impossible to distinguish them. The author is induced to
believe that in the: greater number of cases, this affection is not a
Gangrenous Angina, but a true Croup complicated with aphthe,
assuming sometimes the forms of adynamia or ataxia, when the pre
vailing epidemic itself possesses this character. He has himself
twice seen Croup combined with Aphthe: and in neither of these two
cases did the disease present itself to him as a true Gangrenous
Angina. Malouin, Bard, Lepecq de la Cloture, Ramsey, and some
other authors relate examples of it which all appear more or less
calculated to give the same idea of it.’

In this complication of Croup and of an Angina reputed gan-
grenous although really not so, but which is generally epidemic, and
perhaps contagious, we discover all the characteristic features of
Diphtherite; we may also affirm that this disease was really the
prototype of the Croup of modern writers, and that afterwards the
SPORADIC TRACHEAL DIPHTHERITE, 59

most simple tracheal lesions of the respiration have been ranged
under the same name, although some of their symptoms have not
, the least analogy with those of such a formidable affection.

SPORADIC TRACHEAL DIPHTHERITE.
TRACHEOTOMY (COMMUNICATED JuLy, 1825).

Four years had elapsed since I read at the Académie Royale de
Médecine, the two Memoirs on Diphtherite ; and with the exception of
one case, this disease had not again shown itself at Tours. In the

. spring of 1825, two children died of an affection which had pre-

sented all the characters of Malignant Angina. I saw one of them in .
his last moments, and no doubt remained in my mind that the dis-
ease was the same affection as the epidemic Croup observed during
the course of the years 1819 and 1820; there had existed no
relationship or communication between these two subjects. A litle
later, a third was attacked, and he was still more isolated. I was
‘called-upon to attend him; the disease made rapid progress; and
for the third time I thought that I must perform tracheotomy.
The subject of the following case was one of the youngest daughters
of M. le Comte de Puységur, who had already lost three other
children, carried off by the same disease. A year after the death of the
first, two had died in the same week, a short time before the period
when I began to devote myself to the researches which form the
subject of this work. M. Puységur had had the opportunity of wit-
nessing the success of local treatment, and that which had been
obtained by means of mercurial medication ; but, at the same time,
he was not ignorant of the numerous occasions when this kind of
medication had disappomted my hopes, and he could not conceal
from himself the danger of the fatal disease which had already caused
him so much anguish: and thus it was but too easy for him to re-
cognize the symptoms of Malignant Angina, when, for the fourth
time, he saw them developed in one of his children.

Cast 10.—E. de Puységur, aged four years, of a rather
delicate constitution, had enjoyed good health, since she was cured,
in the month of November, 1824, of a tertian autumnal fever,
the paroxysms of which were preceded by convulsions, when,
60 BRETONNEAU’S SECOND MEMOIR.

in the month of June, 1825, at the close of a slight indisposition,
accompanied by colic and diarrhea, she appeared to have caught a
common cold. On the first day the cough was dry in the morning,
becoming more dry and frequent towards noon; there was swelling
of the tonsils. On the night of the second day there was fever and
shrill cough. On the third day there was noisy respiration during
sleep; during the day the cough was less frequent. On the fourth
day the little patient was brought from the country into town, and
perhaps, in a journey of ten leagues, she had suffered a little from
the coolness of the night. I saw her on her arrival; she preserved
the habits of health; the appetite was maintained ; there was ab-
sence of fever; little cough during the might; but it was again
becoming frequent. On the third day a white spot was very appa-
rent on the left tonsil. (An emetic draught was given.) In the even-
ing, the tonsils were tumefied and moderately reddened; the left
tonsil was somewhat the larger. An oblong, excavated, yellowish spot,
bordered with red, occupied the centre of its surface; the cervical
lymphatic glands situated at the angle of the jaw, were swollen.
One of them, on the right side, exceeded the size of an olive,
although no spots were discovered on the corresponding tonsil. The
cough was short and hoarse.

Although the growths which were seenon the surface of the left tonsil
were lichenoid (resembling aphthe), the swelling of the lymphatic
glands and the tone of the cough ought not to have permitted me to
mistake Diphtheritic Angina, and during the course of an epidemic
there could not remain any reasonable cause of doubt in this respect. [¢
then appeared to me more probable that this sporadic affection ought to
be referred to common Membranous Angina; but Iwas soon undeceived.
Before the administration of the emetic, a sponge lightly dipped in
concentrated hydrochloric acid was applied upon the tonsils ; the sur-
faces touched assumed a whitish tint, due to the action of the acid.
The emetic effect of the draught was rapid and easy. On the sixth day,
at three o’clock in the morning, the cough had become hoarse and
frequent ; however, it was still moist and accompanied by an
abundant mucous expectoration. The lymphatic gland of the right
side had remained very large. Occasionally the cough again became
shrill. (Two grains of calomel every two hours). At noon, there were
slight colicky pains without evacuations. Four drachms of castor
oil, in the form of emulsion, were given in two doses ; the oil excited
vomiting and two abundant alvine evacuations. In the evening, the
SPORADIC TRACHEAL DIPHTHERITE. 61

cough was more loose, and less frequent, deglutition easy ; apyrexia ;
the night was calm. Up to this time, the appetite had remained
good and the child had taken light nourishment. The white spot on
thé left tonsil was circumscribed by a border of bright red. The
lymphatic gland of the same side was rather less swollen, and that of
the right remained hard, voluminous, and sensitive to the touch. In
the evening, the cough again became dry, short and hoarse; still
the base of the pharynx was of a pale rosy tint, and the membra-
nous pellicles of both tonsils, the tumefaction of which was be-
ginning to diminish, had not extended. ‘The tone of the voice was
little altered. (Three grains of calomel, divided into three doses, were
given in the night.) The cough which again suddenly became croupal
was a symptom of the worst description, but I was assured that it had
a still more alarming character on the evening before the day when
the child was brought from the country. I persisted in mistaking
the disease for Tracheal Diphtheritic Angina : and the dose of calomel
prescribed for the night was not in proportion to the danger caused
by the rapid propagation of pellicular inflammation.

On the seventh day, at four o’clock in the morning, after two
hours’ sleep, there was dry cough and sibilous inspiration ; the lips
and the face became of a violet colour; there were cries and alter-
nating efforts of convulsive cough, followed by the ejection of a
bifurcated, rather slender, semi-transparent, tenacious and elastic
membraniform pellicle, eighteen lines long. The pharynx pre-
sented the same appearance as yesterday; the lymphatic gland of
the right side appeared more swollen. There was croupal cough,
more and more short and hoarse. (Two grains of calomel every hour.)
The cough became more and more croupal, and the respiration was
accelerated, each inspiration being sibilous and accompanied by con-
vulsive efforts. The sterno-cleido-mastoid muscles and all the
muscles of the neck which are fixed to the thorax, contracted
forcibly ; and the pressure of the air depressed at the same time the
intervals which separate them. The calomel was given every half
hour ; and twenty-two grains were thus administered. The cough
appeared to become rather loose; and a second portion of thick
elastic membraniform matter was ejected, fourteen lines long and
five broad, terminating in a point and irregularly fringed on its
edges. The form of this pellicle left no doubt that it was of
recent and primitive formation; its dimensions and form indicated
also, that it came from the trachea, and that the morbid affec-
62 BRETONNEAU’S SECOND MEMOIR.

tion had not yet passed beyond this tube. The difficulty of breathing
was not diminished. The doses of calomel were repeated more
frequently, and mercurial ointment was rubbed into the sides of
the neck. The inspirations became still more stridulous, and the
efforts of the inspiratory muscles were more and more marked.

There was tenesmus without evacuations. (Two grains of senega.) A.
flying blister, which, notwithstanding the rapidity of its effects, did
not at all retard the progress of the disease, was applied to the region
of the larynx. The difficulty of fixing an epispastic plaister, induced
me to employ a piece of paper soaked in oil of cantharides, fixed on
with sticking plaister. As I already feared that I should be com-
pelled to have recourse to tracheotomy, I had taken these precautions
to prevent the vesication from extending below the thyroid region,
Some spoonfuls of emulsion of castor oil were given after each dose
of calomel. The cough became less frequent, shorter, and drier, but
it was nevertheless accompanied by great expulsive efforts. The
imminence of the danger induced me to make preparations for
tracheotomy. For several hours the somnolence had been continuous,
and it was scarcely interrupted by the efforts of the cough. The
head was thrown backwards, the neck was swollen, and the lividity
of the face, which announced the progress of asphyxia, no longer
permitted the operation to be delayed.

Judging from the results of two cases which I have elsewhere
related, what could be anticipated? In one case, life had scarcely been
prolonged for twelve hours, and in the other, hopes which had been
better founded, had been painfully disappointed. Ought I then to add
to a misfortune which seemed inevitable, the torment of a long and
useless suspense? J did not conceal from myself that no example
of success justified this attempt; but I ventured to anticipate the
most favourable results from the conditions which had preceded, and
from those which would follow it. Experiments which I had many
times repeated: and which I have described in another place, had
proved to me that to provide for the necessities of respiration, it was
not sufficient for the air to have access to the lungs, but that it
ought also, in a given time, to be renewed in those organs, as well
as to penetrate into them, and pass freely out of them.

Instructed by the example of the animals on which tracheotomy
had been performed with much success, I proposed to myself to
modify my operation. I suspected that the gum elastic sound,
employed in one of my attempts, was far from having a suitable
SPORADIC TRACHEAL DIPHTHERITE. 63

width; I recollected that it had lost some of its capacity by
its flexure and by the accumulation of dried mucous matters with
which it was coated on the inside, so that in proportion as the
necessities of respiration had increased by the entrance of the chyle
into the blood, and by the febrile acceleration of the pulse, the
quantity of air which could penetrate into the air-passages had gra-
dually diminished. In vain I had withdrawn the canula ; I had gained
only a momentary suspension of the progress of the asphyxia; the
swelling of the lips of the wound had soon contracted its aperture,
and it was especially to this circumstance that I attributed the un-
fortunate result of my first operation. I had then intended to make
the dimensions of the canula proportionate to those of the trachea ;
and, in order that it might be.introduced and kept in its place more
easily, I had given it the form of a slightly depressed cylinder, curved
along its course and bevelled off at its two extremities. I hoped,
besides, by means of the artificial opening, to apply calomel upon the
affected surfaces, and I admit that I felt great confidence in the
effects of an agent which so powerfully modifies the greater part of
the ulcerous phlegmasiz of the skin. Besides, I had had occasion to
convince myself that, even in the cases in which the mercurial treat-
ment had disappointed my hopes, the diphtheritic inflammation had
been dissipated on all the points which had been most immediately in
contact with the calomel. Lastly, if I did not have recourse to
tracheotomy, this disease, hitherto so: slight that it. was scarcely
accompanied by a slight amount of febrile excitement, might soon
become fatal: it was about to ‘carry off a fourth child from the same
family, and the medicines which up to that time had shown them-
selves most. efficacious, had now been administered without effect in
checking the progress of the disease.

Nothing more remained but this chance; and, although it offered
only a slight probability of success, yet, under such circumstances,
and when an unlimited confidence on the part of the father added to
my responsibility, I might, in neglecting this last resource, have
failed in a sacred duty. :

Oprration.—The head, held by an assistant, being thrown back
so as to cause the front part of the neck to project, a fold of the
integuments, properly raised, was divided from its free border to its
base, so that the incision, directed by a line traced beforehand, ex-
tended from the inferior part of the thyroid gland to the supra-
sternal depression. The division of the adipose tissue, and of
64 BRETONNEAU’S SECOND MEMOIR.

the parts which cover the trachea, was rendered laborious by the
convulsive movements of the respiration and the turgesence of the
capillary vessels, which allowed the escape of a great quantity of
blood. Two thyroid veins showed themselves on the median line ;
the dimensions of each exceeded those of a crow’s quill; they could not
be avoided, and poured forth at each expiration a hemorrhage much
more considerable than might have been anticipated. It was im-
possible to run the risk of opening the air-tube until the principal
jet of blood was arrested. Two ligatures were applied without effect ;
and it was only after having passed a third and a fourth, by means
of a curved needle, between the trachea and the divided vessels, that
the blood, although it still continued to flow, ceased to spout forth.
Five rings were divided and a curved silver canula was introduced
into the opening made in the air-tube. The breathing became calm,
and more slow, and the oozing hemorrhage still furmished by the
wound, dried up almost immediately. The canula was kept in its place
by means of a twisted thread, tied round the neck, and passed
through rings placed near the orifice of the instrument. The quantity
of blood which flowed during the operation was estimated approxi-
matively at six ounces; there was paleness and depression.

Immediately after the dressing of the wound, the child asked for
drink, and she herself carried the glass to her lips. Some mucus, mixed
with blood, was thrown out by the canula at each repeated effort
of the cough. A pellicular band had just been expelled, and I
ascertained with satisfaction that it was long and narrow and fringed
on its edges. During the night the respiration was calm, not very
sonorous, and moderately frequent. There were three mucous,
greenish, rather abundant evacuations, preceded by colic.

Until the evening, the calmness of the respiration was occasionally
interrupted by cough, followed by the ejection of opaque mucous
matters, of a slightly rose-colour, which were expelled through the
canula. Some fragments of false membrane now and then accompanied
the expectorated matter. Sleep was prolonged for several hours.
The bowels were opened by castor oil and emollient injections.
Hight grams of calomel were insufflated through the canula. (I
perceived afterwards that this pulverulent matter adhered to the walls
of the tube and accelerated its obliteration.)

On the eighth day of the disease, and the day after the operation,
the respiration became noisy and hurried, and required powerful efforts
on the part of the mspiratory muscles; the pulse was also much

oe
CASE OF TRACHEOTOMY. 65

accelerated. Was it not in part to the traumatic fever, or to that which
accompanies the extension of diphtheritic inflammation, that we must
attribute the unfavourable change which was remarked in the state of
the patient, or was the diminution in the size of the canula sufficient to
occasion such a disorder? It was perceived that mucous matters
had contracted its orifice and made it lose more than half of its
dimensions ; it was therefore withdrawn, cleaned, and replaced pretty
easily ; from that time tranquillity recommenced, and we observed at
the same time that the frequency of the pulse and of the respiration
subsided; the edges of the wound were this day slightly tumefied.

On the ninth day, and the third after the operation, the sleep was
tranquil until two o’clock in the morning, when the cough became
more frequent, and fragments of membranous exudation were expelled
through the canula. In the morning, the artificial tube was found
obstructed ; it was cleaned, and replaced with some difficulty. It was
only after several attempts that its extremity, which was bevelled off,
could be introduced into the trachea ; frequent colic was experienced,
attributed in part to the effect of the calomel, and in part to a former
disturbance of the digestive canal; an injection of infusion of bark
was ordered.

On the tenth day, and the fourth after the operation, the cough had
become more frequent ; fragments of false membrane were expelled ;
the extremity of the canula had quitted the opening of the trachea ;
the air did not enter and go out without producing a loud noise,
and the respiration was very much accelerated. The metallic tube,
taken out and cleaned, was replaced with difficulty; it could be in-
troduced only by using some force. During this proceeding, several
portions of membrane were driven out to a great distance. One of
these fragments exhibited the shape of the orifice of the glottis ; it was
thick, consistent, coriaceous, and of a tawny colour. The respiration
became tranquil, the circulation slower, the expression of the face was
animated, and the child played with its doll.

On the eleventh day, and the fifth after the operation; during the
preceding night the little patient turned herself about so freely, that
in one of her movements the canula was displaced. This time, a pair
of forceps with curved blades was used to separate the lips of the
wound, and assisted in replacing the artificial tube more easily.
This precaution prevented the cartilagmous rings of the trachea
(folded in and turned back), from partly intercepting the passsage
of the air; it caused, moreover, two great inconveniences to be

F
66 BRETONNEAU’S SECOND MEMOIR.

avoided. The canula, being more securely held, did not run
the risk of being easily expelled, and its opening could not be obli-
terated, a condition of especial importance ; for we have often seen
the respiration accelerated and the pulse become subsequently more
frequent, every time that any obstacle, even though it is incapable of
intercepting the passage of the air, comes to impede its entrance.

At this time we were able to ascertain, by closing the orifice of
the wound, that at the periods when the canula was taken out, the
air was beginning to force for itself a passage through the larynx.
Indeed the cough still preserved the tone which indicated constriction
of the glottis; but bubbles of air were’ mixed with the saliva, the
spitting of which had up to this time accompanied the cough, although
during each fit, the column of air passed entirely by the artificial tube.
We could not forbear from entertaining hopes of recovery.

At two o’clock the cough became frequent, and was constantly
accompanied with an abundant excretion of saliva; the mucous
* matters which escaped by the opening of the canula were more dif-
fluent; the frequency of the cough, which became convulsive,
induced us to remove the canula, and at the same moment fragments
of membrane were driven out in great numbers. It was only by using
some force and always by the help of the curved forceps that the
canula could be replaced; the cough remained the same. During the
night tranquillity returned, but still the paroxysms of cough were
followed by more exhaustion; the air had not yet passed so freely
through the larynx; but the abundance and the liquefaction of the
expectorated matter, and above all the character of the cough
caused some uneasiness lest the diptheritic inflammation, exasperated
by the irritation which the canula might have occasioned, should
become more extensive.

On the twelfth day, and the sixth from the operation; the sleep
had been sufficiently tranquil during the night; the closure of the
canula rather than the difficulty of the respiration induced us to re-
move it. The air passed with such facility through the larynx
that the little patient could produce a rustling noise with her tins,
and inflate some bubbles of saliva. Some calomel mixed with a few
drops of water was poured, at two different times, into the opening
of the wound. At the second instillation, after a deep movement of
respiration, it was returned almost entirely by the mouth. The
canula was only replaced after an interval of half an hour. During
the whole of this time, the respiration was easy, but’ some bloody
CASE OF TRACHEOTOMY. 67

mucus which proceeded from the wound, stained the expectorated
matter for a few seconds.

Two ligatures had come away. In the evening, after a long calm,
the shocks of the cough disturbed the canula, which had become
incrusted by mucous matters; the sputa and the discharge from the
wound, were again coloured with blood. Some drops of water mixed
with calomel, were poured into the trachea by means of the canula.
On the thirteenth day, and the seventh from the operation, the night
had been pretty tranquil; from hour to hour the sleep had scarcely
been disturbed by the cough, the efforts of which, at seven o’clock
in the morning, had deranged the canula, without the respiration
having been impeded in consequence; eight grains of calomel, mixed
with a little water, were instilled into the trachea, by means of the
canula. The mucous matters of the bronchi, and the exudations from
the fistulous passage, which was covered with an adhesive plaister,
returned easily by the larynx. The voice was heard much more clearly,
and suddenly some words were pronounced quite loudly, and were
articulated distinctly. Ten grams of jalap, and two grains of calomel,
were given in a tea-spoonful of orgeat (One rather abundant evacua-
tion). The cheerfulness appeared to be diminished by the uncom-
fortable feeling which succeeded the effect of the purgative. At
five o’clock, the cough, which had become rather more frequent, was
in the first instance increased by a fresh instillation of calomel, but
half an hour later, the relief which had always been ob-
tained by this measure, was followed by a tranquil sleep, pro-
longed during the whole night. On the fourteenth day, and the
eighth from the operation, in the morning at eight o’clock, the
canula was taken out; the respiration was calmly performed, partly
through the wound, and partly through the natural passages. A
tent to which we had given the shape of the canula by filling with
wadding a little cambric bag, was substituted for the metallic tube ;
but, although it was fastened down by a piece of adhesive plaister,
and held by a bandage, the air escaped through the wound during
the fits of coughing.

During the greater part of the day, the little patient remained
sitting in bed, and the vivacity which she displayed in her childish
games, gave us reason to hope that the assistance of the artificial
tube would soon become unnecessary. The appetite was good; a
slice of bread and butter, the wing of a chicken and the breast of a

partridge were allowed for three meals. In the evening, after two
F2
68 BRETONNEAU’S SECOND MEMOIR.

hours’ sleep, the bandage exactly closed the aperture of the wound,
and the air was no longer heard penetrating into it; the respiration
was acclerated, was becoming sibilous, and the cough remained
hoarse, still resembling that of Croup.

The canula was replaced without difficulty, with the assistance of
the curved forceps, and at the same moment, the respiration became
tranquil and less frequent. Some thin, rectangular fragments of false
membrane, worn away at their edges, were ejected when the canula
was replaced. Other thick and consistent portions were at the same
time expectorated and passed out mixed with the sputa. Was the
larynx still obstructed by false membranes ? Would the diphtheritic
inflammation tend to become chronic in this organ, as most fre-
quently happens when it attacks the gums?

The difficulty of reaching the larynx and applying to it a sponge
dipped in hydrochloric acid through the artificial tube which
was directed towards the bronchi, led me to persevere in the
instillation of calomel. Seven or eight grains, mixed with a little
water and poured into the wound, were drawn in by inspiration
during the efforts of coughing; the instilled liquid was mixed with
the mucus of the trachea, and it was afterwards partly expelled
through the gaping aperture of the wound, and partly expec-
torated.

On the fifteenth day, and the ninth of the operation, the night had
been good; still the general depression and the frequency of the pulse
(100 in a minute) and that of the respiration (28 to 30) left some fear
that the pellicular inflammationhad not yet yielded either to the general
treatment (which had been suspended from the fear of carrying it to
a poisonous extent), or to the local mercurial treatment, which was
not regularly continued. For two hours, the canula was withdrawn ;
the respiration was still noisy and sibilous ; but the cough had lost a
little of its hoarseness. Some portions of concrete matter were per-
ceived in the muco-puriform secretion, which was expelled from time
to time through the opening of the wound, and a small fragment
still preserved a degree of thickness and consistency which led us to
believe that the local treatment had not been sufficiently prolonged.
The lips of the wound were closing so rapidly, that it became
urgently necessary to replace the metallic tube in order to keep open
the fistulous passage which allowed us to apply the calomel directly
to the interior of the affected organ. It was necessary to dilate the
passage of the wound with great force in order to replace the canula.
CASE OF TRACHEOTOMY. 69

The curved ends of the forceps facilitated and directed its introduc-
tion with great certainty.

In the meantime the edges of the wound had sunk, and the canula,
by penetrating more deeply, excited an irritative cough, which was
accompanied by a muco-serous expectoration. Twice in the day, nine
grains of calomel mixed with a few drops of water, were instilled
through the wound each time that the canula was withdrawn. The
cough was certainly less hoarse, and as soon as the passage of the air
through the course of the wound was intercepted, the mucous
matters and the discharge from the fistulous tube were expectorated
with great facility. The next day, the night had been tranquil; and
the hopes and fears, which had alternately succeeded one another, at last
gave place to a certainty of success. The last two ligatures had not yet
come away. During the greater part of the day, the canula was
not kept in the wound, the orifice of which was contracting so rapidly
that the air and the tracheal mucous matters no longer passed through
it except at the time of coughing. Nevertheless the pulse still pre-
served its frequency (98 to 104), the respiration seldom fell to 22
and most usually reached 25. In the evening, the presence of
the canula excited a convulsive cough which necessitated its with-
drawal : it was replaced during sleep, by means of a powerful dila-
tation made with considerable force, which did not, however, cause
any discharge of blood. Two small portions of concrete matter,
rapidly expelled at the moment of the re-introduction of the canula,
came undoubtedly from the fistulous passage of the wound.

The respiration when it was performed only by the natural passages,
was noisy and snoring, especially during sleep. The parents of the
child assured me that this habit of breathing had existed for a long
time.

On the seventeenth day, and the eleventh after the operation; the
sleep had not been interrupted during the night more than three times
by the cough. The respiration, which was performed through the tube,
was noiseless (22 to 26 inspirations in a minute) pulse 90 to 102.
A piece of prepared sponge which was substituted for the canula with
the intention of keeping the wound dilated appeared to cause uneasi-
ness. After remaining six hours it was withdrawn and its place sup-
plied by a tent lightly held. The sustained cheerfulness and the
lively movements of the little patient proved the more clearly that the
wound was not the seat of any painful feeling, because the least pain-
ful sensation generally caused her to complain. The voice remained
70 BRETONNEAU’S SECOND MEMOIR.

low and very indistinct. The canula was not replaced. The next
day, at the period of waking, the respiration which had been tranquil,
became noisy. The cough, which was still loose, was attended with the
expulsion of voluminous, yellowish-white, opaque, muco-puriform
sputa.- There was hoarseness ; 19 to 21 inspirations in a minute: pulse
102. Some sneezing, which had become more frequent since the air
no longer passed except by the natural channels, indicated that a slight
coryza had augmented the guttural irritation, kept up bythe discharges
from the wound, and by the secretions which were still furnished by the
surfaces which had been the seat of the pellicular inflammation. The
appetite was good, and a healthy appearance was observed after each
dressing.

On the nineteenth day, and the thirteenth from the operation ; the
sleep had been interrupted only by two fits of coughing. The
cheerfulness of the patient, her vivacity and her appetite were
all that could be desired. For six months, the respiration had
never been so free and noiseless as on this day (18 inspirations
in the minute). The sneezing was still more frequent. The cough
remained hoarse. The ligature was removed; the aperture of the
wound contracted; and a small tent was lightly placed in its orifice,

in order to allow the cicatrization to take place from within out-
wards.

On the twentienth day and the fourteenth from the operation ;
the sleep had been interrupted only by a single paroxysm of cough.
After an easy expectoration of muco-puriform sputa, the respiration
became quite noiseless, and was performed by movements as slow
and inconspicuous as in a state of health (pulse 84 in a minnte).
The surface of the wound, which was contracted, was slightly granu-
lated, and presented nothing more at its centre than a narrow aper-
ture which would scarcely admit a probe of the size of a straw.

A superficial ulceration which still remained round this aperture
was soon cicatrized, and the health was quickly re-established. On
the nineteenth day from the operation, and the twenty-sixth of the
disease, the voice had recovered its natural tone, but up to this time
the deglutition of liquids had almost always excited a little cough.
This shght inconvenience was scarcely remarked the following days,
and soon afterwards it ceased entirely. The assiduous care taken of
the patient contributed greatly to the success of the operation, and in-
deed, in this respect, I could not have been more ably assisted.
Sometimes the respiration was suddenly accelerated, and in order to
\

PHARYNGEAL DIPHTHERITE. 71

render it difficult, it was only requisite for some of the concretions to be-
come entangled in the canula, or that its orifice should be narrowed
by some dried mucus. This dyspnoea, which I attributed to the ex-
tension of the pellicular inflammation and to its propagation into the
bronchi, had at first caused me the most serious uneasiness; but at a
subsequent period I understood the cause better, and I felt that I
could not pay too much, attention to prevent the obliteration of
the artificial tube.

T have become thoroughly convinced that, in the last stage of
Malignant Angina, the success of tracheotomy depends upon the
amplitude and the freedom of the passage which is opened to the air,
and I have therefore always insisted upon adopting all the means
which were necessary to secure these conditions. If we examine the
works of those who have written upon Croup, we shall find that most
of them agree in thinking that the smallest aperture must be suffi-
cient to allow enough air to enter for the necessities of respiration.
Although these authors might have assured themselves that in the
most intense Diphtheritic Angina, the occlusion of the glottis was never
complete: and although they had heard patients articulate sounds,
which were feeble, indeed, but distintt, up to the last moment; yet they
did not attribute death to its true cause, namely, to the simple contrac-
tion of the aperture of the air-passage, but to a spasmodic condition
which does not exist. When we see that the slightest mechanical
obstacle is sufficient to prolong the agonies of suffocation, and to
aggravate them and render them fatal :—when we see long fragments
of membrane presenting themselves at the aperture of the canula,
protruding and again receding, and escaping from the fingers which
are trying to seize them, we then recognise the importance of
guarding against the obstruction of the artificial tube, and the nar-
rowing of any part of its dimensions.

PHARYNGEAL DIPHTHERITE.

Case 11.—M., a soldier of the 44th regiment of the line; ofa
strong constitution, entered the General Hospital on the third day
of his illness. There was considerable swelling of the lymphatic
glands, and of the sub-cutaneous cellular tissue of the sides of the
neck. There was fetid smell of the breath, and painful degluti-
tion. Some thick pellicular membranes, partly detached, and of a grey
72 BRETONNEAU’S SECOND MEMOIR.

or whitish colour, extended from the surface of the right tonsils.
which was much increased in size, as far as the corresponding edge
of the uvula; the pulse was not very frequent. (Local treatment,
concentrated hydrochloric acid, eighty drops, honey four drachms.)

On the fourth day, the tumefaction of the cellular tissue was
dispersed, and the lymphatic glands alone remained swollen. — The
tonsil was much smaller, and the exudations which. covered it had
lost a great part of their dirty hue. After three more applications,
repeated once a day, there no longer remained in the pharynx the
slightest trace of inflammation ; and on the sixth day from the ad-
mission of the patient, the cure was completed.

A larger number of special cases of this kind would present no inter-
est. Diphtheritic Angina, left to itself, may sometimes be confined to
the pharynx, without attacking the air-passages, and in that case, may
present the most repulsive appearance. I have seen this affection
simulate ulcerated scirrhus of the pharynx. The soldier, who was
affected by it to this degree, declared that he did not begin to feel
any difficulty in the act of swallowing until within ten or twelve days.
I could scarcely understand how the disease which I discovered in
the back of the mouth could have acquired so much intensity in so
short a space of time. A tumour of considerable size occupied the
place of the left tonsil, and pushed forward the velum palati. The livid
hue of this tumour, and the nodulations on its surface, gave it the
most exact resemblance to a cancerous excrescence. The right
tonsil, which was much less swollen, was covered by pellicular exu-
dations of a dirty-white colour. The lymphatic glands of the sides
of the neck had attained a considerable size, especially on the right
side. From the account given by the patient, who spoke with great
difficulty, the swelling which was still observed at the left angle of the
jaw had been much more considerable.

If some other examples, collected during the epidemic, had not
already given me an idea of the enormous swelling which some-
times accompanies diphtheritic inflammation of the tonsils, and, if
especially, the conclusions drawn from the acuteness of the disease
had not cleared up the diagnosis, I confess that under such an un-
usual appearance, I might have been unable to recognise Malignant
Angina. A few applications of concentrated hydrochloric acid were
directed upon the tumour, and the first result which was obtained was
a speedy diminution of its size. The breath had lost its insuffer-
able fetor. The swollea tonsil was then covered with white or
TRACHEAL DIPHTHERITE. 73

yellowish membraniform exudations, and exhibited the usual
characters of Pharyngeal Diphtherite. That of the right side no longer
formed any projection. The sounds of the voice were more clearly
articulated, and the patient scarcely complained of any difficulty in
swallowing. At the same time the lymphatic glands gradually lost
their increased volume, and on the tenth day of the treatment, there
remained no traces of an illness which had presented such serious
appearances, except a slight enlargement of the left tonsil, which was
not reduced after the lapse of several weeks, and which no doubt will
still continue.

TRACHEAL DIPHTHERITE.

ANATOMICAL CHARACTERS.

Autopsy of Five Young Subjects who died in the same week, at the
end of November, 1819.

Casz 12.—I have not been able in this case, to obtain more than
a few particulars upon the progress of the disease and the treatment
which was adopted.

N. L., four years old, of a good constitution, ill for thirty-four
hours; deglutition easy during the course of the disease; all the
symptoms of Croup; death by asphyxia; during the last moments,
fetor of the breath was observed.

Treatment.—Repeated doses of kermes mineral; vomiting and
purging were produced; a collar of blisters was applied round the
neck.

Autopsy, thirty-sia hours after death.—The portion of the tonsils
and of the velum palati, which could be discovered by half opening
the mouth, was in a healthy state, with the exception of a slight
swelling. A membraniform crust of a yellowish-white colour, ex-
tended over all the parts which were beyond the isthmus of the throat.
The pseudo-membranous exudation was thickest and most consistent
upon the surface where the tonsils correspond to one another. Over
all this extent, it had already assumed a greyish tint indicating that
here was the origin of the disease; the exudation extended, becoming
gradually thinner, behind the velum palati, from which it ascended
as far as the posterior aperture of the nasal fossze, then it descended
into the pharynx as far as the cesophagus, covering the two surfaces of
the epiglottis, but not extending beyond the ventricles of the larynx.
74 BRETONNEAU’S SECOND MEMOIR.

The trachea was coated with a thick white mucus, not very ductile
and slightly coagulated*, and the same kind of mucus obstructed
the aperture of the bronchi.

The mucous membrane of the trachea was neither red nor swollen ;
it was only slightly injected; that of the bronchi and of their prin-
cipal ramifications presented a few traces of inflammation ; there was
no indication of inflammation in the pulmonary spongy tissue, the
most depending portions of which were only engorged with blood and
marked with dark livid spots.

The membraniform exudation was detached with more or less
facility from the parts which it covered ; and on lifting it up, we saw
that it was united to the mucous membrane by very slender, elastic
filaments, which were stretched and lengthened before they could be
broken. It was difficult to recognise any alteration on the organic
surface thus denuded; we perceived no erosions except some upon
points of no great extent, where the accidental membrane was more
adherent. The surface of the exudation which corresponded to these
points was spotted with blood. A superficial examination might
have led to the belief that there was a deep ulceration of the tonsils.
The exudation which covered them penetrated into their furrows, and
when it was removed only from their more prominent points with
the back of the scalpel, the white matter which remained in the
mucous crypts of these organs might be mistaken for pus. But by
pressing laterally, we squeezed out pseudo-membranous fragments,
instead of pus; and when the mucous tissue was thus cleared from
them, it would have been difficult to suspect that it had been the
seat of a morbid affection.

Casz 13.—M. A., a child of four years old. The disease had been
evident for forty-eight hours : there were all the symptoms of Croup.
The membraniform exudation was perceived upon the tonsils, on
inspecting the throat: still the death of this child was attributed to
the presence of ascarides by the medical man who had attended him.
The treatment consisted of leeches to the neck, an emetic, and
vermifuges.

* I have many times made this observation in the course of the
epidemic. The coagulation of the mucus exuding from the surfaces which
are beginning to be affected with diphtheritic inflammation, is a marked
character by which this exudation is distinguished from the tenacious Pe
duct of catarrhal inflammation.
TRACHEAL DIPHTHERITE. 75

Autopsy, thirty-six hours after death.—There was the same state
of the pharynx, the tonsils, and the velum palati as in the preceding
case. The false membrane extended, becoming gradually thinner, as
far as the first ramifications of the bronchi; it was easily detached
from the trachea, and was found rather more adherent in the larynx
and the back of the mouth.

Casz 14.—E. V., a child seven years old, of feeble constitution.
During the last three or four days, a white spot was observed behind
one of the tonsils ; there was general uneasiness ; the deglutition was
unimpaired. The spot increased in size, and on the fourth day all
the symptoms of Croup broke out with violence; the paroxysms re-
turned during the night; towards the fifth or sixth day, there was
expectoration of false membranes; the respirationwas less embarrassed, -
and this amelioration excited the most sanguine hopes, but death oc-
curred between the seventh and eighth days. We were informed that,
during the last moments of life, no membraniform exudations were
observed in the back of the mouth. The treatment consisted of
baths and pediluvia ; kermes mineral in strong doses frequently re-
peated; a collar of blisters descending below the clavicles, and
sinapisms to the feet and legs.

Autopsy.—The examination of the body was delayed till six days
after death, and in consequence, decomposition had commenced. A
thick, membraniform layer covered the back of the mouth and
the posterior aperture of the nasal fosse. It was no doubt in con-
sequence of the commencing putrefaction that the false membrane
was softened on the most prominent points, but it was still con-
sistent in all the depressions which it invested.

If former researches had not already taught us to distrust fallacious
appearances, we should have seen in this case only some ulcerated
surfaces, moistened with an abundant suppuration ; and yet, when the
fragments of the false membrane were detached, removed, or pressed
out of the mucous folds into which they penetrated, it was evident
that there did not exist any true loss of substance in all the extent of.
the pharynx. In the trachea the membrane was diffluent only on its
free surface: it adhered in patches to the mucous coat which was
scarcely reddened, and it was much thicker in the larynx.*

* In this case, attempts had been made to ascertain, during life, whether
the walls of the pharynx were really covered with a pseudo-membranous
76 BRETONNEAU’S SECOND MEMOIR.
\

Casz 15.—P., aged four years. From the first attack of the disease,
membraniform exudations were observed in the back of the mouth.
On the third day there was croupal cough; no marked fetor of
the breath; deglutition easy ; and death was caused by a paroxysm of
suffocation on the fourth day.

Autopsy.—The false membrane extended as far as the last divisions
of the bronchi (a considerable swelling of the cervical lymphatic
glands was remarked in this subject, and in the three preceding

ones).

Case 16.—Three days after the death of the last child, his sister,
aged eight months, appeared to experience general uneasiness ; there
were crying, agitation, febrile heat, and refusal of breast-milk ;
- on the next day the case was better marked. On the third day there
was cough with difficulty of respiration ; the eyes were dull; there
was swelling of the parotid regions. At this period the back of the
mouth was covered with a greyish incrustation. A sponge moistened
with concentrated hydrochloric acid was applied to the isthmus of the
throat ; two leeches were applied to the mastoid processes. The next
day, the countenance was less dull, and there was less fever. (The same
treatment was followed for three days, and the applications of con-
centrated acid were repeated night and morning without the cough
becoming more frequent.) Still the difficulty of respiration became
increased ; the pulse was small and frequent; and death took place
at the commencement of the sixth day. It was suspected that the
applications of hydrochloric acid had been too frequent-and too strong.

Autopsy.—The villous coat of the tongue appeared rather deeply
altered by the action of the local remedy. The uniform white tint of
all the anterior part of the velum palati and of the tonsils was manifestly
due to cauterization. The membraniform exudation was not dis- .
covered till beyond the isthmus of the throat. It ascended towards
the guttural aperture of the nasal fossee, where it presented con-
siderable thickness. It did not descend, in the larynx, beyond the
coating ; and yet the pellicular membrane which extended over the walls of
the back of the mouth was confounded with the naked surface of the mucous
membrane. May it not have happened in many cases, that the affection of
the tonsils and of the isthmus of the throat has been misunderstood, where
the symptoms of Croup have alone attracted attention; and is it not more
than probable, that at the period referred to, the researches of physicians
were limited to ascertaining the presence of the false membrane in the air-
tubes?
MERCURIAL TREATMENT. 77

epiglottis. The mucous membrane of the trachea was not reddened
at any point; it was also without any coating and without any
alteration at the.commencement of the bronchi. The solidity of all
the posterior part of the inferior lobe of the left lung appeared to be
due both to cadaveric exudation and to an inflammatory hepatization.
A membraniform exudation which was extremely thick, but not very
adherent, extended from the pharynx as far as the cardiac orifice of
the stomach. Under this exudation the mucous membrane of the
cesophagus appeared in a healthy state. It is not very probable that
its formation was determined by the application of the acid, for every
cauterization occasioned efforts of vomiting.

These five children, together with an appearance of stoutness, seemed
to possess a degree of strength suitable to their age, and in each of
them, the abdominal viscera, although examined with great care,
offered no traces of inflammation.

MERCURIAL TREATMENT.
CASES.

After the departure of the legion of La Vendée, the Western Bar-
rack was occupied by the soldiers of the forty-fourth regiment. A
few days after their admission, three of these soldiers were affected
with Malignant Angina. In the first two the disease was arrested
at its commencement by local treatment. The third, admitted into
the Hospital, was placed in one of the clinical wards (December, 1821).

Casz 17.—Some exudations covered both tonsils, and extended
into the pharynx, beyond the reach of sight. This man, aged twenty-
three years, of a tall stature, had habitually a clear complexion and
enjoyed good health.

The right tonsil, which had been the first affected, but on which,
however, diphtheritic inflammation had not begun to show itself until
four days before, rested upon that of the opposite side, which was also
very much swollen; it carried forward the velum palati. Those exu-
dations which extended beyond the point of junction of the two
tonsils, and also those which bordered the uvula, were of a yellowish-
white colour. By strongly depressing the base of the tongue so as to
excite nausea, we discovered, at the moment of opening out the isthmus
of the throat, the surfaces which were in contact. Their colour was
78 BRETONNEAU’S SECOND MEMOIR.

of a dirty-grey, and the fetor of the breath was insupportable.
There was considerable swelling of the sides of the neck, at the
position of the angle of the jaw. The face was sullen, the pulse
strong and frequent ; since the night before there had been a catarrhal
cough, with mucous, transparent, frothy expectoration.

Although in some respects blood-letting appeared still to be indi-
cated, yet experience had taught us how useless, and even dangerous,
it would be, to have recourse to it. A mixture of equal parts of
honey and concentrated hydrochloric acid was gently applied between
the tonsils, by means of a sponge fixed at the extremity of a short and
flexible stick of whalebone. The tone of the voice did not yet indicate
the existence of a false membrane in the trachea; but the abundance
and the limpidity of the expectorated mucus left no doubt that the
irritation and inflammation which preceded the membranous exuda-
tion were already being propagated into the air-passages.

Now, it matters little, that by the aid of the local treatment, the
diphtheritic inflammation is modified in the pharynx, if by its extension
and its continuous progress in the air-passages it determines the
closure of the larynx or the obliteration of the bronchi.

None of the numerous facts which had been collected in the course
of the epidemic allowed us to hope that general treatment could be
of much service. The mercurial treatment, which was less dangerous
than the hydrochloric fumigations was, therefore, of all the therapeutic
means which had been employed, that which offered the greatest
hope of recovery.

Calomel was at first administered every hour in the dose of three
grams. The tongue, which was covered with a whitish coating,
began, in the evening, to be moist and to clean towards its point.
The swelling of the tonsils was already diminished; we no longer
perceived so much fetor of the breath, and yet the cough was be-
coming hoarse and croupal. Mercurial frictions, every three hours,
each of one drachm, on the neck, the chest, and the arms, were pre-
scribed for the night. ;

On the morning of the fifth day, the mouth did not exhibit any
sign of mercurial affection. The tongue was still cleaner, and over a
greater extent of its surface. Some membraniform exudations floated
in the expectorated matter, which was mucous, abundant and semi-
transparent. It was certain that these exudations were not detached
from the pharynx, and that they came from the trachea; they were
shaped like narrow bands, denticulated and jagged at their edges. Some
MERCURIAL TREATMENT. 79

were as much as three inches long, by two lines, or two lines and a
half broad; they were far from having acquired all the force of co-
hesion of false membranes which have formed complete tubes.
We distinguished in their thick part, on observing them by trans-
mitted light, some rounded pores, or rather some transparent bulle ;
which might be a quarter of a line in diameter ; in fact, they presented
all the characters of commencing diphtheritic exudations. The nature
and origin of these transparent points, which were observed in the
substance of the exudation which was beginning to concrete, did
not appear at all doubtful; they were in fact globules of un-
altered mucus, furnished by the muciparous follicles which were
not yet affected in the same degree as the surfaces which sur-
rounded them. The so-called hydatids or the vesicles observed on
the surface of the tonsils at the commencement of Malignant Angina,
and mentioned by some authors, appear to me to be due also to the
partial elevation of the false membrane, which is slender and im-
perfect, and distended by mucus which is not yet coagulated.

The frictions were continued at longer intervals. A painful and
confluent eruption of pimples which occupied the base of the hairs,
was attributed to the rancidity of the mercurial omtment. The
frictions were continued with recently-prepared ointment upon
the surfaces where the cutaneous irritation did not oppose its
absorption. Calomel was administered as on the preceding day. In
the evening, the cough was less hoarse; and the expectorated matter,
which was less abundant, was distinguished from that of the peoes
night by greater opacity.

The sputa remained distinct in the vessel appropriated to receive
them, andwere isolated by more liquid mucous matters, instead of form-
ing a homogeneous mass as on the preceding days. Some fragments
of false membranes were found in the vessel in great numbers, and were
separated from the other matters with difficulty; they were less long,
and less porous than those of the previous day. (Alvine evacuations
of a deep green colour.)

On the sixth day, after eight frictions and the administration of
a drachm and a half of calomel, the gums and the tongue presented
no indication of mercurial affection. The false membranes of the
pharynx, which were almost entirely detached, left bare the greater
part of the mucous surfaces which they covered, and which were
resuming the appearance of health.

The sputa remained still more separated and more opaque, and it
80 BRETONNEAU’S SECOND MEMOIR.

was difficult to separate from them the pellicular strips with which
they were intimately united. To accomplish this, we were obliged
to shake or rather mash them with water; the mucus was thus
diluted, and the concrete matter, which no longer formed any-
thing but small fragments, was precipitated to the bottom of the
vessel. The frictions were discontinued and we directed an interval
of two hours between each dose of calomel which was now reduced to
two grains.

On the seventh day the pharynx was entirely cleared; the cough
was loose, and catarrhal. We could not suspect that the expectorated
matter, which was abundant, opaque, and muco-puriform, still con-
tained any fragments of false membranes; still, by means of the process
indicated above, a mixture of two pounds weight of water, and of
some ounces of sputa, allowed the deposition of a great quantity of
pellicles, which bore a close resemblance, except in colour, to the
coarse bran of wheat. There were three or four alvine evacuations
during the twenty-four hours. We ceased the mercurial treatment.
Since the previous night, there had been considerable emaciation.
In the space of two days, an ounce of strong mercurial ointment
had been rubbed in, while two drachms and a half of calomel were
administered internally in less than seventy-two hours.

The pulse was frequent, the thirst rather urgent. On the follow-
ing days, the cough, which was simply catarrhal, became less and
less frequent, and the sputa, which were not very abundant, lost
‘their opacity; the appetite was voracious, and convalescence was
now certain.

The severity of the season, prevented me from sending this soldier
back to his Barracks, and for a month, during which he still remained
at the Hospital, he did not experience any mercurial affection of the
mouth; he regained his usual stoutness, and enjoyed perfect health.
This man, who was seen again some months afterwards, still con-
tinued well.

Casr 18.—M. T., aged eight years, of a delicate constitution.
For the last three days, he had suffered from sore-throat, accom-
panied with fever. There was swelling of the sides of the neck,
with tumefaction and redness of the tonsils, which were covered by
enveloping white exudations. Local and not very active treatment,
was repeated three times a day.

On the fourth day, there was slight amendment ; apyrexia ; in the
MERCURIAL TREATMENT. 81

evening, we perceived a membranous spot at the base of the
pharynx ; it descended in a parallel direction to the posterior pillars
of the velum palati, and sunk down beyond the reach of sight.
On the fifth day, the appearance of the pharynx remained the
same; we used local treatment, and the instant the tonsil was
touched, the little patient made a convulsive inspiration. The
cough was attributed to the passage of a small quantity of the acid
mixture into the trachea. Towards the evening, the cough became
frequent and croupal.

Mercurial treatment was substituted for the local applications.
Calomel, in doses of two grains, was administered every hour during
the night and moderate purging was produced. On the sixth day,
there was an abatement of the cough, and the swelling of the sides
of the neck was diminished. On the seventh day, the cough ceased,
and the doses of the calomel were given less frequently: the false
membranes were raised, and in a great measure detached. On the
eighth day, there only remained some small portions of concrete
matter sunk in the clefts of the tonsils. We ceased administering
calomel, and the convalescence was rapid and easy. This child, not-
withstanding all the care which was taken by his parents to preserve
him from the inclemency of the season, was attacked a few days after
his cure, by a bronchial catarrh, which lasted for several weeks.

Casz 19.—V. J., aged thirty months. There was croupal suffoca-
tion, the danger of which we did not recognise until after three days’
fever and uneasiness, attributed to the process of dentition. There
was swelling of the sides of the neck; croupal cough; some white
exudations covered the tonsils, and the lower part of the fauces.
Two grains of calomel were given every half hour,—it seemed
scarcely probable that life could be prolonged until the following
day. On the fourth day, there was slight amelioration of-the most
serious symptoms : the treatment was continued. Moderate purging
was produced ; at intervals, there was imminent suffocation, stupor,
coma, lividity of the countenance; asphyxia was making fearful
progress; but a slight remission followed some of the efforts of
coughing. On the fifth day, the cough, which had been more loose
and catarrhal durmg the night, became hoarse and dry. Five
grains of senega and two of calomel were given alternately every
hour. The emetic effects of the senega were almost instantaneous.
There was a more prolonged interval between the paroxysms of

G
82 BRETONNEAU’S SECOND MEMOIR.

suffocation, and the cough became moist. During the night, there
was imminent danger of suffocation; there were also cough, and
convulsive efforts of deglutition; but the symptoms of Croup sud-
denly ceased.* Liquids were vomited almost as soon as they were
swallowed. The administration of calomel was suspended, and the
doses of senega, which had been already diminished in frequency,
were at last discontinued. The child had now taken, in sixty hours,
three drachms of calomel and a drachm of senega, and he appeared
to be almost restored to his usual state of health. Two days later,
his emaciation and paleness were much more marked. After some
days of satisfactory progress, he was harassed, like the subject of the
previous case, with a loose and frequent cough, unaccompanied by
fever, but eventually he completely recovered.

Casz 20.—P. J., aged six years, of a healthy appearance. For
two days there had been difficult deglutition and considerable swelling
of the sides of then eck; the skin was hot and moist, the pulse
frequent. On the third day, the deglutition had become more pain-
ful; some lichenoid growths, of a yellowish-white colour, and of irre-
gular figure, covered a great part of the surface of the tonsils, which
were red and swollen; hydrochloric acid was applied locally. The
swelling of the sides of the neck was diminished, especially on the
left side. On the fourth day, the morbid growths extended to the
borders of the uvula; the acid was again applied, and portions of a
coriaceous, pellicular membrane remained attached to the sponge.
There was cough; the mercurial treatment was substituted for the
local application. The white precipitate, obtained by the precipita-
tion of the protonitrate of mercury by hydrochlorate of ammonia,
substituted by mistake for English calomel, caused nausea, followed
by three alvine evacuations, accompanied by occasional colicky pains.
During the rest of the day the cough was rather frequent and in its
tone resembled that of catarrh. On the fifth day, the false membranes
were no longer detached, or rather they were being again formed ; they
were circumscribed by an oedematous inflammation. The tonsils

* It was supposed that a membraniform tube, expelled from the larynx,
had been swallowed with the mucous matters which children of this age
are unable to spit out. Notwithstanding the most minute attention, how-
ever, we were unable to discover the remains of it in the vomited matters;
but the same thing had happened in the case of the pharyngeal exuda-

tions, they having been broken up and detached without our even being
able to collect the fragments.”
MERCURIAL TREATMENT. 83

were touched with two grains of white precipitate mixed with honey ;
and half a drachm of mercurial ointment was rubbed into the right
side of the neck. The cough remained catarrhal, but did not become
more frequent ; the application of white precipitate was repeated in
the evening. On the sixth day, the false membranes were losing
their size, and especially their thickness ; they were being detached
without being renewed, and the redness which circumscribed them,
was of a more vermilion colour. The cough, still catarrhal, had
become more soft and less frequent. The cervical lymphatic gland
of the right side had slightly diminished in size, but it was still hard
and painful on pressure; this was the only inconvenience which re-
mained during convalescence. For some days, the return of the
appetite and the child’s generally healthy appearance, left nothing to
be desired, but the swollen lymphatic gland became subsequently the
seat of lancinating pains; it augmented in volume and suppurated
rather slowly. The opening of the abscess allowed some pus of
good appearance to escape, and the health was soon completely
restored.

It cannot be denied that the mercurial treatment has several times
given rise to serious and fatal consequences.

Casz 21.—E. D., aged thirteen, who had a month before been
cured of Diphtheritic Croup by the mercurial treatment, and who had
been often exposed, night and day, in consequence of the misery
and carelessness of her parents, to the influence of cold, died after
two or three days’ illness. Not only had she suffered a mercurial
salivation, but her teeth had been loosened, and three or four of them
had dropped out. Convalescence scarcely appeared to be established
whenthe patient suddenly complained of a circumscribed pleuritic pain,
which, however, yielded in two days to antiphlogistic treatment. On
the third day, she complained only of an intolerable pain in the right
leg, and after having uttered continual cries for a whole night, she
died suddenly.

The opening of the body took place thirty hours after death.

Thoraz.—The right lung was crepitant; but on the left side, the
portion of the pleura which covers anteriorly the lower lobe of the
lung, was slightly rugous, and had a very unusual greenish tint.
The third of the left lung was hepatized. The quantity of rather
deep-coloured yellowish serosity amounted to about five ounces. The

mucous membrane of the trachea was thickened and of a very bright
G2
84 BRETONNEAU'S SECOND MEMOIR.

red colour, as far as the division of the bronchi; the latter were not
obstructed by mucus. The heart and the other viscera of the chest
and abdomen did not deviate from the healthy state. The leg which
had been the seat of acute pain during life was examined with care.
Tt was not swollen, but the cellular tissue appeared by comparison
to be a little more injected than usual. No appreciable lesion was
discovered in the neurilemma or in the nervous filaments of. the
sciatic trunk. Several teeth remained loose ; but there existed no
other traces of membranous mercurial inflammation. Still the last
lesion which I have just indicated was much more serious than had
been at first suspected. The gums no longer adhered to the neck of
the teeth, which yielded to the slightest pressure. On carefully re-
moving the periosteum, in order to examine the state of the sockets, I
discovered a complete necrosis of the two alveolar borders. ‘The forma-
tion of the sequestrum was already sketched out; it was indicated by
an irregular denti¢ulated line, which was advancing more or less on
the body of the maxillary bone, following from within outwards the
two alveolar borders, which would have necessarily exfoliated, if the
patient had survived.

Tur Poisonous Action or Mercury.

The various preparations of mercury (sometimes employed to cure
supposed syphilitic symptoms which might have yielded to ordinary
habits of cleanliness) may occasion severe and obstinate ulcerous
inflammations of the skin and mucous tissue; and the bowels them-
selves are also often affected. In general, additional mercurial treat-
ment is prescribed for inflammations which are caused by mercury, and
there are some facts which induce me to believe that in certain casés
this kind of treatment may dissipate the symptoms by carrying back
the chronic affection to the acute state; but most frequently the dis-
ease is aggravated.

This difference in the action of mercury, or rather this action in
an opposite direction, appears to me to depend principally upon the
mode of administering the drug, which is sometimes given rapidly
and energetically, sometimes more slowly and in a mild form.

The most deleterious effects of this mineral are manifested
after alterative courses, during which it is introduced into the
economy in divided doses. It has been shown, in some of the pre-
ceding cases, that considerable quantities of calomel have been
POISONOUS ACTION OF MERCURY. 85

administered in a very short spacé of time without, producing any
inconvenient results. This difference in the effects of mercury de-
serves the utmost attention on the part of the practitioner. I am
certain that in some cases three grains of calomel have been sufficient
to excite salivation ; that five grains, prepared with suitable precau-
tions, divided into three unequal doses, and taken in the space of six
hours, have also produced salivation, and caused on the surface of
the gums, on the edges of ‘the tongue, and the inside of the cheeks,
pellicular ulcerations which for several weeks have resisted a multi-
tude of therapeutic measures.

The chemical nature of the preparation, the temperature of the air,
and the habits and age of the patient, exercise considerable influence
over the result; though these circumstances operate in a less degree
than the vital manifestations of the organic tissues, which receive
the immediate and direct action of the medicine. The exhalation,
for instance, not being at all augmented, except in proportion as
absorption diminishes, these functions are exercised in an inverse
manner. Thus it may happen that the swallowing of a few grains
of calomel, if followed by constipation, may excite salivation; and
such an effect will be the more rapid, if a discharge, maintained by
a carious tooth, or any pre-existing irritation, draws towards the
mouth the action of the metallic preparation which has been rapidly
absorbed. ‘These circumstances were combined in the cases which I
have just quoted.

The morbid alterations which arise from prolonged mercurial
courses, are often manifested at a very distant interval of time, and
indeed after many years. The most formidable of these affections,
perhaps, is a cachectic state, resembling, in some measure, the scurvy
of seafaring men, but differing from it in several special conditions,
and particularly by its resisting the greater part of the hygienic
measures which are so successfully employed in the cure of true
scurvy. The gums seldom become fungous, and whatever quantity
of blood they allow to escape, the flow of it is not increased by
touching them; but the hemorrhage which takes place at their
surface, is suspended and paroxysmally renewed. In all the cases
which I have observed, the pulse has exhibited considerable fre-
quency (100 to 110), and it habitually preserved a certain degree
of hardness. ’

This is not the place to give an account of some researches in
pathological anatomy bearing upon this subject, and therefore I shall
86 BRETONNEAU’S SECOND MEMOIR.

confine myself to observing that I was not able to discover any
perceptible alteration in the viscera of two subjects who died of
mercurial cachexia, after having presented some of the symptoms
which I have just pointed out.

T have endeavoured, by means of experiments on the lower animals,
to ascertain the effects of some mercurial preparations, and more
particularly to determine the degree of activity of that which is called
by chemists, the protochloride.

First, it was my object to ascertain if we could produce on the
lower animals, effects analogous to those observed on man. One of
my chief aims was also to know if the alterations in the bones were
not constantly preceded by inflammation of the tissues which cover
them.

Three dogs, of average height, were subjected to these experiments
in the winter of 1820. Distinctions of a sufficiently positive cha-
racter were marked between the effects of calomel prepared by sub-
limation, and that obtained by precipitation of the protonitrate of
mercury by means of chloride of sodium or hydrochlorate of ammonia. _
These mercurial salts had a very well-marked emetic and purgative
action. The protochloride, obtained by sublimation through the
steam of water, and known under the name of English calomel, was
the least emetic of all the preparations, and that which exhibited the
most uniform mode of action. These results did not differ much
from those which had been observed in children affected with epi-
demic Croup, except that the strongest dogs could not endure,
without experiencing hypercatharsis, a third of the doses of calomel
which had been administered to the youngest children.

After twelve to fifteen days of this treatment by the protochloride
in divided doses, which were sometimes suspended, the mouth began
to be affected. Chancrous, fungous ulcerations appeared on the
internal surface of the lips ; these ulcers were arranged symmetrically,
and corresponded to the projections of the teeth ; the line of insertion
of the canines exhibited also the commencement of erosion. When
I wished to increase these effects, I obtained only hypercatharsis,
whatever precautions I might take.

I tried the experiment of substituting the protoxide of mercury
for the protochloride; but the mercurial ointment, recently prepared
and administered in small doses, became also violently purgative.

The dog subjected to these experiments was very much emaciated.
We were unable at last to induce it to take the drug, for it recognised
EXPERIMENTS ON DOGS. 87

the presence of the smallest quantity of mercury, in whatever form
we endeavoured to introduce it into its food.

The diarrhoea continued after the total discontinuance of the
treatment ; the evacuations were frequent, mucous and bloody: and
the animal, after refusing all kind of nourishment, expired in the
last stage of marasmus.

The gastro-intestinal mucous membrane was red in a great part of
its extent. This coloration was not easily to be distinguished from
the cadaveric alterations which are so rapidly and strongly mani-
fested in the case of cachectic liquefaction of the blood ; there was no
other connexion with the inflammatory, ulcerative and gangrenous
lesions of the buccal mucous membrane. An alteration of colour,
which indicated a commencement of necrosis, was observed on the
circumference of the alveolus of each of the canine teeth.

Another dog died in the same manner and before the alterations
of the osseous system had been more marked. The mercurial
treatment of the third having been suspended each time that the
diarrhoea had become bloody, the ulcerations of the mouth cicatrized.
The skin of this animal remained for a long time rough; its emacia-
tion was extreme, but in the following spring it recovered consider-
able stoutness and the appearance of perfect health.

Since these experiments were terminated, I have again subjected
many dogs to the action of calomel, for the purpose of ascertaining
the effects of a long irritation directed upon the mucous membrane
of the digestive canal. I shall give an account, in another Memoir,
of the principal results of these last attempts. I shall confine myself
here to the statement that in respect to the effects of mercury, they
presented remarkable varieties.

The first of these animals (a large full-grown spaniel) began
to refuse nourishment, and died on the twenty-second day after
having reached the last stage of marasmus. ‘The night before its
death its limbs were cold, and we could not count more than six
inspirations in the minute. The globe of the eye. appeared entirely
collapsed ; however, we discovered it again under a thick layer of
puriform mucus, but so much atrophied that it occupied only half of
the orbit.

Some saffron-coloured, mucous, sanguinolent motions continued
to be voided with tenesmus and in small quantity. Although the
calomel had not been administered beyond the fourteenth day, the
mercurial ulcerations, which had began to show themselves succes-
88 BRETONNEAU’S SECOND MEMOIR.

sively opposite the projections of the canine teeth, and upon all the
points of the mucous membrane of the mouth exposed to friction,
had extended to the edges of the tongue. Those ulcerations which
corresponded to the last molar teeth, left bare the fibres of the masseter
muscle. In many points the mucous membrane was reduced to a
state of greyish detritus, of the most dirty appearance. Three
hundred and forty-two grains of calomel, divided into unequal and
gradually increasing doses, had been administered.

The second dog (a hound of the same size and age) died in the
same state, but much more rapidly. From the eleventh day, it re-
fused all nourishment, although the strongest dose of calomel had
not been carried farther than sixteen grains, and altogether it had
taken only a hundred and fifty-two grains.

The third dog, a young spaniel, scarcely a year old, and of mid-
dling size, resisted the action of the calomel much longer; the drug
was at first given in small doses gradually increased, namely, it was
carried from two to four, eight, twelve, sixteen, twenty-four and
forty-eight grains, and was continued for more than a month and a
half. When the animal refused the food with which the calomel was
mixed, we succeeded in making it swallow the drug in boluses of
bread-crumb introduced into the pharynx below the isthmus of the
throat. This animal, in spite of its extreme emaciation, preserved a
considerable degree of voracity and a well-marked taste for putre-
fied meat. The superficial mercurial ulcerations which had shown
themselves at first on the upper lip opposite the projections of the
canine teeth, never became fungous and chancrous. They were even
seen to be almost entirely effaced a few days before death.

At the same time, a sanious discharge which escaped from the
orifice of the prepuce, caused the discovery of a very extensive gan-
grenous erosion on the surface of the glans penis, and the rapid
progress of this lesion appeared to be the immediate cause of death.
It ought to be remarked, that this animal, during the time that it was
beginning to experience the effects of the calomel, had made frequent
efforts to cover a bitch of a rather larger size than itself. We
ought also to take into account the difference of temperature ; while
it was submitted to the mercurial treatment, the air was constantly
dry and hot (May and June, 1825). The two other dogs, on the
contrary, had yielded to the poisonous action of mercury, or rather «
to the buccal phlegmasia which it had occasioned, but this was in the
month of September, 1824, and the season had been rainy.
POISONOUS ACTION OF MERCURY. 89

Still it must be admitted that the difference of conditions is far
from giving an explanation of the varieties observed in the results ;
above all, if we consider that to the last dog the calomel was adminis-
tered for a longer period, and in a larger dose than in any of the
preceding cases. The gastro-intestinal mucous membrane, far from
being reddened, was extremely pale, and so atrophied, like the mus-
cular and peritoneal tunics, that the walls of the digestive canal had
become nearly as transparent as gauze.

The experiments which I have just related are not sufficiently
multiplied to decide the greater part of the questions relative to the
variations in the effects of mercury produced by many accessory
conditions ; but they are sufficient to demonstrate a deleterious action
analogous to that which is observed in man. We remarked in neatly
all the cases, liquefaction and decoloration of the blood; pros-
tration of the strength; marasmus and death. Although in man
this action is less marked, and in the earliest infancy the mucous
membrane of the mouth is rarely affected by the use of mercurial
preparations, which easily occasion salivation in adults, still we ought
not to resort to this kind of treatment without due precaution and ade-
quate reasons. ‘The practitioner who knows the danger will alone
know how to prevent it, and if he does not desist in time, he will be
called upon to treat the consequences of his want of caution.

CasE 22.—G. M., aged fifteen months. The uvula as far as its
base, the pillars of the velum palati, and the base of the pharynx
were covered with a thick exudation of a milk-white colour. There
was croupal suffocation. For two days the child’s health seemed
slightly impaired. Calomel was given in four-grain doses every
two hours. Life was prolonged for three days, and death occurred
from asphyxia. /

Autopsy, fifteen hours after death.—The pellicular exudation had
ceased to extend over the anterior part of the velum palati, from
which it was partly detached : it did not descend into the trachea much
below the larynx. The investment which it gave to the epiglottis was
so thick, that, if we had not paid great attention, we might have easily
mistaken the augmentation of its size for an cedematous swelling.
The redness which was observed under the false membrane, and
circumscribed it, was rather vivid. At the posterior part of the
velum palati, the membranous covering was more than a line in thick-
ness, and it lined the whole of the cavity of the nostrils,
90 BRETONNEAU’S SECOND MEMOIR.

Casz 23.—L. F., aged thirteen years, of a feeble constitution, had
been affected, from. the age of nine years with a chronic bronchial
catarrh, which was usually modified by the vicissitudes of the atmos-
phere, although the symptoms were never completely relieved. There
was an habitual, very abundant, muco-puriform expectoration, which
became still more abundant during the period of the exacerbations.

On the first day there was sore-throat, and during the night there
was intense fever, accompanied with delirium: the swelling of the
lymphatic glands was scarcely perceptible; there was swelling of the
tonsils without any appearance of spots. On the second day we
observed, in the middle of the right tonsil, an excavated spot, of a
yellowish-white colour, the appearance of which did not allow us yet
to establish positively the diagnosis of the disease. The right tonsil,
in the greater part of its extent, was of the colour of a piece of flesh
whitened by the action of boiling water. On the third day, the spot
which had been observed on the previous night was elongated, and
now formed a deep, sanious, and greyish furrow. We saw upon a
projecting, isolated point, in the space between the pillars of the velum
palati, a small lichenoid mass, of a yellowish-white colour. Other
similar masses, of an orbicular form and semi-transparent, were. seen
upon the surface of the left tonsil. The most distinct of these, which
was elevated by mucus still in the fluid state, formed one of those
vesicles described by Marteau under the name of hydatids. Two
hours later the spots, which had become more opaque, had ex-
tended; the points, which had presented only a simple alteration of
colour, were now covered with a commencing exudation. There was
swelling of the lymphatic glands on the sides of the neck.

Local treatment was adopted; forty drops of hydrochloric acid
and one ounce of honey. This appplication was repeated in the
evening, and was followed by an appreciable subsidence in the size of
the lymphatic glands on the right side. (This treatment was con-
tinued for two days, and the disease remained quite stationary.)
On the fifth day the cough had become frequent. On the sixth day
the cough was more frequent, and was no longer loose and catarrhal
as usual. The expectorated matter was also very much changed;
it was semi-transparent, frothy, and abundant. The membranous
inflammation of the pharynx continued to extend. The swelling of
the lymphatic glands and of the cellular tissue returned on the night
side of the neck, and at the same time it was much increased. To-
wards the evening, there was cough with croupal suffocation, and
POISONOUS ACTION OF MERCURY. 91

the languishing countenance of the patient was expressive of
fear.

On the seventh day, the respiration became sibilous; there was
somnolence, and lividity of the complexion ; two grains of calomel
were given every half-hour. A cup of coffee dissipated the somno-
lence. The dyspnoea was increased during the night, and the full use
of the intellectual faculties was preserved until the last moment. The
little patient, whose religious principles were a subject of great consola-
tion to his parents, entreated them to moderate the expression of their
grief. He told his mother that he should soon be with God and the
angels, and that he would pray for her. Death occurred in the morning
from the gradual progress of asphyxiawithout anyreturn of somnolence.

The local treatment, which was begun at ihe onset of the
disease and strictly followed up, was not attended with the slightest
success. The conclusions which might have been drawn against
its utility in some cases apparently more desperate, would never-
theless be found to be totally false. I have arrived at the con-
viction, that two accidental circumstances exerted a very unfavourable
influence on the results of the treatment. The antecedent catarrhal
phlegmasia had no doubt hastened and favoured the propagation of
diphtheritic inflammation, and the acid, which was prescribed in
small doses, had not half the strength which it was supposed to
possess.

Autopsy, eighteen hours after death—The body was moderately
stout; the swelling of the sides of the neck was diminished; the
Head was not opened. Thorax.—The pleuree were in a healthy state ;
both lungs were perfectly crepitant, and did not exhibit the slightest
trace of hepatization, either recent or chronic, and we could not dis-
cover the least trace in those organs of any tubercular disease. The
final ramifications of the bronchi were filled with a thick, yellowish,
viscid mucus, completely resembling that which had for so many
years formed the substance of the habitual expectoration. The croupal
exudation reached, on the left side, as far as the fourth subdivisions
of the bronchi, but on the opposite side it penetrated less deeply.
On tracing the course of the air-tubes upwards, we found the false
membrane very adherent; it lost its consistency and thickness in the
trachea. This unusual circumstance was probably due to the fact
that the diphtheritic phlegmasia had been heightened by the old
catarrhal irritation, which no doubt had its principal seat in the
bronchi.
92 BRETONNEAU’S SECOND MEMOIR.

Three days after this child’s death, his mother, who was of |
delicate constitution, and thirty-eight years old, complained of sore
throat, but we could discover only one greyish spot on the surface o
the right tonsil. On the following morning, this spot had becom
larger, though it did not appear to be the commencement of Malig
nant Angina. Still I warned the woman that this slight affectior
might become serious, and that it required careful attention. During
the night between the third and fourth day, the pain became more
acute, added to which there was well-marked fever. We then
perceived three other spots, of a yellowish-white colour, grouped
around the first. The tonsil was swollen, the deglutition was very
painful, and the lichenoid pellicles, which formed the basis of the
spots, were circumscribed by a violet redness of limited extent. A
lymphatic gland, near the angle of the jaw, was very much swollen.

The spots were touched with a sponge. dipped in a mixture of
honey and concentrated hydrochloric acid. A part of the exudations
adhered to the sponge; they were coriaceous and elastic, and they
left. uncovered a surface of a bright-red colour. The fever did not
reappear on the following night. On the morning of the fifth day,
the swelling of the lymphatic glands was much diminished, and the
difficulty of swallowing was less marked. The local application was
repeated on the following day, although no vestige of exudation re-
mained, and the patient did not feel any difficulty in deglutition.

Is it not probable that the affection of the mother and that of
the child were identical? And does not the difference of age and
disposition sufficiently explain the reason why the progress of the
disease was more rapid in one case than in the other?

Casz 24.—E. N., aged nine years, of lymphatic appearance, and
stout.

It was only towards the seventh day of the Malignant Angina
(which was mistaken by the parents for a catarrhal sore-throat, and
was considered as a slight indisposition), that the cough and croupal
suffocation attracted attention. The pharynx was lined with exuda-
tions. I employed only one local application of hydrochloric acid,
somewhat concentrated, and two drachms of calomel were adminis-
tered in divided doses. On the third day of the treatment, the
imminence of the danger induced us to have recourse to frictions, or
rather to repeated mercurial inunctions: we used nine drachms of
strong mercurial ointment.
POISONOUS ACTION OF MERCURY. 93

There was a rapid diminution of the symptoms, and the expectoration
became more easy and catarrhal. On the second day, the coygh
again became drier and more croupal ; continual vomiting was excited
by the calomel, or rather by the frequent passage of lumbricoid as-
carides, which ascended into the esophagus. Light or ten of the
worms were thrown out by this passage. A similar number were
found in the alvine discharges, which were rather frequent. On the
third day of treatment, and the tenth of the disease, the cough re-
mained croupal, but the respiration was free, quite regular, and
scarcely differed from the rhythm of the healthy state ; the same was
the case with the pulse. The tongue was cleaning, and the frequency
of the vomiting induced us to suspend the use of the calomel. During
the night the vomiting ceased, and some spoonfuls of broth were
taken without loathing. On the eleventh day, there was some ap-
petite, and two spoonfuls of soup were allowed. During the course
of the morning, there was sudden aphonia and imminent suffocation
without rhonchus ; the signs of asphyxia were more and more marked,
and death supervened before it was possible to perform tracheotomy.

The mercurial treatment had been pushed with activity, and yet
we could not succeed in producing any sensible affection of the mouth.
The tongue alone was slightly moistened and cleaned, and from the
time when the passage of the worms and the vomitings were pro-
duced by the calomel, the cough became permanently dry and croupal.
I am induced to believe that I have since had recourse, in similar cases,
with some advantage, to the administration of polygala.

It was not unimportant to ascertain how far the diphtheritic
phlegmasia had been modified by the mercurial treatment, and ana-
tomical researches might still teach us if it would really have been
possible to perform tracheotomy with any chance of success.

Autopsy. —The tonsils exhibited, at the base of their folds,
scarcely any remains of the thick exudations with which they had been
covered. We remarked, on the surface of the right tonsil, a slight
erosion, accompanied by an ecchymosis of the sub-mucous tissue,
circumscribed by a pale spot. This spot was composed of a very
slender layer of semi-transparent, very adherent, concrete matter.
A pellicle equally delicate, lined the mucous crypts at the base of
the tongue. We were obliged to look there carefully, in order to
ascertain the existence of this thin layer of concrete matter, which
was removed only with difficulty. At first, we thought that we saw
the mucous tissue naked, and only paler than in the healthy state.
94 BRETONNEAU’S SECOND MEMOIR.

The mucous membrane of the bronchi showed no trace of alteration.
Near the middle of the trachea, some violet-coloured points, which
were pale and faded, and nearly effaced, were the only indica-
tions left of the diphtheritic phlegmasia. The larynx was covered
with a pultaceous exudation of a greyish-white colour, the surface of
which was as if worn out, and detached in strips. At the position
of the ventricles, one of these fragments fell back and obstructed the
aperture of the glottis. The lungs and the rest of the viscera pre-
sented no appreciable morbid alteration.

:

TRACHEOTOMY.
PracticaL OBSERVATIONS.

It is evident that in the case just quoted, tracheotomy could not be
expected to have had immediate success, and that we could not have
avoided placing a tube in the trachea. But it is certain that by intro-
ducing aflexible rod of whalebone, furnished witha fine sponge, through
‘the aperture of the wound, and pushing it towards the larynx, we
might easily have caused the expulsion of the last shreds of concrete
matter.

From that time the air would have had a double means of en-
trance into the respiratory passages; and even supposing that the
surfaces which had been most deeply affected had preserved some
tendency to throw out a new membranous exudation, it was not
impossible that by insufflating calomel in very fine powder into the
larynx, across the wound, this remnant of morbid tendency might
have been efficiently counteracted. Such local treatment would not
have caused us any fear of the inconveniencies which result from
the inhalation of acid vapours.

But in order to facilitate these proceedings, it would be necessary
to prolong, as much as possible towards the sternum, the incision of
the integuments and the trachea, which cannot much augment the
danger of the operation. The facility which would result from this en-
larged incision in withdrawing the detached strips of the false mem-
brane, in introducing a tubular sound, and applying a sponge fixed
upon a flexible rod, from below upwards, across the larynx, can only be
well understood after having performed this operation upon a young
TRACHEOTOMY. 95

subject. In infancy, a great thickness of adipose cellular tissue is
interposed between the skin and the air-tube, the diameter of which is,
in proportion, much less than in the adult. The morbid intumescence
adding besides to the depth of the passage made by the wound, it
happens, if this passage is too limited, that the gum elastic sound can
neither be introduced nor maintained conveniently in its position, and
we find still more difficulty in introducing, into a sinuous channel, the
blades of a pair of forceps, even when we have taken the precaution
to give them the most favourable curve.

The immediate entrance of air into the lungs, before it has been
warmed in the cavity of the mouth and the nose (I had almost said,
before it has undergone a kind of digestion) has been regarded as a
circumstance which adds to the danger of the operation. This mode
of respiration is certainly without inconvenience in the lower animals.
T have left, for more than ten days, a gum elastic tube in the trachea
_ of a young bitch; the animal did not appear at all incommoded,

and the wound cicatrized in a few days after the extraction of the
foreign body.

I have every day occasion to see two horses which breathe by
means of a tin tube of twelve lines in diameter. This tube is fixed to
the centre of a plate which serves to keep it in its place, and which
embraces the anterior part of the neck. These two animals, which
were operated upon three or four years ago, perform their work in a
red-lead manufactory ; they had contracted in this establishment a
noisy difficulty of respiration, which rendered an artificial aperture
necessary for the admission of the air. The tube which had been
placed in the trachea of the animal first operated upon, not having
sufficient dimensions, the respiration remained embarrassed,; but it
became perfectly free, from the period when more amplitude was
given to this channel. During repose, the animal was not too much
out of breath, and the small tube, which was from six to seven lines
in diameter, was sufficient for the necessities of respiration; but as
soon as an attempt was made to set the horse to work, it began

- panting, and could only be made useful when a tube of an inch in
diameter was substituted for the smaller one.

The best argument in favour of this operation would be an ex-
ample of cure obtained by its means, in the last stage of tracheal
Diphthérite. In the case which I am about to quote, it prolonged life
only a few moments.
96 BRETONNEAU’S SECOND MEMOIR.

Cast 25.—P. C., aged four years. Had sore-throat; on the second
day of this slight indisposition, the ordinary medical attendant of the
family prescribed an emetic. On the third day, I was called in in
consultation and recognised pellicular Angina. As both tonsils were
covered with exudations, I advised the application of a sponge dipped
in hydrochloric acid and honey. During the two following days, the
differences of opinion as to the case, caused the suspension of the
local treatment, but the alteration of the tone of the voice and the
cough, which became croupal, induced us to return to it. On the
sixth day, asphyxia seemed imminent, and the parents requested that
tracheotomy should be performed. During the preparations for the
operation, and before the trachea was opened, the little patient ap-
peared to have ceased to live. Atmospheric air was introduced
through the wound, and alternating pressure was made upon the walls -
of the chest. The functions of life appeared to be completely sus-
pended for two minutes; there were doubtful efforts of respiration,
and then deep, noisy, rattling, inspirations, accompanied by spas-
modic movements. The child raised himself and then fell back again ;
there was convulsive cough; and mucous matters mixed with blood
issued through the aperture of a portion of gum elastic tube placed
in the trachea. This instrument, which appeared to be obstructed,
was removed for a moment, and some slender and tubulated frag-
ments of false membranes, mixed with mucus, were expelled through
the wound. The respiration became more calm and easy ; the leaden
tint’ of the face and extremities was changed to an animated hue.
By the movement of the lips the child seemed to ask for drink. The
pulse was regular and moderately frequent ; the respiration was exe-
cuted with facility through the tubular sound. In the evening the
pulse became rapid; there was agitation, anxiety, panting, but not
very noisy respiration. The frequency and the smallness of the pulse
increased every instant ; and death took place twelve hours after the
operation. Up to the last moment, the air had free access into the
respiratory passages.

Autopsy, sixteen hours after death.—The closure of the larynx
was almost complete. The thick, coriaceous false membrane adhered
strongly to the glottis: it was detached more easily from the walls of
the larynx below the ventricles ; in the vicinity of the incision it had
not been reproduced. The mucous membrane of the trachea and
bronchi was slightly reddened in several places, and dotted with points
of a deeper red colour. To a considerable distance in the bronchial
BLOOD-LETTING. 97

tubes, small partial exudations covered the centre of the broadest
spots, and these fragments of pellicle were removed with so much
facility that they appeared to be only applied upon and not attached
to the surface. A common fly had reached as far as one of the sub-
divisions of the bronchi; it had probably been drawn in by inspira-
tion, after having introduced itself by the tube. The lungs were
crepitant over their whole extent. We observed on their sharp edge
an emphysematous swelling which extended over their surface,
following the interstices of the pulmonary lobes. The lesions ob-
served in this case do not explain the suddenness of the death. Did
not the duration of the asphyxia add to the danger arising from the
extension of the diphtheritic phlegmasia ?

BLOOD-LETTING.

Numerous facts have proved to me that blood-letting does not
retard the progress of the diphtheritic phlegmasia. Its inefficacy has
already been proved by the cases above recorded. In the case of a
young Englishwoman who was affected with Malignant Angina, ap-
parently in a mild degree, I saw the symptoms of Croup break forth
immediately after the application of leeches. The flow of blood had
been so abundant and so much prolonged, that the face, the tongue,
and the lips were completely blanched. (The clots and the portion
of blood soaked into the clothes, might be estimated at nearly two
pounds.) The diphtheritic affection of the air-passages made rapid
progress and became quickly fatal. Five or six days after her death
her youngest sister was also seriously affected with Pharyngeal Diph-
theritic Angina. The extension of the disease to the air-passages
was prevented by local treatment, to which was joined the prophy-

lactic employment of calomel. This young person’s governess had
died before her of the same affection, and there could be no doubt
that it had been transmitted to the two sisters by contagion.

I subjoin an example of the inefficacy of blood-letting, and I
have chosen it among many others not less striking.

I was called to give my opinion upon the nature of an anginal
affection with which a child of six years old had just been attacked, and
I at once recognised Pharyngeal Diphtherite, seeing that a whitish,
lichenoid, pellicular exudation already covered a third of the sur-
face of the left tonsil, which was red and swollen. The cervical lym-

H
98 BRETONNEAU’S SECOND MEMOIR.

phatic glands of the same side were considerably enlarged. Twelve
leeches had already been applied, and after an abundant flow of
blood, deglutition was rather less painful. The medical man in at-
tendance, encouraged by this first success, ordered a second applica-
tion of leeches. The blood continued to flow for several hours. The
next day, thick diphtheritic membranes covered the pharynx. In
the evening, there was frequent cough, with mucous, frothy expecto-
ration. In the night, the cough became less frequent, and it was at
the same time short and hoarse. The following day, there was no
longer any doubt that the air-passages were attacked by the diph-
theritic inflammation. The left tonsil extended beyond the anterior
pillar of the velum palati, and appeared to be carried as far as the
front of the ascending ramus of the inferior maxillary bone. The
last symptoms, which had just appeared, characterized epidemic
Croup; they became rapidly aggravated, and the patient died forty-
eight hours after their appearance.

Autopsy.—The false membrane did not reach beyond the first di-
visions of the bronchi; it penetrated far forwards into the nostrils.
The projecting body which had been mistaken for the tumefied tonsil,
covered by a membraniform pellicle, was nothing else than an
agglomeration of concrete matters, formed of successive layers, and
more than eight lines thick.

Not only does blood-letting fail to retard the symptoms of the
diphtheritic phlegmasia, but the latter even seem, on the contrary,
to be developed with unusual rapidity in cachectic persons, whose
blood has been decolorized and attenuated by any previous disease.

Casz 26.—R. C., aged sixty-two years, of a feeble appearance.
This woman, who had suffered from cold since the commencement of
the severe weather, and had endured all the privations of indigence,
appeared to have been attacked with a chronic pulmonary catarrh.
On her admission into the Infirmary, the matter expectorated, the
percussion of the chest, and the pale-yellow tint of the face indicated
that pleuro-pneumonia was joined to the catarrh. ‘This state lasted
for a month, and then appeared to improve a little. There was
slight pain in the throat, neglected by the patient, who passed the
day out of bed. The difficulty of deglutition and the alteration in
the tone of the voice at length induced a student to examine the
state of the back of the mouth; but no redness could be perceived
there; the uvula and velum palati appeared only swollen. The next
BLOOD-LETTING. : 99

day, at the morning visit, there was depression of the pulse, which
was tremulous and irregular ; the movements of respiration were feebly
performed in an almost doubtful manner, and without the least
noise. The patient replied in a feeble voice, but with accuracy
and presence of mind, to the questions addressed to her. There
was no other pain except a slight smarting in the throat. An
alteration of the features was added to the other signs of imminent
danger; the approach of death prevented the exploration of the
pharynx.

Autopsy, twenty-four hours after death—A great quantity of se-
rosity, of a greenish-yellow colour, flowed out of the left cavity of
the thorax ; itescaped in much less quantity from the opposite side ;
the total amount of liquid effused into the pleuree might be estimated
at about two quarts. There was greyish and rather compact cedema-
tous hepatization of a great portion of the left lung.

At first sight, the mucous membrane of the trachea and the larynx
seemed pale, and that which lined the back of the mouth, appeared
at once pale and swollen. The edges of the epiglottis especially were
remarkably thickened. A redness, with points of a more deep-red
colour, exactly resembling that which characterized diphtheritic in-
flammation, was observed towards the middle of the trachea, where
it formed unequally prolonged -strie. This peculiarity caused a
pellicle to be observed, the existence of which might not have been
even suspected if we had not seen it separated and elevated, on
the edges of the incision made into the windpipe.

This pellicle was ‘so easily removed, that it was evidently only a
slender, semi-transparent false membrane, which became thicker in
the larynx, and was extended, though becoming thin again, over all
the mucous membrane covering the back of the mouth. The
apparent swelling of the edges of the glottis proceeded from a sheath
which was furnished toit by this same covering. Although the false
membrane was not very transparent in any of the points where it had
acquired thickness, yet the deep-red colour of the subjacent parts,
and the interposed blood:had given it the colour and appearance of
the mucous coat, while on the other hand, the uninterrupted con-
tinuity of this membraniform layer completed the illusion.

For some time there had existed a serous effusion in the left cavity:
of the thorax, and it had suddenly increased. "Whatever may have
been the influence of the diphtheritic phlegmasia upon the termina-

tion of the primary disease, the points worthy of remark, were the
H 2
100 BRETONNEAU’S SECOND MEMOIR.

rapidity and intensity of its development in a worn-out subject,
all of whose tissues presented an anzemic paleness.

It is probable that, notwithstanding the thickness and extent of
the false membrane, the lesions peculiar to pellicular phlegmasia
would have been mistaken if this case had not been observed towards
the end of an epidemic, during which my attention had been so often
attracted to this kind of alteration.

Cass 27.—G. M., aged nine years, had been convalescent for three
weeks from an attack of autumnal tertian fever, and had remained
emaciated, feeble, and pale. She suffered from some febrile excite-
ment, which, in the first instance, was thought to be a relapse of the
first illness. An abundant excretion of limpid, transparent rose-
tinted sputa led us to suspect that the gums were affected with
diphtheritic inflammation. They were examined and found very
pale. More than a month had elapsed since the epidemic affection
had ceased to exhibit itself, and the terror which it had inspired was
beginning to abate.

The sides of the neck and the lower part of the throat could be
rather roughly pressed, without the child evincing the slightest
pain. It appeared to me useless to depress the base of the tongue
and to examine the pharynx. There was apyrexia in the morning,
slight fever at night, and catarrhal cough. On the third day, a con-
siderable swelling, which appeared under the right ear, behind the
angle of the jaw, and which ought to have excited a salutary appre-
hension, became an object inspiring confidence. It was mistaken
for the result of the contagious and epidemic inflammation of the
parotid gland, known by the name of orei//ons (mumps). The febrile
excitement which had been noticed was attributed to the affection of
the salivary gland. However, the region of the larynx and the sides
of the neck were touched and pressed, and the little patient assured
us that she did not suffer any pain, and that she had no sore-throat.
In the night there was croupal suffocation, and the pupil in attend-
ance found the tonsils covered with pellicular exudations. (Local
treatment of concentrated hydrochloric acid and fumigation of
chlorine.) A membraniform tube, more than three inches long,
floated in the midst of the expectorated mucus. The attacks of
croupal suffocation were renewed three times during the four and
twenty hours, but with less intensity.

- On the fourth day the same treatment was pursued, the attacks of
BLOOD-LETTING. — 101

suffocation were less frequent, the swelling of the sides of the neck
was sensibly diminished. On the fifth day, the tonsils were no longer
swollen, the voice still remained hoarse. (Inhalation of chlorine in
the morning.) The patient was up all day, and in the evening she
joined several other little girls in going into the court-yard of the
establishment, and carried a bunch of flowers. On her return to the
Infirmary, she lay down without feeling any difficulty of respiration,
slept calmly until three o’clock in the morning, and died in a few
moments from an attack of suffocation.

Autopsy, twelve hours after death—The tonsils and velum palati
were in a healthy state. The false membrane reached as far the large
divisions of the bronchi; it was thin, and floating in the inferior
part of the trachea, and adhered feebly to the walls of the larynx.
The passage of the air appeared to have been intercepted less by the
immediate occlusion of the glottis, than by the detached portions of
the false membrane which had performed the office of valves. The
punctiform redness of the mucous coat was not very apparent.

Fumigations had already been employed at the General Hospital,
and with much more successful results, upon a young female orphan
of the same age, and in whom the pellicular inflammation seemed to
have been propagated further into the trachea. A long portion of
tube having been at first expectorated, each fumigation had afterwards
excited the expulsion of large fragments of membraniform layers,
and on the third day of the treatment, after having had recourse, for
the fifth time, to the inhalation of the hydrochloric vapour, the attacks
of croupal suffocation were no longer renewed. During several
weeks, the voice was only hoarse and indistinct.

Case 28.—Z. L., aged twenty-seven years ; an epileptic idiot, con-
valescent from a-putrid fever (dothinentérie), had been reduced, by
her first illness, to a state of weakness and exhaustion which was
showing some signs of amendment, when it was perceived that the
deglutition was embarrassed, although the patient took, without com-
plaining, and indeed with a voracious appetite, the food which was
brought to her. The next day, there was swelling of the sides of the
neck, with livid redness and swelling of the tonsils, of the velum
palati and of the uvula: some lichenoid, greyish-white exudations,
extended irregularly upon the swollen parts; the cough was frequent,
short, and hoarse ; there was abundant spitting of transparent frothy’
102 BRETONNEAU’S SECOND MEMOIR.

mucus ; fetor of the breath, the same appetite as on the preceding
days, and the same coolness of the skin. Pulse, sixty-seven.

Diagnosis.—Pharyngeal and Tracheal Diphtheritic Angina. Mer-
curial treatment. Prognosis.—Approaching death. The next morn-
ing, the anterior third of the tongue became moist and clean ; dyspnea
in the evening; the cough less frequent; aphonia; puffiness and
lividity of the face ; and death occurred in the night.

Autopsy.—There was considerable enlargement of the lymphatic
glands of the neck. The membraniform tube which lined the trachea
did not extend below its inferior third ; it was terminated by irregular
prolongations bordered by diphtheritic redness, which was very well
marked on all the parts which were the seat of the affection. The
false membranes of the pharynx were raised with the same facility as
those of the trachea. A complete sheath of concrete matter enveloped
the uvula.

These last three cases show at least that the diphtheritic phleg-
masia does not lose any of its intensity in subjects weakened by
previous diseases.

BLISTERS.

The insufficiency of the general measures which were resorted to
during the continuance of the epidemic has been so often proved,
that I have, perhaps, been induced too exclusively to restrict the treat-
ment to special remedies. Although these measures are incapable of
modifying the diphtheritic phlegmasia, it is yet possible that they
may be of some utility as auxiliary resources.

Will not flying blisters which exercise such a remarkable influence
over inflammatory swelling of the cellular tissue, diminish also
the swelling of the sides of the neck? Does not the cedematous
affection of all the tissues which are in the vicinity of the larynx and
trachea act in the same manner as the immediate causes of strangu-
lation? The affection of the adjacent parts undoubtedly contributes
very little in diminishing the dimensions of the air-tubes; but the
slightest addition to the obstacle opposed to the passage of the air
becomes of the greatest importance.

We may prove this fact by trying to breathe through the tube of
a pen, the extremity of which presents only a small aperture. It will
be easy to show that a slight difference in the diameter of the orifice
induces a very great alteration, both in the possibility of supporting
BLISTERS. 103

the dyspnoea always manifested after a certain degree of contraction,
and in the rapidity of the progress of suffocation which necessitates
the interruption of the experiment.*

‘The greater part of those who died of epidemic Croup, still bore
on their necks the traces of blisters, the suppuration of which had been
excited and maintained ; but, by this very circumstance, the desired
object may perhaps have been frustrated.

By flying blisters, I strictly mean those the application of which
is not continued beyond the commencement of vesication. I have
noticed that an irritation which extends beyond the surface of the
derma often increases the inflammation which we wish to modify. I
say modify, and I purposely make use of so vague an expression, for
I am far from understanding how a blister can dissipate the redness
of erysipelas in a few houts; how, in this case, the swelling and
the pain of the inflamed surface disappear in proportion as the epi-
dermis is raised ; and how, on the contrary, the rather more prolonged
action of the same agent determines, in other cases, an erysipelatous
affection. Circumstances, apparently of little importance, produce
so great a variety in therapeutical results, that the inflammatory red-
ness of the papillary body, occasioned by the accidental removal of
the epidermis, sometimes counteracts the good effects which had
already been obtained.

This kind of treatment, therefore, requires scrupulous attention, and
the application which is nearest to the seat of the phlegmasia is
the most efficacious; but, in this case also, it is more to be feared
that the irritation of the skin may be transmitted by contiguity to
the tissues already affected, and it is then especially necessary to
limit and to proportion, in some manner, the effects of vesication.

The temperature of the skin, its healthy or morbid state, its dry-
ness or moisture, the thickness of the epidermis, and other peculi-
arities which depend on the patient, and are not under the control of
the physician, may cause variations in the action of cantharides. The
qualities of the vesicant and its mode of application are also causes
of uncertainty which can be more easily determined.

To M. Robiquet we owe the demonstration that the blistering
principle of cantharides is very soluble in fatty bodies. I have been
led, by the analysis which he has published, to employ vesicatories
slightly moistened with oil, and I have never failed to perceive that

* This observation is of the highest importance in the choice of the
canula in the operation of tracheotomy.
104 BRETONNEAU'S SECOND MEMOIR.

their action thus become more prompt and energetic ; that it was not
even sensibly diminished by the interposition of a sheet of paper,
which was easily penetrated by the solution of the active principle.
This mode of application, which I believe is used in England, appeats
to me to have been employed with the intention of attenuating the
effects of the blister, which however become on the contrary, more
rapid and certain.

The epidermis, not being in contact either with the powder of
cantharides or with the matter of the plaister, is sound, and does not
adhere at all to the plaister at the time when it is necessary to remove
it. It is therefore easy to manage the plaister and to prevent the redness
of the derma, since we avoid, on the one hand, the influence of the air,
and on the other, the prolonged action of the particles of the epi-
spastic substance, which, in the ordinary proceedings, it is often diffi-
cult to remove. I have already stated, that the inflammatory redness of
the derma, far from acting in the same manner as a superficial vesica-
tion, may aggravate the phlegmasia which we wish to subdue. It is
another mode of irritation, very different from that which is solely
due to the simple and isolated action of cantharides ; for I repeat,
that the erysipelatous redness does not begin by progressively ad-
vancing: it is dissipated and extinguished in proportion as the
vesication is effected.

The serosity of the phlyctene therefore should be allowed to
escape only by little drops. Another advantage results from this
measure ; we avoid those brown spots, more or less deep in tint, and
sometimes indelible, which blisters never leave unless the derma has
been reddened.

Six or seven hours of the application of such a blister are suffi-
cient, in ordinary cases, for obtaining a very well-marked effect.
When it is desirable to limit the action of the epispastic to a super-
ficial vesication, we must not even wait until the epidermis begins
to be elevated, for it is sufficient for the surface of the skin to be
slightly wrinkled in order to develope a phlyctena in a very short
period.*

* During six years when the mode of application I have just described
was adopted at the General Hospital, ischuria was not once caused by the
most extensive vesications.
LOCAL TREATMENT. 105

Action or Potyeata (SENEGA).

The effects of this medicinal substance are very energetic; in the
dose of a few grains it is emetic and purgative. It also exerts a
special action on the inflamed mucous membrane of the air-passages,
the secretion of which it promotes and modifies. A great number of
cases have proved to me that immediately after the administration
of senega, given in divided doses, the muco-puriform expectoration
peculiar to chronic catarrh, either simple or complicated with tuber-
cular pulmonary phthisis, becomes more fluid and abundant.

The suspension of the medicine was followed by such an imme-
diate modification in an inverse direction, that this kind of influence
permits me to entertain no doubt on the subject. This property
has particularly induced me to associate senega with calomel, especially
in the cases where the dryness of the mucous surfaces, indicated by
the hardness of the cough, appeared to have been the principal ob-
stacle to the expulsion of the false membranes.

LOCAL TREATMENT.
Hyprocutoric Acip.

Concentrated hydrochloric acid, applied to the healthy mucous
membranes, developes a fibrinous inflammation. A superficial touch,
when made for the first time, whitens the epithelium, which is
detached and renewed without causing any erosion. But if the
action of the acid is prolonged, or its application repeated at short
intervals, it produees an ulceration, which is covered with a whitish
coating, and takes more or less time to cicatrize. It is necessary to
be aware of this mode of action when we have recourse to applica-
tions of hydrochloric acid in modifying diphtheritic inflammation,
in order not to confound the phenomena of the medication with
those of the disease ; otherwise we might prolong the treatment much
further than is necessary. It is best for the first applications to
be energetic and less frequently repeated. I have tried various
methods; the following is that to which I have finally given the
preference.
106 BRETONNEAU’S SECOND MEMOIR.

In order to apply the acid to the base of the pharynx and upon
the tonsils, I make use of a fine sponge* firmly fixed at the end of
a flexible rod of whalebone, and I give to this rod a suitable curve
after warming and softening it at the fire. Before touching the
membranous spots on the throat, I take care to dip the sponge in
concentrated acid and to press it so that it shall remain simply
moistened. I take this precaution so that, in the convulsive move-
ments of the isthmus of the throat, the expressed liquid may not
extend its action beyond the point I intend to cauterize.

In this way it is easier to direct and to graduate the action of the
caustic than by weakening it with different proportions of honey.
Although this latter mixture has less activity, yet the quantity we
are obliged to employ does not allow us to circumscribe its effect
within a determinate space ; it flows and spreads far beyond the point
which has been touched. It is therefore only in the cases in which
the diphtheritic inflammation of the pharynx extends beyond the
reach of sight that this last mode of application should be preferred.

The first effect of the local treatment is to give a more serious
aspect to the commencing diphtheritic inflammation ; the exudations
appear at first to be thicker and more extensive; but twenty-four
hours later the effects of the acid are limited, and have attained their
final point. If the exudations do not increase in extent, or they
begin to be detached, we are sure that the specific inflammation is
already modified ; from that period the local applications ought to be
used at more distant intervals (from twenty-four to thirty hours)
restricted in number (two or three are sufficient) and also in strength
and duration (they ought to be more and more slight and confined to
the affected surfaces).

The authors of the sixteenth century agree in reprobating the
forcible removal of the false membranes, and also scarifications, together
with all roughness of frictions and applications. I have had occasion
several times to convince myself of the justice of these precepts, and I
have seen the pellicular inflammation aggravated by all kinds of
mechanical irritation. When the disease is not arrested in its pro-
gress by two energetic applications, made at an interval of twenty-
four hours, and the signs of the affection of the air-passages begin

* For an adult, the sponge at first moistened and afterwards well wiped
ought to be as large as a pigeon’s egg. When shrivelled by the action of
the acid, it is reduced almost to half its volume by suitable pressure.
DIAGNOSIS OF DIPHTHERITE. 107

to be manifested, the local treatment offers very uncertain chances of
recovery, and it would be imprudent not to abandon it in order to
have recourse to mercurial medicines.

DISEASES WHICH PRESENT THE SAME APPEARANCES AS
DIPHTHERITIC ANGINA.

The name of Croup, given by Francis Home to Malignant Angina,
has become the source of misunderstandings which have not been
dissipated by the labours of many able writers who have been called
upon to furnish the results of their knowledge upon this subject.
This is one of the innumerable examples of the magic influence of a
word. In the same manner, the denomination of Gangrenous Sore-
throat, employed to designate this disease, has often prevented us
from recognising it in an affection which offers no trace of true
sphacelus.

Under a new name, Malignant Angina, an affection observed
for many centuries, has become a new disease of a totally different
nature, and one which, far from demanding the same treatment,
requires a totally opposite one. Although the authors of some of
the Memoirs presented to the Concours of 1809 were led, by the
force of truth, to discuss the question of the identity of Croup and
Malignant Angina, they resolved it in the negative, and although the
most positive opinions on this disease had been collected from age to
age, the influence of the word prevailed, and they have been regarded
as valueless.

It is true that at a period when the importance of anatomical re-
searches, necessary to elucidate the nature of the morbid lesions, was
not generally felt, the character of the alterations which render Pel-
licular Angina so formidable was imperfectly understood. But it
cannot be denied that the whole of its symptoms, its epidemic
propagation by means of contagion, and the danger which it causes
by its extension into the respiratory passages, are found very accu-
rately recorded in the treatises left us in relation to this disease by
the physicians of the sixteenth century. During the progress of
the destructive epidemics which ravaged Spain and Italy, experi-
mental investigations, made upon a large scale, had also demonstrated
the inefficiency of the general and most rational kinds of treat-
ment.
108 BRETONNEAU’S SECOND MEMOIR.

The new disease had scarcely been described by Home, when every
practitioner, fearing lest he should mistake it, did not fail to meet
with it. It now became so frequent, that popular instructions were
addressed to parents to put them on their guard against the danger
with which their children were threatened. Several methods of
treatment, placed within their reach, were also advised, as if technical
words, the value of which remains undetermined, and which every
reader interprets as he thinks proper, were capable of transmitting
the difficult art of distinguishing diseases, supplying the habit of
seeing and comparing, and in a word, of taking the place of that
medical education of the senses so well described by Corvisart, and
which he himself so studiously pursued; asif a mother, distressed by
the anxiety she has caused herself by reading these kind of books,
could comprehend and distinguish the importance of every symptom !
Still the observations on Croup were multiplied, and a great number
of special accounts of this disease were collected in the medical jour-
nals, or published in works professedly devoted to the subject.
Distinctions have been drawn between sthenic and asthenic Croup,
acute and chronic, variolous, morbillous, scarlatinal, &c. It cannot
be doubted that Diphtheritic Angina is not named sufficiently
often among some of the stridulous lesions of respiration, especially
among those, the termination of which was fatal; while on the con-
trary, in the cases where the antiphlogistic and derivative treatment
was followed by rapid success, it is probable that another phlegmasia,
of a serious or mild character, but of a different nature, was con-
founded with this formidable disease.

Diphtheritic Pharyngeal Angina is simulated by Scarlatinal An-
gina, by common Membranous Angina, and by different inflammations
of the mucous membrane of the larynx or trachea.

T have already noticed, in the second part of this work, the ob-
scurity which is thrown over the diagnosis of Malignant Angina by
the difficulty of discovering the distinctive characters peculiar to the
different affections presenting themselves under the same appear-
ances. We shall succeed only by the aid of observation and by
directing considerable attention to the subject, in determining the
limits which separate them. In giving a greater scope to this part
of my researches, I shall confine myself to pointing out the prin-
cipal distinctions by which I have seen Scarlatinal Angina, common
Membranous Angina, and some cases of Laryngeal Angina resem-
bling Tracheal Diphthérite, separated from one another, and: from
DIAGNOSIS OF DIPHTHERITE. 109

Malignant Angina. I purposely avoid speaking of Phlegmonous
Tonsillitis, of aphthous inflammation of the back of the mouth, and
of Catarrhal Angina, these three kinds of Angina having too well
marked characters to make us liable to confound them with Diph-
thérite.

The special phlegmasiz of the mucous tissue are besides so diver-
sified, that I have never met, in my practice, with examples of all
those which may assume the appearance of diphtheritic inflammation.

ScaRLATINAL ANGINA.

Although the cutaneous eruption which usually accompanies
Scarlatinal Angina presents a character which is easily discerned,
it cannot be doubted that the phlegmasia of the pharynx proper to
Scarlatina often exists without bemg accompanied by the other
symptoms of Scarlatina. It is especially in this case that the
membranous inflammation of the tonsils presents a fallacious re-
semblance to pellicular inflammation. Some characters, however,
still assist us in distinguishing them. In Scarlatinal Angina, the
superficial ulceration of the tonsils is rather coated with an inti-
mately adherent membranous exudation than covered with mem-
braniform pellicles. Although a white, opaque, caseiform secretion
appears to cover the bright redness of the velum palati and the
walls of the pharynx, it soon becomes furrowed, and assumes
neither the lichenoid aspect nor the coherence of a false mem-
brane. The tonsils are in fact the principal seat of the inflam-
mation, but the whole cavity of the back of the mouth and nostrils
is simultaneously attacked by an acute inflammation, and the origin
of the morbid affection is not, as im Diphthérite, at first limited.
and circumscribed. Lastly, there is a more important differen-
tial character of the scarlatinal phlegmasia of the pharynx; it has no
tendency to propagate itself into the air-tubes.* I will not
now mention the cases which have been observed by myself: let it suffice
to say, that I have thrice ascertained by autopsy, that the larynx

* During the course of several epidemics of Scarlatina which I have had
occasion to observe for twenty years, and some of which have been suffi-
ciently serious to cause the death of a great number of patients, I have
never once seen death caused by the propagation of phlegmasia into the
larynx, and by closure of the glottis.
110 BRETONNEAU’S SECOND MEMOIR.

and trachea remained perfectly free from inflammation, although
the membranous ulceration of the tonsils presented itself under
an appearance most resembling sphacelus of the back of the
mouth, and although the prolonged rattle of the death-struggle
made me doubt whether the difficulty of respiration was not the
result of a mechanical obstacle.

A small number of isolated facts would not suffice to determine a
question of such importance ; but unexceptionable evidence may be
adduced in abundance in the same direction. Since the publication
of this opinion, the results of my first observations have been con-
firmed by new necroscopical researches which I have had occasion
to make on the dead bodies of six individuals carried off by scar-
latina. It has been more and more demonstrated to me that death
did not occur from any appreciable inflammatory lesion. The
blood unequally distributed in the splanchnic cavities, was abundant
in the head, superabundant in the thorax, and was wanting in the
abdomen. The danger of this disease is not at all proportionate to
the intensity of the membranous inflammation of the pharynx; I
have seen it become fatal eighteen hours after its invasion, and with-
out the redness and swelling of the tonsils becoming very apparent.
Even in the very cases in which the sore-throat had presented the
greatest intensity, I became convinced that this symptom, which espe-
cially attracts attention, had little influence. on the result of the
disease. This affection was very destructive in several communes
of this department, but how could we believe that death was
caused by an inflammation which is often limited to a slight tonsillitis,
when after a more or less painful convalescence, we saw a number of
individuals recover, in whom the membranous inflammation of the
back of the mouth resembled the last stage of sphacelus. Pathological
anatomyno longer permits me to doubt that those inflammatorylesions,
whether severe or mild, which do not extend beyond the pharynx,
are not the causes of death, an event attributable to a miasmatic
poisoning leaving no traces behind it. It is to this same
poisoning that we are obliged to refer the frequency and the ever in-
creasing difficulty of respiration ; the frequency and the irregularity,
and in a word, that extreme disorder of the circulation, which does
not allow of the pulse being counted for a quarter of a minute.

It is sufficient to read the learned dissertation of Fothergill to be
made aware that although Diphtheritic Angina was the object of his
historical researches, it was really Scarlatinal Angina which he ob-
DIAGNOSIS OF DIPHTHERITE. 111

served and described. Thus the disease which he has in view, is
very different in its progress, course, mode of termination, and the
combination of its symptoms, from the true Malignant Angina with
which he continually wishes to. associate it, and itis astonishing that
he was not struck by their remarkable diversity.

In no epidemic of Scarlatinal Angina do we find mention of stridu-
lous suffocation as one of the symptoms of the disease; even in
those in which membranous inflammation of the tonsils has principally
attracted attention, and which have been described under the deno-
mination of gangrenous sore-throats, it is most generally diarrhea,
leucophlegmasia, and hectic fever which precede the slowly super-
vening secutive fatal termination.

During the course of a destructive epidemic observed at Peruwelz,
a great number of patients fell into a state of general swelling and
died slowly. Although some of them were more rapidly carried off,
no particular or notable lesion of the respiration was joined to the
ordinary symptoms of Scarlatina. (See the Description of the epi-
demic and gangrenous sore-throats which prevailed at Peruwelz, in
Hainaut, Journal de Medecine, tom. xxxi. December, 1769.) Al-
though the practitioner to whom we owe this notice is manifestly
prepossessed with the idea of finding, in the disease which he ob-
served, the gangrenous sore-throat described by Marteau de Grand-
villiers in the same Journal some years before, yet we perceive that
the crasse aphtheuse, of which M. Plauchon speaks, “which,” says he,
“covers the inflamed velum palati and afterwards is insensibly de-
tached,” cannot be confounded with the coriaceous, membraniform,
diphtheritic pellicles, mistaken by Marteau for eschars or exfoliations.

The distinctions existing between two such opposite affections
overcome the preconceived views of the author, for he himself makes
the remark that “few patients died at the height of the disease,” and
he concludes by adding; “This detail, compared to that which has
been given to the public by M. Marteau, allows us to catch a glimpse
of a notable difference between the two epidemics, the nature of
which was the same, without producing the same effects ; ours was
mild, and its termination was not so treacherous.”

The distinction would have appeared to him still more striking, if
Marteau had not comprehended, under one generic distinction, the
Pellicular and Scarlatinal Angina, diseases which he describes
separately, but afterwards unites together, and which unques-
112 BRETONNEAU’S SECOND MEMOIR.

tionably he met with separately and consecutively in his practice,
so that his opinions on the true character of Malignant Angina,
which at first were pretty exact, appear to have been altered by
the subsequent examination of the analogous lesions presented by
Scarlatinal Angina.

In fact, Dr. Albers, of Bremen, who shared with Dr. Jurine, of
Geneva, the prize decreed to the best Memoir on Croup, says, that
he has often met with the complication of Croup with Scarlatina.
The following passage occurs in the Report addressed to the Minister
by the Commission intrusted with the examination and adjudica-
tion of the works sent to the Concours :—

“The most formidable of all the complications of Croup is, that of
Scarlatina. The author has unfortunately had numerous opportunities
of observing it, and he has related several examples. He has only
thrice seen Croup assume a sthenic character; the disease was
generally typhoid. In the first of these two kinds, the inflammation
was violent ; but the prompt administration of remedies succeeded in
arresting the mischief; in the second, the patients almost all died,
and the author admits having lost as many as thirty-six. The sym-
ptoms of Gangrenous Angina were found in these cases united with
the symptoms of Croup; such an acrid discharge escaped from
the nostrils as to corrode the ale nasi and the lips. An excessive
swelling was remarked in the parotid, sub-lingual and sub-maxillary
glands.* The author quotes the case of an infant three years old, in
whom he found the respiration painful and sibilant, the cough
sonorous and tearing, the expectoration absent, the deglutition very
difficult, the pulse excessively small and of extraordinary frequency.t
He has often observed gangrenous eschars on different parts of the

* It is more than probable that the swelling of the lymphatic glands in
the vicinity, and that of the cellular tissue which surrounds them, may
have been mistaken for the swelling of the organs which secrete the
saliva. In the observations made by myself, whether in cases of Scarlatina
or Diphthérite, I convinced myself that the salivary glands which had
appeared to me, during life, to be the seat of tumefaction, did not at all
participate in the enlargement, and did not in any respect deviate from the
natural state-—BRETONNEAU.

+ This difficulty of respiration, which was evidently guttural, is very
well distinguished, even in Malignant Angina, from that which is due to
the incomplete occlusion of the larynx, even when the two conditions are
met with together in the same subject—BRETONNEAU.
DIAGNOSIS OF DIPHTHERITEL. 113

body; but the post-mortem examinations which he has made, never
showed the gangrene propagated as far as the trachea, as some
authors had alleged.”

But can we conclude from this formal declaration of Dr. Albers,
that no membraniform exudations existed in the air-tubes? He con-
fines himself to affirming that gangrene had not propagated itself
in that direction. Is it not probable, on the contrary, that a false
membrane really lined the trachea* since, even after opening the
bodies, he still regards the disease as a complication of Croup and
Malignant Angina; otherwise, whence could have arisen the idea of
a croupal affection ?

An article in the Report (page 80), replies in the clearest and
most positive manner to this objection. We read there :—“ In some
circumstances, Croup puts on an adynamic form at the very moment
of its attack, and that is the kind which the author calls asthenie or
typhoid. A naturally weak constitution, former diseases, and the
complication of some exanthemata, are the principal causes which
impress upon it this character. We never in such cases see the ap-
pearance of the symptoms proper to synochus. The disease declares
itself without violence, and without spasmodic movements ; the pain
in the larynx is not acute; the thirst is inconsiderable ; the febrile
disturbance is feeble and low; the perspiration is extremely scanty,
and always cold and viscid. In this class of patients, death super-
venes quietly and without suffering, and when the bodies are opened,
the air-passages are found filled with an abundant lymph, but without
consistence, and of a tenuity similar to that of water.”

We may see by this passage that the character of Croup does not
rest, in the opinion of Albers, upon the existence of a false mem-
brane in the respiratory passages, a circumstance which proves how
variable and vague are the opinions of physicians who wrote upon
this disease towards the end of the last century and the commence-
ment of the present. I ought to remark, that in his dissertation, Dr.
Albers, of Bremen, designates Croup under the denomination of
Tracheitis in Children.

A weak solution of acetate of lead which I have found to possess
no efficacy in Diphtheritic Angina, dissipates the painful inflamma-

* May it not even be objected that at the period when Dr. Albers wrote,
the false membrane, which could no longer be confounded with an eschar,
may have appeared to him a lesion very distinct from the membranous
affection of the throat, which was still reputed as gangrenous?

I
114 BRETONNEAU’S SECOND MEMOIR.

tion of the pharynx and accelerates the cicatrization of the fibrinous
ulcerations which often affect the tonsils during the first week of
Scarlatinal Angina.

Common Mempranous ANGINA.

Common Membranous Angina is of all the affections which are
frequently met with in practice, the most difficult to distinguish, at
its commencement, from Diphtheritic Angina. It is of this affection
that Aretzeus says :—‘ Ulcera in tonsillis fiunt, aliqua mitia fami-
liaria, non ledentia; mitia quidem sunt munda, exigua, non alté
descendentia, non inflammata, dolorem non excitantia.”

With the exception of the last two characters* which distinguish
the Membranous Angina only partially from the Diphtheritic
Angina, none of the principal differences presented by these two
affections are omitted in the description of this able observer. Every
practitioner has had occasion to meet: with this disease, which is
often reduced to a slight indisposition. The herpes labialis of Willan
is often exhibited around the mouth or at the orifice of the nos-
trils, at the same time when the membranous erosion occupies the sur-
face of one of the tonsils. A moderate degree of swelling and a red-
ness of slight extent circumscribe the white spot. Although the corre-
sponding lymphatic glands are sometimes swollen and become painful,
we never see them acquire, as in Malignant Angina, an enormous
volume, appearing out of all proportion to the extent and the in-
tensity of the inflammatory lesion of the mucous tissue.

Notwithstanding these distinctions, it must be admitted that
during the course of an epidemic of Malignant Angina, the dia-
gnosis of these two affections often becomes very obscure. The
question can only be decided by the dangerous tendency of Diph-
theritic Angina to propagate itself from the tonsils to the parietes of
the pharynx and to the respiratory passages. It is a fortunate
circumstance that, in cases of doubt, the local applications proper
for arresting the progress of diphtheritic phlegmasia, far from ag-
gravating the membranous eruption proper to common Angina,
actually abridge its duration.

* Contrary to the statement of Areteus, deglutition becomes in general

rather painful, and the pain of the throat often extends as far as the
ear.
STRIDULOUS ANGINA. 115

This affection, like herpes labialis, is almost always symptomatic,
and the febrile state, the wandering pains in the articulations and
the anorexia which accompany it, generally yield to the administra-
tion of an emetic. The local treatment becomes especially useful,
when the fibrinous ulceration of the tonsils has become deep, either
because the administration of the emetic has been too long delayed,
or because the inflammation assumed a great degree of intensity
in the first instance. A strong, but superficial application of hydro-
chloric acid, limited to the extent of the spot, and the use of the lead
gargle, generally induce a prompt cicatrization of the ulcers.

I have had occasion to observe three cases of distinct Laryngeal
Angina, which resembled Diphthérite of the air-passages. The first
was very mild, and resembled Diphtheritic Angina only in the
tone of. the cough, the loss of voice, and the sibilous nature of
the respiration. I shall call it Stridulous Angina. The second was
a case of tracheitis, consisting in an acute and deep inflammation of
the tracheal mucous membrane. As in the preceding species, there
was no production of false membranes. These membranes were ob-
served, on the other hand, in the third species. I think that the
latter differs in its nature, and the circumstances in which it is mani-
fested, from Pellicular Diphtheritic Angina. Still it is no longer
distinguished from it except by less certain characters, and the epithet
of membranous or polypous appears to me to suit it.

In order to avoid adding, by new names, to the confusion of our
nomenclature, I shall borrow from the synonymes of Croup those
which I make use of to distinguish the affections confound_d with
it, and I shall confine myself to restricting and determining the
sense in which I employ them.

SrripuLous ANGINA.
The Pseudo-Croup of M. Guersent.

The anatomical characters of this indisposition are not known to
me. ‘The lesions of the glottis or of the larynx, which produce the
cough and modify the tone of the voice, are, undoubtedly, very slight,
since the general symptoms with which they are accompanied are so
transient and of so little severity. I suspect that they consist of a

catarrhal inflammation, of a simple o:dematous tumefaction of the
12
116 BRETONNEAU’S SECOND MEMOIR.

mucous folds of the ventricles of the larynx ; a tumefaction which pro-
duces a kind of obstruction in the glottis.*

I have previously shown under what a fearful aspect this affection
is at first exhibited; there are, in a few moments, the symptoms of
Croup carried to the most intense degree. At the period when
Malignant Angina was sacrificing a great number of victims at
Tours, a little girl, aged four years, brought up under my inspection,
whom I had left quite well in the morning, had in the evening, the
same cough, the same dyspnoea, and the same loss of voice which,
in another child, had announced the rapid progress of Tracheal
Diphtheritic Angina, and had preceded her death by a few
hours.

The pellicular inflammation which was generally preceded by a
more or less marked difficulty of deglutition, had surreptitiously
made sufficient progress for the respiratory passages to be already
attacked. We did not observe the least swelling in the lymphatic
glands which are situated at the angle of the jaw; the tonsils and
the walls of the pharynx were neither reddened nor swollen. This
could not be the Diphtheritic Angina, for, in the case in which the
larynx had been affected in the first instance, the sides of the neck
had been found swollen. But was there not reason to fear that this
croupal sporadic affection, although different in its nature from
Diphtheritic Angina, was not less formidable? The child did not
complain of any pain in the larynx. We held ourselves in readiness
to resort to mustard pediluvia and the application of leeches ; we
also thought of administering an emetic. But during these prepara-
tions the hittle patient had fallen asleep, and the pulse was not
accelerated ; every inspiration was sibilous; the movements of res-
piration did not become more hurried. The cough, which was

* A sudden exposure to cold and prolonged crying are sufficient, in
adults, to cause loss of voice, which is dissipated in a few days without
any other inconvenience. I have seldom found that the lesion of the
laryux corresponded to the alterations of the tone of the voice in pul-
monary phthisis, even when a rather acute pain and a complete aphonia had
been the predominant symptoms of the disease; I have often found nothing,
to my great astonishment, except a superficial erosion with or without
thickening of the cords. Ina case of chronic aphonia, in which serious
alterations were suspected, there was no notable lesion in the interior of
the larynx; perhaps its internal surface had lost something of its polish;
but far from being reddened, it presented, on the contrary, a tint of a duller
white than in the healthy state.
STRIDULOUS ANGINA. 117

infrequent, short, and hoarse, interrupted the sleep only for a moment;
it was dull, and caused the same impression on the ear as if it had
been heard at a much greater distance. It soon began to soften,
which induced me to defer the application of leeches. A slight
perspiration which we did not wish to interrupt, hindered us from using
the foot-bath. The cough became more and more catarrhal, and on
the morning of the following day, it scarcely differed from that which
accompanies a slight cold; and on the day after, the health of the
child was completely re-established.

I saw four other children affected by the same indisposition, but
in a less alarming degree. Notwithstanding the intense anxiety of
the parents, I succeeded in abstaining from any active treatment in
the first three cases. When I was called in consultation to the
fourth, mustard poultices had already been applied to the calves of
the legs: the redness thus produced was very vivid, and several attacks
of vomiting had been excited by syrup of ipecacuanha; the cough
was beginning to soften. Far from thinking that the treatment had
brought about this slight amelioration, I was led to attribute to it
the fever which was manifested, and which was rather violent during
the night. The febrile state yielded on the morning of the second
day. ‘The cough had become quite catarrhal, and if the tumefaction
of the legs, caused by the application of the mustard poultices, had
allowed the child to walk, he would have enjoyed complete health,

I do not think that a spasmodic constriction of the glottis either
produces or aggravates this affection. The intermittent nature of
many morbid phenomena has too often induced us to look upon
them as nervous affections. The observers who have attributed the
croupal suffocation to the spasm of the trachea, cannot have paid any
attention to the structure of this tube, for it is sufficient to glance at
the cartilaginous semi-circles of which it is formed, to perceive that
the action of the muscular fibrils entering into its composition
must be very limited, and that it is no less capable of resisting the
contraction of the muscles which surround it, than it is capable of
resisting the atmospheric pressure.

This opinion on the influence of spasm is expressed in the greater
part of the works which appeared upon Croup at the time of the
Concours of 1809. It is the opinion of Vieusseux, of Albers of
Bremen, and of Jurine, and it is easy to recognise, in the subjoimed
passages, that it was shared by the Commission. “ We had equally,”
they say, “recognised the intervention of spasm in the production
118 BRETONNEAU'’S SECOND MEMOIR.

of the phenomena of Croup, but we had not ascertained in so exact
a manner the part which it played, nor had we determined with so
much precision the degree of action which it exercised. Not only
does the author demonstrate the existence of a spasmodic irritation ;
but he proves that it is essentially to this irritation that we ought to
attribute the development of the attacks, and the suffocation which
accompanies them.” (Analyse du Mémoire de Jurine; rapport de la
Commission sur les ouvrages, etc. p. 70.)

The Commission expresses itself in a still more positive manner
in the analysis of the work by Albers of Bremen.

«The true cause of this extraordinary difficulty of respiration is
the spasm of the trachea, a spasm which is itself produced, either by
the inflammation of the mucous membrane of that organ, or by the
presence of the plastic lymph which is poured out into it, or in fine
by one or other of these agents combined. Sometimes also the plastic
lymph, by its quantity, iis consistency, and the membranous form
which it assumes, becomes a purely mechanical obstacle to the
passage of the air ; but these cases are extremely rare, and generally
at is the spasm alone which arrests or embarrasses the respiration by
contracting the air-tube. The author dwells forcibly upon this latter
opinion, and the alternations of attacks and remissions which are ob-
served in Croup, especially appear to him an unexceptionable proof
in support of it; he will not, however, allow that like certain authors,
we should therefore admit two species of Croup, the one inflam-
matory, and the other purely spasmodic. This distinction is, in his
eyes, only an empty hypothesis constantly falsified by the exact ob-
servation of the disease. The remissions certainly demonstrate the
existence of spasm, but this spasm is secondary and not primitive.”
(Analyse du Mémoire d’Albers de Bremen, rapport sur les ouvrages,
etc. p. 78).

No constriction can contract or diminish the dimensions of the
nostrils, and yet the snuffling ceases and augments several times in
the same hour ; only a slight change of temperature is sufficient to
produce these vicissitudes. At the commencement of coryza, the
transition from cold to heat often occasions a sudden turgescence of
the pituitary membrane, which causes a momentary closure of the
nostrils. Nevertheless, in this case, the hel which gives passage
to the air is double, and much more widely open than the cleft in
the glottis, and the mucous secretion which is accumulated, in greater
or less quantity, at the contracted orifice of this single passage, must
STRIDULOUS ANGINA. 119

evidently leave it either more free or more obliterated. We see,
therefore, that the air may have alternately a more or less ready
access into the air-passages without spasm taking any part in the
proceeding.

‘The convulsive efforts of the inspiratory muscles during the pa-
roxysms of suffocation, have undoubtedly suggested the opinion
that even in the cases in which a mechanical obstacle was opposed
to inspiration, the dyspnoea arose in part from a spasmodic con-
striction of the glottis; for I shall say nothing more of the spasm
attributed to the bronchial canals, as it cannot even be supposed
to exist. Everything leads us to believe, on the contrary, that the
contraction of the muscles of the larynx then tends simultaneously
with all the inspiratory powers, to enlarge the passage which is to
allow the air to penetrate into the lungs.

The Stridulous Angina which I have just described is very pro-
bably the Acute Asthma of Millar in its first stage. The historical
researches of Dr. Albers prove how undecided and vacillating the
diagnosis of Stridulous Angina has remained, and especially how the
influence of preconceived ideas has modified the opinions offered as
toits nature, causes, and treatment. It is also to this disease to
which we ought to refer the kind of Croup spoken of by Dr. Jurine,
and concerning which he quotes an instance of spontaneous cure.

“ A cure may be effected at all the stages of the disease; it is
announced by the diminution of the symptoms, and above all by the
weakening of, and the interval existing between, the paroxysms ; it
sometimes takes place spontaneously, and the author (Dr. Jurine)
relates an example of it on the authority of one of his fellow-prac-
titioners who was accustomed to observe and recognise Croup, but it
must be confessed that it is very rare to see so dangerous a disease
thus disappear of itself; it is true, however, that very slight measures
are sufficient, occasionally, to make it yield. This favourable result
is pretty frequently obtained by a single application of leeches, and the
author has even cured it by means of a simple fumigation of mallow-
water charged with sulphuric ether.” (Rapport sur les ouvrages
envoyés au Concours sur le Croup, p. 21. Paris, 1812.)

Quite recently, and since the publication of this article, I have
seen a child affected with Stridulous Angina to a really fearful
degree.

On the 2nd of September, 1825, M. L., aged thirty months, of a
healthy constitution, after coming out of a bath, remained naked and
120 BRETONNEAU’S SECOND MEMOIR.

wet, running and playing in an apartment the temperature of which
was moderately elevated. In the evening there was hoarseness ; in
the night, dyspnea, frequent noisy respiration, nasal expiration,
sibilant and stridulous inspiration ; the head was thrown back at each
inspiration. The cough was infrequent and hoarse, less short than
in epidemic Diphtheritic Angina, was maintained during pretty long
intervals, and was then very noisy; each inspiration, which was
laborious and sonorous, was accompanied with convulsive extension
of the extremities ; at the same time the face and the lips became of
a violet colour; the skin remained cool, the respiration was not
accelerated, and in the interval of the paroxysms, the child continued
’ to play ; there was no tumefaction at the sides of the neck. Mustard
pediluvia were employed ; leeches were to be applied to the sides’ of
the larynx, and subsequently a blister, if the dyspnoea did not yield
to the employment of the pediluvium. On the second day, the
tonsils were not reddened, nor were they either swollen or covered
with exudations; I ascertained that the lymphatic glands pre-
served exactly their natural volume. During the night the child had
several fits of suffocation, the voice was feeble, and the cough pre-
served all the characters which it had on the previous night ; it was
only a little less dry, a new inducement not to delay any longer the
application of the leeches. (Jalap, four grains ; calomel, two grains ;
an emulsion of castor oil in a laxative dose.) The appetite remained,
the cough became more soft, but at the same time the frequency of
the pulse and the heat of the skin indicated rather intense febrile
excitement. The leeches were not applied, but the two pills were
given in the evening, and the emulsion the next morning. On the
third day, the respiration was less frequent and more easy, the cough
had become more soft and less painful; the little patient then re-
mained exposed to the cold, and the cough again became more dry
and hoarse; but on the same evening, the amelioration of all the
symptoms prognosticated a rapid convalescence. The sixth day,
there remained nothing more of a state apparently so dangerous, ex-
cept a little hoarseness, which soon completely disappeared.

I never met with such a severe case of Stridulous Angina. The
mucous membrane of the larynx was undoubtedly affected with a rather
acute catarrhal inflammation; such at least appeared to me to be in-
dicated by the febrile excitement, and the intensity and the duration
of the paroxysms.
TRACHEITIS. 121

Or TRACHEITIS,

I have collected three cases of Tracheitis. The first is very in-
complete ; the information which 1 was able to procure offered me
only a vague idea of the symptoms and the treatment; but I was
able myself to make an examination of the body.

Casz 29.—H. L., aged three years, had been ill six days when he
died. The physician who attended him considered that he died of
Croup. I was assured that to a hoarse cough was added a slight
alteration in the tone of the voice. (Emetic tartar in repeated vomit-
ing’ doses ; a blister to the nape of the neck.)

Autopsy, thirty hours after death—The base of the tongue was
very red; the mucous membrane of the trachea and of the bronchi
was thickened, and of a uniform deep-red colour. The back of the
mouth was filled with mucous matters of a grey-greenish tint; the
same matter also obstructed the bronchi. The lymphatic cervical
glands were slightly reddened but scarcely at all swollen. The
tonsils presented no appearance of morbid alteration.

The disease terminated favourably in the next case.

Casz 30.—N.D., aged six years; constitution strong and plethoric.
On the first day there was coryza attributed to catching cold. On
the second day there was dry cough, which was frequent and rather
short, soon becoming hoarse ; the tonsils and the pharynx, examined
with care, exhibited no swelling, nor spots ; there was acute pain re-
ferred to the larynx and increased on pressure; the lymphatic sub-
maxillary glands were not sensibly swollen ; the pulse was accelerated
(110 in the minute); the cough became more and more hoarse, and
assumed a fearful resemblance to croupal cough. On the third
day there was dyspnoea and frequent respiration ; inspiration gave
rise to a remarkable sibilous sound; twelve large leeches were ap-
plied on the sides of the larynx, and caused an abundant flow of
blood ; the difficulty of respiration diminished ; the cough remained
dry and hoarse (syrup of ipecacuan was given with the addition
of ipecacuan in powder, one spoonful every hour, which caused
vomiting). The cough became moist and assumed the character of
that which accompanies tracheal or bronchial catarrh; there was
general moisture. Abundant alvine evacuations were produced in
122 BRETONNEAU’S SECOND MEMOIR.

the evening by the administration of an emollient glyster. On the
fourth day the cough was soft, the expectoration muco-puriform,
scanty ; there was some appetite ; the skin was constantly perspiring
(pulse 90). On the sixth day the patient became convalescent.

Case 31.—N. F., a child six years old, habitually enjoying good
health, had coughed a little for three days, as if he had been affected
with a slight cold. The cough soon became dull and hoarse, and
was accompanied with an acute pain, referred to the larynx. I saw
the patient only a few hours before his death ; forty leeches had been
applied on the previous evening, at two intervals, to the sides of
the larynx. The blood had flowed so long and so abundantly,
that a great paleness of the face had been induced; the cough
remained the same; the voice was more feeble; the pulse was
extremely frequent, and the respiration became more and more
painful and hurried. No painful swelling was remarked at the
angles of the jaw or at the sides of the neck. The walls of the
pharynx and the tonsils were neither reddened nor swollen; the
cough appeared to me to have more extent than in Diphtheritic An-
gina; I found it less short, less suddenly interrupted, and, indeed, I
recognised a simple case of tracheitis. The treatment had been emi-
nently antiphlogistic. The patient had taken only a little syrup of
gum in water, and a mustard pediluvium was up to that time the
only derivative stimulation which had been employed; some spoon-
fuls of syrup of ipecacuanha were administered a few hours before
death, which was announced by rattling in the throat.

Autopsy, sixteen hours after death—The dorsal surface of the
body, which had remained in a supine position, was dotted with
bloody spots. The opening of the body confirmed the opinion which
had been offered, that no false membranes existed in the trachea. The
mucous coat of the larynx and trachea was thickened and of a very
bright red. A small quantity of creamy puriform mucus (about three
drachms), filled the first divisions of the bronchi; the lungs were
crepitating, and no other alteration was discovered in the rest of the
viscera. I did not pay sufficient attention to ascertain whether the
dimensions of the glottis were sensibly diminished by the tumefaction
of the mucous folds of the larynx. It did not appear possible that
the mucus accumulated in the principal divisions of the bronchi
would have opposed an insurmountable obstacle to respiration.
SPORADIC DIPHTHERITE. 123

Mempranous orn Potypous Sporapic ANGINA.

T have already had occasion to make the remark that some special
accounts of Membranous Angina did not appear to refer to Malignant
Angina, and I have quoted a case which leads me to believe that there
may be. developed inthe larynx certain exudationswhich are not the pro-
duct of diphtheritic inflammation. It is from memory that I have
pointed out the particular characters which seem to be presented in a
case in which false membrane was expectorated by an adult woman,
affected with Sporadic Membranous Angina. In comparing the de-
tailed accounts which are found scattered over different periodical
works, we find that this affection has always shown itself in an isolated
form; and it appears generally to be the consequence of appreciable
causes. The inflammatory symptoms which accompany it are much
more marked than in Diphtheritic Angina. An acute pain is felt in
the larynx from the commencement of the disease; it becomes still
more acute after the expulsion of the false membrane, which does not
appear to increase and propagate itself like the diphtheritic pellicles.

SPORADIC DIPHTHERITE.

Tracheal Diphtheritic Angina, like every other epidemic conta-
gious affection, may undoubtedly sometimes show itself in an isolated
form. We also see smallpox, an eminently communicable disease,
sometimes attack a single individual in the midst of a numerous
population, without this individual communicating to another the
affection which he has himself taken. It may be a varioloid fever
without eruption, vaccination, unfavourable atmospheric conditions,
or other circumstances still less easy to ascertain, which preserve
from the contagion those persons who have had immediate commu-
nication with the patient.

In 1823, I saw a child, five years old, die of Tracheal Diphtheritic
Angina. The symptoms of the disease of which he died were exactly
the same as those observed during the course of the epidemic of
1819; there could be no doubt as to the identity of the morbid alter-
ations. The false membrane extended from the larynx to the last
ramifications of the bronchial tubes. On the third day after the
disease was recognised and. established, the mercurial treatment was ~
124 BRETONNEAU’S SECOND MEMOIR.

adopted. The cough, which’ was already infrequent, short, and -
hoarse, began to be moist eight hours after the commencement of
the administration of the calomel. It was impossible, until the fol-
‘lowing day, to succeed in inducing the patient, whose self-will and
obstinacy were inflexible, to take a single dose more of this medicine.
The cough became more and more dry and hoarse, the voice was feeble,
and every inspiration gave rise to an acute sibilous sound. We
succeeded at last in administering pretty regularly some fresh doses
of calomel, and we made some mercurial frictions round the neck ; a
slight amelioration was at first obtained. From the sixth to the
seventh day, the disease appeared to be stationary; the pulse was
scarcely febrile ; the dyspnoea augmented and diminished alternately.
The eighth day the pulse had become small and rapid ; somnolence
was joined to a kind of agitation, or rather the sleep was interrupted
by sudden movements; respiration remained after that time more con-
stantly embarrassed, and on the ninth day death supervened, without
being preceded by a more violent paroxysm of suffocation. The
temper of the patient was preserved up to the last moment ; with his
finger, he examined the temperature of the drink which was offered
to him, and if we persisted in making him drink it before he found it
to his taste, he succeeded, by using as much force as dexterity, in
making the vessel fall from the hands of the person who presented it
to him. The calomel, the doses of which had been sometimes given
at longer, sometimes at shorter intervals, had constantly produced a
laxative effect.

At the period of death, the mouth presented no appearance of mer-
curial affection. The diphtheritic inflammation had been sensibly
modified on all the points which had been longer and more imme-
diately in contact with the calomel. The exudations were in those
parts worn away and almost destroyed. Behind the velum palati
they had preserved a considerable degree of thickness and were pro-
longed irregularly as far as the aperture of the nostrils. The false
membrane which descended into the bronchi, and which we followed
up almost into their last subdivisions, possessed considerable tenacity
and consistence. It was more than probable that tracheotomy, which
we had been on the point of performing, might not have had any
advantageous result at this stage of disease in the air-passages.
The idea of resorting to it, as to a last resource, had been suggested
in the hope that, the diphtheritic phlegmasia having been modified
by mercurial treatment, the reproduction of the exudations would
SPORADIC DIPHTHERITE. 125

not be so likely to occur. I thought at first that rather positive signs
indicated the extension of the disease to the bronchi; but the
more I endeavoured to distinguish them, the less valuable and certain
I found them.

During the epidemic of 1819 and 1820, three other children of
the same family died of Diphtheritic Croup. Can we suspect that
the germ of this affection had been preserved and transmitted after so
long a period of time?
126 BRETONNEAU’S THIRD MEMOIR.

THIRD MEMOIR. (November, 1825.)
EPIDEMIC OF LA FERRIERE.

"The epidemic of Malignant Angina which commenced at La
Ferrigre in the month of November, 1824, and of which I have
already had occasion to speak, has not yet ceased. In a population
of two hundred and fifty individuals, twenty-one were attacked and
eighteen died. The disease remained circumscribed in this hamlet,
and has not been observed in any other commune in the neighbour-
hood. In a single neighbouring farm, a man, forty-five years old,
was affected with it; but he had frequented a house in La Ferriére °
at the time when two children were dying from Diphtheritic Angina ;
his cure was scarcely accomplished by means of local treatment when
one of his children died of Croup. ;

It was particularly young subjects who were carried off by this
disease. Of the total number, however, we reckoned three adults,
and two children who were approaching puberty. Malignant Angina
had never before been observed in this locality in the memory of
man, and not only was it reproduced there with all the symptoms under
which it had shown itself at Tours in 1819; but it has preserved,
as an epidemic affection, a particular character which has already
been often described; it has only reappeared from time to time,
and at long intervals.

In the month of November, 1824, three children died in this
locality from Croup. For three months there did not appear any other
instance of the disease, but after that period, five other individuals
were attacked. Four months elapsed, and six persons more were
carried off in a few days by epidemic sore-throat. From this time to
the month of October, 1825, the disease ceased to appear, and the
inhabitants of La Ferriére began to hope that they would be m
future delivered from this scourge, when a child of thirteen years
old, a young girl of eighteen, and a woman of thirty, were attacked
and died.

At the period when I was sent into this commune, the symptoms
of Croup were manifested in a child four years old; but before
EPIDEMIC OF LA FERRIERE. 127

giving an account of the facts which I had occasion to observe, I
think I ought to call attention again to the irregularity of the pro-
gress of Diphthérite. I have already made the remark, that it is not
according to the habit of cutaneous exanthems, nor of other epi-
demic diseases, that it is maintained and propagated in one canton.
M. Guersent says in the article Angine Maligne of the Dictionnaire
de Médecine, that the disease sometimes appears suddenly in one of
the wards of the Hépital des Enfans, and that it ceases there as soon
as three or four have been attacked, but reappears in another
ward, after a longer or shorter interruption. Marteau de Grandvilliers,
in his Treatise on Gangrenous Sore-throat, expresses himself on this
subject in the most distinct manner. “This disease,” he says, “ like
the smallpox, passes from one village to another, but it does not re-
semble other epidemics which seize a great number of persons on
a sudden, and then pass away ike a storm. It attacks in detail, and
in this respect it is most treacherous, because it excites less alarm
and attracts less attention from those who are appointed to watch
over the health of the citizens. In great national maladies, the
ministry opens its eyes, and sends assistance ; but here the multitude
of sick people is not striking, and yet a whole household is insensibly
undermined and depopulated. They are the persons who are the
most solid hopes of the state, they form the posterity which is to
succeed us, who are swept away by this cruel contagion« The
little village of Elcour, composed of forty households at the most,
lost forty-two children in one winter; Nullemont, fifteen in five
weeks; Goureleis, seven in a week, of whom four were in one house.
What disasters are these!”

This affection is undoubtedly contagious, as is attested by obser-
vation at all periods ; but it is certainly under particular conditions,
and those which are peculiar to itself, that it is transmitted. How
is the germ which preserves it reproduced? Four days after the
death of the woman of thirty, the child she was suckling died of the
same disease. A young woman who had nursed her complained of
sore-throat, and died a week afterwards in a paroxysm of croupal
suffocation. It is easy to arrive, in these two cases, at the origin of
the contagion; but the child, who, at the same time, presented all
the symptoms of the last stage of Croup, lived in a farm a quarter of
a league distant from the village, and his isolation appeared sufficient
to protect him from the contagion.

If the symptoms of the disease of this child had allowed me to
entertain the least doubt as to the nature of the case, it would have
128 BRETONNEAU’S THIRD MEMOIR.

been dissipated by the inspection of the throat. Membraniform
layers of an opaque-white colour covered the tonsils and extended
into the pharynx beyond the reach of sight. The dry, infrequent,
short, and hoarse cough, was altogether croupal, and every inspira-
tion was accompanied by a very well-marked sibilous sound. It
therefore became almost useless to endeavour to verify the anatomical
characters of an affection, the diagnosis of which left not the least
uncertainty. Still, I opened the body of the woman thirty years
old, and it was, clear to me that the propagation of the diphtheritic
phlegmasia into the respiratory tubes had been the cause of her death,
Tubular membraniform layers extended as far as the subdivisions of
the bronchi. The false membrane formed a tube in the trachea of
more than half a line thick, which, in the greater part of the extent of
this air-channel, was free and floating. Towards the bifurcation of
the bronchi, we easily distinguished, in the thickness of the false
membrane, several distinct layers, partly separated from one another ;
but the detachment I have first mentioned did not leave the mucous
membrane naked; it was already being covered with little grains of
pseudo-membranous matter, arranged more or less closely together,
which were evidently the rudiments of a new membraniform layer.

The pellicles covering the tonsils retained but little thickness
or extent, and it was easy to ascertain that the diphtheritic inflam-
mation had been irregularly modified in the pharynx by the immediate
action of the calomel, the administration of which had been com-
menced thirty-six hours before death.

Except a slight emphysematous tumefaction which was observed
at the extremity of the lobes of the lungs, these organs did not. exhibit
any deviation from the healthy state. All the depending parts of
the intestinal canal were very much injected. Still, notwithstanding
the distention of the venous ramifications, and although the body had
been opened twenty-nine hours after death, the blood had not yet
been extravasated, and there did not exist any hypostatic ecchymosis
on the surface of the gastro-intestinal mucous coat.

The results of this examination left no doubt as to the nature of
the epidemic affection. This new proof was even superabundant, for
one of the officers of health of the district had already found the
same morbid alterations in a child who had died in the month of
July in the same year.

Abundant general and local blood-letting, emetics, blisters, and
mustard pediluvia, had been prescribed without success for this
EPIDEMIC OF LA FERRIERE. 129

dangerous disease; and as I have already said, of twenty-one indi-
viduals who were attacked, only three escaped death. One owed
his recovery to local treatment. The well-established inefficacy of
this therapeutic agency at an’ advanced period of the disease had
generally dissuaded us from resorting to it. The mercurial treat-
ment, preceded by the application of hydrochloric acid to the tonsils,
had been employed in the second case. Notwithstanding the pro-
longed administration of calomel and emetics, the third patient, who
was a child eight years old, of a delicate constitution, appeared
many times on the point of death, and it was only after several con-
vulsive paroxyms of suffocation that he expectorated fragments of
membrane and long tubulated masses, which had certainly lined the
first divisions of the bronchi. This child in the interval of the
paroxysms had scarcely any febrile excitement; he recovered his
health slowly, and his voice was for a long time inaudible. The
wound of a flying blister which had been applied to his neck, and
which was dressed with simple cerate, was covered with membrani-
form exudations, and increased so much as to extend from the
anterior part of the neck to the front of the chest. The cure was
accomplished only with difficulty and after a long space of time.*
I myself was able, by the extent of the scars, to judge of the size
which the wound of the blister must have attained.

The same inefficacy of general treatment had been demonstrated
to me during the epidemic of Tours, and I had but too often been
called upon to witness the failure of the mercurial treatment, whether
it was resorted to at a too advanced period of the disease, or had not
been followed up with sufficient perseverance, or whether it offered
only a feeble opposition to the too rapid progress of the disease.
With still less success was calomel administered several times at
La Ferriére.

The little child to whom I was called, presented such positive
symptoms of the extension of the pellicular inflammation into the
respiratory passages, that very probably the closure of the larynx
could no longer be prevented by the action of the calomel. Since
the night before, nine doses of this medicine, of two grains each every
two hours had been administered, without the cough having lost
anything of its dryness, and judging by the increasing progress of
the dyspnoea and by the propensity to stuper, it could not be

* Samuel Bard made the same observation during the epidemic at New
York.
K.
130 BRETONNEAU’S THIRD MEMOIR.

hoped that life would be prolonged beyond twenty-four hours. In
such a pressing danger I saw no hope except in tracheotomy, which
could not be performed under more favourable auspices. The
diphtheritic inflammation had only very recently extended into the air-
passages. The little patient, who was of a strong and healthy consti-
tution, was almost free from fever, and whatever might have been the
difficulty of respiration, he seemed scarcely to suffer from it. Ought
not the operation to be performed immediately P I had ascertained
that the possibility of introducing the calomel into the air-passages and
of thus modifying the diphtheritic inflammation was one of its principal
advantages. But there remained the chance of expelling the false
membrane ; and besides, as I was obliged to leave the patient imme-
diately after the operation, I was not able to take the most appro-
priate measures for securing its success; on the other hand, it was
easy to take the child to the town in a few hours, and the inconveni-
ence of this short delay was amply compensated by the possibility of
seizing the most favourable moment for performing tracheotomy, for
arranging the preparations for it, and for following up the after
treatment.

I recommended that suitable precautions should be taken for the
convenient removal of the patient, and before leaving him, I saw the
preparations for his departure being made. But I waited in vain,
and I was grieved to learn that the parents having allowed them-
selves to be diverted from their project, the child had fallen into a
deep state of somnolence, and that it had died on the evening of the
day after that on which I had left him.

The young woman whose case I have already mentioned, began,
three days after the death of the neighbour whom she had nursed, to
experience symptoms of Malignant Angina, but although she knew all
the danger of her disease, which was prolonged to the eighth day, it was
impossible to persuade her to allow us to perform tracheotomy.* I had

* The symptoms of her disease were followed out from day to day by
M. Brault, who communicated to me the subjoined account ta complete
the history of the epidemic of La Ferriare.

CasE 32.—M.C.,agedtwenty-two, whose constitution had not been affected
by any previous illness, began to feel a slight pain in the sides of the neck
on the 21st of October, 1825. On the 22nd, the deglutition had become
painful. On the 24th, she was visited. Pellicular exudations entirely
covered the left tonsil, and seemed to pass beyond it. Superficial cauteri-
zation was practised with concentrated hydrochloric acid; some white
EPIDEMIC OF LA FERRIERE. 131

flattered myself with the hope that by means of this operation, one at
least of the two patients would escape death, and I confess that it was
with the deepest regret that I was disappointed both of the occasion for
better understanding the advantages of tracheotomy, and of the hope
of a success which was the more desirable inasmuch as the medicines

points were perceived on the right tonsil. On the evening before, the
patient had applied fifteen leeches on the sides of the neck. (Three grains
of calomel every two hours, and eight grains of polygala after every third
dose of calomel.) Only one emetic action has been produced ; four blackish
stools. On the 25th, the pellicular exudations were stationary on the left
‘tonsil; they were increasing and extending on the right, which on this day
was also superficially cauterized. The same dose of calomel was given
every two hours, and three grains of tartar emetic were given in three doses.
Abundant vomiting was obtained with facility ; there was no more cough;
no change in the tone of the voice; abundant expulsion of frothy matter ;
four stools similar to those of the previous evening. On the 26th,
some membraniform pellicles which appeared to have come from the ton-
sils were discovered in the sputa. The affection of the back of the mouth
was assuming a better aspect, but the voice began to be hoarse, and the
cough which followed excited an abundant expectoration of frothy sputa.
There was constipation which did not yield either to tartar emetic or to
calomel. The latter medicine was given in the same doses as on the pre-
vious evening. On the 27th, the cough was more frequent and hoarse. In the
‘night the dyspnea increased, the patient left her bed, opened the window,
and endeavoured to breathe the external air ; the sputa preserved the same
appearance; some strips of false membrane of small dimensions were
found mixed with them. Three grains of tartar emetic and eighteen
of ipecacuan were administered in a single dose, without any vomiting
being produced. A blister was applied to the nape of the neck, and
sinapisms to the feet. The mercurial treatment was continued, and at
noon eight grains of calomel were given in a single dose. On the 28th
there were frequent paroxysms of croupal suffocation; but the cough had
become more moist, and the expectoration was muco-puriform. Death
took place at noon. The gradual progress of lividity and paleness of
complexion had marked the advance of asphyxia. This decoloration was
remarkable.

The obstacle offered by the embarrassment of the respiration to the
return of the blood, and its accumulation in the venous system, sufficiently
explain the lividity of the complexion ; but it is less easy to understand
how paleness is joined to, and at last succeeds, this lividity. Without
doubt, it is one of those phenomena which M, Laennec calls semi-cadaveric ;
at least, it is certain that it constantly marks the fatal progress of
asphyxia. The same succession of tints is observed upon the buccal
mucous membrane of animals which have been made to die by strangu-
lation.

K2
132 BRETONNEAU’S THIRD MEMOIR.

hitherto employed against such a fatal disease had been utterly in-
efficient.

I donot conceal from myself that in the case described at the com-
mencement of this Memoir, the false membranes reached as far as the
subdivisions of the bronchial tubes, and that in such a deplorable
conjuncture, it would be undoubtedly useless to open the trachea,
not to mention the danger which might result from the obliteration
of the bronchi. The difficulty of expelling a voluminous mass of
false membranes, would in itself present a great obstacle to the success
of the operation; nevertheless we ought the less to allow ourselves
to be deterred by this apprehension, inasmuch as we have.sometimes
seen patients disembarrass themselves from long tubular false mem-
branes by the natural aperture of the glottis. We may easily conceive
how rare such a favourable termination must be without the help of
an artificial opening, if we consider that the anfractuosities of the
larynx, arrest, at the narrow passage of its orifice, the strips of false
membrane at the very time when they are ready to yield to the efforts
which have prepared the way for their expulsion. The affection of
the air-tubes is, perhaps, less to be feared in children than in adults.
In the latter, the ample space of the glottis retards the period of its
closure, and leaves time for the pellicular inflammation to extend
itself. We have seen that in fifty-five post-mortem examinations, its:
extension to the subdivisions of the bronchial tubes was found only
in the proportion of one to nine. I have not remarked that it was
much greater in adults.

Besides, in a subject old enough to understand our motives, tra-
cheotomy may be performed with facility, and if further observations
should be favourable to the effects of calomel applied imme-
diately to the mucous membrane of the air-passages affected with

‘ pellicular inflammation, we should then admit that we ought to hasten
to perform an operation which of itself does not expose the patient
to any danger. By this proceeding we should not only open a free
passage for the air, and favour the expulsion of the false membranes,
but, besides, we should have in the air-tubes a mode of access which
would permit of our using, in time, a more sure method of stopping
the progress of diphtheritic inflammation, which is always superficial,
and does not become dangerous, except by its situation and its
extension.

For two years, Scarlatina had progressively extended in this de-
partment of the country, and it had already run through the greatest
EPIDEMIC OF LA FERRIERE. 133

part of its course, when, towards the commencement of the summer,
it reached La Ferriére. It showed itself there as destructive as in
most of the other rural communes, and six individuals of different
ages were carried off by the disease. But whether the Scarlatinal
Angina was accompanied with a cutaneous efflorescence, or the
eruption was wanting, it was always possible to distinguish it from
Diphtheritic Angina, by the signs I have indicated. I was convinced
that these two diseases had not a common origin, and that, with the
exception of one single symptom (the membranous inflammation of
the tonsils), they differ very much from one another. One last proof
is decisive; one of these affections is not a preservative against
the other, for many of those who were at last carried off by Diph-
theritic Angina had had Scarlatina.
134 BRETONNEAU’S THIRD MEMOIR.

SPECIFIC CHARACTERS OF THE DIFFERENT KINDS OF
ANGINA.

Six distinct inflammatory affections of the isthmus of the throat
are pretty frequently met with, and at first they seem to present almost
the same aspect ; but they afterwards exhibit such varieties in their
progress and modes of termination that it is impossible to deny to
each a special and distinctive character.

In treating of the diseases which resemble Pharyngeal Diphthérite,
I have already described the distinctive marks of the affections which
it is most essential to avoid mistaking for this formidable disease. I
shall not return to this subject except to trace, in this new Memoir,
after the manner of nosographers, the specific characters of the different
kinds of Angina, in order, by this comparison, to present a better pic-
ture of the peculiarities which exclusively belong to each. The
greater or less embarrassment of the deglutition is a character common
to all of them.

CaTARBRHAL ANGINA,

Redness of all the mucous surface of the isthmus of the throat;
moderate tumefaction of the tonsils ; enlargement of the muciparous
follicles, which at first allow the escape of an abundant secretion of
lmpid mucus, gradually becoming more opaque. There is a pungent
pain without any remarkable obstacle to deglutition ; scarcely appre-
ciable tumefaction of the cervical lymphatic glands, and more or less
intense fever.

TonsttLaR Ancina. (AMYGDALITIS oR ToNSILLITIS.)

Tumefaction of one of the tonsils, often of both; painful degluti-
tion; subsequently augmentation of volume and hardness of one of
the tonsils ; deglutition becomes more and more difficult and painful ;
edematous swelling of the parotid region without considerable en-
largement of the lymphatic glands ; termination by resolution, by sup-
puration before the end of the second week, or by induration.
DIFFERENT KINDS OF ANGINA. 135

Mercurrat Mempranous ANGINA.
(Zoo often designated as Syphilitic Angina.)

Fibrinous, corroding, and chronic ulceration of the tonsils and
velum palati; deglutition not very painful as long as the disease has
not made much progress—Apyrexia.

Common Fisrinovus ANGINA.

Tumefaction of one of the tonsils, sometimes of both; a central
ulcerated depression of a yellowish-white colour. This tint is due to
a fibrinous and intimately adherent coating. Deglutition very pain-
ful, fever generally rather intense; the elevated papille of the
tongue are dirty with a slimy coating ; a yellowish tint of the cir-
cumference of the mouth. A slight herpetic eruption often shows
itself in the vicinity of the lips; the cervical lymphatic glands are
moderately painful and slightly swollen. Even when the duration of
this disease is not shortened by suitable treatment, it is rarely pro-
longed beyond the seventh day.

: ScaRLaTINAL ANGINA.

The symptoms of this kind of Angina are accompanied and gene-
rally preceded by fever ; there is frequency, smallness and irregularity
of the pulse. The difficulty of respiration and its acceleration often
foretell the nature and the danger of the disease. The deep redness of
the velum palati and tonsils, and the swelling of these glands,
precede the appearance of multiplied white points, closely arranged
together, and forming by their union on the velum palati a whitish
coating, which is easily furrowed. The tongue, the surface of which
is a little slimy, presents almost the appearance of the healthy state ;
the deglutition is at once painful and difficult and a membranous in-
crustation covers a more or less extensive portion of the surface of
the tonsils.

From the beginning of the disease the cervical lymphatic glands*

* It pretty frequently happens that the inflammation of the swollen
glands terminates in suppuration. During the course of an epidemic
which has just been spreading over the greater part of the rural communes
of this department, we have so often seen scarlatinal glandular tumours
136 BRETONNEAU’S THIRD MEMOTR.

which are situated at the angle of the jaw, and especially those which
are under the superior attachment of the sterno-mastoid muscle,
acquire a considerable volume and become sensitive to the touch.
Fever, always characterized by the frequency and the disorder of the
circulation, continues to accompany this second period.

The tongue, denuded of the coating which invested it, is sometimes
dry, sometimes moist, and assumes a very deep violet colour. In the
cases in which this Angina has the greatest intensity, the membranous
coating adhering to the tonsils becomes corrupted, changes its
colour, is partly detached, exhales a fetid smell and resembles a
gangrenous affection ; but even in this case, the membranous inflam-
mation of the pharynx is not the most dangerous symptom of the
disease. At the same time that the cutaneous eruption, which is
generally manifested from the second to the third day, begins to
grow pale, and when the epidermis is raised and detached in scales
and shreds, the inflammation is rapidly dispersed, and generally, from
the eighth to the tenth day, there remains no trace of a disorder
which had appeared so dangerous.*

DreutTHeritic ANGINA.

Redness and tumefaction of one of the tonsils, rarely of both; erratic
fever, generally slightly marked. Some white spots are soon discovered
on the surface of the swollen tonsil. These spots, which are more or
less numerous, are due to the production of a pellicular, lichenoid exu-
dation, which falls off spontaneously and is very easily detached. There
is considerable enlargement of the lymphatic glands of the sides of the
neck. From the beginning, this enlargement is marked by its dis-
proportion with the extent and intensity of the inflammation of the
mucous surfaces ; the deglutition is not very painful, and it becomes
less and less so; the tumefaction of the tonsil, which has been
first affected, augments; a redness, of a very variable tint, cir-
cumscribes the exudation, which is sometimes rapidly extended to

yield immediately under the bites of leeches, that the local bleeding has
undoubtedly exerted some influence over this mode of termination. Per- ,
haps we ought to search for the cause of this result in the morbid alteration
of the fiuids, but at present this discussion would be premature.

* It seldom happens that the membranous inflammation of the pharynx
is prolonged beyond this period, and from this time it loses its special
character, in the same manner as, after a certain time, the ulcerations
which succeed confluent smallpox, preserve none of the inflammatory
characters which are proper to that disease.
DIPHTHERITIC ANGINA. 137

the velum palati, the uvula, the pharynx, and the tonsil of the op-
posite side. After this sudden extension, the progress of the
diphtheritic fibrinous inflammation most frequently remains tem-
porarily suspended. The intumescence of the lymphatic glands either
diminishes or does not continue to increase; there is no fever, or
hardly any. After a more or less prolonged absence of symptoms
for a few days, sometimes for a few hours, the cough begins, which
is either dry or accompanied with a frothy expectoration ; it soon
becomes hoarse, and indicates the first symptoms of the propagation
of the diphtheritic inflammation into the air-passages.

J shall not add Aphthous Angina to the affections of which I have
just treated, because it is distinguished by characters which are too
well marked, and because it is most frequently an affection which is
only symptomatic of another disease.

In bringing together in this succinct manner the characters which
are peculiar to different special inflammations of the pharynx, generally
well known to practitioners, my object has been to show that each
of these inflammatory conditions is limited to a particular course,
and shows itself invariably under the same forms. However severe
Scarlatinal Angina may really be, we shall never see it, even under
the influence of the most stimulating treatment, putting on the cha-
racter of Diphtheritic Angina, passing beyond its. own limits, or
extending into the air-passages. The closure of the glottis will
not be the cause of the fatal termination of the disease, while
even when the Diphtheritic Angina has shown itself only in a form
of extreme benignity, the extension of the pellicular inflammation,
cannot be retarded by the most energetic antiphlogistic treatment ;
thus it is not by the intensity of any of the phenomena which charac-
terise phlegmon that the pellicular inflammation becomes formidable.
Being essentially superficial, we find that it cannot cease being so,
without losing its principal character, and without a fibrinous incrus-
tation, or a purulent secretion, taking the place of the pellicular ex-
udation which accompanies it, and which constitutes the whole of its
dangerous character. It is, besides, the nature of diphtheritic in-
flanmation to be encroaching, and it is precisely this union of cha-
racters which constitutes its peculiarity and speciality, that “ quid
divinum ” which cannot be seized, and which, according to the avowal
of Hippocrates, escapes all explanation. We cannot conceal from
ourselves that the laws of the physics of organised bodies, which are
still so little known, are incapable of furnishing us with a knowledge
138 BRETONNEAU’S THIRD MEMOIR.

of the cause of this disposition which is manifested by different phleg-
masize to run through their successive periods in a determinate time,
to affect in preference, one tissue, and one region of this tissue, and
to modify, in a certain manner, both its texture and its appearance.

Doration anp Mopr oF Termination oF DIPHTHERITIC
INFLAMMATION.

After so many treatises published on Croup and Malignant Angina,
the question may still remain whether Diphthérite is capable of yield-
ing, when in its acute form, to general treatment, or whether it can
only be efficiently subdued by special medication. Being obliged to
leave a question of so much importance undecided, I may at least
affirm that the former mode of termination must be very rare, since it
is so difficult to meet with authentic examples of such cases.*

I feel how paradoxical this proposition must appear, but I beg it
may be understood that I do not here intend to speak of anything
except Diphthérite properly so called, and that I do not comprise
under this name the numerous dissimilar affections too generally con-
founded under the denomination of Croup.

It is extremely rare for the diphtheritic inflammation not to
extend from the pharynx into the air-passages, and the disease
then becomes so rapidly fatal, that two of the principal and truly cha-
racteristic features of this inflammatory condition have escaped the
attention of practitioners ; it has not been noticed that it is the nature
of diphtheritic inflammation to encroach from spot to spot, and not
to be extinguished on the points which it previously occupied. I
insist upon these tendencies of Diphthérite, because in them resides
all the danger of Malignant Angina, and because it will almost always
happen, if they are mistaken, and if the most efficacious therapeutical
plans are not directed against them, that the extension of the disease
into the air-passages cannot be prevented.

Lastly, it must be stated that these plans should still be taken into
consideration, even after an artificial opening has been made in the
trachea, for, if we do not then redouble our precautions, the persist-
ence of the pellicular inflammation in the larynx, or its extension into
the bronchi, will invincibly oppose the success of the operation.

* This remark applies only to Diphthérite which is still recent and in
its acute stage ; for by being prolonged and becoming chronic, it loses, like
certain cutaneous phlegmasie, some of the characters which are peculiar to
it.
EPIDEMIC OF CHENUSSON. 139

FOURTH MEMOIR. (Marck, 1826.)
EPIDEMIC OF CHENUSSON.*

Since the end of October, 1825, Diphtheritic Angina had not re-
appeared at La Ferriére, until, in the early part of November, a child
died of Croup at Souchet, a small hamlet to the south of that town,
and at a short distance from another hamlet, where, at the beginning of
the preceding month, a child had died of the same disease. Some
days later, Malignant Angina carried off a third child in an isolated
house, situated in the midst of the woods, halfway between Chenusson
and Souchet, still in the same direction from north to south. Some
ties of relationship existed between the inhabitants of this latter farm
and those of Souchet. In the middle of November, two children
died suddenly at Chenusson, in the same house, their death being
preceded by croupal cough and dyspnea. Soon afterwards, a young
woman, eighteen years old, suffered from a slight sore-throat ; cough
supervened, and on the sixth day of the disease, she died during a
paroxysm of suffocation, after having expectorated some strips of
false membrane and tubular exudations, which were seen by M. Brault.

I have already had occasion to notice that this young surgeon had
attended the chief part of the patients at La Ferriére and that he had
observed and noted with great accuracy all the diagnostic signs of
the disease. By the end of December, eight children and one girl of
fifteen or sixteen years old had suffered the same fate as the first
three subjects just mentioned.

In most of these cases, leeches were applied in small numbers to
the sides of the neck, and some of the patients had their tonsils
scarified, After the local application of hydrochloric acid, calomel
was given in small doses, frequently repeated, to two children who
appeared to be in a state of convalescence, but, in both cases, the
wound caused by a blister placed on the nape of the neck, became
gangrenous and the children died tranquilly without feeling the

* A small market town a league south of La Ferriére, with a scanty
population residing in fourteen or fifteen houses.
140 BRETONNEAU’S FOURTH MEMOIR.

slightest inconvenience in respiration. Uncleanliness and want of
care perhaps contributed to this termination ; but we shall soon see
whether there is not reason to suspect that it may have been caused by
a cachectic state of the system, produced by the mercurial treatment.

Tracheotomy had been proposed in vain as a last resource ; it was
impossible to obtain permission to perform it on any of the patients
who died. Perhaps the fear which the epidemic sore-throat had be-
gun to create, might have triumphed over a remnant of prejudice, if
several persons had not expected a cure to be performed by scarifi-
cation of the tonsils. This mode of proceeding, generally censured
-by the physicians of the seventeenth century and the inconveniences
of which had been ascertained by Van Swieten himself, was far from
being attended with any favourable results, and indeed it appeared to
ageravate the disease. In some subjects who had not even a
catarrhal Angina, it was employed as a prophylactic agent. A boy
fourteen years old, who was admitted into the General Hospital,
had just had the anterior pillars of his velum palati scarified,
although we could not discover the slightest trace of inflammation in
his pharynx. A few days afterwards, he was attacked with Malig-
nant Angina.

It is no doubt in consequence of a mistake in diagnosis, too often
committed, that this erroneous practice, which has always been cen-
sured by experienced physicians, has been retained. Scarifications
practised in Scarlatinal Angina, which tends to a favourable termina-
tion, generally of a spontaneous and rapid character, may have been
considered beneficial for this very reason, namely, that they are not
opposed to the cure. In Malignant Angina they are hurtful by their
direct effects; but perhaps their most serious drawback is, that
they are substituted for efficacious remedies, the opportunity of em-
ploying which, if it is allowed to escape, cannot be regained.

On the 1st of January, 1826, seventeen persons had already been
attacked with epidemic sore-throat, and as not one had escaped death,
the resolution was at last taken to convey all those who were affected
with this malady, to the General Hospital. Out of twelve persons
admitted in succession, three died.

I have collected, with great care, the practical facts which were
presented to my notice, after an interval of five years, by an epidemic
affection the dangerous character of which had so long attracted my
attention, and I am now about to record the results.
EPIDEMIC OF CHENUSSON. 141

Cass 83.— —. O., aged five years, of a good constitution, had
been taken from Chenusson to Tours, on the 26th of December,
1825, with the intention of removing her from the contagion. On
the previous night the back of the mouth had been examined with
great attention, but nothing remarkable had been observed in the
pharynx. During her removal there was rather acute febrile excite-
ment ; either from the fear of being subjected to a painful examina-
tion, or because deglutition was really unattended with any pain,
the little patient constantly denied having any sore-throat. Yesterday
the same feverish excitement continued and the appetite was di-
minished.

On the 29th of December the child was seen for the first time at
ten o’clock in the morning. On the third day of the disease, not-
withstanding the feverish excitement, the strength was not impaired.
Since the middle of the night there had been coryza without sneez-
ing, and only marked by a snuffling, which rendered the respiration
by the nose, noisy and difficult. There was swelling of the lymphatic
glands of the neck, principally on the night side. Some white, thick,
lichenoid masses covered a portion of the surface of the tonsils, which
were moderately reddened and swollen. Beyond the posterior pillars
of the velum palati, the pharynx was lined with pellicular exudations
as far as the base of the tongue, which was slightly covered with a
slimy fur. Pulse 100. The skin was cool, the respiration easy,
and there was no cough.

Some concentrated hydrochloric acid was lightly applied to the
affected parts, and induced nausea, followed by the expulsion of a
thick, elastic, membraniform layer, of the size of the thumb-nail.

At six o’clock the child was taken to the Hospital, and
a second cauterization was performed by one of the resident
pupils. There is reason to believe that it was not extended over
the whole of the affected surfaces, and a third cauterization, which
was much stronger, was applied with care, and the pharynx was
thus entirely berated from the membraniform pellicles with which
it had been covered. There was no alteration in the tone of the
voice. (Pulse 116. Resp. 20.) A collar of mercurial ointment
was applied round the neck. A grain of calomel was given every
hour, and a mixture of calomel and gum in powder was ordered to
be inhaled in the same manner as snuff. On the fourth day, some
membranous exudations, of a grey, or rather of a yellowish-white
142 BRETONNEAU’S FOURTH MEMOIR.

colour, covered the surface of the tonsils. , The elongation and tume-
faction of the uvula prevented our discovering the state of the
pharynx beyond the isthmus of the throat. Ten grains of calomel
were given internally every hour, and the child also frequently in-
haled some through the nostrils.

This morning the snuffling was less; opaque mucous matters
flowed from the nostrils; the swelling of the lymphatic glands was
not diminished. (Pulse 104. Resp. 20.) The calomel to be con-
tinued. On the fifth day, respiration was so tranquilly performed,
that it was difficult to count it. A white, opaque, slender pellicle
covered all the surfaces touched by the acid; the uvula was less
swollen; the child complained of no pain, and there was no cough
(Pulse 104; resp. natural); one ounce of castor oil to be givenin an
emulsion. On the sixth day, the tumefaction of the cellular tissue
on the sides of the neck was diminished; but the sub-mastoid lym-
phatic glands preserved their volume and hardness; some opaque
membranes, having the whiteness of curdled milk, still covered the
uvula and the tonsils; the lower parts of the pharynx could not be
explored; the cough was rather infrequent; there was hoarseness,
and guttural embarrassment of the respiration. (Pulse 88. Resp. 16.)
Infusion of polygala, eighteen grains to two ounces of water; one
ounce of castor oil.

The guttural embarrassment of the respiration remained during the
sixth and seventh days of the disease; the cough was even a little
hoarse, but on the eighth, it became moist and altogether catarrhal.
The membranous coating of the surfaces affected with the diphtheritic
inflammation was being worn away and attenuated; a deep, vivid
redness circumscribed the semi-transparent spots which were still
being formed here and there on the tonsils and on the sides of
the uvula. A purgative draught prepared with an infusion of poly-
gala and an ounce of castor oil, was given on the sixth day; on the
seventh, ten grains of jalap and four drachms of castor oil; on the
eighth, eight grains of jalap and three grains of scammony in one
dose ; and every day several alvine evacuations were obtained. Sixty-
five grains of calomel had been taken internally, forty grains of the
same substance were inhaled like snuff, and two drachms of mercurial
ointment were applied by inunction round the neck.

There was emaciation and anorexia: a superficial erosion of the
lps and the chin, produced by some hydrochloric acid which the
child had apphed to her mouth, at a time when the phial containing
EPIDEMIC OF CHENUSSON. 143

it, had been imprudently left within her reach, was cicatrized in a
few days; from the twelfth to the sixteenth day, there was slight
puffiness of the face, without mercurial ulceration of the mouth. The
pulse remained habitually frequent; but still the appetite began to
return, On the twentieth day, a small scabby ulceration was still
seen at one of the commissures of the lips; but the health in other
respects was completely restored.

Casz 34.—F. R., aged fourteen, of a strong constitution, living in
the same house with the subject of the last case, experienced some
feverish excitement acompanied with difficulty of deglutition, on the
29th of December, 1825, and on the 30th she was admitted into the
Hospital. There was swelling of the cervical lymphatic glands,
cedematous swelling of the sides of the neck, redness and swelling
of the tonsils. A semi-transparent pellicle extended, growing thinner
as it advanced, from the edge of the anterior pillars of the velum
palati to the surface of the tonsils ; a topical and superficial applica-
tion of concentrated hydrochloric acid, was ordered; a grain of
calomel was given every two hours; a mixture of calomel and pow-
dered gum was used like snuff; and a collar of mercurial ointment
was applied round the neck. On the third day, the pellicular exuda~
tions were more opaque ; the base of the throat was lined with mucous
matters, which were seen descending from the nostrils, and which
were loaded with calomel. Deglutition was painful; the same treat-
ment was pursued. On the fourth day, a vivid redness circumscribed.
the exudations, or rather the membranous, slender, and semi-trans-
parent coating which covered a part of the surface of the tonsils.
(Pulse 64.) No snuffling or hoarseness. (An ounce of castor oil
in emulsion.) The mercurial treatment was discontinued. On the
fourth day there was painful sensibility of the incisor teeth; one
ounce of castor oil emulsion was given; there was anorexia, and
slightly-marked emaciation. On the fifth day, fifteen grains of jalap
were given, and four drachms of castor oil in an emulsion. On the
seventh day, twelve grains of jalap were given with five grains of
scammony. Every day two or three evacuations were procured ;
on the twelfth, the patient had recovered her stoutness and the
freshness natural to her age; forty grains of calomel had been taken
internally, and twenty grains had been inhaled like snuff. A drachm
of mercurial ointment was employed by inunction on the neck.
144 BRETONNEAU’S FOURTH MEMOIR.

Case 35.—J. B., aged fifteen, of a strong constitution, was ad-
mitted into the Hospital on the same day as the subject of the last
case. The first symptoms of Diphtheritic Angina were developed
twenty-four hours later than in the former girl, and they yielded still
more rapidly to the local applications and to a less prolonged mer-
curial treatment.

Case 36.—N. B., an infant at the breast, aged one year, of a pale
and delicate appearance, but in other respects in good health, was
admitted into the Hospital on the 4th of January, 1826. White,
opaque, pellicular exudations covered the tonsils and extended to the
walls of the pharynx. There was considerable swelling of the sides
of the neck. The health of the child appeared altered for the pre-
ceding two days, the alteration commencing on the day after the
death of one of its brothers, who had just died of Diphtheritic Angina.
An application of concentrated hydrochloric acid was ordered super-
ficially, but to be frequently repeated, and exactly extended over all
the affected surfaces; a parteof the pellicles covering the tonsils ad-
hered to the sponge. One grain of calomel was given every hour;
calomel in powder mixed with gum was applied to the nostrils by
means of a little pledget of lint, and a collar of mercurial ointment
was ordered round the neck. On the fourth day the swelling of the
lymphatic glands was a little diminished. The white, opaque exuda-
tions which covered the tonsils, did not appear to be larger than
on the previous night; the mercurial treatment was continued. On
the fifth day the swelling of the lymphatic glands of the left side
was completely dissipated, and it was sensibly diminished on the
opposite side ; a vivid redness circumscribed the pellicular exudations
which had become less extensive; four drachms of castor oil were
given. On the sixth day, we could no longer distinguish anything
on the tonsils except some membranous spots which were rapidly
being effaced; some of the lymphatic glands had returned to their
normal size. The child continued to suck, and refused every
other kind of food. The mercurial treatment was discontinued. The
convalescence made rapid progress, and by the tenth day the child
was quite well. The mouth had shown no trace of mercurial affection.

Casz 37.—F. B., aged ten years, brother of the last patient, and
who had been admitted into the Hospital on the 80th of December,
had remained there until the 8rd of January, affected with a slight
EPIDEMIC OF CHENUSSON. 145

sore-throat. In the night of the 8rd to the 4th, there was in-
tense fever, redness and swelling of the tonsils with painful tumefaction
of the lymphatic sub-maxillary glands. Although no pellicular exu-
dation was yet observed on the inflamed surfaces, twenty grains of
calomel mixed with powdered gum were used for the next two days
hke snuff. In exploring the state of the back part of the mouth,
the mucous matters were seen ta descend from the nostrils into the
pharynx, whitened by the protochloride of mercury. From the third
day, the swelling and redness of the tonsils were completely removed.
Had this child been really affected with Diphtheritic Angina? J am
the more induced to think so, as the lymphatic glands of the right
side, the swelling of which had at first diminished, became swollen
again afterwards, and formed an abscess. After the opening of this
abscess, recovery made rapid progress, and when the child left the
Hospital, his health was perfectly re-established.

Case 38.—F., aged ten years, of a slender stature and pale com-
plexion; had painful deglutition since the 25th of December. Forty
grains of calomel had been administered in two days by M. Henri
Brault. The calomel was discontinued on the 28th of December.
The parents of the patient had given him some garlic boiled in
vinegar. On the fourth day he entered the Hospital ; he was hoarse,
the voice was feeble; there was swelling of the sides of the neck ;
the tonsils were tumefied, of a livid red colour, partly covered with
greyish shreds of exudation; they touched each other, and the
deglutition remained difficult and painful. (A grain of calomel was
given every hour, and a collar of mercurial ointment was applied.)
On the fifth day there was the same appearance of the pharynx; the
same state of the patient, and the same treatment. On the sixth
day there was a diminution of the swelling of the lymphatic glands ;
the tonsils were laid bare, but they preserved a violet colour and re-
mained swollen; the hoarseness and feebleness of the voice remained.
(Four drachms of castor oil.) On the seventh day the tonsils had
subsided, the engorgement of the lymphatic glands was dissipated,
deglutition was easy, and the appetite returned. On the eighth day
the mercurial treatment was discontinued ; the appetite was very keen,
the voice became clear, and from this period the progress of the con-
valescence was no longer interrupted. On the ninth day four drachms
of castor oil were given, and ten grains of jalap. On the twelfth day
ten grains of jalap were given with four grains of scammony; the

L
146 BRETONNEAU’S FOURTH MEMOIR.

health was completely restored. The little patient, placed near a
stove, enjoyed, during the whole of the treatment, the advantages of
a temperature which was never lower than ten degrees.* The diph-
theritic inflammation of the pharynx appeared to have been already
modified by the mercurial treatment when the child was admitted
into the Hospital; no local treatment was resorted to ; forty-eight
grains of calomel were taken internally and forty were inhaled.

Casz 39.—L. Bodier, aged twenty-four, of middle stature, gene-
tally enjoying good health, was admitted into the Hospital on the 6th
of January, 1826. For five days there had been sore-throat, accom-
panied with fever; scarifications had been practised on the tonsils,
which, on his admission, were swollen and covered with pellicular
exudations. Before his departure from Chenusson, the patient had
taken twenty-eight grains of calomel administered in fourteen doses.
He was afterwards, during a journey of five leagues, exposed to cold
and wet. On the fifth day, at nine o’clock in the evening, the
tonsils were swollen, livid, bloody, covered with greyish pellicular
strips; there was hoarseness and feebleness of the voice ; tumefaction
of the sides of the neck. One grain of calomel was ordered every
two hours. On the sixth day, in the morning, there was puffiness of
the face, membranous mercurial ulcerations of the edges of the tongue
and of the internal part of the cheeks ; a dirty and bloody appearance
of the surface of the tonsils, which remained swollen ; hoarseness and
anorexia; four grains of calomel had been taken in the course of the
night ; the mercurial treatment was discontinued. On the seventh
day, the state was the same as on the previous night, but the tongue
was more painful. or the last two days the temperature had fallen,
and the patient had remained in a ward without a stove, where he
suffered much from cold; he was removed into a warmer apartment;
there was anorexia, with mercurial salivation. On the eighth day
there was mercurial membranous inflammation of the internal part of
‘the lips and cheeks ; the oedematous swelling of the face was increased ;
there was emaciation and constant thirst; deglutition was more
easy; the tonsils, less livid and less swollen, were covered here
and there with a diphtheritic membranous coating, which was progres-
sively becoming thinner and disappearing ; the swelling of the cervical
glands had subsided. On the ninth day there was some appetite.
From the tenth to the eighteenth day, hunger was more and more

* M. Bretonneau does not state what thermometer was used, but it was
probably the centigrade. (Ep.)
EPIDEMIC OF CHENUSSON. 147

felt, the ulcerations. of the mouth were circumscribed and gradually
disappeared ; the complexion was more animated, but the cedematous
swelling of the cheeks and chin had not diminished. In spite of our
remonstrances, the patient insisted on leaving the Hospital; he was
cautioned to protect himself with the greatest care against the in-
fluence of cold and moisture. I learned that this patient, on his
return to his parents, enjoyed pretty good health for four days; but
that he complained of severe illness as soon as the temperature
had again fallen, and that at last he died on the 10th of February of
an attack of hemoptysis, which lasted for several days, and that it
was constantly accompanied with dyspnea.

Casz 40.—T., an orphan, aged thirteen, who had been kept at
the Hospital in consequence of a relapse of intermittent fever, had
not been more intimate with the children brought from Chenusson,
than two other girls of her own age ; she had only inhabited the same
ward, and been warmed at the same stove. On the 10th of January,
1826, she had had rather intense fever since the previous day; deglu-
tition was difficult and painful; there was swelling of the lymphatic
sub-mastoid glands; redness and swelling of the tonsils; a slender,
semi-transparent pellicle covered their surface; some hours later this
pellicle became opaque and lichenoid ; the treatment was local. On
the third day, the pellicular exudations were detached; the surfaces
touched by the concentrated acid preserved only a whitish tint.
(Calomel was given in grain doses every three hours ; and two grains
suspended in gum-water were injected into the nostrils three times a
day.) On the fourth day, fresh pellicular exudations were produced,
but not to any great extent. From the fifth day they began to wear
away and dissappear; the mercurial treatment was interrupted ; de-
glutition was no longer painful ; scarcely twenty-four grains of calomel
had been administered. On the seventh day, there was cedematous
swelling of the face. The patient, who was placed near a door, had
suffered from cold ; she was removed near to a stove. On the eighth
day, a large membranous mercurial ulceration extended to the inside
of the cheeks ; the blood which exuded from the ulcerated surfaces was
deposited around the teeth, and there it formed thick clots ; the swollen
tongue preserved the impression of the teeth ; its edges were ulcerated,
and the swelling of the face was considerably increased. (Gargle of
hydrochloric acid.) On the twelfth day the breath was fetid; the
exudation of blood had ceased; the membranous ulcerations were

more painful, but they were beginning to clean; the tongue was less
%2
148 BRETONNEAU’S FOURTH MEMOIR.

swollen, the pulse was scarcely febrile. On the fourteenth day the
ulcerations were less painful, were beginning to clean, and to become
circumscribed, and the puffiness of the face was rapidly disappearing.
On the fifteenth day, in the place of the membranous ulcerations,
only some superficial rose-coloured excavations were seen, and they
were on the point of disappearing ; mastication was less painful. On
the seventeenth day all the mercurial ulcers were cicatrized, and on
the twentieth day the health was completely restored.

Casz 41.—B., aged fourteen, of a feeble constitution, was ad-
mitted into the Hospital on the 15th of January, 1826. This boy had
accompanied the man Bodier (Case 39), on the 6th of January, and
although he had no swelling of the tonsils, he bore, on the anterior
pillars of the velum palati, the traces of scarifications to which he had
been subjected two days before. During his residence at the
Hospital, none of the symptoms of Malignant Angina had been
manifested, and he had gone out in perfect health. On the 15th of
January, the tonsils were swollen, reddened, and covered. with white,
opaque, lichenoid exudations. Two white points were distinguished
at the base of the uvula, and three or four spots, also white, of a
lenticular figure, beyond the posterior pillar of the velum palati, on
the walls of the pharynx. The sub-mastoid lymphatic glands were
considerably swollen. Concentrated hydrochloric acid was repeatedly
applied locally ; the diphtheritic exudations adhered to the sponge.
The patient said that on the previous night he experienced some
febrile symptoms followed by pains in the sides of the neck, and by
difficulty of deglutition. On the third day, the mucous membrane
of the tonsils appeared to be slightly whitened by the contact of the
acid ; it was not covered by exudations ; deglutition remained painful ;
the swelling of the lymphatic glands was diminished; the nostrils
were injected with water having calomel suspended in it. On the
fourth day, some slender pellicles were again formed on the surface of
the tonsils, and others bordered the sides of the uvula; the mercurial
treatment was continued. On the fifth day, the pellicular exudations
were not extended in surface, but they had increased very much in
thickness. Some were seen between the base of the anterior pillar of
the velum palati and the base of the tongue. The parts surrounding
the pellicles were lightly touched with a little sponge soaked in con-
centrated hydrochloric acid ; no more swelling remained except in the
lymphatic glands of the right side. On the sixth day, the appear-
EPIDEMIC OF CHENUSSON. 149

ance of the pharynx was the same ; for two days the doses of calomel
were less frequently administered. The patient was brought near
the stove and the temperature was not allowed to sink below ten
degrees in the part of the ward where he was placed; a superficial
application of concentrated hydrochloric acid was again made.
On the seventh day, the diphtheritic exudations assumed a grey
tint ; they were partly detached and had diminished in size. The
mercurial treatment was discontinued. From the eighth to the tenth
day the swelling of the lymphatic glands had altogether disappeared,
and no further trace of morbid affection remained except two little
white spots towards the base of the uvula, and a red fringe following
the free and floating border of the velum palati. On the twelfth
day, the two little white spots at the base of the uvula had extended ;
each of them was formed by a concrete matter which assumed the
figure and the dimension of a lentil. Hydrochloric acid was applied ;
deglutition was easy and the general state of the health left nothing
to be desired. On the fifteenth day the two spots had disappeared.
Each day two or three alvine evacuations had been procured by giving
a few grains of jalap or an emulsion of castor oil.

Case 42.—N. Rameau, aged ten, of a plethoric constitution, an
idiot, and epileptic, admitted into the Hospital on the 14th of January,
1826, began to experience some difficulty in deglutition on the 1st of
January. He was seen on the third day of the disease by M. Brault,
who found the pellicular inflammation of the pharynx too exten-
sive for the trial of any local application. On the fourth day, at ten
o'clock in the evening, the tonsils were so much swollen that they
touched one another ; these organs as well as the uvula were covered
with a greyish exudation ; the fetor of the breath was insupportable ;
respiration was accompanied by a guttural rattle. A great abundance
of viscid, semi-transparent mucous matters flowed from the commis-
sure of the lips and from the orifice of the nostrils. Some swollen
lymphatic cervical glands formed a great projection behind the angle
of the jaw; the papillae of the tongue were erected and covered
with a slimy coating; the respiration was frequent. (Pulse 94 to
96.) Concentrated hydrochloric acid was twice applied locally by
means of a sponge slightly soaked in it ; a grain of calomel was given
every hour. A mixture of powdered gum and calomel to be applied
to the nostrils and inhaled like snuff. On the fifth day of the disease,
the difficulty of deglutition was not diminished; the swelling and
150 BRETONNEAU’S FOURTH MEMOIR.

hardness of the lymphatic glands were still more marked ; the
mercurial treatment was continued ; there was no cough; the fetor of
the breath was diminished. On the sixth day, the state of the patient
was the same, and the treatment was the same. On the seventh day,
there was a sensible diminution of the swelling of the lymphatic glands;
deglutition was rather less painful; the tonsils were less swollen, but
still covered with greyish exudations, and the uvula, falling very low,
prevented anything from being discovered below the isthmus of the
throat ; the redness of the borders of the tongue made us anticipate
and fear mercurial salivation ; the administration of calomel was there-
fore suspended. On the eighth day, the swelling of the cervical
lymphatic glands was sensibly augmented. During every inspiration
the passage of the air through the glottis caused a hissing sound to
be heard. The attendants stated that the patient had not yet coughed.
Still the alteration of the tone of the voice made us fear that the
pellicular inflammation had attacked the air-passages ; and very soon
the croupal cough excited by the examination of the pharynx no
longer permitted us to doubt that this dangerous symptom had
escaped the attention of the nurse. Semi-transparent mucous matters
flowed abundantly from the nostrils. It was decided that tracheotomy
should be performed as soon as the difficulty of respiration should
threaten suffocation. The patient was left at eight o’clock in the
morning, to be re-visited at noon, and I was ready to come before
the time indicated, if the symptoms should become aggravated. At
eleven o’clock, the dyspnoea increased ; the imminence of the danger
led to the administration of extreme unction, and it was only after
having fulfilled this pious office with a somewhat inconsiderate zeal
that the sister of the ward sent forme. The operation, for which
preparations had been made beforehand, could not be performed
until twenty minutes after death. The movements of respiration
having been for a long time fruitlessly imitated, the commencement
of cadaveric rigidity permitted the opening of the body two hours
afterwards.

Autopsy.—None of the abdominal viscera were altered from the
healthy state ; the mucous membrane of the stomach was of a pale-
rose colour, becoming a little deeper at the dependent part of this
viscus ; a slight, very superficial erosion, of a line and a half long
in its greatest diameter, was the only lesion to be discovered. In
general the mesenteric vessels were moderately injected, and the
mucous coat was pale in the small as well as in the large intestine.
EPIDEMIC OF CHENUSSON. 151

Thorax.—The lungs were crepitant and very permeable to air,
except where there were two small, partial, very circumscribed hepa-
tizations, which were seen on the surface of the right lung. The
mucous membrane of the bronchi was pale, and it was only towards
the middle part of the trachea that the punctiform redness peculiar
to diphtheritic inflammation was seen; it frmged the slender semi-
transparent floating border of a tubular membraniform exudation,
which became very thick and more and more adherent in proportion
as it was traced into the larynx. We found it again less intimately
united to the epiglottis. The grained redness was converted into a
violet colour, which was uniform and more deep in the regions where
the false membrane could only be detached by the aid of strong
traction, or by means of the back of ascalpel. It was easy to discover
that the inflammation of the air-passages had not acquired more in-
tensity in any part than below the arytenoid notches, that is to say,
beneath the only parts which gave a more easy passage to the
exudations from the pharynx.

Over the whole extent of the back part of the mouth, the exuda-
tion, being closely adherent to the surfaces which it covered, so
exactly resembled the appearance of eschars in its aspect and fetor,
that it was necessary to guard against this fallacy, in order that we
might not confound the putrid alteration of the inorganic pellicles
with a true gangrenous lesion. A thick and soft mass of concrete
matter obstructed the upper part of the pharynx, and, in the nostrils,
was converted into a supple, elastic membrane, of a yellowish-white
colour, which projected beyond their orifice. It is difficult to conceive
how this exudation did not completely intercept the passage of the
air, A pseudo-membranous sheath, more than two lines thick, ad-
hered so closely to the uvula, that it could be separated from it only
with great difficulty. The alteration of the appearance of the tonsils
was now reduced to a fibrinous ulceration, presenting a dirty aspect.

Although the operation was not a certain method of remedying
this accumulation of diseases, it cannot be doubted that it might
have prolonged life, and offered a chance of recovery. What might
have been, in this case, the mode of termination of the diphtheritic in-
flammation in the nasal cavities P

Having performed the operation on the dead body, I found, by the
dissection which followed, that the incision of the trachea ought to
have been commenced immediately below the thyroid body, which
might have been divided without danger. Three serious considerations
152 BRETONNEAU’S FOURTH MEMOIR.

forbid the prolongation of the incision below the supra-sternal de-
pression. First, the danger of meeting with the right carotid artery,
the direction of which at this point, obliquely crosses the trachea.
Second, the risk of dividing the thyroid veins near their origin, an
accident which would have the inconvenience of giving a passage not
only to the blood which they themselves carry, but also to that which
is flowing from the dilated venous trunks. In the present case, for
example, the jugular veins were so much dilated, that they would
easily admit the thumb of an adult. Third, the depth at which the
trachea is situated, for this tube follows the curvatures of the vertebral
column, and thus it tends to retire more and more behind the integu-
ments which cover the supra-sternal depression.

In the night preceding the death of this child, its mother, aged
forty-three, who had remained at Chenusson, died of the same disease.

Cast 43.—Cormery, aged eight years, of a feeble constitution, was
received into the Hospital on the 12th of January, 1826. After some
lengthened attacks of autumnal fever, this child was affected with
anasarca, from which he was scarcely convalescent when he experienced
the first symptoms of Malignant Angina. He was brought from Che-
nusson during a severely cold day, and had travelled five leagues, being
still able to ride alone on a donkey. The matter which he had spit
up was frozen on his clothes. For the last four days, deglutition
had been painful and difficult; the voice was hoarse, the cough harsh
and frequent, accompanied with a viscid, frothy, semi-transparent
expectoration.

Some white, lichenoid, pellicular exudations were seen upon both
tonsils, which were moderately reddened and swollen. These exu-
dations occupied only a portion of their surface, and no other similar
appearances were observed in the pharynx, with the exception of two
small, isolated white pomts on the sides and towards the base of the
uvula. There was a painful and very prominent swelling of the
lymphatic glands of the neck; those of the right Bide, which were
the most hard, formed a mass, of the size of a pigeon’s egg, under the
superior attachment of the sterno-mastoid muscle.

Two hours after the arrival of the patient, his cough became more
frequent ; it was hoarse, and, although often repeated, was generally
reduced to two expirations. The respiration, which was already
accelerated, was not yet stridulous, and was only beginning to be
rattling (rdleuse), when the child fell into a state of somnolence
EPIDEMIC OF CHENUSSON. 153

after each attack of coughing; the matter expectorated was very
abundant, four ounces being collected in a spittoon in two hours ;
it was frothy, fluid, semi-transparent, and sometimes marked with
streaks of blood. A great quantity of these mucous secretions cer-
tainly proceeded from the back of the mouth ; skin cool, pulse 120.
The functions of the life of relation were normally performed. A
grain of calomel was given every half hour, twenty grains more were
to be mixed with powdered gum, the patient to inhale from time to
time a pinch of this mixture in the same manner as snuff. A collar
of mercurial ointment to be placed round the throat. On the fifth
day of the disease, at six o’clock in the morning, the cough, which
was short and hoarse, was still frequent; the lymphatic glands of the
neck were painful, although less swollen; the respiration was more
stridulous ; respirations 20; the sides of the uvula were bordered
with concretions.

At eight o’clock, the cough had become less frequent, but there
was the same rapidity of breathing; the depression and irregularity
of the pulse, rather than its frequency, prevented us from counting
it; there was the same integrity of the functions of the life of rela-
tion; the skin was cool; the expectoration retained the characters
~ already indicated ; powdered gum was dissolved in water and injected
at intervals through the nostrils into the back of the mouth. At
eleven o’clock, the inspiration became sibilant, and was only per-
formed by great muscular effort. During its performance, the interval
between the sterno-cleido-mastoid muscles, and the interstices between
all the muscles of the neck which are fixed to the clavicles, were
strongly depressed.

The infrequency of the cough, and the abundance of matters which
were expectorated (an abundance which allowed us to presume that the
diphtheritic inflammation was already propagated over a great extent of
the mucous membrane of the air-passages) induced me to hasten the
period of the operation, with the double object of preventing the
danger of suffocation which proved so rapidly fatal in the subject of
the last case, and, by dropping in water charged with calomel, of
arresting, if possible, the propagation of the pellicular inflammation.

At noon, the operation was performed ; the dilated trunks of the
superficial thyroid veins were easily placed out of the way on the sides
of the incision, which was extended from the middle part of the thy-
roid body to the supra-sternal notch. A moderately abundant flow
of blood was arrested by the ligature of one of the deeper veins.
154 BRETONNEAU’S FOURTH MEMOIR."

The trachea was laid open, and the trickling hemorrhage from the
wound did not prevent the introduction of a steel bistoury into
this canal and the division of one of its rings. The air passed
out bubbling and driving with it mucous secretions mixed with blood.
By the help of a narrow and button-headed bistoury, introduced
during the time of expiration, into the small opening, the incision was
prolonged from five to six lines. The blood flowed abundantly ; it was
wiped away with a sponge at the time of each expiration.* A silver
canula, of suitable size and shape, was easily introduced by means of
forceps with curved blades. In less than three minutes, the hemor-
rhage was completely arrested. Some mucous matters mixed with
blood were expelled by a fit of coughing, which produced vomiting.
From this time the respiration became calm and noiseless ; the pulse
remained frequent and irregular. Although the respiration. was ex-
tremely calm, in the evening at eight o’clock the pulse was irregular,
148 in the minute, and the respiration was 32.

On the sixth day of the disease, at six o’clock in the morning, the
respirations were 32, and the pulse was 120; an injection of bark
was administered. At noon, the canula was drawn out to afford an
easier passage for the mucous secretions thrown up by the cough,
which was excited by an application of calomel. At eleven o’clock
the respirations were 52, and the pulse was 127. In the afternoon the
respiration became more frequent, namely 56; the canula was with-
drawn, and it was not obstructed, but exudations were seen through
the separated lips of the wound in the trachea. A band, two lines
wide and two inches long, was drawn away by the brush (écowvillon).
A portion which presented itself at the inferior commissure of the
wound could not be seized. The respiration became less noisy with-
out losing its frequency ; the pulse was 180, and the respirations 44.
The canula was again withdrawn, and two masses of concrete matter,
enveloped in mucus, required some tedious efforts for their expulsion.

* I was in too much haste to penetrate into the trachea, and I suspect
that the fibrous threads which were afterwards expectorated, proceeded
from the blood which was introduced. This hurry on my part produced
other inconveniences, for, with the intention of carrying the opening of the
air-tube to the left rather than remaining on the other side of the median
line, just the contrary happened. The incision, also, could not have been
prolonged for two lines without reaching the right carotid artery. A few
moments devoted to arresting the hemorrhage and exposing fairly the part
of the trachea which is to be opened, simplify the results of the operation
and secure its success.
EPIDEMIC OF CHENUSSON. 155

After having mashed them in water, they were found to be composed
of diphtheritic pellicles of rather slender consistence and of a reticu-
lated branching structure, which may have been portions of fibrine,
coming from the blood which flowed from the trachea at the period
of the operation. At eight o’clock in the evening, the inspirations
were dry, noisy, and irregular, 65 in the minute; the functions of the
life of relation were normal. The pulse was much depressed, ex-
tremely frequent, and could scarcely be counted; it exceeded 140.
_At eight o’clock the instillations of calomel into the trachea and the
nostrils were discontinued.

On the seventh day, at one o’clock in the morning, the respirations
were 60, and the pulse was 122. After an injection of gum-water,
some thick mucous matters, and a clot composed of concrete matter,
of membraniform pellicles, and of dried mucus were expelled; the
canula was displaced. A fresh injection was made of gum-water ;
mucous matters were again expelled, enveloping the thin and ragged
shreds of diphtheritic exudations.

There were every day three or four alvine evacuations of a greenish
colour. Two carious teeth on each side of the lower jaw became
violently painful, and caused the patient much uneasiness.

From ten o’clock in the morning till ten at night, a very small
quantity of gum-water was injected into the trachea at different
times, and each time some tenacious mucous matters were expec-
torated. The membraniform pellicles which were found to be inter-
mingled with them were nowsmaller in size; the anorexia still remained.
Nevertheless the little patient took, of his own accord, half a cupful
of broth; the yolk of an egg beaten up in two ounces of decoction
of bark, was also given to him as an injection. Three alvine evacua-
tions were passed, loaded with green mucus. In the first we dis-
tinguished two half-digested clots of blood ; the functions of relation
were perfect. The patient rose without help, to satisfy his wants.

On the eighth day at seven o’clock in the morning, the pulse was
120, there was great heat of skin, redness of the cheeks, respirations
78 ; injections of gum-water were passed into the trachea. The ex-
pectorated matter was mixed with pellicular exudations, and exhaled a
fetid odour ; three or four stools were passed during the day. We suc-
ceeded in making the patient take a little broth, and an injection with
six grains of sulphate of quinine was administered ; this was retained
for anhour. On the ninth day, about ten o’clock in the morning, the
respiration became more noisy and there was swelling of the face. The
156 BRETONNEAU’S FOURTH MEMOIR.

canula was taken out. The frequency of the respiration was dimi-
nished after the dressing. The edges of the tongue were at first
ulcerated at all the points which were in contact with the asperities
of some decayed teeth, and afterwards the same appearance was ob-
served opposite the projections of the other teeth. (Sulphate of
quinine, three grains.) | Some reddish mucus and putrefied pellicles
were thrown up. It was discovered that the incision did not occupy
the median line of the trachea and that some of the cartilaginous rings
had been pushed back and folded in by the canula; the respirations
were 44; the pulse was less frequent and more distinct, A decoction
of bark was substituted for the gum-water in the injections.

At four o’clock in the afternoon, the respirations were 54 ; sulphate
of quinine was given in the dose of four grains. The mouth of the
patient exhaled a gangrenous odour, and the mercurial ulcerations of
the internal part of the cheeks and of the edge of the tongue pre-
sented a very dirty appearance. The tonsils, which were no longer
swollen, the uvula and a part of the velum palati, appeared actually
sphacelated. A sponge, soaked in a mixture of alcohol and hydro-
chloric acid was applied to the pharynx. The animated expression
of the countenance was succeeded by a dejected and morose appear-
ance. The respiration, which remained noiseless, became more and
more frequent. Death took place on the 18th of January, at two
o’clock in the morning, without suffering and without-any- attack of
suffocation.

Since the second day after the operation, the canula, after having
remained a short time in the passage made by the wound, was always
taken out blackened at the points which were in contact with the
exudations of the larynx.

Autopsy.—There was an edematous swelling of the sides of the
neck ; grey, mercurial, blackish ulcerations, of an exceedingly dirty
hue, covered all the points of the mucous membrane exposed to the
friction of the projections formed by the teeth ; the gums no longer
adhered to the neck of the carious teeth, and the separation was in-
dicated by the blackish tint of their line of insertion. The part of the
pharynx which had been attacked by the diphtheritic inflammation
was ulcerated, grey, blackish, and from this part was exhaled an in-
sufferably fetid odour. Some pellicular strips of membraniform
exudation, still adherent, were observed at different points. There
was no doubt that the mucous tissue was completely sphacelated ; the
gangrene was not circumscribed at any part ; it was being propagated
EPIDEMIC OF CHENUSSON. 157

to the base of the tongue, to the velum palati, and to the uvula; the
pituitary membrane was of a deep violet tint, and was covered, in
its whole extent, with a thick, soft, membraniform exudation, both
surfaces of which were speckled with greyish spots.

Thorax.—At the base of both lungs there were numerous partial
spots of hepatization ; below the incision in the trachea there were
no false membranes in the air-tubes. Those which still lined the
larynx were only slightly adherent and possessed but little consistency ;
their colour had become grey, and the mucous membrane beneath
them was of a livid violet colour. The child had frequently en-
deavoured to speak since the operation, but had never been able to
articulate a word.

Abdomen.—There was extreme paleness of the whole gastro-intes-
tinal mucous coat.

Casz 44.—F. Bodier, aged sixteen years, whose previous good health
was indicated by a moderate degree of stoutness, with an animated
tint of the skin, and all the freshness proper to youth, experienced
the first attack of epidemic sore-throat on the 8rd of January. On
the 4th, scarifications were performed on the tonsils, the swelling
of which had considerably increased. The patient, who had been
exposed to a very cold temperature during a journey of five leagues,
was admitted into the Hospital on the 6th of January.

On the third day of the disease, at ten o’clock in the evening, the
tonsils were swollen so much as to touch each other, and to be pushed
backwards, while they thrust forward the uvula, the point of which
was directed toward the palatine vault ; some thick, white and greyish
exudations covered the portion of the tonsils which was exposed to
view; the sub-mastoid lymphatic glands formed on each side a hard,
resisting tumour of more than fifteen lines in diameter. ach inspi-
ration was noisy, and accompanied with a guttural rattle; there was
no cough; the breath was very fetid. A sponge moistened with con-
centrated hydrochloric acid, and suitably squeezed, was cautiously
introduced between the tonsils, and applied twice, as far as the
pharynx. A nauseous smell, resembling that of burnt flesh, was
diffused at a distance, the moment the parts were touched. (A grain
of calomel was given every hour, and a collar of mercurial ointment
was applied round the neck. A mixture of powdered gum and
calomel, ten grains of each, to be inhaled like snuff.) On the fourth
day, the tonsils no longer touched each other ; the uvula was lowered
158 BRETONNEAU’S FOURTH MEMOIR.

a little; some shreds of false membrane were mixed with the matter
which was spit up. The patient articulated rather more distinctly ;
a band covered with mercurial ointment was reapplied round the
neck ; the calomel was continued. The temperature fell below zero.
On the fifth day the pulse was feeble and depressed ; the tongue was
moist and clean at its point; there was anorexia; the lymphatic
glands were diminished in size; the tonsils, which remained swollen,
were covered with blackish exudations; the exploration of the throat
constantly caused an excretion of bloody mucus; deglutition was
always very difficult, and a part of the liquid returned by the nostrils ;
the breath remained fetid; the mercurial treatment was continued.
On the sixth day, the skin was cold, and the pulse, very much de-
pressed, could hardly be felt in the left arm. (Pulse 76.) There
was the same appearance of the pharynx, and the same difficulty of
deglutition. An emulsion of castor oil, prescribed with the intention
of preventing the consequences of a too active absorption of the
mercury, had not been taken. (An acidulated gargle.) There was no
cough ; the difficulty of respiration was always guttural ; the patient
spoke low, but distinctly ; the calomel was continued; injections of
decoction of bark; injection of broth; the surface of the tonsils
which was presented to view, was touched with powdered alum ; there
were no alvine evacuations. On the seventh day, the pulse was very
weak ; the tongue moist and clean in the greatest part of its extent ;
the tonsils, partly denuded of exudations, remained swollen, and pre-
served a violet, ecchymosed, bloody colour; the uvula was still
covered with. blackish exudations. The respiration was less noisy;
the voice feeble but distinct; the fetor of the breath had ceased; an
injection of vegeto-mineral water was made into the back of the mouth;
a laxative draught was given with four drachms of manna, three
drachms of Epsom salts, and ten grains of jalap. A very small
portion of the laxative draught was taken ; fifteen grains of jalap were
given in the course of the day; there were one or two slight alvine
evacuations; the doses of calomel were given at longer intervals.
On the eighth day, the pulse was extremely depressed ; the skin
cold, the tongue red and moist; a semi-transparent fibrinous layer
took the place of the exudations which covered the tonsils. Some
vegeto-mineral injection was thrown into the back part of the mouth ;
the swelling of the lymphatic glands was almost dispersed ; the tonsils
left a small interval between them ; the respiration was easier and the
voice clearer ; the mercurial collar-was discontinued and the doses of
EPIDEMIC OF CHENUSSON. 159

calomel were given at still less frequent intervals. On the ninth day
the pulse was somewhat less depressed, but rather frequent; the
face was red, there was emaciation ; pain on the left side of the neck,
and there was the same appearance of the tongue and the pharynx ;
the deglutition was difficult. The patient could scarcely swallow a
cupful of broth. At a time when she was held sitting up to make
her bed, she fell unexpectedly, and in her fall, she excoriated and
bruised one side of her face. The mercurial treatment was discon-
tinued. On the tenth day, the exhaustion was less; pulse 84.
The tonsils were clearing; anorexia and difficulty of swallowing re-
mained ; there was a regular return of the menstrual discharge. On
the eleventh day there was hoarseness; the respiration was 16, the
pulse 80. There was the same appearance of the tonsils; the lym-
phatic glands were no longer swollen. On the twelfth day, there
was hoarseness ; respiration painful and stridulous, but not frequent ;
hoarse cough without expectoration. It was thought that these
symptoms might be caused by a tracheal catarrh, occasioned by the
fall of the temperature. Notwithstanding the care which was taken
to shelter the patient from the influence of the cold, during several
nights the thermometer was scaxcely elevated more than three degrees
above zero in the inside of the ward, while it sunk to more than
seven degrees below zero on the outside. On the thirteenth day, in
the evening, the voice was more hoarse; the cough was so dry and
hoarse as to occasion the fear that the pellicular inflammation, the
progress of which had been so long suspended, might have at
last extended to the air-passages ; the inspirations and expirations
were noisy and stridulous; and pain was referred to the region
of the larynx. From eleven o’clock at night to four in the morn-
ing, the respiration, instead of becoming more frequent, became
slower; it sunk from 16 to 14, and then to 12. Every inspiration,
as if suspended voluntarily at first, was suddenly hastened and ter-
minated by a kind of explosion. The extreme dryness of the cough
induced the belief that an erosion, with intumescence of the mucous
membrane of the glottis, rather than a propagation of the diph-
theritic inflammation into the larynx, was the cause of the morbid
phenomena observed. Far from being accompanied by an abundant
and frothy expectoration, the cough excited no expulsion of tracheal
or pharyngeal mucus ; still every arrangement was made for the per-
formance of tracheotomy without delay, if it should become indispen-
sable to resort to it.
160 BRETONNEAU’S FOURTH MEMOIR.

On the fourteenth day, at four o’clock in the morning, the difficulty
of respiration increased every moment without becoming more fre-
quent. After a convulsive attack of aless dry cough a membraniform
exudation, an inch wide, and two inches and a half long, was expec-
torated; its edges were attenuated. Only one of its extremities,
which was the thicker, was obliquely torn. It was easy to perceive
that this strip of false membrane had lined the trachea, and that
it had been separated from a portion which remained fixed in the
larynx; it was spotted with blood on one of its surfaces, and was
not more than a quarter of a line in its greatest thickness. (Pulse
96.) The dyspnoea increased, and the opening of the trachea could
no longer be delayed.

Operation.—The head of the patient, a little inclined backwards,
so that the extended neck made a projection, was held by an assistant.
A coloured line was traced from the thyroid cartilage to the supra-
sternal depression. By pinching up in succession two transverse
folds, the skin and subcutaneous cellular tissue were incised in
the direction and extent indicated by the line traced beforehand.
The aponeurotic sheath which covers the sterno-hyoid muscles was
next divided. An arterial branch, two veins and an artery, poured
out so much blood, that it was indispensable to stop the hemorrhage
by ligatures. Hach vein required two, because the flow of blood took
place in a double direction, and because that which proceeded from a
kind of reflux, caused by the efforts of respiration, was, perhaps, the
most abundant. Below the upper third of this long incision (and the
necessity of placing so many ligatures, made us perceive the advantage
of having given it such an extent,) the trachea was easily laid bare.
One of its segments was at first divided with a sharp pointed bistoury,
afterwards the incision which divided four other segments was com-
pleted by a narrow-bladed and button-headed bistoury. A silver
canula, resembling that which has been before described, but of a much
stronger construction, was placed in the trachea by means of a pair
of forceps with curved blades. The sudden loss of voice caused
the patient considerable astonishment mixed with fear. At the
same moment, the respiration ceased to be noisy, and its number
rose from 12 to 22. During the whole day, it remained noiseless
and infrequent.

Some thick, white, and consistent, nasal, concrete membranes were
near the orifice of the nostrils, and in raising them lightly with the
smooth blades of a pair of forceps, several drops of blood escaped.
EPIDEMIC OF CHENUSSON, 161

The previous night, the patient could make the air pass through
only a single nostril, and with great difficulty. Three grains of
calomel suspended in a little water, and dropped into the trachea,
induced coughing and the expulsion of some mucous secretions mixed
with blood. The same application was repeated in the evening. In
endeavouring to substitute a longer and stronger canula for that
which had been introduced at the time of the operation, the cough
which was thus excited, caused the expulsion of two layers of false
membrane. One, which was thin, came from the portion of the
trachea below the artificial opening, and the other, which was thicker,
adhered to the portion of false membrane covering the larynx, and
could be detached from it only by using considerable force. (Respi-
ration 22. Pulse 80.) There was dejection, with anorexia; the
deglutition still remained difficult, and some cups of broth were
taken, but only with repugnance, in the space of twenty four hours.
Calomel was instilled during the night.

On the fifteenth day, and the second of the operation, there was
cedematous swelling of the cheeks, of the eyelids, and of the supra-
hyoid region ; the tongue, which was slightly swollen, retained upon
its edges the impression of the teeth, and two or three superficial
and membranous erosions were remarked at its point. The out-door
temperature was seven degrees below zero, and although every pre-
caution had been taken to elevate that of the ward, it was, this
morning, scarcely above four. Notwithstanding the appearance of
symptoms which announced the near approach of a mercurial affec-
tion, the patient was conscious of feeling generally better, and her
features were animated by the hope of a speedy cure; she participated
in the joy of her relatives, and warmly evinced her gratitude for having
been preserved from the danger which she had incurred. @ She
took her broth without reluctance, and swallowed it with less diffi-
culty. The tonsils preserved a dirty aspect, and remained swollen
and very near to each other. In the evening, there was prostration ;
(respiration 24, pulse 84,) want of appetite. An injection of infu-
sion of bark, produced a stool; the matter spit up was serous, and
similar to the washings of flesh. On the sixteenth day, and the
third after the operation, there had been a stool during the night,
and there were two other alvine evacuations of a serous and bloody
character ; the last was of a vermilion colour, and like blood mixed
with water. The eyes were almost closed by the swelling of the

eyelids, and the puffiness extended from the sub-mental region to
M
162 BRETONNEAU’S FOURTH MEMOIR.

the front of the chest ; the respiration was still noiseless. (Respiration
28. Pulse 88.) This morning the temperature of the ward scarcely
rose more than two degrees above zero. To-day, the physiognomy
expressed the sadness and the resignation of despair; the mercurial
ulcerations of the tongue had not extended ; but the mouth was filled
continually with bloody saliva; the breath exhaled a gangrenous
fetor, and the appearance of the tonsils was still more dirty than on
the previous evening. At four o’clock in the afternoon, there was
anxiety, with sighing, and very frequent respiration ; a great quantity
of reddish serosity similar to the washings of flesh flowed out by the
commissures of the lips and through the orifice of the canula; the
respiration, which had become slower, was gradually accelerated
without becoming noisy ; the puffiness of the face was a little dimi-
nished. The patient despaired more and more of her restoration to
health ; she uncovered herself continually, sought for air, and died
without suffering, at six o’clock in the evening.*

Autopsy.—The general tint of the back of the mouth was livid
and bloody ; some remains of membraniform exudation had contracted
the same colour; and the same was the case with a thin fibrinous
layer, very adherent to the surface of the tonsils and penetrating into
the interior of their folds. The mucous membrane, being cut through
its whole thickness, exhibited different shades of slate colour, of red-
ness, and of lividity, successively becoming fainter in proportion to the
distance from the surface. The uvula was speckled internally
with livid spots, which appeared to me to have less relation to. a
gangrenous alteration than to the black colour succeeding pro-
longed inflammations. In some points to which a few remains of
false membrane were adherent, the polish of the mucous surface of
the pharynx was slightly altered. The epiglottis was tumefied, and
was lined, on its two surfaces, with a thick, very adherent exuda-
tion ; shreds of false membrane still lined the larynx and extended
into the trachea as far as on a level with the artificial opening into
this tube ; their adhesion was not the same in all the extent of the

* The parents of this girl having expressed a desire to perform the last
duties to her body, and being anxious to prevent its mutilation, I acceded
to their wishes, and began to open the body by removing the vertebral
column from the occiput as far as the extremity of the sacrum. The in-
cision, which comprised a part of the ribs, lays open so clearly the buccal
cavity, as well as that of the nostrils and all the viscera of the abdomen and
thorax, that this mode of exploration appears to me as expeditious and
convenient as the greater part of those which are usually resorted to.
EPIDEMIC OF CHENUSSON. 163

surfaces which they covered. In no part was it more marked than
in the vicinity of the depression formed by the base of the epiglottis
and the horns of the thyroid cartilage.

It cannot be doubted that the pellicular inflammation, in propaga-
ting itself into the air-passages, followed this kind of gutter. During.
the whole time when the epiglottis was not exactly lowered over the
aperture in the larynx, it was a passage by which the exudations of
the back of the mouth could be transmitted, or which, at least was
not closed against them so exactly as against the liquids which were
swallowed. The false membrane which was continued into the
trachea up to the level of the incision, became, at that point, free and
floating, and it was easy to recognise, by its black colour, the shred
which was in contact with the canula, and the extremity of which was
several times seized and torn by the dissecting forceps. The mucous
membrane, under the exudation, was of a rather deep-violet tint.
The thyroid body had been divided as far as the half of its vertical
length. The incision into the trachea occupied exactly its median line ;
it might have been prolonged more than six lines without reaching
the right carotid artery. Below the artificial opening the mucous
membrane was of a red and bloody tint. Rudiments of false mem-
brane adhered to various points of its surface. Near the division of
the bronchial tubes the mucous membrane was covered with a very
slender semi-transparent pellicle, terminating suddenly on the right
side, but extending on the left (the side on which the patient habitu-
ally lay) into one of the bronchial tubes, to the last divisions of which
it was prolonged.

Both lungs were perfectly crepitant ; only a few ecchymoses were
found disseminated throughout the whole thickness of their tissue.
These extravasations were no doubt very recent, since they had not at
all changed either the force of cohesion, or the organic disposition of
the spongy structure of the lungs. Above the middle region of each
lung, we began to meet with tuberculous agglomerations, all of which
were surrounded with a considerable ecchymosis. These agglomera-
tions were formed by the union of crude, semi-transparent miliary
tubercles; the most voluminous of these aggregations scarcely ex-
ceeding the size of a nut. Some isolated granulations, perceived
beneath the pulmonary pleura, were also surrounded by an ecchymosis.
The small, tubercular masses were not more numerous, nor more
close together at the apex of the lungs than in their middle portion.
The pleurze were perfectly free from adhesions, and did not at all de-

M 2
164 BRETONNEAU’S FOURTH MEMOIR.

viate from the healthy state. The spongy pulmonary structure in
the vicinity of the tubercles had not lost its permeability. A very
different alteration from that which has just been described was ob-
served towards the middle part of the left lung. An abruptly
sircumscribed oedematous hepatization gave to the free border of the
upper lobe the appearance of currant jelly. It was in this same
portion of hepatized lung that the ramifications of the bronchial tube
were distributed to which diphtheritic inflammation had extended.
I have observed in the lungs of dogs, subjected to the experiments
of which I have elsewhere given an account, some lesions altogether
similar when cantharidic pellicular inflammation had extended into
she pulmonary cells.

Abdomen.—The edges of the folds of the mucous membrane of
she stomach were ecchymosed. The valvule conniventes of the small
ntestine were also ecchymosed, and the chymous paste which was
found in the more depending folds of this intestine had contracted a
nous colour by the mixture with the blood which had transuded.
The same alteration was observed in the whole extent of the mucous
nembrane of the large intestine ; it was much more manifest towards
the termination of the rectum, where the ecchymoses of the mucous
aembrane were covered with pseudo-membranous exudations which
ould be detached by the aid of a spatula. Under this fibrinous,
lender, elastic, semi-transparent layer, the villous tissue was not
nore easily isolated than in the normal state, and after having de-
tached it from the cellular layer, which was very white, I was con-
vineed that it had not acquired any thickness, and that it preserved
all its normal force of cohesion.

The blood contained in the cavities of the heart was half dissolved,
and there was no portion of fibrine separated from it.

T do not think that the. membranous coat which covered the
ecchymosed and rather rugous mucous membrane of the rectum was
the product of diphtheritic inflammation; it was rather more than
probable that the affection of the extremity of the digestive tube as
well as that of the mouth, and the ecchymoses of the pulmonary
spongy texture were consequences of the mercurial cachexia. Although
exudation of blood was followed in this case by the production of a
fibrinous pellicle, it is a result analogous to that which I have ob-
tained in the experiments already quoted, and it is an additional fact,
which confirms the theory of the formation of false membrane. ;
EPIDEMIC OF CHENUSSON. 165

Cass 45.—L. Dezaunay, aged one year, generally in feeble health.
In the night of the 23rd to the 24th of January, 1826, he had a hoarse
cough. On the first day, there was want of appetite; the child con-
tinued 1o suck, but refused any other food; two grains of calomel
were given at intervals of two hours; the respiration was sibilant.
On the second day, the respiration was stridulous and very difficult ;
the cough was hoarse and became very infrequent, and death followed
at ten o’clock in the morning.

At the time of death, the tonsils were neither red nor swollen, and
we could not discover any white spots on their surface, nor upon any
point of the pharynx. The group of lymphatic glands which were
found below the-attachment of the sterno-mastoid muscle, were not
sensibly swollen. Did the inflammation develop itself in the first
instance in the air tubes ?

Autopsy.—An elastic, white, thick, false membrane lined the
larynx and the trachea, and extended as far as into the large divi-
sions of the bronchi. It was more adherent in the larynx, and
afterwards became floating. The mucous membrane, which it
covered, was neither reddened nor thickened in any part of its extent.
If we might judge by the degree of adhesion of the false membranes,
it was at the position of the ventricles of the larynx, that the
diphtheritic affection commenced. The epiglottis, the laryngeal sur-
face of which did not appear at first sight to be covered with any
pseudo-membranous layer, was certainly lined with a membraniform
semi-transparent pellicle, which was easily detached. The pharynx,
examined with the most scrupulous attention, appeared completely
exempt from pellicular inflammation; only in one of the crypts of
the right tonsil did we discover a portion of concrete matter, which,
perhaps, was not the product of the diphtheritic phlegmasia.

The nurse to whom this child had been entrusted, lived near
Tours, where for many months, with the exception of the patients
admitted to the Hospital, there had not been a single subject attacked
with Diphtheritic Angina. It was not probable that there had existed
any communication between the inhabitants of Chenusson, and those
of the faubourg where this woman lived, and every inquiry on this
point appeared to me almost absurd; but on hearing, to my great
astonishment, that she was born at Chenusson and was aunt to
Cormery (case 43), I confess that I was not able to avoid suspect-
ing that Malignant Angina might have been transmitted to her
nursling, either by the communication which she might have pre-
166 BRETONNEAU’S FOURTH MEMOIR.

served with her dwelling-place, or by that which she might have
had with the patients admitted into the Hospital, or with the relations
and neighbours who had accompanied them. She declared, in fact,
that the fear of the contagion had hindered her from receiving any
one; but in the very terms of her denial, proof was found that she
had had communication with several of them.

The facts observed in the course of the epidemic of Tours were
reproduced during the short duration of that of Chenusson ; and in

such a circumscribed locality it was still more easy to observe its
details and its general character.

The diphtheritic inflammation has usually increased in the
pharynx and the air-tubes in an inverse proportion ; the more it has
extended in the back of the mouth the less has it penetrated into
the air-passages; and when at last it has extended to the latter,
it was not with the same rapidity nor to the same depth. In the
first of these cases which had a fatal termination, the symptoms
of Malignant Angina (pharyngeal Diphthérite) predominated, and the
croupal suffocation was announced by scarcely any precursory sign.
Thus the cough, which becomes an indication of so much value,
especially when it is short and hoarse, was observed in Rameau only
two hours before death (see case 42), and it was nearly the same in
the case of Frangoise Bodier (see case 44). The symptoms of Croup
or Tracheal Diphthérite, on the contrary prevailed in the case of Cor-
mery (see case 43), whose slightly swollen tonsils were scarcely covered
with exudations when the cough began to manifest itself. It was casy
to recognise in such a diversity of aspects, the source of the distinction
which was established between Croup and Malignant Angina.

Lastly, the disease of the little child who died so rapidly of Diph-
theritic Tracheal Angina (see case 45), without the pharynx having
been affected with pellicular inflammation, really presented all the
symptoms of Croup described by the authors of the last century. It
is the second time, and in the proportion of one to thirty that I have
met, after death, with diphtheritic inflammation limited to the air-
tubes.

The more easy it is to discover the relations which the inhabi-
tants of a thinly-peopled hamlet maintain with one another and with
strangers, the more do the facts relating to the contagion of an
epidemic affection become certain and positive. All those which I
have collected, while proving that Diphthérite had not, for fifteen
months, passed over the territory of the two small communes of La
EPIDEMIC OF CHENUSSON. 167

Ferriére and Chenusson, still leave us in the obscurity which has
always prevailed as to the mode of transmission of this formidable
malady. I have several times received on my face and lips diph-
theritic concretions discharged to a great distance by the artificial
opening of the trachea. I have been struck, in common with a
great number of pupils, with the fetid smell exhaled by the breath
of some patients. Several attendants at the Hospital had continual
communication with them. How did it happen that not one of us
was attacked by the disease, when the child who forms the subject
of the last case, appears to have contracted it on the occasion of a
much less intimate association ? © How was it that the girl Thérése
was alone affected in a ward where there were several other little girls P
All these questions have remained as much in doubt as at the period
of my first observations.

In conformity with its usual character, Malignant Angina made at
La Ferriére and Chenusson, more victims among children than among
adults; still, of thirty-nine individuals carried off in those two com-
munes, there was one woman of forty-three years old, one of thirty,
one of twenty-two, and several others who had passed the age of
puberty.

The epidemic of Chenusson has but too well demonstrated the
tendency of Diphthérite to persevere in its course. It has been
seen that the pellicular exudations had arrived, in the larynx of
Cormery, at the degree of putrid alteration which they generally
exhibit only in the isthmus of the throat. Lastly, it has been seen
in the case of Francoise Bodier, that on the thirteenth day of Malig-
nant Angina, the diphtheritic inflammation came, and rapidly
propagated itself from the trachea into one of the divisions of the
bronchi. No example of spontaneous termination was remarked
either at Chenusson or at La Ferriére, and of forty-six patients thirty-
nine died.

The superiority of the local treatment over all other kinds of me-
dication was never more positively manifested ; and independently
of the dangerous consequences of the mercurial treatment, it was but
too easy to convince ourselves that it was not by its general effects
that it became curative. The action of mercury on the whole con-
stitution was carried to such a point as to liquefy the blood, to pro-
duce hemorrhagic discharges, and to occasion gangrenous ulceration
of the surfaces which had been the primitive seat of the disease,
without the diphtheritic inflammation having been arrested in its
168 BRETONNEAU’S FOURTH MEMOIR.

course. As in my first cases, the most beneficial effects of calomel
appeared to be confined to an immediate and local action; so it is
more than probable that this action cannot be exerted through the false
membrane which covers the affected tissues. We cannot be surprised
at this circumstance in the case of a substance so insoluble as the pro-
tochloride of mercury. After seven days of treatment and frequent
injections, the nasal fosse of Cormery were still lined throughout all
their extent by thick exudations. After a general and local mercurial
treatment, still more prolonged, the false membrane reached, in the
case of Francoise Bodier, to near the orifice of the nostrils ; and on the
thirteenth day of the disease, we were unable to attempt its detach-
ment without exciting a flow of blood.

I am induced to believe that even in the cases in which Tracheal
Diphthérite has been favourably modified by mercurial treatment, it
is by insinuating itself into the air-tube that the protochloride of
mercury succeeds in modifying the pellicular inflammation. I sup-
pose that it penetrates there by means of the continuity of the
mucous coat of the back of the mouth and of the air-passages; by
reaching one portion after another ; and by obeying the impulse com-
municated by each movement of inspiration. We may conceive how
smal] the quantity must be which can be introduced in this manner ;
and the progress of the diphtheritic inflammation is very rarely
suspended in the air-passages if the treatment does not closely follow
the attack of the phlegmasia.

The solution of this therapeutic question would be of great in-
terest—for the more it were proved that we ought to depend less on
the general than on the local action of calomel, the more proper
would it be to prevent the danger of its influence on the constitution
‘by lumiting its use to injections into the back of the mouth and the
nostrils, and these injections might be allowed to penetrate as little
as possible into the digestive canal. We might even direct more of
our attention to the promotion, by means of purgativés, of an exhala-
tion which would be opposed to the absorption of the mercurial
preparation.

In spite of all these precautions, the consequences of the mercurial
treatment become so formidable under the influence of cold, that it
would be desirable to modify the diphtheritic inflammation by an
agent, the subsequent effects of which would be less dangerous than
those of the protochloride. Perhaps alum, so much praised by the
ancient physicians, possesses these great advantages. A practitioner,
EPIDEMIC OF CHENUSSON. 169°

Doctor Pommier, affirmed some years ago that this salt reduced to
powder and insufflated into the back of the mouth, was a specific
against Croup, and it is from motives which are far from being
based on observation, that his proposition has been contemptuously
rejected. Alum applied to the mucous surfaces does not exercise any
escharotic action; it has been administered in substance, and in
pretty strong doses, by several Danish physicians in dysentery. I
have often taken boluses of twelve grains of it with relief of chronic
intestinal pains. The elongation and cedematous intumescence of
the uvula, which often increases the difficulty of deglutition caused
by a phlegmonous tonsillitis, almost instantly give way to a strong
inspersion of powdered alum. I have ascertained on myself that
the inflammation of the mucous membrane was not at all exasperated
by it, and that the deglutition became more easy, and less painful.
The relief lasted for several hours, after which we could again
resort several times to the same means without producing the least
erosion.

The fear of consuming valuable time in useless attempts, has alone
prevented me from trying to modify the diphtheritic inflammation of
the pharynx by the application of alum. I have said that I had
employed it with success in the treatment of diphtheritic stomacace.
The extension of this affection being less to be feared than that of
diphtheritic inflammation of the pharynx, different methods of treat-
ment may be tried comparatively without much inconvenience, and
I should have again tried to ascertain the advantages of this treat-
ment if I had found an occasion for doing so.

I have just seen at last the Scorbutic Gangrene of the gums which
I had no longer met with since 1820. A soldier recently come to join
his regiment, communicated it to his bedfellow ; it may be stated, in
addition; that these two men had frequently made use of the same
pipe. In both, the pellicular inflammation was limited to the gums of
the incisor teeth and occupied only their undulating border. After
two applications of alum, the first was completely cured.

The second, a short time after his admission into the Hospital,
rubbed his gums three times a day with a grain of calomel. I was
obliged to have recourse to this treatment, because, during the ap-
plication of a simple emollient gargle, the erosion of the gums first
attacked, made too rapid progress to allow the antiphlogistic treat-
ment to be continued without inconvenience. The disease ceased to
spread, but the cure being too slow, I had recourse to the alum,
“170 BRETONNEAU’S FOURTH MEMOIR.

and the success of this treatment was not less rapid than in the pre-
ceding case.

When I gave an account of the experiments by which I had ascer-
tained the poisonous action of mercury on dogs, I was induced to
believe that it was much less dangerous for man than for these
animals ; but I can no longer doubt that the differences between the
.effects which have been observed, depend often upon the difference
of the temperature. The damp cold which so powerfully favours
the progress of scorbutic cachexia, renders that of the mercurial
cachexia so rapid, that it becomes impossible to prevent its fatal con-
sequences. In this case, an accessory condition, namely, the action
of surrounding circumstances, has really more influence on the issue
of the treatment than the dose, the total quantity, or the nature of
the mercurial preparations administered.

I have observed on dogs, which I had compelled to take large
doses of calomel, the development of dirty and gangrenous ulcera-
tions which made their appearance sometimes on the surface of
the penis, sometimes in the interior of the mouth, and which were
excited by the least accidental irritation. I had seen death occur
after a prolonged intestinal hemorrhage, but from these cases I was
far from drawing deductions which I could believe strictly applicable
to practice. I attributed the greatest part of the effects which I had
sought to obtain, to the augmentation of the doses of calomel which,
in proportion, had been too strong, and to an irritability peculiar to
these animals. We have just seen that a mercurial treatment, pur-
sued with distrust and circumspectjon, might, on man, produce, conse-
quences quite as severe, and still more rapidly fatal. I have been
compelled to reveal these sad results; they prove that under the in-
fluence of cold, mercurial cachexia may become suddenly fatal.
Let me be permitted to add that they present more analogy than might
be expected between clinical observations and experiments made upon
living animals.

The advantages of tracheotomy were limited to prolonging, for a
few days, the lives of Cormery and of Francoise Bodier ; however, after
these two unfortunate events, it remains still clearly proved, that the
artificial opening of the trachea alone offered a chance of cure. I
feel that the results obtained up to this time are very unfavourable
to this operation, and I do not seek to prejudge its advantages, but
the same impartiality obliges me to call the attention of practitioners
to the circumstances which opposed the success I had antici-
EPIDEMIC OF CHENUSSON. 171

pated in the two cases just mentioned. One of these circumstances
is the more deplorable, as we are less-sure of being able to avoid
it. The results of the experiments which I have mentioned are repro-
duced in this unfortunate occurrence. In vain I had guarded against
the influence of cold, the whole danger of which I was acquainted
with ; by asad fatality, all my efforts to preserve my two patients from
it were useless. The external temperature had fallen suddenly to
seven degrees below zero, and it was impossible for me to succeed in
keeping it at more than two and four degrees above it in the ward
where Francoise Bodier lay; the mercurial treatment also produced
upon her some effects which became rapidly aggravated.

Louis Bodier had scarcely taken twenty-eight grains of calomel,
when, after having remained a long time exposed to the action of cold,
he experienced the symptoms of a constitutional affection, which, not-
withstandmg a temporary amelioration, caused a fatal hemoptysis.
This same influence made itself felt in a manner still more striking
on Thérése, who experienced more early a mercurial salivation after
the administration of a few grains of calomel, undoubtedly because,
placed near a door, she had suffered more from the inclemency
of the season. These fatal effects are the more remarkable, as
in 1820 they had not been observed, except in one person placed
in analogous circumstances, and as even still more recently, the
mercurial treatment had not produced any bad consequences on
any of the patients of Chenusson who were under more fortunate
conditions.

The mercurial hemorrhages which young Bodier experienced,
almost resembled those which are observed in yellow fever. I had
recognised, at the time of the operation, the extent of the diphtheritic
affection of the nasal fosse, and I feared that this extension of the
disease would retard the convalescence, but I was secured against
the fear of a fatal termination by the slowness of the pulse, and by
the calmness of the respiration. It is remarkable that the diphtheritic
inflammation extended to the whole of the pituitary membrane in the
three patients who died inthe Hospital. What would have been the
manner of termination of this affection if the two last had survived
the operation? This question cannot be resolved except by ulterior
observations, and I shall not venture to answer it by conjectures ; but
what cannot be doubtful is, that the mercurial cachexia, which was so
clearly manifested by numerous ecchymoses of the lung, and by intes-
tinal hemorrhage, was alone the cause of the death of Francoise Bodier.
172 BRETONNEAU’S FOURTH MEMOIR.

It is also to the morbid state of the blood that we must refer
the livid colour of the surfaces which had been affected with diph-
theritic inflammation, as we must also impute to the mercurial
diathesis the gangrenous ulcerations observed in the mouth and
pharynx of young Cormery, and which resembled exactly those I had
developed on dogs subjected to the prolonged action of calomel.
We shall be little surprised that on this child the tonsils and
the uvula were more seriously affected than the edges of the tongue
and the interior of the mouth, if we remember that the mercurial
ulcerations developed on the lips of the spaniel, the subject of my
last experiment, were cicatrized, while he died from a gangrenous
ulceration of the prepuce and penis, an affection caused, as we have
seen, by a mechanical irritation of these surfaces.

This occasional cause generally takes such an active part in the
production of mercurial chancres, that it deserves to attract the at-
tention of practitioners. I was far from suspecting that it contributed
so powerfully to their development, when I was struck by the sym-
metrical distribution of these ulcerations on the lips of the dogs
subjected to my experiments. In fact, it was always opposite to the
canine teeth that the upper lip began to be inflamed. We saw suc-
cessively the appearance of new erosions on every point of the mem-
brane which corresponded to some dental eminence, and sooner or
later, according as the projections were more or less marked.

It is the same in man, and I have often assured myself of the fact.
The contact of the asperities of two decayed teeth, which, two days
before, had been the seat of acute pains, caused in Cormery a slight
erosion of the edges of the tongue, and this erosion had been rapidly
converted into a chancrous ulceration, at the same time that the sur-
faces which had been affected with diphtheritic inflammation became
the seat of much deeper lesions.

At last, at the period when Louis Bodier was affected with mer-
curial salivation, a superficial excoriation of the internal malleolus
of the right foot was converted into a sanious and dirty ulcera-
tion.

As long as the pellicular inflammation is not modified, the mer-
curial treatment cannot be suspended without inconvenience; but
the very formidable danger which this treatment involves when we
omit the least precaution, especially when the patient is exposed to a
low temperature, has made it incumbent on me to insist on the
poisonous action of mercury and on its peculiar effects.
CONTAGION OF DIPHTHERIA. 173

FIFTH MEMOIR.

ON THE MEANS OF PREVENTING THE DEVELOPMENT AND
PROGRESS OF DIPHTHERIA.*

(Archives Générales de Médecine, Jan. and Sep. 1855.)
To Drs. BuacHe anp P. GuERsant.

My dear friends,—Before the misfortune which has just fallen upon
you, and since Diphtheria has shown itself in a more and more en-
demic form in Paris, several examples have occurred of those sudden
cases of toxemia which destroy life without closure of the larynx.

Thirty years ago, Angina Maligna, imported into Tours by the
military legion of La Vendée, carried off, in a few months, sixty per-
sons of all ages, but especially children. Impressed by the increasing
interest inspired by such calamities and also by the desire of arriving
at a positive knowledge of truths which I had only glanced at, and
led by a curiosity which never rested, I applied myself to the study
of everything which had reference to the reappearances of this
terrible scourge from the most remote ages; and for this purpose I
examined all the periodical French and English publications, and
all the old books which I bought or borrowed, or obtained at the
libraries. I do not recollect having ever met with an example of
such terrible visitations of toxeemia, nor have I observed any in the
localities to which the epidemic of Tours has so widely extended.
But it must be admitted that original works did not abound in my
ample collection of old books ; for investigations, inspired by the love
of science, are little suited to the taste of bibliographers, to whom
the probable is more pleasing than the true.

From this lengthened inquiry, it nevertheless resulted that at each
period of its return, the Egyptian disease (malwm Agyptiacum) had

* M. Bretonneau here changes the word Diphthérite into Diphthérie.—
Ep.
174 BRETONNEAU’S FIFTH MEMOIR.

struck with terror the physicians and the populations among whom
it raged, destroying those who were attacked by it, until the treat-
ment proposed by Areteus, which was always forgotten, was at last
more or less successfully adopted.

A picture resembling these fearful invasions may have probably
been drawn by some witness of the terrible epidemics of the sixteenth
century which burst from Spain and Sicily over the whole world, and
subsequently came to America, where Washington died of Croup.

The work of an observer undoubtedly lies forgotten in a corner.
Attention has no echo except for those who are attentive ; and where
are they? Certainly not among ourselves, especially at the periods
when fatal maladies are devastating populous cities.

In finding you and yours, my dear Blache, exposed to the dangers
of treacherous epidemics, which are generally denied or ill-under-
stood, I feel that it is necessary to speak to you of the precautions,
the efficacy of which I have ascertained. I do not wish to force my
convictions upon you, but I must endeavour to make you share
them. Unfortunately, in this case as in others, our presumptuous
age advances in opposition to truth by repelling any belief in con-
tagions with all the means in its power.

As I am obliged to proceed by induction, and consequently to rely
upon facts which are more studied than those of the contagion of
Diphtheria, I allude first to the contagion of smallpox.

Inoculation, imported from the East towards the middle of the
last, century, was soon practised in several states of Europe, and es-
pecially in England, where this proceeding became the forerunner of
the discovery of Jenner. It was soon fashionable, and being on its
pedestal, attracted attention. Different methods of transmission were
then vaunted, studied, compared, adopted and rejected, and truth,
which was seldom consulted, was neglected as a guide.

The important conditions of the mode of transmission were gener-
ally so ill understood that many inoculations were practised from one
arm to another, at the bed of smallpox patients, by some inoculators,
while others crushed the variolous crusts, and used them for powdering
slices of bread and butter, to be eaten by children who were suitably
prepared for the transmission of the disease.

At this period, the existence of spontaneous variola was much be-
lieved, and this belief is not yet sufficiently abolished. The develop-
ment of a germ formed from birth was admitted. (This germ takes
a long time for its development.) Physicians also believed in a ne-
CONTAGION OF DIPHTHERIA. 175

cessary despumation which it was sufficient to bring into existence
in time, and to guide to beneficial results. They accepted the in-
genious opinion of the worthy precursor of MM. Carnot and Bayard,
namely the Arabian physician, Rhazes, who imagined that the child,
being nourished on the menstrual blood, required this purification.

Lastly, in the present day, after the learned disputes of the Val-de-
Grice, and the insane views of the Académies on contagions, the
occasion being that of the plague, the transmissibility of smallpox is
but little contested. It is, in fact, transmitted, and like many other
epidemic ‘diseases, it is developed only by transmission, whether it
remains sporadic or becomes epidemic; and such is its power of
transmission, that it attacks passers-by at pistol-shot distance. This
fact, since the provisional adoption of vaccination has interrupted the
free course of variolous epidemics, has been several times as positively
ascertained as it could have been by the most rigorous experiments ;
for it is easy to know that on such a day, when passing at a known
distance, near an isolated focus of contagion, variola has been con-
tracted, and that it has been developed on such another day after the
usual period of incubation. Everyone may ascertain this fact by
paying attention.

But the contagious power of the ens variolarum is not thus limited.
It may and does attack the foetus in the uterus of a woman who has
not smallpox, and who, during her pregnancy, has attended smallpox
patients, without herself contracting the disease. How has this
transmission been accomplished? The more deeply we investigate
the conditions of such a contagion, the less are we able to comprehend
its possibility. The contagious principle, dissolved in the air, and
attenuated by this dissolution, must have traversed the different layers
of several tissues, and in this passage must have undergone the
powerful action of intestinal digestion and the action of hematosis
in the respiratory apparatus. Nothing arrests its course or subdues
it; but it arrives at its destination. Although the circulation of the
foetus is distinct from that of the mother, and being merely the
outline of a mammal, it does not breathe, and as yet possesses only
the life of a fish, yet the variolous contagion reaches it and penetrates
it when bathed in the waters of the amnion.

Two cases of variola supervening in the foetus, without the mother
being attacked by the disease, have been already ascertained and
carefully noted by Mead; three more have been described by the.
Committee on Vaccination of Paris; a sixth was observed at Tours
176 BRETONNEAU’S FIFTH MEMOIR.

in 1827. A poor woman, under the above-mentioned circumstances,
was confined of a child at the usual period; this child’s body and
face were sprinkled with variolous pustules of the fourth day of the
eruption ; the development continued under my inspection, and was
regularly accomplished. I attentively examined these pustules, and
notwithstanding the previous immersion of the skin (in the liquor
amnii, Ed.), they presented all the characters of cutaneous variola, for
they were prominent, rounded, and not level like those which are
developed on the surface of mucous membranes. ‘The subject of
this case is now in the army.

In order to arrive at the contagion of Diphtheria, I have taken
rather a circuitous course; but the facts of the old Egyptian con-
tagion are so strange, that, to make them credible, it was, perhaps,
necessary to have under our eyes some ascertained examples of the
prodigies caused by another contagion.

Tt is unnecessary to repeat that atmospheric air is the vehicle of
the variolous virus, and that this virus is volatile; but it has another
more material method of transmission in the dust of dried variolous
pustules, the contagious property of which is so long preserved.
Tissot, in successfully inoculating smallpox, was able to make use of
a sewing-thread, which he had impregnated with variolous pus, by
passing it across a pustule, and which he had deposited in a book
where he had carefully kept it for thirty months. The collections of
variolous pus made by inoculators, have furnished innumerable ex-
amples of the tenacity of the contagious property possessed by preserved
variolous matter. I insist on this point, because it is to this second
process of transmission of variola that we must refer. the mode of
transference in Diphtheria, for undoubtedly the air is not the vehicle
in the latter case. Innumerable facts have proved that those who
attend patients cannot contract Diphtheria, unless the diphtheritic
secretion, in the liquid or pulverulent state, is placed in contact with
a soft or softened mucous membrane, or with the skin, on a point
denuded of epidermis, and this application must be immediate. In
a word, a true inoculation is the only mode of transmission of the
Egyptian disease.

Since 1818, the facts supplied by the epidemics of Diphtheria
which have broken out in the department of Indre-et-Loire, or which
have extended to the surrounding departments, prove, in the most
evident manner, that the atmosphere cannot transmit the contagion of
Diphtheria, The most unexceptionable and most clearly significant
CONTAGION OF DIPHTHERIA. 177

facts have been collected by attentive observers assiduously devoted
to the practice of their profession in very small localities, observing
and noting carefully every peculiarity exhibited by their cases, the
day and hour of the importation of the disease, its seat, its migration
from one family to another, the conditions of this migration, its
transmission to hamlets and different communes, together with a
notice of the distances, and the periods of the year when they occurred.
On these subjects I have received much valuable information from
Dr. Henri Brault, of Beaumont-la-Ronce. I might admit that such
precise information might cause some doubt if it had been furnished
only by a single locality, or by the same observer, but for thirty-five
years, in a great number of places, the same observations have been
reproduced, and they are always the same, and identical with those
of past ages.

Being transmitted only by inoculation, the diphtheric virus is
propagated by peculiar means which it is important to understand,
and if we trace these means carefully we shall find that they are still
more astonishing than the modes by which smallpox is transmitted.
It is true that Diphtheria possesses a method of transmission
which is common to it and syphilis, and moreover, itis true that the
relations of the Syriac and the Neapolitan diseases are so intimate,
that in a nosological classification, these two diseases would be allied
together. Although Areteus was not able to connect the Egyptian
disease with another malady which was unknown in his time, yet in
the sixteenth century, the remarkable analogy of the Syriac and
Neapolitan diseases did not escape Alayma, a physician of Palermo,
who expresses his opinion very explicitly on this point :— Ita dum
Egyptiaca ulcera dicimus varios modos quibus hic morbus humanum
genus insultat, unico verbo explicamus,” preferring, he says, the
name of Egyptian ulcer, because it is applied to all the forms of the
disease, as the denomination French disease suffices to designate the
various forms of syphilis.

A motive similar to that of Alayma has induced me to propose a
denomination which may be applicable to the variable effects of the
Diphtheric or Egyptian contagion, and perhaps I should have done
more wisely in preserving this ancient name; but I have yielded to
the desire of obtaining by a specificname the distinction of a specific
phlegmasia, which it is important not to confound with other
affections presenting only some general points of resemblance to
it. The application of this name, made erroneously every day,

N
178 BRETONNEAU’S FIFTH MEMOIR.

proves to me that I was in the wrong. The resemblance of Diphtheria
to Syphilis has caused serious mistakes ; and at the time of the epide-
mics of Sologne Trousseau, and Ramon collected some cases of vulvar
and cutaneous Diphtheria, which became rapidly fatal by toxemia.

I should add that great importance remained attached to the
epithet Zyyptian, which, undoubtedly, was already a very old one; it
designated to the Greeks the region from which the disease was im-
ported to them; these country names, like that of Asiatic Cholera,
Egyptian Ophthalmia, Oriental Plague, French or Neapolitan
Disease, indicate that the disease, being unknown in the region where
it appeared, is an exotic production. I cannot too often repeat that
it is imported by an infected person or by articles impregnated
by the contagious principle. Such is emphatically the truth
with regard to contagion which alone has transmitted and still
transmits the Egyptian disease, for it is abundantly demonstrated
that temperature, season, climate, and soil, exercise only a secondary
influence and not a creative power over the mysterious effects pro-
duced by the agents of contagion.

It is vain to deny that contagion, if not the source of endemics,
is the source of most epidemics; and through it we must endeavour
to exterminate the scourges which strike down the human race in
various degrees, in its different races, whether white, red, or black-
skinned, and not only the human race, but also a multitude of animal
and vegetable species united together.

It was at the time when the Greek word Aoimogs signified
plague, contagion, contagious object, that. Diphtheria, imported into
Greece by a numerous succession of Egyptian colonies, received
there the name of Lgyptian disease, at a time more near to that of
Homer than of Hippocrates, and you will observe that at this same
period arose the denomination of Hyyptian ointment, a solution of
verdigris in honey (mel cupratum) and this is an eminently anti-
diphtheric preparation which bears the same name in the present
day in our Pharmaceutical Codex.

You see, my dear friends, the extent to which the medical art is yet in
its swaddling-clothes. You observe that from time immemorial it
has been provided with a valuable remedy for a fatal disease, but in
vain! for when and how has the Egyptian ointment been opposed to
the progress of the Egyptian disease? The name of the medicine
remains, but its use has disappeared.*

* The powerful anti-diphtheric power of the salts of copper was dis-
CONTAGION OF DIPHTHERIA. 179

Ten centuries later, a richer gift was bequeathed to us by a Greek
physician, the great Areteus, At this remote period from Hippo-
crates, he was the most accomplished of his disciples and the contem-
porary of Galen ; and more than the latter was he the true successor
of the divine old man (Hippocrates). Areteus’s work, mutilated by
time, is still a faithful exponent of our diseases. One of his magni-
ficent pages contains an admirably finished picture of the Egyptian
disease, while another page presents us with a choice of curative
medicines, and of sagacious precepts on the art of using them.
Until the invention of printing, the precious manuscript remained in
the hands of Greek scholars, but long before the epidemics of the
seventeenth century, several translations of Areteeus had been pub-
lished. I here repeat, to what purpose? for when have physicians
had recourse to his admirable sanitary precepts ?

I now come to modern times (1809-1815). About this period,
Queen Hortense was for several months affected with Gingival
Diphtheria, without any curative means having been employed
against the disease; and then her first-born child died of laryngeal
Diphtheria. At the period of the second invasion of Paris, her
mother, the Empress Josephine, who had been for a few days suffering
from Pharyngeal Diphtheric Angina, died in a fit of croupal suffoca-
tion, without any attempt at an efficacious method of treatment
having ‘been made to arrest the progress of her disease.*

You have not forgotten the celebrated Concours, ordered by the
Emperor at the death of the young prince, his nephew, nor the
division of the great prize between Jurine of Geneva, and Albers of
Bremen, authors of Memoirs in which they both declare that Angina
Maligna is a distinct and opposite disease from Croup. No matter.

Such is the progress of scientific doctrines; but at the time when

covered, by mistake, thirty years ago at Moscow. Gingival Diphtheria
was raging at the Children’s Hospital, where many patients had been
attacked and several had died. The progress of the disease was scarcely
retarded by a timid mode of treatment, when a concentrated solution of a
salt of copper was entrusted to a servant, who was to take care that it
was diluted with an ample proportion of water before being distributed
to the nurses in each department. From forgetfulness, the solution was
employed pure, and the disease yielded so rapidly to the energetic treat-
ment that it disappeared from the establishment.

* I have heard from one who was present at her last moments, that in
the state of agitation so well described by Aretzus, not being able to
remain either sitting or standing, and being -unable to speak, the Empress
Josephine made a sign for a pen when she was dying of croupal suffocation.

N2
180 BRETONNEAU’S FIFTH MEMOIR.

the Empress was seized with Diphtheria proceeding, I am convinced,
like the Croup of her grandchild, from the Gingival Diphtheria of
Queen Hortense, she was surrounded with attention. A highly
endowed physician, who had attained the apogee of his scientific
talent, the great Corvisart was in attendance, together with many
other eminent men of our profession, the chiefs of the medical service
of the armies assembled in the capital.

Proceeding according to evidence in explaining the different modes
of inoculating Diphtheria, I shall shew some examples :—

We sometimes meet accidentally with a case of inoculation where the
mode of transmission is so evident that this kind of inoculation of
diphtheria is seen to be effected in the same manner as is done with
a lancet in the case of syphilis or smallpox. I shall quote for you some
authentic examples of the kind, and according to the narration of
M. Herpin, surgeon of the Hospital at Tours, I shall show you
how he contracted nasal Diphtheria ;* I give the case in his own
words:—

 

* In Paris, the influenza, which at its last visitation, seriously affected
the nostrils, predisposed the nasal mucous membranes to the inoculation
of Diphtheria. The pituitary membrane, being thickened and eroded by a
serous discharge and frequent sneezing, was often prepared to retain the
least atom of diphtheric dust, (received in the channel of a meatus) in the
antrum of Highmore. In no other part is its action better protected, and
although it cannot bore an aperture, (as it can in the spongy tissue), upon
the delicate and transparent membrane lining the antrum, yet it gives
origin to a wide-spread diphtheric excoriation, indolent at the beginning,
but becoming the abundant source of an epispastic liquid flowing down
from this position, without having its activity attenuated by either drink
or food, as happens in the back of the mouth; the attack may then break
out snddenly. On one occasiun, the curious spectacle of the diphtheric
affection of this great cavity, called the antrum of Highmore, presented
itself at the Hospital at Tours. A poor Jew came there every morning for
a gargle which had been prescribed for him, as it was said, for a Syphilitic
Angina. I was requested by the pupils to examine this poor man’s throat,
when the error of diagnosis became manifest, as he was suffering from
Diphtheric Angina, extending beyond the reach of sight. He was soon ad-
mitted, and treated, and I desired that at the first fit of coughing, I should
be apprised of it, as tracheotomy seemed to me inevitable. The next
morning at the ordinary visiting hour, which was five o'clock, there was
suffocating dyspnea which had not been preceded by any attack of cough-
ing. The period of cough was passed, and I learned from the patient that
he had coughed considerably for two days. Everything was quickly pre-
pared for the operation; I ran to the town and came back with the neces-
sary instruments, but the occasion was passed, and life was extinct. My
CONTAGION OF DIPHTHERIA. 181

“Tn the Spring of 1843, I was inoculated with Diphtheria from
a child who had come from Epinal. In passing through Paris, he
had advice for an abscess, and he had soon afterwards been sent to
Tours, where he went to the house of an uncle in order to be treated
there for a sore-throat from which he had been suffering on his arri-
val in Paris. From all the characteristic signs, I recognised Pharyn-
geal Diphtheric Angina, which had become croupal. It yielded to
energetic cauterizations with solution of nitrate of silver, frequently
repeated for six days. A nurse who took care of the child was at-
tacked with Pharyngeal Diphtheria, which soon yielded to local
treatment. The child, being intractable, coughed and violently threw
out the sputa. The orifice of my left nostril once received some of
this excretion, but from being obliged to continue the cauterization,
I had no time either to wash or to wipe the part.

“A few days afterwards, there was snuffling on the left side, and
nasal voice, then suddenly painful Pharyngeal Angina, sleeplessness
at night, extreme uneasiness, weakness, coldness, and pain.

“Tn the morning, both tonsils and the uvula were completely en-
veloped in a white incrustation (twenty-six cauterizations). Three
times a thimble (dé) of false membranes which enveloped the uvula
was detached and reproduced. (Simple inhalation of alum taken
like snuff, moderate diet) ; deglutition difficult ; sputa abundant and
fetid ; stools loaded with false membranes. Incomplete ‘recovery ;
paleness ; a fortnight later there was pain in the wrists; confusion
of sight; constriction of the throat; paralysis of the palatine vault,
which had become completely insensible; regurgitation of food by
the nostrils. Rather later, there was a sensation of tingling in the
great toes, ascending as far as the knees.

“T walked with difficulty and very slowly, and my weakness was

only satisfaction was that a useless operation had not been performed. A
bronchial tree with two large branches, boughs, and twigs, exactly
moulded upon the respiratory canals, was extracted entire from the air-
tubes. I found the maxillary sinuses lined with diphtheric exudations,
filled with serous fluid and with an opaline liquid. Bands of false mem-
brane floated in’this fluid as in a pleuritic effusion. What waves of epi-
spastic serosity must have flowed, at every lateral inclination of the head,
into the pharyngeal funnel, and by the arytenoid channels, must have in-
sinuated themselves into the trachea; and how extensive were the effects
of its action! The width of the air-passage gave free admission to the
air, and asphyxia was produced only by the obliteration of the last
bronchial ramifications.
182 BRETONNEAU’S FIFTH MEMOIR.

especially painful when I went up stairs, and this state continued
without improvement for six weeks. The same tingling had reached
my hands and fingers, and I had completely lost all tactile power.
On the 10th of August, I took sea-baths, and at the second bath, I
was entirely cured of all my complaints.”

I shall here add some information for which I am indebted to M.

Herpin. During and after the energetic treatment of the pharyngeal
Diphtheria, that of the nasal Diphtheria had but little attracted his
attention, and for this original affection, the medication was reduced
to a few inhalations of powdered alum taken like snuff.
' The lesion of motility, the alteration in the condition of the blood
and the innervation, and the prolonged weakness, are the too frequent
consequences of nasal Diphtheria which has passed into the chronic
state. In such a case, as after Gingival Diphtheria, diphtheric ton-
sillar chancre, and prolonged primary syphilitic affections, the activity
of expansion is followed by an almost inverse disposition, until the
activity, already much diminished, terminates almost by being ex-
tinguished, when the phase of localized primitive Diphtheria has been
succeeded by that of the secondary or constitutional affection.

I have had too many occasions to observe nasal Diphtheria passing
into the chronic state, and to meet it by efficacious treatment, to
induce me to entertain any doubt as to the truth of these clinical
observations.

The following case of nasal Diphtheria with fetor of the breath,
observed in a young girl, fourteen years old, deserves to be
studied.

The nasal Diphtheria having become pharyngeal, arrested in its
course by nasal injections of solution of nitrate of silver, and by
pharyngeal cauterizations, was prevented from penetrating into the
larynx, but the dread of every kind of solid or liquid food, paleness,
coldness, and prostration of strength, were making the most fearful
progress. By great persuasion, I succeeded in causing a little
sugared wine to be swallowed at ten o’clock at night, and at midnight
an egg and some more teaspoonfuls of sugared wine were taken. The
next day, everything that could be imagined was offered to tempt her
appetite, and small and scarce articles of food were accepted ; but,
from the second day, the food did not excite the same repugnance,
and the nasal source of the infection being quickly dried up by nasal

injections, this last phase of the disease yielded to restorative diet
and suitable medicine.
CONTAGION OF DIPHTHERIA. 183

‘To seize upon the opportunity of introducing food at the period
when loathing is about to become insuperable, is to cast the anchor
of safety and to resort to the most efficient of all treatment.

You understand that there is no longer any question of contagion
or inoculation, but of imminent danger of sinking. You know that
efficacious treatment alone will ward off the danger, and in order to
allow us to have recourse to it, life must not be too much depressed,
nor all the doors left open, by inanition, to a fatal toxemia. Give in
small injections everything which, being nutritive, is yet refused with
great repugnance, but do not cease to offer and to insist on the ac-
ceptance of everything nutritious, such as white of eggs lightly boiled,
yolks of eggs mixed with Spanish wine, or milk, wine with or without
sugar, coffee ;—in fact, everything that can be imagined or suggested
either by the fancy of the patient, or by the sagacity of the attendants.

A short time after the inoculation of nasal Diphtheria under
which Dr. Herpin nearly sunk, my friend Dr. Gendron, of Chateau-
du-Loir, being obliged to perform tracheotomy, received on his lips,
at the moment of opening the air-tube, a shower of tracheal exuda-
tions thrown out by the efforts of a convulsive fit of coughing.
Pharyngeal Diphtheria was the immediate consequence of this acci-
dent. Originating in one tonsil, the special phlegmasia so rapidly
reached the larynx that I was obliged to have recourse to energetic
treatment. The cure was rapid and complete, and none of the sym-
ptoms of constitutional Diphtheria were developed.

In 1826, being summoned to the Hcole Militaire by an invitation
from the Minister of War, on the occasion of an epidemic of Malig-
nant Angina, I there collected some cases of great interest, and espe-
cially an instance of contagion of such a marked character, as to
leave indelible traces on my memory. It wasa striking example of
the inoculation of the Egyptian disease in the moist way. From the
estublishment of the school, which dates from the commencement of
this century, the physician and surgeon attached to the institution
had neither of them observed a single case of Malignant Angina, but
the death of four pupils and of the sister of charity who had nursed
them, all five being carried off by Malignant Angina, had excited
alarm and powerfully attracted attention.

My Treatise on Diphthérite had just appeared, and the treatment
of Aretzeus was explained in it with the additions rendered necessary
by the progress of chemistry. At this period, as well as at the most
distant times, it was attended with the best results. The throats of
184 BRETONNEAU’S FIFTH MEMOIR.

the inmates were examined every day. Sixty pupils were found to
be attacked, at a more or less advanced stage of Malignant Angina ;
but all were immediately treated and cured.

At the period when those whose cases had been mistaken, were
dying of the disease, one of their comrades, who was kept in the
Infirmary for excoriated chilblains, wetted one of his feet in a little
pool of sputa which moistened the brick flooring at the bedside of
one of the patients. An excessively painful ulceration was the con-
sequence of the contact ; it was established between the toes and was
covered with a false membrane, and the Egyptian disease, thus inocu-
lated, yielded only to the employment of a solution of nitrate of silver
and afterwards to the soothing and cicatrizing action of calomel.

A similar transmission of Diphtheria was observed at the same
period by MM. Trousseau, Ramon, and Leblanc.

During the course of their mission in Sologne, which was
prolonged in that unfortunate district, they saw a woman who, in
suckling her child affected with buccal Diphtheria, had contracted
Diphtheria of the nipple. The disease had extended to the breast,
with a production of false membrane and excessively painful swelling.

The cases collected in the departments of Vienne, Deux-Sévres,
and Loiret, abound in instances of the transmission of Diphtheria
observed in all its forms. On this point, my dear Blache, I ought
to abstain from reminding you of the conditions of the sad event
which has befallen you. The principal features of the publications
emanating from the medical societies of these departments will find a
place in a forthcoming edition of my Treatise on Diphtheria.

In restricting myself to the exigencies of the present work, I must
insist on some facts which are little known or generally ill-interpreted.
Tn order to understand properly the mode of action of the Egyptian
and the syphilitic virus, we must examine them both; the only
method by which we shall discover the resemblances connecting them
together is to establish the distinctions by which they are separated.

In the first part of this Memoir, I have stated that the Egyptian
disease is not communicated by volatile invisible emanations, sus-
ceptible of being dissolved in the air, and of acting ata great distance
from their point of origin. It no more possesses this property than
the syphilitic disease. If the liquid which issues from an Egyptian
chancre as visibly as that which proceeds from a venereal chancre
has seemed, in some circumstances, to act like some volatile forms
CONTAGION OF DIPHTHERIA. 185

of virus, the mistake has arisen from its not having been studied
with sufficient attention ; the appearance has been taken for the reality.

It must not be forgotten that smallpox, besides its volatile virus,
possesses also one which is inherent in the visible variolous crusts of
every pustule of variola, and in the pus which the inoculator allows to
dry on the point of a needle or of a lancet, or preserves in a sewing-
thread which he keeps impregnated. ‘There preserved and incorpo-
rated, it may be transmitted by inoculation to-day, to-morrow, or in
several years ; it may be sent to China, and if well wrapped up, may
go round the globe without losing its reproductive power and without
becoming inefficient.

The same is the case with the Egyptian virus, which, for many
ages has been reproduced at so many periods and at such long in-
tervals, and has always been the same. We follow the progress and
the phases of its operations. We see the Egyptian sanies act like
an oily solution of cantharidine; it raises the epithelium and the
epidermis, extends the area of its attacks and covers it with a false

, membrane which is seen to thicken in proportion as it is produced 3

with this difference, that it acts less powerfully and expeditiously
than the oil of cantharides. But the diphtheritic virus is an epi-
spastic agent which, acting through the epithelial coats of our inner
or outer integuments, takes much less time to produce the same
effect.

At the period when the Hgyptian disease attacks the point of in-
sertion of an incisor tooth, some time is required for the epithelium
to be raised and detached by the epispastic sanies, which, from the
chancrous point, runs off and moistens the corresponding part of the
lip, raising and detaching its epithelium, which is soon replaced by a
false membrane ; while in spreading with the pulp of the finger (which
is unaffected), a little drop of oil of cantharides on a dog’s tongue,
previously wiped, over an extent corresponding to the size of a two-
franc piece, we find the epithelium detached in less than five minutes.
Then to the papillary appearance succeeds the smooth aspect of
a surface which secretes only serosity instead of mucus, and also be-
comes less soft to the touch. In a moment the rosy tint of the
denuded space is covered over with a white, opaque false membrane,
which is seen to thicken in a short time.

I cannot resist the opportunity of quoting an instance of this kind,
which I have seen over and over again with the same degree of as-
tonishment.
186 BRETONNEAU’S FIFTH MEMOIR.

A ball of the ethereal extract of the powder of cantharides, having
scarcely the volume of a hemp-seed, dissolved in a small spoonful of
olive oil, was administered to a goat. There was fatal poisoning and
the body was examined. There were no traces of the coriaceous
epithelium which covers the tongue, the cesophagus, and the first sto-
mach; but the enormous concrete exudation which occupied its
place exhibited the most exact model of the surfaces from which the
exudation was being detached in prodigious quantity.

After having pointed out this similarity of epispastic action
existing between two agents of such different origin, why should not
something be said of the similarity exhibited by death from Egyptian
poisoning and that from the poison of cantharides?

In both cases, there was the same coldness, yielding to no process of
warming, even in the midst of summer; the same absolute adynamia,
which cannot be compared to any other adynamia, or rather it is a
complete extinction of muscular power; no other movements remain
except those of the heart or of the respiration, and even these move-
ments are so slow that the pulse falls to 50, 80, 20, 5 pulsations in
the minute, then to only 1 in two minutes ; there is a corresponding
decrease in the expiratory movements, and at last extinction of life,
with this remarkable difference that the death caused by the Egyptian
poison is read. There is a cireumstance which can only be observed
in man, namely, that while in children and adults there is a constant
exaltation of the affective sentiments and of the intellectual faculties,
the same exaltation of the powers is observed even in very young
subjects. But here the similarity ceases. There is another difference
peculiar to death caused by the poison of cantharides, and experi-
ments often repeated on young dogs, made with the same or with
different objects have given very strange results in this respect.

After the poison of cantharides, death is only apparent before be-
coming real. We have twice and even thrice seen this fictitious
death repeated ; on those occasions this apparent death so closely
resembled real death, that the instinct of the great blue fly was de-
ceived by it. A swarm of these flies which deposit their larve on
meat when it is begining to turn, covered the commissures of the
eyelids, the lips, and the apertures of the nostrils, with a thick and
rounded layer of these heaped up larve.

Each of these successive fits of lethargy was generally prolonged
more than twenty minutes, without our being able to perceive any in-
dication of life, or to excite even a dubious movement of the heart
CONTAGION OF DIPHTHERIA. 187

during the continuance of this apparent death, when to our great
astonishment we saw a kind of resurrection, at first slow, then rapid,
so that the animals became able to stand and walk; subsequently
there was a more prolonged relapse, and finally, complete extinc-
tion of life.

One of the young dogs, whose toxemia in the morning had
been less deep and prolonged, began to eat in the evening and ap-
peared to be advancing towards a complete revival; but although
drinking milk and being kept warm during the night, he had ceased
to live by the next day. This circumstance occurred in the presence
of a dozen pupils in the year 1825.

This is a digression which has slipped out of its place, but the
speciality of contagious diseases and that of their treatment belong
to the great medical truths revealed by clinical observations, against
which no prejudice can avail anything. Still the medical journals
resounded with strange and deplorable objections offered by phy-
sicians. Truth, even if it is not listened to, ought at least to
endeavour to make itself heard. I therefore repeat that a special
germ peculiar to each contagion, gives origin to every contagious
disease. Epidemic visitations are engendered and disseminated only
by their reproductive germs, as all languages have declared from the
remotest time.

At the most distant periods, the transmission of epidemic diseases
attracted the attention of the precursors and the successors of
Hippocrates ; the word contagion indicates that the transference
of epidemic diseases is effected and accomplished directly by
‘the contact of the patient, and indirectly by the contact of
contaminated articles; then the prevailing disease is imported,
exported, and transferred by a person who is attacked by it.
Although in a populous city the importation is not even sus-
pected and we may seek in vain for the source and traces of con-
tagion, yet, without examining, we find in a small village, whether
we wish it or not, the person ‘who imports it, as well as him who
receives it and- him who exports it. Although this is sometimes in-
sufficient evidence, even in a village, after fallacious explanations, yet
by dint of seeing the prevailing disease extended from one subject to
another during the course of different seasons, and its transmission
accomplished, physicians and rustics are compelled to agree that the
disease is gaining ground.

This fact is too transparent and too palpable not to attract the
188 BRETONNEAU’S FIFTH MEMOIR.

attention of those who are obliged to contend against contagious
diseases; thus it has been repeatedly observed and published ; but
fatal errors have always crept in to obscure and eclipse it, or what is
worse, to misrepresent it. In the interest of the medical art, it is
better that a prominent fact should be forgotten than perverted.
When contagion becomes too evident to be denied, it is admitted ;
the self-sufficient theoretical infallibility then comes to terms and
offers to make the most fatal concessions. It then says :— A disease
which was not contagious, may become so under such and such
conditions,” and a thousand dangerous fallacies are substituted for
the protecting truth which arrests epidemic scourges and prevents
their extension.

The blind multitude, who are ignorant of everything and who
doubt nothing, when meeting with the mysteries of life, of which
they do not understand the secrets, hasten to impute every epidemic
to innumerable chimerical possible or impossible causes.

“Impossibility is the dream and the predilection of the profane
vulgar ; thus at several periods the people exterminated the Jews, who
invented the plague, and in our own days, they have attacked or
murdered those who took upon themselves the duty of throwing into
the rivers and wells the poison which propagates cholera. Can the
inclination of the vulgar of the nineteenth century for the incredible,
be possibly denied in the presence. of homceopathy, magnetism, and
table-turning P

It is painful to observe medical men travelling and meeting to-
gether on this road, some of them being in high situations, and
engaged in teaching the healing art, outbidding one another upon the
perverse decisions of the common people, so difficult is it to under-
stand a special cause of disease and the speciality of its action! And
yet this speciality is not limited to the effects of invisible, imponder-
able causes, which are only revealed by varied symptoms peculiar to
each. There is no caustic, or poisonous puncture, or local irritant
which does not leave its traces after the accomplishment of its object.

Without passing beyond the category of these powerful caustics,
these anhydrous acids, observe the constant diversity of their action ;
that of sulphuric acid is limited to a narrow and almost indolent per-
foration ; that of nitric acid produces an extensive, burning, erysi-
pelatous inflammation; and hydrofluoric acid, dreadful and very
painful corrosion. ach of these well-known agents operates in its
own peculiar manner, without much regard for individual conditions.
INFLUENCE OF HABIT. * 189

In the great number of species of the genera melie, mylabris,
cerocoma, &c., which compose the numerous family of the canthari-
dize, we have seen that a physiological blistering secretion transudes
from the articulations of these insects as soon as they are touched,
and that a contagious disease gives to several of our tissues the power
of generating a morbid blistering secretion. What an astonishing
resemblanée in effect between two products so dissimilar in origin !
Both of these secretions are blistering, both cause death in the same
manner, in the manner as you know most opposite to all the known
methods of dying.

If arguments were drawn against the speciality of the Egyptian
disease, from the similitude of the blistering and poisonous action of
the oil of cantharides and of the Egyptian sanies, a great error would
be committed, for, notwithstanding their apparent identity, there is a
marked difference in the operation of these two agents.

Cantharidic Croup, developed by the injection of a small quantity
of oil of cantharides into the trachea of a dog or a goat, produces the
symptoms of Hgyptian Croup ; but this cantharidic Croup is far from
extending or becoming aggravated. As soon as the expulsion of
‘the false membranes is effected, the animal begins to recover, and
after this expulsion, I have tried in vain to prolong and aggravate
the disease by repeated cantharidic injections, for the mucous mem-
brane resisted more and more the vesicant action of the epispastic
oil, and was seen exposed on the surface of the dog’s tongue when
wiped, as I have before stated. In the same manner the effects of
croton oil when reapplied several times to the same region of the
skin, have been seen to cease to be reproduced.

Thus we have learned from Rasori that large doses of tartarized
antimony gradually increased, no longer excite vomiting, and we have
admired the wonderful consequences of this temerity. It has just
been ascertained that from the most formidable of poisons, namely,
arsenic, taken in poisonous doses, poison-eaters derive beauty, health,
and strength ; and moreover that a courier and his horse kept upon
the same regimen, acquire the useful faculty of running quickly*
and for a long time on steep roads without losing breath.

Opium, in a dose which would destroy a person unaccustomed to
its use, becomes in Turkey an inexhaustible source of gaiety, comfort,
and warlike valour. The charm of poisoning produced by opium

* M. Bretonneau is here in error, as all the stories about the beneficial
effects of arsenic-eating have been proved to be fabulous.—(EDITOR.)
190 | BRETONNEAU'S FIFTH MEMOIR.

when smoked should not be forgotten ; has it not lately worked an
immense revolution in China?

As to our tobacco-smokers, we meet them so often enraptured in
their ineffable intoxication, that we are no longer astonished at seeing
them swallow down at full breath the vapours of nicotine, and thus
braving a poisoning worse than that of Circe. Besides, in order to
obtain the pleasure of a poisoning which does not kill, there is not a
small community on the surface of the globe which has not recourse
to accustomed habits; so that a few years have been sufficient to
allow alcoholic intoxication, assisted by variola (which is also only
subdued by habit), to extinguish almost completely the indigenous
races of the two Americas.

Then what is this undeniable fact of habit converted ne tolerance P
This immeasurable faculty belongs to man, it is born and developed
with him, and does not confine itself to withdrawing him from the
effects of poisons; it is in man the progressive means of arriving at
everything, which, if presented all at once, could be neither supported
nor obtained. The prerogative of habit confers a high authority on
man ; habit has endowed him with the means and the power of con-
quering himself, and of subjecting a multitude of living beings to his
control, from the wild beast which he renders docile, affectionate, and
grateful, to the spider of the prisoner.

Ah! if habit were not abused, what immense benefits it might
confer on man! Let us turn away our eyes from mad, infamous, and
strange habits, and look only at the blessings which habit has lavishly
bestowed on the lord of the creation ; first it makes him the workman
of every art, the possessor of vegetables and domestic animals, then
it brings to perfection, from age to age, the innumerable races which
God permits man to create. At his command, custom and habit
prepare for him birds and dogs for hunting, and a race of animals
for every kind of game; they harness for him packs of animals for
his sledges, prepare for him learned dogs, speaking birds, dancing
and ploughing horses ; they give to the blind man a dog to lead him,
and from a dog they make for man a friend, who dies of sorrow and
despair at the tomb of his master.

The beneficent effects of this magic power are not limited to these
results. It is upon habit and custom that the most laborious, ele-
vated, honourable, and most justly rewarded of human faculties rests,
namely, attention. The fine arts are due to this power; the medical
art is its work, as Corvisart acknowledges in a beautiful page of his
INFLUENCE OF HABIT. 191

preface to the translation of Avenbrugger. He there shows us that
to acquire the medical acumen, the physician requires the medical
education of each of his senses, which ought to be put upon their
trial, and their report ought to be waited for and listened to with
calmness.

What power is given to the will by the persistent habit of wid/ing,
and what power is given to the attention by the sustained tension of
this noble faculty! To attention the hippocratic art owes the good
which it has already accomplished, and will owe what still remains
for it to accomplish. Attention is the most powerful of all healing
measures, and that which chiefly brings about unexpected cures.

I should repent having allowed myself to enter into this long di-
gression, if I was not certain that habit, which subdues the wild
animals, also mitigates the various kinds of morbid poisons. By pene-
trating into our economy, the morbid poisons multiply there, which cir-
cumstance, however, does not prevent the amount of each dose of the
virus successively absorbed from exercising a weakening influence
over its operation, so that at the period of an epidemic, the physicians
who have a large practice, running from one patient to another, and
absorbing only fractional portions of virus, succeed in attaining an
immunity which is often observed and generally ill-understood.

As an example, our friend, the courageous Lachéze, remained shut
up for five months in a large hospital of plague-patients at Cairo.
In the course of a single meal, he saw the death of two servants at-
tached to his service. The vertiginous intoxicated appearance of
these two servants revealed to him the suddenness of their attack, and
they fell, one after the other, asif thunderstruck ;* and still, though
operating every day, dressing the sick, studying and comparing the
diversity of the organic lesions peculiar to all the stages of the plague,
the brave doctor remained invulnerable. It was in 1838, on his
return from Egypt, that Lachéze, passing through Tours, related to
me very modestly the account of his long struggle with the plague.
On returning to Paris, Lachéze was not able to raise sufficient money
to print a small memoir, which was an excellent collection of useful
clinical observations. Among other things I had remarked the
method of arresting the fatal progress of cutaneous carbuncles by a
circular cauterization. This memoir was neither read nor considered,
and the Académie determined that the little book was one of those

* In these cases of sudden poisoning there were no posthumous traces
of disease.
192 BRETONNEAU’S FIFTH MEMOIR.

unseasonable superfetations with which, at this period, it was over-

whelmed.

Of local applications employed to modify the Egyptian ulcerations,
there is none so painful as that of alum and hydrochloric acid, while
a solution of nitrate of silver is the least painful and the most effica-
cious. It isto Dr. Mackenzie, of Glasgow, that we owe the successful
substitution of a non-poisonous salt of silver for the salts of copper,
which probably we might not be able, without danger, to carry up
to the elevated doses of the silver salt.

Being accused in a London Medical Journal, of having derived
from the Zreatise on Diphthérite the knowledge of the medicinal
power of caustic applications, the doctor invokes the testimony of his
fellow-practitioners, who, like him, have recognised the necessity of
having recourse to this treatment during the course of a fatal epi-
demic of Croupal Angina, no other treatment having been found
efficacious, and then he congratulates himself upon our agreement on
a method of treatment which is essentially the same, this coincidence
confirming the confidence felt in both kinds of treatment, whether
at Tours or in Glasgow.

Tonsillar Diphtheria, by its vicinity, threatening the air-passages
with imminent danger of extension, requires the most expeditious
and complete local treatment.

You will remark that at the first day of the appearance of the
Egyptian chancre, a radical cure may be obtained in forty-eight hours ;
remark also, that every hour and every day the necessity of a more
active, complicated, and prolonged treatment goes on increasing in
a melancholy proportion.

At the first stage, in order to obtain this favourable result, it is
sufficient to employ, on the first day, two local applications, one in
the morning and one in the evening, and to repeat the same pro-
ceeding the next day. This superficial cauterization is conveniently
performed only by means of a spatula holding a piece of caustic. The
thin layer of sponge covering the right surface of the spatula, ought
to be only slightly moistened with the solution of nitrate of silver
and not soaked. That the action of the caustic may not spread be-
yond the point which it is intended lightly to cauterize, it is expedient
that a slight pressure should keep up the contact with the caustic
without allowing it to slip over the white spot formed by the false
membrane. ~
LOCAL TREATMENT. 198

From this first stage I pass to the last, or to the most serious case
of Pharyngeal Angina which has become croupal. Between these
two extreme conditions, it will be easy to establish the degrees of
treatment which it will be necessary to oppose to the different intey-
mediate stages.

When the sponge has been charged with the caustic solution, it
is pressed at the edge of a saucer, and wiped so as to make it
certain that it will not allow a drop of caustic liquid to flow into the
bronchial tubes, an accident which might cause fatal tubular pneu-
monia. I have ascertained by numerous experiments on animals,
that the most inert substance, such as wetted chalk, injected into the
trachea and deposited in small quantity in the bronchial tubes,
has caused a fatal attack of pneumonia, even if this pneumonia was not
very extensive. It is therefore better that the solution should be
active than difiluent.

The explanation of what remains for me to say of the subsequent
proceeding will show you the necessity of these precautions,

The caustic-holder having been introduced obliquely on the left,
between the left tonsil and the uvula, slip under the epiglottis the spa-
tula with which this valvular flap is to be raised and kept supported
on the base of the tongue, for it is thus that the epiglottis should
remain pitilessly held (for pity would be negligence) until, when
the instinct which suspends all respiratory movement yields to
another still more imperious necessity, you see a deep and prolonged
convulsive inspiration drawn, and a second inspiration succeed to
the first. At this moment the pharyngeal mucous matters previously
whitened by the accessory cauterizations, then afterwards whitened
and re-whitened at the entrance of the glottis, are swallowed up
together, swept down by the alternating movements of convulsive
respiration, while the viscidity and the consistence which they have
just acquired do not allow this kind of cataplasm to be drawn down
into the bronchial ramifications. The thick varnish remains where
it is most useful, for it stops in the ventricles of the larynx, passing
. and repassing over the false membranes which are to be impregnated
by it.

I wish to hasten to a termination by relating another instance of
cruelty. After some minutes’ respite, the same proceeding must be
repeated a second time in all its details; the caustic-holder must be
withdrawn, its sponge must be washed, wiped, and dried by the
pressure of a very dry piece of linen, then it may again be moistened

0
194 BRETONNEAU’S FIFTH MEMOIR.

at the proper part, and the caustic-holder may be re-introduced as at
first.

You may be frightened with this barbarity, but it must also be
said that it is justified by an amelioration in the patient’s condition
from a state of semi-asphyxia, for he has been re-animated by his
deep inspirations. Add to this that the local soaking of the false
membranes subdues the pain instead of increasing it. Thus modified,
they protect the tissues which they cover. The proceeding may,
indeed, be a severe one; but the preparations for tracheotomy which
might otherwise be performed under the most fatal circumstances,
may, by such means, be deferred until a pupil, appointed to watch
the patient, comes to tell us that the operation can no longer be
delayed.

During the first day, there are strips of expectorated false mem-
branes, which, being well washed, float suspended in water, and
being exposed to the light, do not yet assume a violet tint; but
from the second to the third day this coloration takes place, and
the cough, less shortened, inclines on the fourth day to a catarrhal
tone. We then see that tracheotomy need not be performed, and a
cure results on the fifth to the sixth day, without any other treat-
ment than an imperative or coaxing administration of food, offered
or forced under all possible forms.

I have under my notice four persons restored to life by this rude
practice, without any unfortunate occurrence. Dr. Leclerc records
the cases of two who were quite restored to health.

The details of a story recalling the scenes of the most horrible
period of the disease would here be out of place. TI leave it for the
next edition on Diphtheria ; but I must give you a rapid summary
of the principal facts. .

Being summoned in consultation, in 1837, to the house of an
innkeeper named Viel, by M. Haime, we saw a child, seven years
old, sink under an attack of croupal suffocation. We warned the
parents that a child three years old, who remained to them, might
be attacked by the same disease. They were urgently recommended
to call on M. Haime at the least sign of illness in this child. Some
few days afterwards we were summoned again. We endeavoured to
examine the back of the mouth, and at the time when we ascertained
the pharynx was completely occupied by the disease, we saw this
unfortunate patient expectorate, during the resistance made to our
examination, a tube five or six centimeters in length. (Twenty to
,

LOCAL TREATMENT. 195

twenty-four lines, Ed.) Its expanded extremity, which bore the
shape of the larynx, was thick; and what was still more alarming,
its broken bronchial extremity, the termination of which we could
not see, had also the most alarming thickness. The principal divisions
of the bronchi were undoubtedly already affected, and tracheotomy,
under such circumstances, could not be performed without hastening
the loss of life. A fictitious local treatment, devoid of all efficacy,
did not suit us. The barbarous proceeding, the efficacy of which
I had already several times ascertained, was proposed, accepted, and
executed. Four applications were ordered, each one repeated (namely,
eight every day), the first at four o’clock in the morning, and the
last between ten and eleven in the evening.

From the fourth day all anxiety had ceased. On the fifth, in the
evening, we saw the child through a glass-door at supper with its
father and mother, and we refrained from entering, as our presence
always excited fear. On the sixth day, the inspection of the throat
left nothing to be discovered which in any way deviated from the
healthy condition. On withdrawing, M. Haime and I remarked to
one another: “If this throat had been ill-treated with a sponge
dipped in white of egg, or mucilage of linseed, as it has been with
our ounce of nitrate of silver, should we not have been convinced
that the pharynx would have resented it more ?”

An enormous proportion of the solution was drawn into the
digestive tube by the inevitable movements of deglutition, and this
happened eight times a day, without any other effect than a slight
‘purging. The large black spots exhibited by the linen when washed
and dried in the sun attested the unusual quantity of the salt swal-
lowed. No slaty tint of the skin was manifested, the laxative effect
being, no doubt, opposed to absorption. This case may afford
encouragement to the most timid.

I hear lamentable stories of the ingestion of nitrate of silver by
the lower animals and man, and I listen to them as patiently as I
can. I affirm that, without any error in calculation, a solution of
thirty-two grammes (about one ounce, Ed.) of the crystallized nitrate
of silver was completely employed in the horrible treatment. Although
the washing of the sponge, and the spitting which followed each
cauterization may have wasted two-thirds at the most, yet the rest
was in great measure mingled with the mucous matters drawn in at
the time of the cauterizations.

Your letters, my dear Blache, become more and more alarming,
02
196 BRETONNEAU’S FIFTH MEMOIR.

and I can understand that you and Trousseau are terrified at witness-
ing the cases of sudden loss of life after forty-eight hours’ illness.
Mothers, you tell me, are attacked with the disease which has just
carried off their children, and in other houses the servants do not
escape from the scourge. You ask my opinion, and appeal to my
long experience. I have hastened to transmit to you the facts which
are most applicable to the present condition of the epidemic of Paris ;
they have been collected since 1827, during the continual succession
of a multitude of epidemics.

Believe me, this sudden loss of life which so naturally alarms you
is not real, for when the disease appears and, as it were, explodes, it
existed before, and’ was silently, though abundantly developed in the
nostrils. Do not object to me that I have said it, and explained and
repeated it in every possible manner. After having clearly pointed out
the insidious occurrence of nasal Diphtheria in large or small localities
where the sudden extinction of life struck so much terror into medi-
cal practitioners and populations, and having said to my colleagues,
“You cannot sufficiently suspect the secret seizure of the disease
upon the nostrils,” I was still far from knowing my lesson, for it is
only recently that I have completely acquired the conviction that
the Egyptian disease is developed in the nostrils, and extends there
without any warning and without any apparent symptom. It must
be confessed that such is the case.

Under these circumstances, a minute and attentive vigilance is
imposed upon us. When the Hgyptian disease prevails and is pro-
pagated with the intermittent march which characterizes its irregular
outbreaks, and when, from one year to another, it has raged so ex-
tensively as it has been seen to do in Paris within the last six ‘years, ~
it is incumbent on us not to wait for visible symptoms ; but at the
least sign of snuffling, at the slightest indication of coryza, to feel
and not to dook beyond the angle of the lower jaw, below the lobe of
the ear, and thence down the sides of the neck. If in this region
we should find any swollen lymphatic glands, our attention should
be redoubled, for if we feel a glandular swelling, it is more than
probable to be a consequence of the absorption of the Egyptian
virus.

Do not be satisfied with this examination, for it is necessary that
the diagnosis should leave no doubt ; examine, therefore, the upper
lp below the nostrils ; in the most simple coryza the skin is red-
dened equally under each nostril, while in the case of the Egyptian

,
LOCAL TREATMENT. 197

disease, it is only on the side of the glandular swelling. If the
swelling exists on both sides it is unequal; on the side where the
swelling is least, the redness of the lip of the same side is least.
From the period of this discovery, we are certain that there is a
special affection, in fact, the Egyptian disease.

We see what value the information obtained by this inquiry pos-
sesses, for we may discover the day on which the reproductive germ
has begun to develop itself in the nostril first attacked, and the day
of transmission to the nostril secondarily affected, as exactly as we
follow, from. the fourth to the fourteenth day, the age of a variolous
pustule. This knowledge will besides accurately guide the treatment
which ought to be pursued according to the age and the stage of
the disease.

Then let me advise you to act instead of talking, and with a glass
syringe, the padded extremity of which ought to be yielding and in-
capable of causing pain, inject into the nostrils alternately a solution
of nitrate of silver, and although the injection may flow back through
the nostril which has not been injected, it will be well that the latter
should also receive an injection of suitable strength, if, on the corre-
sponding side, there is the least swelling of the cervical glands.

In descending along the course of the pharynx, the caustic solution
will accompany the epispastic secretion as far as the arytenoid car-
tilages, and up the sloping channels formed by these cartilages it will
penetrate into the larynx, and in the air-passages it will follow the
blistering secretion, thus preventing or arresting its action.

At the commencement of the affection of the larynx, two fatal re-
sults may be prevented by two different proceedings, one for children
and the other for adults. First, in children we must prevent the
formation of a valve, the insidious mechanism of which becomes ra-
pidly fatal, and in adults we must oppose the production of a long
tracheal tube taking the form of a bronchial tree and throwing out
branches as far as the final divisions of the air-passages, thus tending
slowly, but inevitably, to the destruction of life. Remember the poor
Jew bearing for a week, without much uneasiness, his slow and fatal
asphyxia. Let us leave this rare case like all the rare cases presented
by the strangulatory Egyptian lesion, which, in the present day, makes
so many victims; this lesion abounds in therapeutical and prognostic
indications, and we will study it.

The fibrinous production, appearing like a membrane, has scarcely
fixed itself and attached its roots to the ventricles of the larynx,
198 BRETONNEAU’S FIFTH MEMOIR. a

when it moulds itself as it advances towards the trachea, upon the
expanded walls of this organ, and at the same time becomes thinner.

Attached by its base, and having its tracheal point free and float-
ing, this cone becomes a valve, the horrible mechanism of which is
perfectly completed. At the period of inspiration, the valve elongates
and extends itself, unfolding and allowing the air to ‘pass when deéply
and strongly inspired, while at the moment of expiration, the free
extremity of the valve being pushed back, opposes an insurmountable
obstacle to the passage of the air outwards. Being thus retained,
the air is imprisoned without giving place to the fresh air. Hence
arises a sudden asphyxia, the fatal importance of which is so well
described and so admirably depicted by Areteeus when he says,
* Pallida his...livida facies. Inspiratio magna est, expiratio verd
parva... hac signa in pejus ruunt cum subitd in terram collapsis anima
deficit.” ,

Let us accord to this great master the tribute of a grateful admi-
ration! Although deprived of the information which we moderns
have gained from necroscopical researches, what a picture does he
leave us of the last scene of the Egyptian disease !

My dear Trousseau, we have many times made the observation to-
gether, that it is one of the blessings of the art of medicine that it
inspires an affectionate esteem for an able practitioner of the time
past and for one of the time to come; it is besides a consolation for
the bad conduct of some of our brothers. My heart swells with
tenderness when I hear Morton saying of old Sydenham, “ If it were
permitted me to praise such a man!” <A hundred years later, Stoll,
speaking of Sydenham being blamed, says, “ Quem virum, et quan-
tum!” Think also of our Laennec, so forbearing as to himself,
but so ready to resent offence, when physiologism dares to touch
Bayle, his much regretted rival and friend.

Thanks to heaven, the catalogue is long, and it will be prolonged
still more. You will continue to regard me when I am no more.

By the prognostic signs which I have just pointed out, Areteeus
knew, and by these signs it will always be known, that death is ap-
proaching, but the time has come to add to the therapeutical measures
which are necessary, some proceedings which carry the treatment
beyond the limits im which this learned disciple of empiricism had
left it. In the present day, the cause of the livid paleness which an-
nounces the approaching asphyxia, is well known. An obstacle is
opposed to the entrance of the air, and this obstacle is removable and
LOCAL TREATMENT. 199

must be taken away. It may be reproduced, and we must imme-
diately, and on the spot, have recourse to proceedings which may put
an end to this reproduction. These indisputable conclusions rendered
tracheotomy imperative ; the natural horror of even the least opera-
tion yielded to the despair of anxious friends. I had performed it
five times and had obtained from it only a cruel half success, but I
had learned why my success was not complete.

You have not forgotten that the rapid progess of lividity remarked
by Aretzeus indicates the threatening progress of asphyxia. By this
terrible sign, I was able to foresee that Elizabeth Puységur, the
daughter of my best friend, was about to sink under the rapid effects
of Croupal Angina. Three other children of this family had been
previously carried off by the same disease. My friend knew my ob-
stinate perseverance, and he knew of my ill-success, and he said to
me, “ Do asif this was your own child!” Twelve days later, the little
gitl’s cure was completed.

You see that the prognostic symptoms of Aretzeus announce the
time when it is proper to perform tracheotomy; and they also
announce that it will then be performed under the most favourable
conditions ; that the air will enter below the valve, which permits
long inspirations and suspends the expirations, and it does this when
the disease has had only a short duration, when it is still local, and
when the toxemia, more formidable and irremediable than strangu-
lation, may be prevented.

“It is unnecessary to add, that with the precaution of keeping
everything prepared for the operation, tracheal cauterization through
the larynx may be attempted. In such conditions, it is proper to
wait and see what may happen; perhaps the valve, hardened by the
imbibition of the caustic, may become insusceptible of being pushed
back, and even if the operation should eventually become necessary,
there will be a gain of time before the performance of tracheotomy.

These minute details are not addressed to you, my dear sir; but
we must share an apprenticeship in our practice which cannot be
extemporized. With your senior, Velpeau, I commenced it, with
you I have continued it, and if the art is not taught, it cannot be
learned, except at the expense of our patients.

At the Hospital of Tours, since the importation of the Egyptian
disease by the legion of La Vendée, we have been compelled to
recognise the necessity of opposing all the artifices of treatment to
the insidious variations of a proteiform disease.
200 BRETONNEAU’S FIFTH MEMOIR.

The occurrence of croupal strangulation has attracted too much
notice, and has diverted attention from other still more dangerous
results of the Egyptian disease. It is difficult to believe that it
could be otherwise. ;

At its insidious commencement, Egyptian Croup is the least ter-
rible of all diseases; it is especially less so than stridulous Angina,
the nocturnal attacks of which excite the greatest alarm, and often
cause physicians to be summoned to the patients. ‘ In fact, it is only
-after a tranquil onset that the Egyptian Laryngeal Croup begins to
be aggravated. A child, whose illness for some days had scarcely
attracted notice, apparently dies and revives at short intervals; these
painful alternations, these rapid changes from hope to terror, which
have been so often mentioned, lead at last to a fatal asphyxia, and
leave a deep impression of terror in the parents of the sick children
and on medical practitioners.

This picture of Kgyptian Laryngeal Croup is found everywhere,
and I intentionally revert to the word Jaryngeal, because it is the
laryngeal croup which is most commonly met with, and because I
have yet to write of Croup which has not passed beyond the larynx
and trachea, and not of that which descends almost into the bronchial
ramifications.

This portrait has, indeed, some resemblance, but it is a deceptive
one, inasmuch as it represents exactly the death-struggle, the apparent
extinction of life; but life which appears extinct is not really so, and
the prolonged duration of asphyxia is not the certain sign of its
complete extinction. :

In the first part of this Memoir, several cases of nasal poisoning
by Diphtheria have been mentioned. Under this disguise, in Paris,
the Egyptian disease had just attacked several children, and also old
persons, and had led to so many sudden deaths, that the attention of
‘the medical profession was especially‘ called to the calamity. On
this occasion I must recall my reminiscences from 1817 up to the
present day, and collect together the facts which may explain the
pathogenesis of this mode of attack; these facts resemble those
which have just been mentioned.

A sad period of security generally intervenes, and in a great
number of cases lasts until the period of death; and this security
is not only the illusion of a patient who can only judge by his
feelings, but it deceives the relations, and even physicians.
CASE OF DIPHTHERIA. 201

The more I have examined this serious question, the more I have
been convinced that it will be difficult for a long time to distinguish,
from a cold in the head, or from a simple coryza, the surreptitious
affection of the nostrils in the Egyptian disease, since it is upon one
part of the pituitary membrane, namely, the mucous lining, that
the development of this affection occurs without any salutary suspicion
having been excited by the complication of any collateral and more
manifest attack.

Since such is the case, I wish to describe once more the deceptive
appearances which must be distrusted, and to call attention to the
treacherous want of meaning presented by illusory symptoms, which,
instead of attracting attention, actually divert it!

I fear that I have not sufficiently insisted either upon the danger
of the disease or upon the difficulty of avoiding it. Several of the
symptoms of a simple and slight coryza are common both to this
indisposition and to the fatal disease; it is, therefore, of the greatest
importance to distinguish those which may excite a salutary appre-
hension and put physicians on the track of the disease lurking in the
nasal anfractuosities.

Several of these signs have already been mentioned. The follow-
ing is a summary of the fearful but faithful recital which recals what
is necessary to be known upon the danger and the treatment of this
insidious disease. It is the extract from a notice written in my
leisure for our friend Trousseau, while expecting one of his kind
visits, and while I had under my notice the most formidable attack
of nasal toxemia I had ever seen.

My friend, residing at six leagues from Tours, in the little town of
Amboise, lives with the family Saint B.— with whom you are ac-
quainted. George St. B.—, alarge robust boy about twelve years old,
came from Paris with his nother, both of them being alarmed at the
danger of Malignant Angina. Since his return, George made some
long excursions on horseback. On Saturday, May 20th, 1854, and
on Sunday, the 21st, there was pain in the ears, especially the right,
but so slight that it scarcely attracted attention. These symptoms
became aggravated, and on the 28th of May, his rjdes were in-
terrupted in consequence of a sore-throat of which he complained
the night before. The pharynx was attentively examined, but
it was ascertained that there did not exist the slightest white spot
upon the mucous membrane. On Monday, the 29th of May, at
five o’clock in the afternoon, I was sent for by the boy’s uncle, and
202 BRETONNEAU’S FIFTH MEMOIR.

I was told by the messenger that I should probably not find him
alive.

Half an hour afterwards we were with the patient. Every measure
which the case required had already been adopted by our friend
Miguel. I saw and listened, and learned from three of my colleagues
and from the family, all that was passing, and all that had passed for
the last week. The pulse was irregular and thready; the hands
were cold, and exhaustion was continuing to make rapid progress.
What the boy’s uncle had told me was now repeated tome. I again
heard that after the exploration of the pharynx, while having a glyster
administered, the patient was unable to stand; he had sunk down
in a fainting condition, and being thrown on his bed he remained
there in a state of icy coldness since his uncle’s departure. In the
morning, white exudations enveloped the tonsils, and the snuffling in
the right nostril, of which the patient complained on the previous
days, had scarcely at all increased. Cauterizations with nitrate of silver
had been immediately performed. At the period of my visit, the
pharynx and the tonsils were coated with false membranes, rendered
opaque by two successive cauterizations, The sub-mastoid and

‘cervical glands were enormously swollen ; they presented the dimen-
sions, the nodulations, and almost ‘the hardness of middling-sized
potatoes ; the lateral swelling of the neck, particularly on the right
side, passed far beyond the border of the lower jaw. I do not recollect
having seen anything of a similar kind. The extreme loathing for
food evinced by the patient, as well as his continual somnolence, added
to my consternation.

The ¢reatmené consisted of a nasal injection of a strong solution
of nitrate of silver, the proportion of the salt being gradually in-
creased, and employed every six hours, and three times a day the
pharynx was cauterized. A grain of calomel ‘to be given in the
morning. Dr. Lagarde, at intervals of two hours, had given alternately
two grains of alum and then two grains of calomel. We insisted
continually upon the patient taking some nourishment, no matter of
what kind and however difficult it might be for him to take it, such as
clear broth prepared with milk and wheaten flour, white of egg,
boiled eggs, wine and water, &c., &c.

The family were in the deepest distress. “How long will these
cruel sufferings last, and how will the poor mother bear the
miseries of seeing her son’s dying moments?” said the brother-in-
law of the poor widow to me. “It is desirable that this state should
CASE OF DIPHTHERIA. 203

last four days at least,” I replied, “and we shall hope for the possi-
bility of a slow and painful convalescence.” For three days, the
volume and the hardness of the sub-mastoid glands continued ; but the
power of taking food, acquired with some difficulty, was progressively
increased, and without a distinct reaction coldness gave way to perspira-
tion. The patient was even able to change his position in bed with-
out assistance. On the fourth day, a positive improvement was at
length manifested and acknowledged by the family and by my three
colleagues. The appetite was good, and the food, which was varied,

was asked for and allowed, and then the medicines, which had already
been diminished in quantity, were rapidly discontinued. The exca-
vation in the right tonsil to be carefully watched, and, if necessary,
to be cauterized by a lateral application of the caustic.

A subsequent communication announced to me that the patient
was beginning to return to the habits of common life, and with a
playful gaiety he said to the doctors that he was better in health than
themselves, and that for a long time he had suffered no other incon-
veniencies than those which they had made him undergo. Three
months later, young St. B. followed his mother to Paris. On his de-
parture he had been brought to me, walking by himself, but looking
at his feet to know if, after three months, they touched the ground.
They still remained so destitute of all tactile power, that he appeared’
to himself to be walking in the air. Warm salt water baths, as salt
as sea water, appeared to be beneficial.

It is evident that the consequences of this nasal toxemia were
much more severe than those experienced by M. Herpin, and I firmly
believe that without the domestic attentions of a whole family and
the assiduous superintendence of three zealous physicians, the patient
would, without doubt, have sunk. This is a new proof that we ought
to give the utmost attention in checking the treacherous progress of
such a disease, and use all our efforts to avert an extreme danger.
The following are some commemorative pieces of information which
offer us instruction of great importance.

The mother of George St. B.—, learning that a lady of her acquaint-
ance, whom she saw every day in Paris, was treated by Dr. Blache,
the usual medical attendant of the two ladies, for an Egyptian affec-
tion of the gums, a contagious disease, had hastened to take refuge in
Amboise with her family. There the progress of her son’s illness,
and especially the great tumefaction of the sub-mastoid lymphatic
glands, as well as the swelling and redness of the nose, whenever the
204 BRETONNEAU’S FIFTH MEMOIR.

young horseman returned from his excursions, had attracted the at-
tention of a lady who frequently visited the family of St. B—. She
several times exclaimed, “ You do not pay sufficient attention to
George’s health; the boy, who is habitually good-looking, changes
visibly in appearance ; he is hardly to be recognised, and is quite
frightful, with his neck larger than his head; he is certainly ill.”
It was three and even four days before the catastrophe that this
prudent warning was given; what a difference would it have made
if the warning had been taken !

At the period when Dr. Lagarde saw the patient he under-
stood that there had been a long duration of the disease before
any attention was paid to it. Preconceived views and the ex-
pectation of a Croupal Angina, which did not manifest itself, had
dissipated all anxiety. The disease became aggravated; but the
symptoms, as they appeared, were different from those of Croup,
which was the only danger apprehended.

The attention of the relations was so much diverted, that the
enormous swelling of the lymphatic glands was attributed to the
mumps, an epidemic contagious affection which was prevalent in the
district. The same mistake, as you know, was committed quite
recently in the case of a schoolboy in the Faubourg St. Germain.
The physician of the establishment, being very much astonished, at-
tributed the loss of two patients to mumps, complicated with Angina
and cold in the head, this epidemic affection having a malignity
which he had never seen it possess.

In the spring of 1852, George had had a slight attack of mumps.
GUERSANT.
GUERSANT ON CROUP.
TRACHEAL DIPHTHERITE OF BRETONNEAU.

(Dictionnaire de Médecine, 1885.)

ON CROUP.

Tus Scotch name, employed at first by Home to designate an acute
inflammation of the larjnx and trachea, characterized by the rapid
formation of a false membrane, has become a popular term, which is
now generally adopted by physicians of all countries, and is common
to all languages. It is the same disease as the garotillo of the
Spaniards, and the male in canndé of the Italians. Authors have
assigned to it a number of different scientific names, which may be
considered as synonyms; the principal of which are, strangulatorius
affectus, Carnevale; eynanche stridula, Wahlbom ; morbus strangu-
latorius, Starr; suffocatio stridula, F. Home; angina. stridula,
Crawford; angina suffocativa, 8. Bard; angina polyposa sive mem-
branacea, Michaelis ; cynanche trachealis, Cullen; tracheitis infantum,
Albers ; angina laryngea easudatoria, Hufeland ; diphthérite tracheale,
Bretonneau.

Croup is certainly not a new disease, but the passages in the most
ancient authors which appear to refer to it are the more obscure to
the greater part of our modern writers, inasmuch as the early ob-
servers described the symptoms of gangrenous Angina and Croup,
such as they were met with most frequently in nature; namely,
united together, or succeeding one another like different degrees of
the same disease, as may be very well observed in the excellent de-
scription of the Syriac Ulcer by Areteus. He presents a faithful
208 GUERSANT ON CROUP.

picture of the alterations which may be perceived_in the pharynx,
and he describes with admirable truth the phenomena of the painful
asphyxia which most commonly terminates this dreadfnl disease ; but
as it was impossible for him, and for many of those who succeeded
him, to make post-mortem examinations, he could not have ascer-
tained the true causes of the death by suffocation ; and yet it is evident,
even by the description of Aretzus, that the patients died in his day
as they do now, and in the same manner. Still it is only in 1576
that Baillou, in the seventh note which is found at the end of the
Constitution of that year, page 148, vol. I., first alludes to a case in
which a kind of false membrane was found in the trachea of a child
who had died of a rapidly suffocating disease, unknown up to that
time; itis evident that no one had thought of referring it to gangrenous
Angina. This disease, however, prevailed almost at the same period
in an epidemic manner in Spain and Italy, where it cut off many
patients. All the descriptions of contemporary authors agree com-
pletely, such as Carnevale, Nola, Heredia, Mercatus, Marcus
Aurelius Severinus, &c., and they all appear to be copied from the
description of the Syriac Ulcer of Areteeus. All the patients died as
if they were suffocated, instar laqueo suffocati. In no case, how-
ever, except in that related by Baillou, had the post-mortem appear-
ances been ascertained, and Morgagni is justly indignant at this
' neglect.

Marcus Aurelius Severinus alone, among all the physicians who
had had occasion to observe this fatal disease, had opened a body,
and in speaking of the result of his researches, he says, “ Larynge
investigaté contecta erat pituité quidam crustaced, citra ulceris
speciem.” Still this anatomical observation remained unnoticed,
like that recorded by Baillou, when Ghisi, during the epidemic of
gangrenous Angina which prevailed at Cremona in 1747, having
ascertained the presence of a false membrane in the larynx of a child
who died of the epidemic, first conceived the idea of distinguishing
this mode of termination as a peculiar disease, which he designated
under the name of perfidious or mortal Angina, in order to separate
it from ordinary gangrenous Angina, which does not terminate by
suffocation. ms : e

Up to that period, all the observers had seen only one kind of
gangrenous Angina. The error of Ghisi involved the greater part
of his successors in the same mistake. The alterations of the
pharynx were, as it were, forgotten, in the gangrenous Angina, and
DEFINITION OF CROUP. 209

only the larynx was regarded as the seat of the disease. The Memoir
of Dr. Home, by attaching considerable importance to the distinction
of Ghisi, and by assigning the common name of Croup to this
disease, diverted the minds of physicians more and more from the
true path. Nevertheless, the work of Home was very useful, as M.
Deslandes has well remarked ; for he first gave a good description of
this disease. The monograph of Michaelis confirmed the minds of
physicians more and more in the ideas of Ghisi and Home.

Several more or less remarkable works were published on the same
subjects principally at the commencement of the present century, on
the occasion of the Concours proposed by the French Government on
Croup, and the works of Vieusseux, Jurine, Schwilgné, Albers of:
Bremen, Double, Royer Collard, &c., undoubtedly contributed very
materially to the better knowledge of Croup, considered as an isolated
disease. Nevertheless, the true starting point had been missed, and
the tradition of the ancient writers had been forgotten ; Johnston had
indeed said that Malignant Angina and Croup were diseases of the same
nature ; Starr and M. Double had proved that they were often united
together; but the greater number of physicians rejected Johnston’s
views.

M. Bretonneau, by the publication of some excellent observations,
collected together from the most authentic historical documents, has
at last dissipated all doubts upon the subject. He has demonstrated
that epidemic Malignant Angina is not at all of a gangrenous nature,
as was heretofore supposed, but that it is a true pellicular inflamma-
tion similar to that of Croup; he has proved that these two morbid
alterations, erroneously considered as very different, are identical in
their pathological relations, and differ only in the spot which they
occupy. He has also proved in an incontestable manner that Gan-
grenous Angina and Croup have almost always presented themselves
in combination in all the epidemics of Malignant Angina described
by ancient and modern authors, as they have done in the epidemics
of Tours and of the neighbouring district under his observation. °
The works of M. Bretonneau have therefore thrown a great light
on the pathology of Gangrenous Angina and Croup. The obser-
vations which I have been enabled to make for myself for more
than fifteen years, and which have been published either as extracts
from my Clinical Lectures, or in the first edition of this Dictionary,
are entirely in conformity with those of my friend.

Still, I admit that there yet remains considerable uncertainty, and

P
210 GUERSANT ON CROUP.

even obscurity, in the distinction between Croup and certain diseases
which most resemble it. Almost at the same time when Home
published his dissertation on Stridulous Suffocation, Millar endea-
voured to distinguish from Croup a very similar disease which may be
very easily confounded with it. The loose definitions, however, which
he assigned to his Acute Asthma of children, served only to obscure
the matter still further. The efforts made by Wichmann, Dreysig,
and M. Double, to give a more distinct character to the asthma of
Millar, have not thrown much light upon the subject.

Although the existence of stridulous laryngitis is at present ad-
mitted by many practitioners, it is still rejected by many others who
persist in confounding Croup with Acute Asthma, and who make no
difficulty in recognising Croups, with or without false membranes,
as simple varieties of the same affection. I do not think that in
the present state of our knowledge, itis possible to admit the abso-
lute identity of diseases which present different symptoms and such
dissimilar anatomical characters. The presence of a false membrane
in Croup is a character which belongs to it as essentially as the
purulent and pseudo-membranous exudation does to inflammation of
serous membranes. These facts are indisputable; but not being
able to deny the facts, some persons have made war against words.
To these_disputes I attach very little importance. The name of false
Croup (which I had introduced in the first edition of the Dictionnaire
de Médecine to supply the place of that of the acute asthma of
Millar, which I thought ought to be abolished because it has given
rise to confusion and error), is certainly, as the critics have remarked,
not very scientific; but my intention, in proposing it, was merely to
associate a word, pitch might be easily popularized, with that of
Croup, which was already popular; and thus I wished to introduce
into common language a distinction which I believe to be absolutely
necessary. For the use of physicians I shall more willingly adopt
the expression of stridulous laryngitis, admitted by M. Bretonneau.
Whatever may be the value of words, let us rather examine that of
the things which they designate.

The only objection which is raised to the distinction between the
pseudo-membranous and non-membranous Croup is drawn from a
simple theoretical induction ; it results, say the critics, from experi-
ments made upon the lower animals, that an acid applied to the
glottis, or to the internal part of the larynx, in the same degree of
concentration, produces sometimes a membranous exudation, and
DIAGNOSIS OF CROUP. 211

sometimes a simple inflammation without exudation ; therefore Croup
and ‘pseudo-Croup are only different degrees of the same disease.
The reply to this objection is easy. Although the action of a
chemical agent and that of a spontaneous organic cause are but
slightly comparable, these experiments prove only what daily obser-
vation confirms, namely, that the same cause may give rise to very
different effects, according to the peculiar state of the individuals on
whom it acts. Thus the same iced drink taken by several persons
when perspiring freely, will cause in one a simple aphonia, in another
an attack of cold, in a third one of severe laryngitis, &c.; but these
diseases are not, therefore, the same, and no person would maintain
that they were so. We are, therefore, fully convinced that mem-
branous and non-membranous Croup are produced by the same
causes, for we find them both in the same circumstances and in the
same epidemics, but the identity of their causes cannot suffice for
the establishment of a perfect similarity between the morbid symptoms
and the organic alterations which are connected with them, or con-
sequently between the therapeutic measures which are suitable to
each case, and this latter is the most important part of the question.

The identity which some authors attempt to establish between
diseases which are unquestionably different, under the pretext that
they originate from the same causes, is an error which involves the
most serious consequences, inasmuch as the treatment of the cases
is very different, as will be hereafter shown ; and, therefore, mistakes
in this respect may be attended with the most serious results. In
order to prove the truth of this remark, it is sufficient to recollect
that in several cases, of recent occurrence, some very distinguished
physicians have performed tracheotomy on persons affected with
suffocation and with croupal voice, who were considered as suffering
from Croup; but the consequences of the operation, and the post-
mortem examinations, demonstrated that there was no false membrane,
and consequently there was no Croup. ‘This mistake which has
already taken place several times, ought to make us sensible of the
necessity of insisting more than ever upon the diagnosis of the
diseases which. are frequently confounded with Croup, in order that
we may the better appreciate their distinctions and their relations to
each other.

NosogRaPHy oF THE DISEASES COMMONLY DESIGNATED UNDER

THE NAME oF Croup.—When we take a general view of the diseases
P2
212 GUERSANT ON CROUP.

generally designated under the name of Croup, we find that they
present themselves, in relation to their anatomical characters, under
two principal, but very different aspects; either the internal surface
of the pharynx, and consequently that of the larynx, the trachea
and the bronchi is covered by membranous or pseudo-membranous
exudations, which are easily perceived on all the parts within the
reach of sight, and which the expectoration afterwards contains; or
all these parts are simply reddened or very slightly swollen, as in
slight cases of pharyngeal and laryngeal Angina, and then no plastic
exudation is discovered. I shall give to the first class of diseases
the name of membranous or pseudo-membranous pharyngo-laryngi-
tis, or the true Croups; and the second class will have the name of
stridulous laryngitis, or false Croup.*

Or Mempranovus on Pszupo-Mempranovus Paaryneo-Laryn-
GITIs, on TRUE Croup.—In general or partial epidemics, and even
in the greater part of the cases of Sporadic Croup, the disease
almost always presents itself under the same forms, and follows
pretty nearly the same course. Three very distinct periods may be
recognised in its progress. At the time of the invasion of the
disease, nineteen-twentieths of those who are attacked by it are
generally seized with slight shivering, followed by more or less fever,
and a sore-throat, which is seldom very intense at first, but is rather
frequently accompanied by a little pain in the anterior parts of the
neck, and a greater or less swelling of the sub-maxillary glands.
The pharynx which ought always to be examined early in every kind
of Angina, and more particularly in that now under notice, generally
presents a manifest degree of redness, with more or less swelling of
the tonsils, and generally more marked on one side than on the
other ; but the appearances which ought especially to attract attention
are the little white patches which are observed on the tonsils, the
velum palati, the uvula, and sometimes on all these parts at once.
There is often also a slight serous oozing, of a fetid smell and a
yellowish colour, from the nostrils, and there are pseudo-membranous
eschars on different parts of the body. This first period of Croup
is, in fact, exactly like that of gangrenous or membranous Angina.
It most frequently lasts from four to five days, and sometimes seven;
but in some cases in which the disease advances with great violence

* The remarks on false Croup are omitted in the translation, as being
unconnected with the subject of Diphtheria.—(Ep.)
STAGES OF CROUP. 213

and rapidly attacks the larynx, it may scarcely comprise more than
twenty-four hours, and the first two periods seem then to be con-
founded together.
The second period is at first distinguished by a small, dry cough,
-which returns by very short paroxysms at more or less brief intervals,
and which is accompanied, from the commencement, with aphonia
and symptoms of suffocation. These symptoms afterwards assume
considerable intensity in a more or less rapid manner. The cough
and the voice then present those peculiar characters which it is so
important to recognise thoroughly, and which are easily distinguished
when they have been once observed, but which it is very difficult
clearly to describe. The rough comparisons which have been drawn
by authors with the crowing of a cock, the barking of a dog, &c.,
give an idea of it which is the more false, inasmuch as by these com-
parisons the writers have combined together the two kinds of cough
and of voice which are observed in the cases of membranous and
stridulous laryngitis which are very different from each other. The
cough, in membranous laryngitis, is not loud and sonorous, as in
stridulous laryngitis; on the contrary, it is hoarse, stifled, dry, and’
appears as if going back into the larynx. It appears to be almost
smothered by a rapid and more or less deep inspiration; each shock
of cough is followed by a short, dry, and sibilant inspiration, as if
the air was passing into a dry and metallic tube: and independently of
this short and well-marked sibilous breathing, which is remarked at
the end of every fit of coughing, there is always observed, in the in-
terval of the paroxysms, a laryngo-tracheal sibilant sound at each
inspiration, which is heard very well at a distance, and which is per-
ceived still better by applying the stethoscope or the naked ear on
the course of the trachea, or at the posterior part of the chest. It is
generally so strong that it completely masks the sound of the vesicu-
lar expansion which it is consequently impossible to recognise. The
paroxysm of cough most frequently induces pain in the larynx, in the
trachea, and in the anterior part of the sternum ; it it most usually
accompanied, from the commencement, with a feeling of great anxiety.
The patient starts from his seat, and appears to be seized with a
feeling of suffocation which is out of proportion with the short dura-
tion of the paroxysm. The voice presents in Croup a character which
is no less remarkable than that of the cough; itis not simply hoarse,
as in Stridulous Angina, but it is suppressed ; the patient is almost.
completely voiceless, and the tone of his voice has something of a
214 GUERSANT ON CROUP.

metallic character like the cough. Every word is followed by a small
and very short hissing sound, so that the articulation of the words
appears to be formed during the inspiration, which gives to the voice
somewhat of the character of that observed in ventriloquists, although
it is much lower and weaker. To the characteristic signs of the
cough and the voice are added a greater or less frequency of the res-
piration and the pulse, a violet tint of the lips, puffiness, paleness,
and very remarkable lividity of the face, except during the time of
the febrile exacerbations. ‘The patient is inclined to somnolence and
sadness, but delirium and convulsive movements are never observed,
even in children. The fits of coughing are sometimes followed by
vomiting of mucous matters and of membranous shreds. After these
kinds of vomiting, which are either spontaneous or produced by arti-
ficial means, the difficulty of respiration temporarily diminishes, the
dejection ceases, and the patient returns for a longer or shorter
time to his natural cheerfulness; but he remains silent and is afraid
of speaking, from the embarrassment which he feels. When the
disease is about to terminate favourably, the intervals between the
paroxysms are more numerous, the cough is less dry, the pharynx is
filled with transparent mucous matters, and the patient regurgitates
or expectorates viscid, transparent, or opaque sputa, mixed with small
membranous shreds. Sometimes, however, long intervals of tran-
quillity are observed after the expectoration of membranous tubes,
but they are followed by fresh and rapidly fatal fits of suffocation.
The third period of Croup supervenes more or less rapidly, some-
times barely at the end of twenty-four hours, reckoning from the
period of the development of the first symptoms; at other times,
only after the disease has lasted several days. But in the cases where
its progress is most slow, this last period always supervenes shortly
after the first week. It is characterized by the increase of all the
symptoms. ~The aphonia is almost complete, the fits of coughing
are rare and absolutely dry; and the laryngo-tracheal hissing sound,
very dry, metallic, and sonorous, is heard at avery great distance.
The inspirations are very much accelerated and almost as noisy
as in asthmatic patients. All the muscles concerned in respira-
tion are in a state of convulsive contraction. The pulse, very
frequent and sometimes irregular, is in proportion to the res-
piration ; the face is pale, the lips violet-coloured, and the head is
thrown backwards. In this last stage of the disease, drowsiness is
almost constant, and the patient arouses from it only when he is tor-
TERMINATIONS OF CROUP. 215

mented by the fits of suffocation, which are almost always excited by
the cough. Then he makesa forcible effort to breathe as he rises to
the sitting posture, with his body thrown backwards and covered
with perspiration ; sometimes the unfortunate patient places his hand
in front of the neck as if to pull away something which is strangling
him ; at other times he starts out of his bed, runs a few steps as if
in search of air, and falls back to expire in a fit of suffocation. The
efforts made by the patient to breathe are so violent, that in a case
of Croup in an adult, quoted by M. Bretonneau, there was a lacera-
tion of the pulmonary vesicles, and the air passed into the large blood-
vessels. If the patients have been much weakened by previous diseases,
or by avery lowering treatment, the period of death is not marked
by these signs-of agitation and violent strangulation, and they
sink by degrees into a kind of tranquil asphyxia.

When the patient recovers spontaneously, which is a very rare
circumstance, or by the combined efforts of nature and art, the cure
usually takes place during the second period of the disease. There
is hardly any example of patients having escaped, at least without
operation, after the disease has reached its last stage; nevertheless,
Jurine gives a remarkable case of the kind. If the disease proceeds
favourably towards recovery, the cough gradually becomes more
moist, and the laryngo-tracheal hissing ceases to be so dry; a more

- or less abundant mucous rhonchus is recognised in the bronchi; the
vesicular expansion is well perceived ; the fits of suffocation disap-
pear, and the patient becomes convalescent a few days after these
symptoms of improvement have presented themselves, unless pneu-
monia or any other consecutive diseases should supervene. During
convalescence, the pulse always remains more or less frequent, and
aphonia lasts sometimes more than two months after the disease.
Recovery does not appear to ensue in Croup or in Membranous
Angina, except when the false membranes have been cast off and
expectorated; or in consequence of a kind of solution of the
plastic exudation in the: mucus of the bronchi, the specific croupal
inflammation ceasing to act. But I am induced to believe that
there may be, besides, a third mode of favourable termination,
by absorption of the false membrane when it adheres firmly on
all points to the mucous membrane, and that this absorption
‘may take place layer by-layer on the internal surface of the larynx,
as we have observed it to do on the velum palati, in Membranous
Angina. Several facts in pathological anatomy, which will be
216 GUERSANT ON CROUP.

described hereafter, give a certain degree of probability to this
opinion.

Croup does not always present such a regular progress, and does
not always extend by descending from the pharynx towards the
larynx ; sometimes the development of the plastic inflammation takes
place simultaneously on the pharyngeal and laryngeal surfaces; the
first two periods are mingled together, and the disease advances very
rapidly towards a fatal termination. At other times, in some cases
of sporadic Croup, the disease, instead of beginning in the pharynx,
commences at once in the larynx and trachea, and then the first
period is altogether wanting. The number of cases in which Croup
is not preceded by Membranous Angina and presents itself in its
most simple state, is, moreover, much more restricted than was
formerly supposed, and than I myself believed some years ago.
Perhaps the number of such cases may amount to a twentieth, for
since a more minute attention has been paid in exploring the pharynx
in these diseases, some traces of false membranes are almost con-
stantly found there at the commencement. M. Bretonneau saw only
a single patient who did not present plastic exudations in the pharynx.
It may also happen in certain cases still more rare, that the disease,
commencing in the bronchi and the trachea, advances in the reverse
direction towards the larynx. I have seen at least one very remark-
able case of this kind. A little girl, attacked with lobular pneumonia,
having been seized with a dry and croupal cough, attracted my at-
tention. The examination of the pharynx, made with the greatest
care and at several intervals, exhibited to me no kind of alteration ;
but the isthmus of the pharynx being very wide in this child, I was
able, by lowering the tongue, to observe easily the glottis and the
surface of the epiglottis, and for three or four days while the patient
struggled against the disease, I fully convinced myself that the false
membrane was progressively extending from the edges of the glottis
to the superior surface of the epiglottis. At the opening of the
body, we found that the pellicular membranes occupied the principal
bronchi, the trachea and the larynx, as far as the convex surface of
the epiglottis, where they ceased.

Whatever may be the progress of Croup, whether it begins at first
only in the pharynx, or the larynx, or the trachea, or whether it
attacks all these organs simultaneously or successively, the physio-
logical characters presented by the disease, when it is confirmed, are
the same, while its anatomical characters are still more positive and
NATURE OF THE FALSE MEMBRANE. 217:

constant. At the commencement of the disease, when it begins in
the pharynx, which is usually the case, we find membranous patches
on the tonsils, the velum palati or the uvula, &c. In the second or
third period, when the patient dies, we no longer observe at the au-
topsy, any plastic formations in the pharynx even when the disease has
commenced in this region, because they have been destroyed by local
applications, or even by the efforts of nature, especially when the
pseudo-membranous patches have been of small extent; but they are
always more or less considerable in the larynx. The plastic formation
is sometimes limited to the orifice of the glottis and to the epiglottis,
it is always very adherent to these parts and appears covered with
epithelium, especially if the patient has died rapidly. But if death
does not ensue until several days after the disease is fully confirmed
the epithelium is often softened and destroyed, and the false mem-
brane is then laid bare. In the larynx, the membranous patches are |
also always more or less adherent, but never covered with epithelium
and only coated with a frothy, sometimes puriform mucus. Some-
times the whole of the internal surface of the larynx is uni-
formly lined with a false membrane penetrating into the ventricles,
where it adheres more firmly than elsewhere; sometimes only some
membranous strips are found on the posterior surface of the thyroid
cartilage or only on the arytenoid cartilages. Most frequently the
false membrane penetrates into the trachea in the form of a more or
less extensive lamina, applied to the anterior or posterior surface of
this organ, or, more rarely, under the form of a complete cylinder.
In some cases, it is prolonged into a part of the large bronchi, and
sometimes even into their final ramifications, either in a tubulated
form or in that of more or less narrow and almost linear strips. The
false membrane is almost always rather adherent in the trachea
towards the upper part near the larynx, and free in the rest of its
course, between two layers of mucous and puriform or flocculent
matters. Still I have sometimes found it intimately adherent to the
anterior surface of the trachea; the dry mucous membrane then
presents longitudinal strive: and red points which are not found so
constantly when the pellicular formation is floating, and the surface
of the membrane is moistened by mucous matters. The red points
sometimes penetrate even into the tissue of the plastic formation, and
are not the product of simple bloody spots, for they still exist after
‘maceration in water. These little points are undoubtedly the com-
mencement of the vascular lines which have been described by some
218 GUERSANT ON CROUP.

observers, which I have noticed myself, and which are shown in the
specimens of pathological anatomy preserved in Soemmering’s cabinet.
We do not find reddish strice nor red points in the bronchi as in the
trachea ; the mucous membrane is merely of a rose-colour or some-
times even pale, principally in subjects weakened by former diseases
or by blood-letting. The bronchi also contain more or less mucus of
a greenish-white colour or of a puriform character. It is important
to know the relative proportion of the plastic formations in the
larynx, the trachea, and the bronchi, especially in relation to the
chances which may be prevented by the operation of tracheotomy.
We find, on this point of the pathological anatomy of Croup, some
curious results in the thesis of M. Hussenot, on Croup and Trache-
otomy. He has made an abstract of a hundred and seventeen pos¢-
mortem examinations recorded in different authors. In all the
subjects in whom symptoms of Croup had existed,’and death had
occurred from suffocation, false membranes were found in the larynx
only, or descending a few lines down the trachea, in fifteen; not passing
beyond the trachea, in thirty; in the large divisions of the bronchi,
in ten; in the small bronchi, in patches and mixed with mucus, in
five ; in the small bronchi in the form of ramifications, in four; in the
larynx or trachea, without mention being made of the bronchi, in
thirty; nothing in the air-passages, or rather some alterations with-
-out false membranes, in twenty-one. In fifty-four post-mortem ex-
aminations, M. Bretonneau found false membranes, terminating at
different points in the trachea, in thirty-one; penetrating into the
large bronchi, in sixteen; in the terminal bronchi, in seven.

Out of one hundred and seventy-one cases of post-mortem exami-
nations in Croup, one hundred and fifty exhibited false membranes
in the air-passages, and there were seventy-eight in which these false
membranes were confined to the trachea, and only forty in which they
penetrated to the bronchi. This result, is very favourable, as will be
perceived, to the success of tracheotomy.

The characters of the false membranes vary considerably. They are
sometimes as delicate as the external membrane of an egg. Those of
the second or third formation are generally more delicate than those
which are developed at the commencement of the disease; still I have
found them in several cases very thin in patients who had died in
the space of forty-eight hours from sporadic Croup; but most fre-
quently they are, at the period of the invasion of the disease, thick,
jwhite or yellowish, and opaque. They are often a line in thickness,
VARIETIES OF-CROUP. 219

and sometimes much less. The surface which corresponds to the
mucous membrane is sometimes dotted with little red points; some-
times reddish lines are observed. The false membranes do not
always present a homogeneous tissue in their structure; they are
often composed of small rounded agglomerated, opaque flocculi,
disseminated through 4 more transparent tissue. Their consistence
is very variable; in most cases, it is firm and almost coriaceous; in
others, on the contrary, it is soft and diffluent, being especially so in
proportion to its distance from the larynx.

Whatever may be the varieties presented in other respects by the
pseudo-membranous formations of Croup in their texture and con-
sistence, the results of chemical analysis are identical. They are all
insoluble in cold and even hot water. The dilute sulphuric, nitric,
and hydrochloric acids shrivel and harden these plastic productions.
Concentrated acetic acid, liquid ammonia, and alkaline solutions,
dissolve them, and convert them, according to M. Bretonneau, into
a diffluent and transparent mucus, exactly in the same time, in the
same vessels, and at the same temperature. This excellent observer
has ascertained that they are also softened and dissolved in a strong
solution of nitrate of potash. The croupal exudations afford, on
incineration, sulphate of lime and carbonate of soda.

In Croup, as in most diseases, a pretty large number of varieties
-have been observed, to which, however, we shall abstain from giving
as many different names, after the manner of certain authors. The
most important of these varieties are those which relate to the
different forms under which the disease presents itself, and to its
different complications. Some authors, and particularly Jurine, have
admitted intermittent Croups. In the three cases on which he has
founded this distinction, the patients had a kind of croupal voice, but
in the individual whose body was opened, he discovered only some
thick mucous matters in the bronchi. Thus the observations of
Jurine must refer to-catarrhs attended with remissions in the fits
of cough and the febrile exacerbations. I do not know of a single
well-authenticated case of really intermittent Croup ; for we must not
consider in this light the cases which present a true intermission
between the first and second period, when the Croup is not yet con-
firmed. The examples of this kind of intermission are not very rare.
I have seen a well-marked case of this variety. A child, after
having coughed a little and suffered from a fit of croupal voice during
the night, had completely resumed its habits and cheerfulness, and
220 .GUERSANT ON CROUP.

had gone to walk and play all day in the’ garden of the Luxem-
bourg: but on the following night all the characters of Croup
were developed, and in spite of the most active treatment, adopted
during the night by M. Magendie, the child was on the point of
death when I was called to see it at ten o’clock in the morning. All
the usual measures having been adopted and the death of the child
being imminent, we proposed tracheotomy, which was performed
immediately, in my presence, by M. Magendie. We were able to
extract, by means of a feather introduced into the trachea, several very
delicate membranous strips which readily diffused themselves in
water. But the amelioration was only temporary, and the child died
in twenty-four hours. The intermission had here been very evident,
but it was between the first and second period. When Croup is con-
firmed, we sometimes also observe, more or less lengthened remis-
sions between the fits of cough and suffocation; but then the patient
always retains some aphonia and a laryngo-treacheal hissing during
these intervals ; the intermission is not really complete, and is only a
kind of remission due undoubtedly to the fact, that the membranes,
not being yet free in the trachea, are only partially detached by the
fits of cough. It would, in fact, be difficult to conceive an absolute
suspension of all the symptoms, when the false membrane has once
been formed.

ComPLicaTIoNsS oF Crovp.

Independently of the varieties presented during the progress of
Croup, it is essential to describe the different diseases with which it
may be complicated, because they may require important modifications
in the treatment. The most frequent complication of Croup is that of
Membranous Pharyngeal Angina, since in almost all cases it com-
mences in the pharynx, and it is evidently the same disease, being
distinguished from it in this treatise only in conformity with the
system pursued in most nosological works. Membranous coryza,
which is also only a simple extension of laryngo-tracheal Diphthérite,
coincides with it rather frequently and adds considerably to its
danger, but it is much less common than Pseudo-Membranous
Angina. Diphtheritic esophagitis must be rare, for I have never
met with it, and I do not know that any author has mentioned it ;
diphtheritic inflammation generally ceases at the limits of the pharynx,
but I have found it several times in the stomach, the internal surface
of which was partly covered with a false membrane exactly similar
COMPLICATIONS OF CROUP. 221

to that observed in the larynx. When Dr. Albers of Bremen, came,
in 1828, to visit the Hépital des Enfans, I showed him the autopsy
of a little girl who had died of Croup, and of this last-mentioned
form of pseudo-membranous gastritis, which he had never before seen.

Enteritis and entero-colitis, which are so frequent in children, some-
times appear as complications of Croup, but I have never remarked
that they then assumed the pseudo-membranous character which I
have just described in gastritis. Bronchitis, more or less extensive,
is met with pretty frequently with Croup, and this complication is
not so serious as I .at first imagined. It has even appeared to me
to be rather favourable, because it facilitates the separation and a
kind of solution .of the plastic exudations. It may even happen,
sometimes, that the abundance of mucous matters in the bronchi and
the larynx entirely masks the croupal cough. I saw, at the Hépital
des Enfans, a phthisical young girl die of a very intense attack of
Croup, which lasted only four days. The false membrane extended
into the pharynx and larynx, and descended in the form of a band
into the trachea; but-still the cough had never once been croupal,
from the great quantity of mucus and pus which was thrown up at
each time by the fits of coughing. In this remarkable case, aphonia
and laryngo-tracheal sibilation united with Membranous Angina were
the only symptoms which could give rise to the suspicion of Croup,
for the cough was as moist as in a simple catarrh. Besides this case,
I have sometimes met with Croup in the advanced stage of pulmonary
phthisis, and it has then always been very speedily fatal. Authors have
not sufficiently insisted upon the complication of Croup with pleuro-
pneumonia. These complications are, however, very frequent, and
add considerably to the danger of the disease. Croup may supervene
during the course of pleuro-pneumonia, an instance of which has
been related by.M. Blache. At other times, pneumonia may be de-
veloped at the end of the disease, or even after it, and cause death
after the patient has apparently escaped from danger. Hooping-
cough sometimes complicates pseudo-membranous laryngitis. Joseph
Frank quotes several cases of this kind, and Dr. Finaz has described
in the Revue Médécale, a curious case of this complication, in which
the patient, aged ten years, recovered. He observes, with some
reason, that the repeated shocks of the hooping-cough, by promoting
the excretion of the false. membranes, may have contributed to the
favourable termination of the disease. The complication became,
in fact, a favourable circumstance.
222 GUERSANT ON CROUP.

. Croup may be complicated with all the erruptive diseases, and
develope itself during their progress or towards their termination.
Tt has even been supposed that the acute cutaneous eruptions might
be placed among the occasional causes of Croup, but this is evidently
an error, for the examples of Croup with measles, smallpox, and
scarlatina, are rather rare, although some cases of the kind are to be
found in books. I have seen Croup only once during scarlatina,
and in one of these cases I had the operation of tracheotomy
performed, which favoured the expulsion of some membranous
shreds, but the improvement was only transient. In three cases of
variola which I once observed, the disease was complicated with
Croup and terminated fatally. Croup must not be confounded with
a kind of laryngo-tracheitis which is not rare during the course of
smallpox. In this kind of laryngitis, the cough is dry, harsh, painful,
and even tearing; but it is not accompanied with the peculiar sibila-
tion and the fits of suffocation which are observed in Croup. No
trace of false membrane is observed in the pharynx, nor any swelling
of the cervical glands. The voice is simply hoarse and feeble, and
presents nothing of the tone resembling that of ventriloquists.

Dusenosis or Crovr.

Croup may be confounded with several other diseases. Ordinary
laryngitis, of a merely mucous character, is considered by many phy-
sicians, Croup in a less acute degree ; but it differs essentially from it
in several characters, for the cough is not sibilant as in Croup; it is
more sonorous, more sharp, less dry, and very painful. Difficulty of
breathing and suffocation are constant, but are not renewed by par-
oxysms as in membranous laryngitis. The voice is low, in consequence
of the pain experienced by the patient in speaking, but it has not the
tone peculiar to Croup, and, lastly, it differs in all its antecedents.

Acute laryngitis and cedema of the glottis, although presenting sym-
ptoms rather analogous to those of Croup, differ from it in the absence
of the false membrane ; while other diseases in the vicinity, although
very distinct, resemble it, on the contrary, by the very presence of
the plastic exudations. The spitting up of a false membrane formed
in the trachea or the bronchi, is not, in fact, sufficient alone to charac-
terize Croup ; for several inflammations of these parts may terminate.
by a membranous exudation, and yet may not present the symptoms
TREATMENT. 223

of the ciphtheritic affection of the larynx.. The principal anatomical
character is the same as that of Croup; but the physiological pheno-
mena which are observed in these different cases are essentially
distinct. Non-diphtheritic pseudo-membranous tracheitis is not
very rare, and I have seen several examples of the kind without any
complication with other diseases, or complicated with measles. This
disease does not present any of the signs of the first ordinary period
of Croup ; it commences by a more or less intense fever and a dry,
sharp cough, which causes a more or less tearing pain in the trachea ;
the patient speaks in a low voice, in consequence of the acute pain
which he experiences in speaking, but there is neither loss of
the voice as in Croup, nor laryngo-tracheal sibilation between the
fits of coughing and the articulation of the words ; it is evident that
the larynx is free. In the second period of membranous tracheitis,
the cough becomes more moist, and the respiration, although difficult
and wheezing after the fits of coughing, and between the fits, presents
nothing comparable to the dry and metallic rhonchus of Croup and
the fits of croupal suffocation. In the third period of this disease,
the wheezing and the difficulty of breathing increase, and the patients
generally throw up, after violent fits of coughing,. membranous
ribbon-shaped shreds of greater or less extent. If the inflammation
is confined to the trachea, the spitting up of this false membrane
generally puts a stop to all the symptoms, and the patient becomes
almost immediately convalescent, because in this case the reappearance
of the false membrane is not to be dreaded as in Croup. But if the
tracheitis is complicated with bronchitis and measles, as I have seen
in an epidemic which some years ago attacked some orphan children,
then the patients often sink with all the signs of most serious and
extensive bronchitis, and on opening the bodies there is found a puri-
form mucus which is sometimes propagated from the trachea to the
extremity of the bronchi, and in the midst of which float several
thickened flocculi or small shreds of false membrane.

TREATMENT OF Crour.—When Croup commences in the pharynx,
as is usually the case, the treatment indicated is that of Membranous
Angina. We must immediately have recourse to the cauterization
of the affected parts, either with weakened hydrochloric acid, or
almost pure citric acid, or, better still, a solution of nitrate of silver,
applied to the parts by means of a sponge fixed upon a flexible piece
of whalebone. When we have reason to fear the supervention of
224 GUERSANT ON CROUP.

Croup, the solution of nitrate of silver must not be employed too
strong, because the concentrated solutions of nitrate of silver produce
by themselves a kind of false membrane, a sort of fictitious Croup ;
they coagulate the mucus as they do albumen, as may be shown by
shaking mucus with a very strong solution of this salt. It will be
sufficient, in order to modify the plastic inflammation on the walls of
the pharynx and at the orifice of the glottis, to employ a solution of
four grains of nitrate of silver to half an ounce of distilled water.

If Croup, instead of commencing in the pharynx, begins in the
larynx, which is rare, or even in the trachea, which is much more
rarer, the first period is altogether wanting. The local treatment,
which is very useful when the disease begins in the pharynx, is useless
at this period. It is only in a few persons, who have the isthmus of
the throat very wide, and in whom the surface of the epiglottis may
easily be perceived by lowering the tongue, that it might perhaps be
possible, by raising the epiglottis, to apply the sponge, moistened
with the caustic solution, to the larynx, or to insufflate into it some
powdered alum; but whenever the pharynx is very narrow, it would
be very difficult to penetrate into the larynx, and the patient would be
very much fatigued without any good result. We must, therefore, in
such a case, renounce topical applications for the time, and have re-
course to general therapeutical measures, as in the cases where the
disease has regularly passed from the pharynx into the larynx.

The general therapeutical measures which may be employed to
subdue pseudo-membranous laryngitis have undoubtedly a very
limited action; but to reject them entirely, and thus to allow our-
selves no hone of curing the patient, except by having recourse: to
tracheotomy, would be as dangerous and blameable an error as that of
the physicians who repudiate the use of all local remedies in the
treatment of Croup. Experience proves that children and adults,
evidently affected with membranous laryngo-tracheitis, have recovered
under the influence of general measures only, and without any local
treatment. The exclusive partisans of local treatment will undoubtedly
say, that the patients in such cases have recovered spontaneously and
in spite of the general measures. Still it is at least evident that these
measures have not been injurious, and to every impartial observer it
is probable that they may have assisted the efforts of nature, which
has never, perhaps, in this disease, effected a spontaneous cure.
There are two principal indications to be fulfilled in the second stage
of Croup, namely, to limit, if possible, the progress of the phleg-
TREATMENT. 225

masia, and to facilitate the excretion of the false membranes, if the
disease does not terminate by the adhesion of the membrane itself,
which is the rarest possible method of cure. It must be admitted
that we possess scarcely any means of limiting the phlegmasia when
it has penetrated into the air-passages, because it is impossible to
apply caustics without running the risk of great danger, as will be
seen hereafter; and although the contrary has been asserted, and is
still ianintined. it must be allowed that blood-letting has certainly
not succeeded in arresting this specific phlegmasia as it has unques-
tionably done in most ordinary inflammations. As long as the disease
is confined to the pharynx, the false membranes are seen to extend
and to be renewed in spite of blood-letting, and when it has
penetrated into the larynx, this therapeutical measure possesses no
efficacy in limiting its extension. In order to be convinced of this
truth, it is sufficient to read over the greater part of the cases
of true Croup, published up to the present time, and we shall find
that the disease advances with more or less rapidity under the influ-
ence of general and local blood-letting, and almost always terminates
fatally, although the depletion has been often carried to the utmost
possible extent. Still I do not think that we ought in all cases to
banish this powerful therapeutical agent from the treatment of Croup.
It even appears to me useful to have recourse to general and local
bleedings in adults and in strong, vigorous children, when symptoms
of imminent suffocation are manifested at the beginning of the
disease, in order to retard, at least for a time, the supervention of
asphyxia, and, by re-establishing the freedom of the circulation, to
give time for the action of other remedies. I have seen a nun
attached to the Hépital des Enfans recover from Croup, under the
influence of a bleeding alone, for she constantly refused to adopt any
other remedial measure. After some violent efforts she expectorated
several strips of membraniform exudation, and remained almost en-
tirely speechless for a month after her cure. Bleeding is especially
indicated when Croup is complicated, from its commencement, with
pleurisy or pneumonia, or other inflammatory diseases; but the more
useful this measure is in all these cases, the more injurious will it be
in feeble persons and those who do not present the indications of a
strong reaction ; for we must not lose sight of the circumstance that
by weakening these patients, we evidently accelerate their death, and
that the only chance left for them to escape from danger is by pre-
serving their strength.

Q
226 GUERSANT ON CROUP.

The employment of mercurials is a very valuable therapeutical
measure which ought never to be neglected in confirmed Croup when
we are summoned at the beginning of the disease, and when the
symptoms are not too urgent, or the patient too weak. These
medicines undoubtedly fail in many cases, but still their use is
attended with considerable success. I have seen three cases of Croup
recover under the influence of mercurial frictions, and in one of these
cases the symptoms ceased as if by magic as soon as salivation com-
menced, M. Bretonneau has collected seven cases of cure by mercu-
rials. Frictions -on the sides of the neck, the armpits, the inside
of the arms and the edges of the gums ought to be employed almost
simultaneously with the internal use of calomel. But this latter medi-
cine ought to be administered only as an alterative, and never with
the intention of producing a purgative effect; for if it purges abun-
dantly, it weakens, and this is a result which must, if possible, be
avoided. In order to obviate this inconvenience, it is a good plan to
give the calomel at tirst in divided doses of a quarter of a grain to half
a@ grain every half-hour or every hour, and to mix it in mallow paste,
powdered gum, or sweetmeats, recommending the patients to let them .
melt in the mouth. If these small doses-do not produce any laxa-
tive effect, the mineral is then administered in larger proportions, but
always in the same manner. But it cannot be denied that mercurials,
especially when they produce salivation, often throw the patients
into a very distressing state of debility which may become fatal, and
M. Bretonneau has mentioned several instances of the kind. It is
therefore prudent never to try this method of cure in subjects of a
feeble constitution, or who have been weakened by former diseases,
and even to suspend the action of the mercurials as soon as their
injurious effects are observed, and to have recourse to the use of
tonics. For this reason, it is better to adopt this kind of treatment
in summer than in winter, and perhaps even to abstain from it
altogether during moist seasons,

Tn endeavouring to modify the diphtheritic phlegmasia by mercu-
rials, we must attempt, on the other hand, to promote the separation
and the excretion of the false membranes by all possible means.
Expectorants and emetics should especially be employed. The sul-
phuret of antimony and the tartrate of antimony and potash are
especially preferable to all other medicines in producing these effects.
We may add still more to the efficacy of the emetic by administering
TRACHEOTOMY, 227

it in a strong decoction of polygala (senega) with syrup of ipecacuanha.
The oxymel of squills may also be advantageously combined with
emetic and expectorant draughts. The action of these therapeutical
resources is sometimes promoted by tickling the pharynx with the
feathers of a pen. None of the measures which tend to excite vomit-
ing, should ever be neglected. As to the sulphuret of potassium,
so much extolled for sometime as a pretended specific, and now
almost universally and justly abandoned, it acts only by exciting
nausea and the regurgitation of liquids secreted in the pharynx ; if it
were taken into the stomach in certain proportions it might cause, as
I have observed, a more or less intense attack of gastritis.

Sternutatories, in powder or in vapour, and irritating purgatives
with vinegar, have certainly been sometimes beneficial, but the shocks
caused by such means as well as by emetics can only be followed by
successful results, when abundant mucous deposits are secreted in
the bronchi, raising the false membranes and thus facilitating their
expulsion by spittmg. All these therapeutic agents fail when the
cough is constantly dry.

Energetic purgatives, and especially purgative injections, so much
praised by some practitioners, may, perhaps, momentarily diminish
the difficulty of respiration; but for my own part I am convinced
that we cannot attribute to them the cure of a single case of true
Croup, and that on the contrary, by weakening several patients, they
have accelerated their death.

Cold effusions, employed in the last stage of Croup by Dr.
Harders of St. Petersburg, and practised by some other physicians
in Germany and France, have manifestly excited a vivid reaction in
certain cases, and produced fits of coughing which have facilitated
the expulsion of several membranous strips; still there is no well-
ascertained example of a cure obtained by this measure alone, which,
besides, appears to me to be attended with serious inconveniences in
a disease which is so often complicated with inflammation of the lungs.

TRACHEOTOMY.

When the most energetic general therapeutical measures, which we
have just passed in review, have been employed in a suitable manner,
according to the particular indications presented by different cases,

Q2
228 m GUERSANT ON CROUP.

and when, nevertheless, Croup is making rapid progress and is arriving
at its last stage, we must then renounce all medicinal agents which
only fatigue and weaken the patients and have recourse to the only
measure which still offers any chance of success, namely, tracheo-
tomy. M. Dupuytren, in the last stage of Croup in a child of
Bonaparte’s Mameluke, employed a very simple method; for he
attempted to detach the false membranes of the larynx and to extract
them by rapidly sweeping out the interior of this organ with a sponge
fixed upon a piece of whalebone. He in fact succeeded, although
with great difficulty, in extracting some membranous shreds, and
this painful and delicate operation was followed by a momentary
calm ; but still the child died, and on the autopsy it was discovered
that the pellicular exudation extended into the bronchi. This
operation, which is a very difficult one and requires great dexterity,
cannot, besides, be attempted with any probability of success, except
when the membranous exudations are confined to the glottis, which
is rarely the case, as we have seen above when treating of the
pathological anatomy of Croup. But as in most cases the false
membranes are prolonged more or less into the trachea and it is
impossible to ascertain their extent, we should run the risk, by thus
introducing a sponge into the larynx, of pushing back the false
membranes into the bronchi, and of inducing asphyxia which might
become speedily fatal. It is therefore more prudent to renounce this
operation, and to adhere to tracheotomy, which causes the immediate
cessation of all the symptoms of asphyxia, and indisputably prolongs
the life of the patients, even when it does not rescue them from
certain death. Every time that I have seen this operation performed,
even without success, I have observed a sensible improvement, at least
for several hours, and sometimes for several days.

The necessity for the operation appears to me evident whenever
Croup has arrived at its last period, and when the cough is very
infrequent and dry, the voice suppressed, the laryngo-tracheal
rhonchus dry and metallic, the inspirations deep and frequent, with
violent contraction of the muscles of the neck, and of the alee nasi, and ,
swelling of the abdomen. We must not wait until asphyxia is immi-
nent and the weakness too great; the favourable chances of the
operation depend principally, as we have stated, upon the strength
of the patient. Although the signs we have just described indicate
the most pressing danger and the necessity of the operation, we
i TRACHEOTOMY. 229

must, nevertheless, renounce it if the patient is evidently phthisical
or is affected with a very extensive double pneumonia; death being
certain in these two cases, we should not induce the patient to submit
to the sufferings attendant upon a useless operation. If pneumonia
existed only on one side, I should still advise the operation in such a
case, although it presents very few chances of success; but I am
certain that it does not add to the danger of the disease. My son
has four times performed the operation of tracheotomy in Croup,
and twice in cases of complication with pneumonia. In one of the
cases the patient lived to the eighth day and in another to the four-
teenth day, the wound being almost cicatrized. The younger the
children are, the more the operation should be accelerated, because
the disease advances much more rapidly in them than in those who
are approaching puberty, and in adults. The danger is less pressing
in young children if Croup is complicated with Hooping-cough or
Catarrh.

Tracheotomy has been proposed from the most remote antiquity
in serious cases of Angina, and was more particularly advised in the
fifteenth century by René Moreau, in answer to Bertholin, who had
asked his advice during the epidemic of Gangrenous Angina which
prevailed in Italy. The operation has been attempted in Croup a
great number of times for many centuries back. Several distin-
guished practitioners have performed it in the last forty years in
England, France, Geneva and Germany, and yet it was not until
1825, when M. Bretonneau met with his first successful case, that
a single instance of success had been recorded, and this was one by
Dr. André of London, first related in Borsieri. After six unsuc-
cessful operations, M. Bretonnean had the courage to perform it for
the seventh time, and this seventh operation. was crowned with suc-
cess. He has performed altogether seventeen operations, and has
succeeded five times. The service rendered by M. Bretonneau to
the treatment of Croup is immense, and has never been so much ap-
preciated as it deserves. Tracheotomy did not usually succeed in Croup,
because no precautions were afterwards taken to ensure its advantages.
The mere performance of the operation does not alone constitute the
cure. Success depends essentially on all the means which are em-
ployed to facilitate.the free access of air by means of a wide canula
well adapted to favour the elimination of the membranous strips,
while at the same time the renewal of the false membrane is opposed
230 GUERSANT ON CROUP.

by the employment of local applications. Still I must observe that
great caution must be exercised in the use of caustic solutions, even
in a weak form, in the interior of the larynx and trachea; for these
measures are seldom necessary, and if they were employed without
great precaution, and a few drops of a very caustic liquid, or even
some portions of calomel or alum should penetrate into the extreme
bronchial tubes, these substances would infallibly give rise to fatal
pneumonia, The experiments made upon animals by M. Bretonneau,
and since repeated by M. Miguel of Amboise, have demonstrated this
truth in the most evident manner. Since the success of M. Breton-
neau, one of his most distinguished pupils, M. Trousseau, has had
occasion to perform tracheotomy a great number of times in Croup,
and in following the proceedings of his master, he has succeeded nine
times in thirty-four cases. M. Scoutteten at Metz, M. Gerdy at
Paris, also reckon one case of success each, and according to Samuel
Cooper, Mr. Chevalier, an English surgeon, and Messrs. Lawrence,
Blicke and himself, have had equal success. We may, therefore,
reckon more than twenty examples of the success of tracheotomy in

Croup.

PROPHYLACTIC MEASURES -AGAINST THE DISEASES DESIGNATED
AS CROUP.

The means of preventing the attack of diseases consist entirely
in hygienic precautions. All that, has been said of the utility of
exutories is unsupported by any positive experience; on the con-
trary, examples of fatal Croup are recorded in individuals who bore
the marks of cauterization or blisters. Nor do spontaneous suppur-
ations act as preservatives, for I have seen children die of Croup
who had eruptions on their head and skin ; others who had scrofulous
ulcers, and even several who were phthisical at the last stage. The
frequently repeated use of emetics and purgatives which has been
advised as prophylactic, is quite as useless as exutories, and may
produce the further inconvenience of determining inflammatory affec-
tions of the intestinal canal to which children are naturally very liable.
No greater confidence is to be placed in the other methods of treatment
which have been proposed ; some have recommended the employment
of depressing agents, and in particular, frequently renewed applications
of leeches to the neck, tepid baths, &c. ; others, on the contrary,
PROPHYLACTIC MEASURES. 231

have recommended stimulants and diaphoretics. All these measures
may be, undoubtedly, useful if the child is ill, and if, moreover, they
are employed in suitable cases; but they will always be more or less
dangerous and hurtfal if the child is in good condition, because they
alter the health, and we have seen that diseases do not secure the
patient from Croup any more than the most robust state of health.
We must, therefore, reject from the prophylaxis of Croup, all the
therapeutical measures which have been proposed only in accordance
with isolated and unmeaning observations, and are invested with the
charm derived from illusory views, from which it is so difficult to
guard ourselves when we desire to make ourselves useful.

We can protect children from the influence of croupal affections
only by removing them from moist or cold parts of the country, where
these catarrhal diseases are frequent, and prevail in an endemic or
even epidemic manner. M. Valentin quotes the case of a merchant
who quitted Geneva because his children had frequently had Croup
there (most probably stridulous laryngitis), to come and live at
Marseilles, where they enjoyed perfect health for four years. The
case quoted proves that these diseases are in fact unknown, or at
least, very rare, in certain parts of the country. But since it is im-
possible to resort to this prophylactic measure which, to say the truth,
is the only one known, what precautions ought to be taken, in moist
and cold districts, in order at least to diminish the influence of the
causes which give rise to croupal diseasesP These precautions are
the same as those which are adapted to guard persons from all ca-
tarrhal affections in general. It is, however, necessary here to
remember the distinction which we have established as to the
frequency of these diseases in the different classes of society. Mem-
branous laryngitis is perhaps more common, as we have stated, in the
indigent classes than in those in better circumstances, because all
the causes which may produce severe catarrhal affections are found
united in this class of society rather than in the others, and because,
when this disease prevails epidemically and sometimes becomes con-
tagious, it is much more difficult for the poor person to remove from
it than for the rich; yet there is in the manner by which this disease
manifests and propagates itself, something specific as in the disease
itself, and which appears to be independent of the causes which usually
produce the other catarrhal affections. Croup, in fact, strikes into
all classes of society, and upon persons who have very different man-
232 GUERSANT ON CROUP.

ners and habits of life; and the principal cause of these unforeseen
and insidious attacks is entirely concealed. How, then, would it be
possible to protect ourselves from the attacks of a disease the cause
of which is not known? We must adhere to general precautions
which tend to ward off catarrhal affections; but it must be admitted
that these precautions are not always sufficient when the disease pre-
vails in an epidemic manner ; it may then in certain ‘cases become
contagious. It is, therefore, always prudent to isolate the patients;
and for those who can do it, the safest of all prophylactic measures
is to remove from the places where the disease prevails,
TROUSSEAU.
CUTANEOUS DIPHTHERITE. 235

TROUSSEAU ON DIPHTHERITE.

(Dictionnaire de Médecine, 1835.)

M. Bretonneav has given the name of Diphthérite to a special
disease which may develop itself upon the mucous membranes and the
‘skin, but which shows a marked preference for the pharynx and the air-
' passages, where it constitutes the diseases commonly known under the
denominations of Membranous, Malignant and Gangrenous Angina,
and also under that of Suffocating Angina, and more particularly of
Membranous Croup.

Before M. Bretonneau, some physicians, and Starr in particular,
had remarked that, in certain cases of Malignant Angina, the skin
was covered with white, putrid, false membranes, terminating in the
production of gangrene; these authors had partially seen the analogy
which might exist between the lesions of the pharynx, and those of
which the skin was the seat. But M. Bretonnean determined the
facts in an explicit manner, and he demonstrated that Diphthérite had
everywhere the same characters, whether it was observed on the skin
or on the gums, the tongue, the pharynx, the cesophagus, the ex-
ternal auditory canal, the nasal fosse, the air-passages, &.; and he
gave a complete description of the disease. Having been a pupil of
this learned physician, and being acquainted with all his ideas upon
this important pathological subject, I have been enabled, in the midst
of extensive epidemics of Diphthérite, to see the disease in all its
forms in the course of a very short time. I shall describe it succes-
sively upon the skin and upon the mucous membranes. .

Cutaneous Diphthérite-——1 have never seen Diphthérite develop
itself on the skin unless it was previously deprived of its epidermis,
or ulcerated, that is to say, unless it approached more or less to the
organization of the mucous tissue. Thus, in the course of an epi-
demic, I have seen leech-bites, slight cuts, herpes supervening upon
236 TROUSSEAU ON DIPHTHERITE.

an attack of fever, blisters, cracks of the breast, excoriations of the
scrotum, of the ears, of the hairy scalp, of the nose, of the anus, and
different wounds ; all these have become the causes of the develop-
ment of cutaneous Diphthérite ; and this has not occurred in a small
number of isolated persons, but among some of the members of
almost all the families in the same village; so that it is quite as-
tonishing that so common and so severe a disease could have remained
unnoticed.

As soon as Diphthérite attacks a wound, the spot becomes painful,
allows the escape of a great quantity of colourless and fetid serosity,
and is soon covered with & greyish, flabby, and more or less thick
membrane. The edges of the wound are swollen, assume a violet-red
tint, and are considerably elevated above the base of the ulcer ; still
the disease does not usually extend, but it remains stationary for
whole months. Sometimes, however, even when the epidermis alone
has been removed, it has been seen to be covered again immediately
with a white membrane analogous to that which is observed on
blisters. A kind of erysipelas is soon developed round the excoriated
part. On the surface of this inflammation the epidermis is elevated,
in a multitude of points, by small masses of lactescent serosity, so
that the skin is covered with confluent vesicles in the vicinity of the
wound, but less and less numerous in proportion as they approach
the integuments which are still healthy. Among these vesicles there
are some which seem to have been formed by the union of several
others which, whether simple or united, burst asunder, and then,
in their place, the dermis is seen covered with a white membrane;
these excoriations are united to others which are smaller and unite
with the principal one, and thus the disease gradually gains ground.

Thus, Diphthérite commencing with a slight excoriation of the
hairy scalp or of the back of the ear, may attack the skin as far as
the loins, as I have elsewhere proved. (De la Diphthérite cutanée;
Archives gén de Med., t. xxi. p. 541.) The pellicular concretions,
which are at first thin, gradually become thicker, those which are
forming on the surface of the dermis incessantly elevating those which,
have been first secreted, so as to form a kind of foliated membrane,
the thickness of which may amount to four, five, or six lines. The
layers of exudation in contact with the skin always preserve a certain
degree of density ; but the most exterior, bathed in the serous secre-
tions, become softened and’ putrefied, change colour, assume a grey
and sometimes blackish tint, and exhale a dreadfully fetid odour,
b BUCCAL DIPHTHERITE. 237

tendering it almost impossible to believe otherwise than that the
whole skin is sphacelated. Here the same error is committed as in
the case of pharyngeal Diphthérite, which is still, in the present day,
in spite of the labours of M. Bretonneau, often regarded as a‘ gangrene
of the back of the mouth.

I do not assert that the gangrene may not, in certain rare cases,
attack the parts affected with Diphthérite. I have observed this oc-
currence only twice; ard besides, the sphacelus was confined to a
small portion of the velum palati in one case, and of the skin of the
arm in the other. Still when the disease extends rapidly or occu-
pies several poirits at once, the fever may be very acute; but most
generally it is almost insensible, and approximates to the form of the
hectic fever accompanying suppuration.

Ihave mentioned just now that, although Diphthérite remains most
frequently limited to the portion of the skin originally attacked,
cases also happen where the phlegmasia gradually gains in extent,-
and finishes by attacking large surfaces. The mode of invasion has
this peculiarity, that it generally takes place from the superposed
parts towards the depending portions ; thus Diphthérite is never seen
ascending from the arm to the shoulder, and from the nape of the
neck to the hairy scalp; but, on the contrary, descending from the
shoulder to the arm, from the nape of the neck to the back, from
the abdomen to the lois, and from the nipple to the rest of the
breast. The diphtheritic inflammation is very probably propagated
by the irritation excited by the prolonged contact of the serous se-
cretion, whether this secretion bathes the depending parts as it flows,
or is retained by the dressings.

But this extension of the disease differs very much from its repe-
tition, if I may so express myself. Thus it is sufficient for one point
of the skin or for one mucous surface to be the seat of Diphthérite,
in order that the malady should repeat itself in several different points,
under the influence of the least occasional irritation. Thus it happens
that a simple coryza or a slight otitis, or a mild sore-throat, or a
slight bronchial catarrh may become the imrhediate occasion for the
repetition of the Diphthérite, which then constitutes a formidable
complication.

Buccal Diphthérite—This disease has been very-well described by
Van Swieten under the name of Scorbutic Gangrene of the Gums and
of Watery Cankers: it is one of the forms of the stomacace of the
ancients, and of the /égarite of the Spaniards. The distinguished
238 TROUSSEAU ON DIPHTHERITE.

commentator of Boerhaave, who believed it to be of a scorbutic
nature, nevertheless, recognised its identity with Malignant Angina ;
but M. Bretonneau has removed all doubts upon this point.

Buccal Diphthérite is far from having always the extreme severity
which would seem to be indicated in the description given by this
pathologist. The disease often remains limited for a long time to the
commissure of the lips, to one of the gums-surrounding a carious
tooth, or to a portion of the tongue corresponding to a broken
one; but in cases unfortunately too common, it is also propagated
from the mouth to the pharynx, and thence, with fearful rapidity, into
the larynx, where it destroys the patients from croupal suffocation.
It is remarkable that Diphthérite has such a manifest tendency to
propagate itself from one point to another on the skin, in the
pharynx, in the nasal fosse, &c.; and that it remains sometimes
several months in the mouth, and that there it gradually wears itself
out, without attacking the throat or the lips. Such an anomaly
could not certainly be anticipated & priori.

I have just stated that Diphthérite, when it occupies the mouth,
has very little tendency to propagate itself; but, on the other hand,
it has a considerable tendency to repeat itself on other points. Thus,
Malignant Angina, Croup, and membranous ulcerations of all kinds
will freqnently affect those whose buccal mucous membrane is the
seat of Diphthérite.

Pharyngeal and Tracheal Diphthérite—It is a sad reflection that
the most frequent seat of Diphthérite is the mucous membrane of the
pharynx, and that of the air-passages, without our being able to
assign the causes of this fatal predilection. This greater frequency,
which is evident at ordinary times, and when the disease is sporadic,
is no longer observed when the affection prevails epidemically: at
such periods, we may see, in a village, the greater part of the in-
habitants presenting diphtheritic ulcerations in their skin, and Croup
numbering but few victims. 1 must here refer to the articles An-
gina and Croup in the Dictionnaire de Médecine, and also to the
work of M, Bretonneau, for the demonstration of the identity of
Croup, Malignant Angina, and buccal Diphthérite ; and I should rely
on the same arguments as he has adduced, in order to prove the
identity of cutaneous Diphthérite and the diseases of which I have
just spoken, under whatever denomination they may have been known
in science. :

Of the causes of Diphthérite.—When I saw Diphthérite prevailing
CAUSES OF DIPHTHERITE. 239

as an epidemic at Tours, I thought that the position of this city,
which is situated in the midst of a valley watered by two rivers, had
some influence upon the development of the disease, and I attributed,
like almost every one else, the cause of this formidable affection to
cold, and especially to humidity. But in glancing over historical
documents I soon became convinced that these supposed local
causes could be considered at most only as accessories; and after I
had myself made some statistical and comparative observations in
four departments where the disease had presented itself in an epi-
demic form, and was dreadfully destructive, I became certain that
Diphthérite did not depend either on seasons or localities. Thus, in
the towns and hamlets of the Department of Loiret, which are re-
markable for their salubrity and for their excellent geographical
position, I saw Diphthérite raging with excessive violence, while some
villages of Sologne situated in the midst of marshes, remained —
exempt from the scourge; and on the other hand, some hamlets and
towns situated on the banks of ponds were depopulated by the epi-
demic, while others enjoyed a perfect immunity, which was thought
to be attributable to the ordinary salubrity of the place.

If we examine into the habits of the population in order to find
the causes of the disease, we find the same difficulty; for while some
communes covered with vines and rich harvests, in the Blaisons, the
Orléanais, and in Berry, lost more than a tenth of their inhabitants,
very few losses were experienced in some poorer cantons, where the
peasants procure only a scanty subsistence from the soil; but the
contrary was equally observed.

Hygrometrical, thermometrical, and barometrical influences gave
no better explanation of the appearance, the increase, or the dis-
appearance of the epidemic; for while in 1825, a year remarkable
for its extreme dryness, some communes situated to the north of
Orleans were ravaged by Diphthérite, it was ascertained that the com-
mencement and the maximum intensity of the epidemic in one com-
mune, did not occur at the same time as in the neighbouring
commune placed under the same appreciable conditions. On the
other hand, in the year 1828, which was not very hot and rather
rainy, Diphthérite was found to number, in the south of Orleans, as
many victims as it had made in the north, in 1825; and when I
consulted the tables of mortality of the different villages which had
been attacked by the scourge, I found that the first deaths coincided
in one case, with the commencement of the winter, in another with
240 ‘TROUSSEAU ON DIPHTHERITE.

the rainy days of spring, and in a third with the middle of summer.
It is therefore necessary to exclude from the causes of the disease all
the conditions which were not uniform.

It must be admitted that misery, if not an exclusive condition,
was at least rather an ordinary one, of the development of Diph-
thérite ; for it was evident that the epidemic seized upon the poor
inhabitants in preference to those who were in easy circumstances.
But inasmuch as the richest families also experienced several losses
from the disease, it is necessary to seek for some more general cause
than poverty for its development.

It is evident to me that contagion performs the principal part in the
propagation of Diphthérite, as I have, I think amply demonstrated in
the work which I have published in the Archives. Thus, it was
sufficient for a patient attacked with Diphthérite to come into a
family in order that the disease should develop itself in all its forms.
But of all the modes of transmission, the most common is unquestion-
ably the cutaneous Diphthérite, and for the following reasons. The
disease lasts so long, that mediate and immediate contact is the more
easy and the more frequently repeated. Among poor families, the
same bed, the same clothes, and the same utensils, often serve for
almost everybody, and it must happen that the virus, accumulated in
greater force in proportion to the want of cleanliness, quickly attacks
all the members of the same family. Thus J have seen, in 1828,
thirteen persons out of seventeen die in the same farm-house.

Still, I wished to perform upon myself a direct experiment, with
the view of ascertaining the communicative action of the serous
secretion which flows in such abundance from the cutaneous surfaces
attacked with Diphthérite. I accordingly steeped a lancet in a false
membrane which I had just extracted from a diphtheritie wound, and
I made one puncture in my left arm and five or six on the tonsils and
the velum palati. I found, on my arm, at the seat of the puncture,
that a vesicle was developed very similar to that of vaccination ;
but there was no result upon the mucous membrane. Experiments
of a similar character would require to be repeated ; but even if they
should not be followed by the development of Diphthérite, it must
not be concluded that the disease is not transmissible, but only that
inoculation is not the method of transmission. The same remark
applies to rubeola and scarlatina, the contagious properties of: which
are denied by none, so far as I am aware.

Of the danger of Diphthérite——Diphthérite may be dangerous
TREATMENT. 241

by the mere fact of the intensity of the phlegmasia since it may,
although rarely, induce gangrene of the parts. But what renders it
especially dangerous is the rapidity with which it may attack large
surfaces, as well as the mechanical obstacle which it may offer to one of
the most important functions of life, and the obstinacy with which it
resists therapeutical resources which generally modify other inflam-
mations. Thus, although it is generally not very dangerous on the
skin, it becomes so when it attacks the mouth, the nasal foss,.
the vulva, or the vagina; but it is most frequently fatal when it
attacks the pharynx, and unless it is immediately combated by ener-
getic treatment, it scarcely ever spares the patient when it has once
reached the larynx and the bronchial tubes.

Treatment of Diphihérite. —If Diphthérite did not differ from
simple inflammations in its form, its progress, its danger, and in a
word, in numerous characters which make it an altogether special
disease, it might be supposed that antiphlogistic treatment would be
serviceable, but we may conceive @ priori, that blood-letting and
emollients would have no favourable influence’ in this disease, and
experience has confirmed what analogy had led us to surmise. It is
in vain to attempt the cure of Diphthérite by means of the antiphlogistic
regimen. Theinflammatory complication may indeed be subdued, but
the disease remains without losing any of its malignity. It is thus,
that by means of emollients, we may diminish the inflammatory
swelling which surrounds a vaccine eruption; but vaccinia, never-
theless, preserves its indelible characters. The revulsives which are
often recommended, either to subdue the diphtheritic diathesis,
or to draw away the disease which is fixing itself upon important
organs, are attended in general with no other result than to
occasion the development of Diphthérite on the spots where the
revulsives have been applied, and in this manner the disease is
augmented rather than diminished. The same remark applies to
all constitutional methods of treatment, which can only be employed,
in this disease, to remedy the general, and never the local conditions.
It is in the use of topical remedies, which are so powerful in most
external diseases, that the practitioner must confide, in order to effect
the cure of Diphthérite. In the first rank must be placed caustics,
nitrate of silver, the acid nitrate of mercury, sulphate of copper,
hydrochloric acid ; after these come alum, mercurial sublimate, and
the chlorides of potassium, sodium, and calcium.

But the mercurial preparations,wherever they can be applied locally,
R
242 TROUSSEAU ON DIPHTHERITE.

modify most powerfully the diphtheritic inflammation. Those to which
Ihave particularly had recourse are calomel and red precipitate. The
affected parts are dusted with calomel, or a fine powder composed
of a mixture of powdered sugar and red precipitate, in which the
mercurial oxide has only the proportion of a twelfth, is sprinkled
upon them. When Diphthérite occupies the nasal fosse the patients
inhale calomel, or the powder which has just been described. The
same powders may be insufflated into the auditory canal, the
vagina, &c.

As to the treatment of the Diphthérite which occupies the mouth,
the pharynx, or the air-passages, it differs in reality but little from
that of which I have just spoken.

Still, when Diphthérite is repeated uponagreat number of parts, the
patients at length fall into a deplorable state of cachexia and feeble-
ness, and a general mode of treatment is then indicated. Bitter
drinks, such as the infusion of calumba, bark, or quassia; the
simultaneous administration of iron and quinine; the use of succu-
lent aliments and fermented drinks, will then become the ground-
work of the treatment.

On TracHEoTomy IN Croup.
(Dictionnaire de Médecine, 1835.)

Croup is so obscure at its commencement, and its progress is so
rapid, that death is often already inevitable when we are called
upon to attend patients attacked with this disease. Even when the
case appears desperate, we nevertheless adopt an active mode of
treatment which has no other effect than to torment children in their
dying hours, while it augments very slightly their chances of recovery.
Still there remains an important resource, namely, tracheotomy :
“Si omnibus his non, serd, vel frustra tentatis, morbus sit maximé
recens et strangulans...statum post acerbam prognosin instituenda
erit bronchotome.” (Stoll Aphorism. p. 32, Vindob. 1786.) Thus
recommended by Stoll, who appears never to have seen it performed,
this operation was practised, for the first time and with success by
John André, in London, in the year 1782. Caron afterwards ex-
tolled it with an ardour which appeared almost absurd; and it was
strongly forbidden by the Académie de Médecine, if we may judge by
the Report of M. Royer-Collard on the celebrated Concours of 1807.
TRACHEOTOMY. 243.

M. Bretonneau, however, ventured to perform the operation in
1818 and 1824, and both his patients died ;. he performed it a third
time in 1825, with success; and since that period he has performed
it fourteen times, and has saved four patients. Since 1826, I have
myself performed this operation thirty-six times in cases of Croup,
and nine children survived, who up to the present time enjoy
good health. M. Scoutteten, Senn of Geneva, and Gerdy have fol-
lowed the example of M. Bretonneau, and three children more have
been rescued by them from certain death. Lastly, MM. Velpeau,
Guersant, junior, Sanson the elder, and Blandin have also practised
tracheotomy in children attacked with Croup, and if they have not
saved the patients, they have at least prolonged their life for a suffi-
ciently long time to render the utility of the operation incontestible.
Thus, reckoning the operation of André, which, however, is rather
apocryphal, there are in the present day (1835) eighteen authenticated
cases of cure out of about sixty operations.

Such a result no longer permits us to neglect in future a thera-
peutical agent which will probably obtain more extensive success when
the method of treatment is better understood. [I shall, therefore,
study the question under three divisions:—1. Is the operation ne-
cessary? 2. The operation being deemed necessary, at what period
ought it to be performed? 3. The operation having been performed,
what are the methods of ulterior treatment ?

Is the operation necessary ?—-If we suppose Croup to be arrived
at such a stage that death is imminent, the event may be retarded by
tracheotomy ; this is an indisputable and uncontested fact. If the
operation were nothing more than a simple measure of delay, it ought
still to be attempted, for it is the duty of the physician to prolong
the life of the patient, especially in acute affections, since a few addi-
tional hours are often sufficient to enable the organism to triumph
over a morbific cause, the action and the effects of which are essen-
tially temporary. Besides, the necessity of operating should be judged
by the results of the operation itself. Sixty children otherwise doomed
to inevitable death have been subjected to tracheotomy ; eighteen
have recovered, and therefore the operation ought to be per-
formed.

The only objection which can be offered is the following :—Nothing
proves that the children who survived would have died if they had
not been operated upon. To this argument I reply, that almost all

were operated upon in a state so near death that it is impossible to be-
BR 2
244 : TROUSSEAU ON DIPHTHERITE.

lieve that they could have lived, and that the symptoms were those
which always announce a fatal termination ; and this objection has no
more value against tracheotomy in the case of Croup, than against
this same operation in the case where a foreign body is lodged
in the larynx, or against the ligature or compression of a large vessel
which is allowing the escape of large quantities of blood ; for if the
patient recovers, it may always be said that he might have done so
without the operation.

The operation, therefore, ought always to be attempted whenever
the symptoms lead us to believe that in all probability there remains
no other resource.

Let us now consider what may be its inconveniences. Tracheotomy
in itself is an operation which is more delicate than difficult; it
requires only care and presence of mind. The details of this opera-
tion are given in the article on BroncHoromy in the Dictionnaire de
Médecine. shall merely remark, that in that article and in almost
all those which have been published on the subject, the necessity of
tying the veins is very properly insisted upon; but this precept,
which is useful in cases where tracheotomy is performed for a chronic
disease of the larynx, should no longer be followed when the opera-
tion is performed for Croup, or for the removal of a body lodged in
the air-passages. At present, 15th of January, 1835, I have per-
formed tracheotomy thirty-eight times; thirty-six times on children
or adults attacked with Croup, and twice on adults who were sinking
from a slow asphyxia, caused by a chronic inflammation with swelling
of the glottis. “I had only a single and very slight hemorrhage in
one of my patients who was attacked with Croup, and in both the
others, on the contrary, there was a terrible hemorrhage.

Thus, when I perform tracheotomy in an acute affection, I always
neglect to tie the blood-vessels. MM. Bretonneau and Velpeau
adopt a similar practice, and we have never had occasion to regret it.
I have therefore only occasion at present to describe the accidents
which may follow the operation, independently of the disease for
which it is performed. This question could evidently be determined
only by way of experiment, and I instituted, together with M.
Hamard, a series of experiments on dogs, with a view of ascertaining
the influence of tracheotomy and of the presence of a canula in the
trachea. The result of these experiments is, that the animals expe-
rienced different bad symptoms, oppression and fever, for several
days ; and some, who were ill at the period of the experiment, were cut
TRACHEOTOMY. 245

off by pneumonia. It is then natural to suppose, that children with
fever, and those whose lungs are already engorged, will more easily
suffer from dangerous symptoms which may threaten their existence.
Thus I have several times. seen children sink after tracheotomy,
without my being able to attribute death and the inflammatory lesions
of the lungs to the extension of the false membranes. I must state,
however, that none of the healthy dogs on which I tried these experi-
ments, experienced any dangerous symptoms, and that the immediate
consequences of tracheotomy appeared also to be less dangerous i in
children who had not deen depressed by a lowering method of treat-
ment, and who had not reached the last stage of the disease.
I may add, that having had occasion quite recently to place a
canula for some time in the trachea of a lady thirty years of age,
‘who was on the point of suffocation from a chronic engorgement of
the larynx, I did not observe any pulmonary embarrassment to
ensue.
The operation being considered necessary, when ought it to be per-
Jormed ?—As Yong as tracheotomy was in my hands a measure of
almost uniform danger, I said, “It must be performed as late as
possible,” but now when I have had numerous successful cases, I
say, “It must be performed as soon as possible.” ‘Now the period ,
ought to be that in which, judging from known indications, there no
longer remains any hope of recovery. I shall not repeat the reasons
for operation, which have been urged by M. Guersant, in the article
on Crovur in the Dictionnaire de Médecine; but cases of well-ascer-
tained tracheal Diphthérite, cured without operation, are so rare that, _
in my opinion, the operation should be performed as soon as the dis-
ease is well-marked ; for if the diphtheritic phlegmasia has been rapidly
propagated to the larynx, and if the examination of the bodies after
death proves that it penetrates from the larynx into the bronchi
with still more rapidity, we should be more likely to find false
membranes in the bronchi, in proportion to the advanced period
when the operation is performed; and experience has proved to me
that not more than one patient in ten was lost, in cases where the
operation was performed while the false membrane was still only in
the larynx; but scarcely one in ten was saved in operations on
children whose bronchi were already invested with pellicular con-
cretions.
I may say in the case of Croup what experienced surgeons say in
the case of strangulated hernia, namely, that it is rare to lose patients
246 TROUSSEAU ON DIPHTHERITE.

when we operate soon, and it is rare to save any when we wait till
the last moment. .

In practising tracheotomy when children are about to expire, we
‘run the risk :—1st of finding the false membranes occupying a very
great extent: 2nd, of not being able to remedy congestion, en-
gorgement, inflammation, and pulmonary emphysema, which are
rather frequent occurrences in the last stage of asphyxia: 8rd,
the operation is rendered much more difficult, in consequence of the
enormous swelling of the cervical vessels, the swelling bemg greater
in proportion to the embarrassment of the respiration.

Of the treatment which ought to follow the operation.—As soon as the
incision in the trachea is made, at that very instant blood is sucked
down into the bronchial tubes, and as the respiration becomes still more
difficult, the venous hemorrhage, far from stopping, flows with more
violence. It is necessary, at the very moment, to be provided with
the dilator. This instrument is nothing more than akind of dressing
forceps, the two blades of which form at their extremity a little
spur projecting externally, intended to hook into the lips of the wound
in the trachea, so as not to be continually displaced during the
movements of respiration. It is introduced closed between the lips
of the wound, and when it is lodged there, it is gently opened by
bringing together the rings of the handle. This proceeding, however
easy it may appear, requires considerable practice. It has very often
happened to myself, that I have placed the extremity of the instru-
ment between the muscles, or that I have introduced only one of the
blades in the trachea. J¢ is necessary to proceed slowly and pass
an the instrument as deeply as possible. When the dilator is well
placed, the air easily penetrates ; the blood, the false membranes and
the mucous matters are expectorated, and the respiration generally
becomes easy. The dilator is left in the trachea during the continu-
ance of the syncope which usually follows the operation and until
the canula is introduced, The canula should never be placed in the
trachea until ten or twenty minutes after the operation. The trachea
and the bronchi should be previously cleaned, and the mucous mem-
brane which lines them should be cauterized.

1. Cleaning the trachea and bronchi.When, during the efforts
of coughing, a false membrane presents itself between the blades
of the dilator, it is seized with a pair of forceps, and it is drawn
away gently in order to avoid tearing it; but most frequently,
the pellicular concretions and the semi-plastic mucus adhere firmly
TRACHEOTOMY. 247

to the mucous membrane, and then they must be removed by means of
of a kind of brush called écouvition. This little instrument, devised by
M. Bretonneau, is of two kinds. One is nothing else than a small
piece of fine sponge at the extremity of a rod of flexible whalebone,
rounded, and about six or eight inches long: The other is a small
brush similar to that which is used to clean bottles, and is con-
structed in the followmg manner. Some pieces of flexible horse-
hair, laid between the branches made by an iron or brass wire doubled
upon itself, are arranged equally and in a parallel direction in a
space of seven or eight lines ; they ought to touch and even to cover
one another. The two wires, seized with a pair of nippers immedi-
ately beyond the horse-hair, are twisted into a spiral. Being drawn
in by the twisted wire the hairs lose their parallelism to converge
round the axis on which they are fixed. As soon as they are thus
seized and firmly held between the revolutions of the double helix,
nothing remains to be done except to cut them in order to give the
little brush the form of a ball borne on a stem formed by the two
wires turned round upon one another. It-is advisable to fit this
brush on a little handle made with a pen or a small piece of wood.
The brushing (écouvillonnement) is such an indispensable pro-
ceeding, and so important in the treatment following the operation,
that. I shall carefully describe the manner of performing it. In
ordinary circumstances I prefer the sponge brush; it is introduced
rapidly to the depth of three, four, five, or even six inches, while it
is made to execute a rotatory movement ; then it is passed several times
from above downwards, and is finally withdrawn while the operator
impresses upon it the rotatory movement which I have described.
Each brushing does not last longer than two or three seconds ; when
the sponge is withdrawn, an assistant squeezes it with a piece of
linen, and removes the mucus which covers it. The instrument is
immediately re-introduced, and the re-introduction is continued until
the removal of the mucous matters, or false membranes which
are heard rustling in the trachea. Before commencing the brushing,
it is generally necessary 10 inject half-a-teaspoonful of tepid or cold
water into the bronchi: this water, together with the brush, and the
air which enters and goes out, shake up, mash together, and draw
outwards everything that is found in the air-passages. The brushing
most frequently excites an extremely distressing cough ; but when the
children have not been exhausted by the loss of blood, when the
pellicular inflammation is already modified, and nothing except mucus
\

248 TROUSSEAU ON DIPHTHERITE.

is secreted, then it is sufficient to pass the brush once or twice, and
the proceeding is so simple, that most frequently children who
are asleep are not aroused by it.

The first brushing ought to be performed immediately after the
operation ; by this means the mucus, the blood, and the greater part
of the croupal concretions are drawn away. Thus the mucous mem-
brane is laid bare, a necessary condition for the modifications which
may be effected in it by the topical remedies; and here the precept
ought to be laid down, ¢o brush thoroughly whenever it is desirable, in
order to act directly upon the mucous membrane. The horse-hair brush
is serviceable when a false membrane is too adherent and the sponge
cannot draw it away; and it is always preferable to the other brush
in clearing the canula.

2. Cauterization.—W hen the trachea and bronchi are well cleaned,
we may proceed to cauterization. This is performed in two modes ;
Ist, dy touching, 2nd, by instillation.

Cauterization by touching. —The sponge-brush is moistened with
the caustic liquid, and it is introduced at several intervals upon all the
points of the mucous membrane which it can reach. In this manner
the caustic solution is not diffused in the bronchi. This cauteriza-
tion ought to be repeated at least three times the first day, and twice
on the two following days.

Cauterization’ by instillation—Cauterization by instillation is
performed in the following manner :—A writing-quill is filled with
the caustic liquid, which is poured into the trachea, while the ope-
rator takes advantage, as much as possible, of a movement of inspi-
ration. Immediataly afterwards, water is dropped in, and the brush
vigorously employed until the air-tubes are well cleaned. This kind
of cauterization ought to be repeated two or three times during
three days. If after the operation we are able to ascertain that
there are no exudations beyond the larynx, it is sufficient to employ
the cauterization by touching.

On the first two or three days after each cauterization, a very abun-
dant serous exudation takes place on the surface of the mucous
membrane. This hypersecretion usually continues for twenty or
thirty minutes, and in general it lasts the longer in proportion as the
patients have been reduced by powerful depletion. It is then essen-
tial to brush the mucous surface lightly and often with the sponge
well pressed out, so as to remove all these watery secretions.

The caustic solution for cauterization by touching and that which is
TRACHEOTOMY. 249

employed in instillation are not prepared of the same strength ; the first
is composed of eighteen grains of nitrate of silver to a drachm’of distilled
water ; the second, of only four grains to the same quantity of liquid;
and it is the more important to observe this proportion because if
we made use of the first solution for instillation we should run the
risk of coagulating the mucus contained in the second or third
divisions of the bronchi and thus of causing immediate asphyxia,
while the solution, No. 2, cannot produce such a serious result; it
only whitens, but does not coagulate the albumen. I do not dare
to affirm that cauterizations by instillation are often useful; the
success obtained by M. Bretonneau, who employs only the cauteriza-
tion by touching, ought to make us cautious in the use of instilla-
tions which I have often recommended and which I have, perhaps, too
often employed.

Of instillations of water—I have already explained the import-
ance of instillations of water into the bronchi when it is desirable to
detach and draw away the false membranes. They have besides
andther advantage, which is, that they dilute the mucus and render
its expectoration more easy. The rapid contact of the air with the
trachea often dries the mucous matters which cover it, exactly as in
the nasal fosse; the instillations of water obviate also this serious
inconvenience. When the object is to detach and to draw outwards
any tenacious membranes, it is necessary to- inject a large quantity
of water, a teaspoonful at a time, and to brush out the trachea
immediately afterwards; but in order to dilute-or soften the mucous
matters it is sufficient to pour in two or three drops every quarter of
an hour. The larger instillations are especially suitable during the
first two or three days, and they ought not to be repeated more than
four or five times a day; the small instillations may be performed
more frequently, but they are especially adapted for the subsequent
days.

Of canule and their introduction. —When, after the operation, the
wound, the trachea, and the bronchi have been properly cleaned and
cauterized, it is proper to introduce a well-fitting canula which is to be
firmly secured. I generally make use of the canula described by M.
Bretonneau, and of those which I have figured in the Jeanine des
Connaissances Medico-chirurgicales. Sept. 1834.

All these canule have a much more considerable diameter than
that which was formerly recommended. The precept laid down by
M. Bretonneau who invented them is, that the artificial conduit
250 TROUSSEAU ON DIPHTHERITE.

should always have at least the normal diameter of the glottis of the
subject ; an excellent precept which should never be forgotten.

Before introducing the canula we pass into the rings which are
made at its anterior aperture two portions of string, thread, or rib-
bon, intended to keep the instrument firmly fixed. With one hand
the operator holds the dilator with its ends separated in the trachea,
while with the other hand he holds the canula, which he slips into
the trachea between the blades of the dilator. When the canula
is introduced, he withdraws the dilator, and firmly ties the threads
round the neck. The introduction of the instrament is often very
difficult ; sometimes the opening of the trachea is missed and the
instrument is plunged, in front of this tube, into the cellular tissue.
When the canula is properly lodged, the fact may be known by the
free passage of air and mucous matters, and by the facility of respi-
ration. It is important and even indispensable that the canula
should be long and should enter into the trachea for several lines
beyond the inferior angle of the wound in the trachea. If the
canula is too short it is disarranged in the efforts of coughihg,
and becomes lodged in front of the trachea in a cul-de-sac which is
always formed there, and the patient dies asphyxiated in a few
minutes. I have met with this fearful accident on three occasions,
although I had left some pupils of considerable experience in attend-
ance upon the patients. The error, in this case, is the more easily
committed, as the canula is displaced only in its posterior portion,
and inexperienced persons are ignorant of the cause of the sudden
embarrassment of respiration. Added to this, children are seized at
the same moment with violent movements which render the measures
necessary to replace the instrument much more difficult. The prac-
titioner, therefore, should remember, on the one hand, that the
canula should be plunged about five or six lines into the trachea, and on
the other hand, that he should fix it sufficiently to prevent its expul-
sion during the efforts of coughing.

When the finger is placed in the front of the neck, in a child or
an adult, in order to explore the trachea, before the integuments are
divided, or even when the operation of bronchotomy is performed on
a dead subject, a just idea is not formed of the depth at which the
trachea is found in the living body after the operation ; the depth is
at least double of that which it is supposed to be. Therefore there
should never be any fear of having the canula too long; and this is
the more important, because, on the day after the operation, the
TRACHEOTOMY. 251

wound is swelled to such an extent that the canula which is suitable
in thé evening, ceases to be so on the following morning. It is in
order to remedy this inconvenience that I have devised some canulz
with a lengthening tube, like an opera-glass. The advantage of these
canulz is that they may be used as well on the first day as on the
three following days; but on the fourth day, the swelling of the lips
of the wound begins to subside, and this subsidence is so great that
the trachea is found even less deep than it was before the operation ;
and at this period it is necessary to use shorter canule. These
canule, which scarcely enter at all into the trachea, do not prevent
the air and the mucous matters from striking against the larynx in
the efforts of coughing, and from detaching the croupal membranes
which remain still adherent to the vocal cords. But these short
canule may sometimes be disarranged; and although the opening
in the trachea is then gaping, and does not close again until after
the expiration of some hours, still I have thought that I ought to
provide for the cases where the medical practitioner can visit his
patient only once in twenty-four hours. I have therefore had canule
constructed with dorsal openings; each opening is placed quite
near to the posterior extremity of the instrument. If it had
been placed more in front it would be in contact with the superior
wall of the wound, and then the fleshy matters which would
have been introduced into it might have caused a hernia into
the canula, and might thus have completely obliterated its cavity.
This accident happened to me upon one occasion, and it would
have been attended with the death of the child, had not its father
had the presence of mind to remove the instrument. The best
precept therefore is, that the dorsal opening should be entirely in
the trachea. Besides, this aperture has the advantage of permitting
a direct communication between the trachea and the larynx; and
when it may be supposed that the larynx is beginning to be free
from obstruction, the canula is loosely closed with a cork, and then
the air and the mucous matters pass without: difficulty from the
bronchi to the back of the mouth.

The canule which I have described are usually made of solid
metal, and are consequently inflexible. I have often had reason to
complain of this inflexibility, and in order to remedy it I have had some
canule constructed of silver-wire flattened and turned in a spiral form.
It is easy to adapt to them an elongation in the form of an opera-
glass, but it is not so easy to make the dorsal aperture in them. I
252 TROUSSEAU ON DIPHTHERITE.

sometimes make use of these canulz in the first days which follow
the operation,

Several physicians, and among others MM. Bretonneau, Gendron,
and Coqueret, have proposed to substitute for the canule, which I
have above described, instruments which might be applied at all
periods of the disease, and which might be firmly kept in their place.
I have elsewhere described the greater number of these instruments.

Whichever canula may be selected, it is not only necessary to in-
troduce and retain it, but it is also essential to remove it, clean
it, and replace it as often as may be required, and I shall point
out the results of my own experience upon this subject. When the
canula is wide, it is barely possible to remove it more than once a
day; but it is expedient, as soon as it is practicable, to take it out
three times in the twenty-four hours during the three days which follow
the operation, twice on the two following days, and then only once up
to the time of closing the wound. It is not removed merely for the
purpose of cleaning it, for most frequently it is not at all stopped up ;
but experience has proved that the thorough brushing out of the
trachea can only be accomplished by removing the canula, whether
the mucus and the false membranes were attached to the internal
extremity of the instrument, or that the posterior and membranous
wall of the trachea was applied to the opening of the canula and par-
tially closed it. When the brushing (écowvillonnement) is performed
with the canula in the wound, this operation can be performed
neither with the same facility nor the same safety ; for frequently the
brush, in returning, becomes caught at the edge of the canula, and
would carry. it away if it were not cautiously retained in its place.

I may sum up my observations on this subject by stating, that in
ordinary brushings of the trachea, the canula may be left, but that it
is convenient to remove it in order to brush it out thoroughly.

During the first two or three days, the wound of the trachea begins
to close, however little the canula may be removed, and it is, there-
fore, advisable to introduce the dilator as soon as the tube is taken
out. The dilator remains in the wound as long as the brushing of
the trachea is going on, and until the canula is replaced.

If, on the fifth or sixth day, the air is not heard passing in small
quantity by the natural passages in great efforts of coughing, it is proper
to apply the caustic solution once or twice to the larynx, by means of a
strong curved piece of whalebone, armed with a little sponge; this
very simple treatment is sufficient to facilitate the passage of the air
TRACHEOTOMY. 253

and the mucous secretions, and then the canula may be closed alto-
gether or partially, according as the larynx is more or less free. On
the first occasion, the canula should remain closed only a quarter of
an hour, or an hour at most; then it is closed again, some hours
afterwards, for two or three hours, and then for ten or twelve hours.
If, then, the respiration remains easy, the canula is removed, the
wound is cleaned, and the edges of the wound are exactly brought
together by strips of adhesive plaister. The dressing is covered over
with carded. cotton and a loose cravat, the broad part of which is
applied behind the nape of the neck, and the ends are brought across
the neck and passed under the armpits to be tied behind the back.
The bandage is changed twice a day, and generally, after four, six,
or eight days, the aperture in the trachea is entirely cicatrized ; there
remains then only a simple wound which is soon healed. If the ex-
ternal wound is covered by exudations, which happens rather fre-
quently, itis to be dusted with calomel, which in a short time modifies
this morbific disposition.

From the result of my observations, I have found that when
children: have been weakened by blood-letting, a sanguinolent serosity
oozes incessantly from the lips of the wound. This fluid enters into
the bronchi at each inspiratory movement, and rapidly engorges the
lung; but the most serious inconvenience which results from this
depletion, is that the little patients have not power to expectorate
the plastic mucus which fills the small bronchial tubes, or the false
membranes which line the trachea and the first divisions of the
bronchi, or even the medicinal substances which are instilled into
the air-tubes. They never recover from the deep stupor in which
they were plunged before the operation, and they die at the end of
ten or fifteen hours, without having expectorated anything except a
little white froth. The same thing happens, though to a less degree,
when mercurials have been administered before the operation in doses
capable of producing salivation. 7

Although the operation of tracheotomy may have been performed,
the practitioner should not neglect the treatment of the Diphthérite
in the pharynx, where it is almost constantly present, and in the
mouth, where it is also often met with. To fulfil this indication, it
will be sufficient to apply twice or thrice a day, on the diseased parts,
a mixture of two drachms of hydrochloric acid to two ounces of
honey of roses, or else a strong solution of alum in syrup or honey.
It is the more important to pay attention to the Diphtherite of the
254 ' TROUSSEAU ON DIPHTHERITE.

pharynx and the mouth, inasmuch as this special phlegmasia is often
the only cause of the dyspepsia of children, and nothing is more es-
sential than to support these patients with nourishment.

When once the operation is performed, it is essential, almost as a
necessary condition of success, to feed the patients well; milk, broth,
and light soups, must be given as long as the traumatic fever con-
tinues ; and more nourishing substances must be resorted to, as soon
as the febrile orgasm has entirely ceased. If the appetite fails and
the strength is not restored, quinine wine will be useful.

On Curanzous DIPHTHERITE.
(Archives Générales de Médecine, 1830.)

M. Bretonneau, in his Treatise on Diphtherite, has clearly proved
that the most common seat of this affection is the back of the mouth
and the larynx. He has demonstrated the manner in which it often
attacks the nasal fossee, and he has shown that the disease known to
the ancients under the name of Scorbutic Gangrene was no more a
gangrene than the Angina which was said to be gangrenous; and
that both these affections were nothing more than pellicular inflam-
mation, modified either by the position which it occupied or by its
duration. Still, some rather numerous facts had convinced him that
the special inflammation which he had called Diphthérite, might
occupy not only the pharynx, the air-passages, the nasal fosse, and the
mouth, but also the integuments themselves, and all the mucous mem-
branes of the organs of generation. This truth, which had already been
partly perceived by some modern writers, but which was demonstrated
by M. Bretonneau, will derive additional weight from the numerous
facts which have been collected by Dr. Ramon and myself i in Sologne,
during the summer of the year 1828.

We were informed, in the early part of September, 1828, that
Malignant Angina had just appeared in the Department of the Loir
et Cher, at Nouan le Fuselier, a village situated on the road from
Orleans to Bourges, and that many persons there had fallen victims
to it. We went there, and M. Leménager, a physician residing in
the locality, was so kind as to accompany us in our visits to the
patients. We began with the house of a woman, named Josephine
Pressoir. It was situated at the northern extremity of Nouan, and
CUTANEOUS DIPHTHERITE. 255

up to the time of our visit there had been no patients, except in the
southern part, in a hamlet a little separated from the village and
named des Rois. The daughter of Josephine Pressoir, aged eight
years, had had some communication, as we were informed by the
roother, with an infected family of the hamlet of les Rois, and a short
time afterwards, she was attacked with pharyngeal Diphthérite.
When we saw her, on the 13th of September, she was at the eighth
day of the disease; M. Leménager had applied leeches to the neck,
had touched the back of the mouth three times with a solution of
nitrate of silver, and had employed several insufflations of alum.
Besides these measures, this gentleman had been induced by the
fear of a gangrenous affection, to order for the throat some injections
with a decoction of bark and camphor, and to prescribe gargles with
alum and bark. On the fifth day of the disease a blister was applied
to the nape of the neck, and was followed by an abundant sup-
puration, the excoriated surface being covered with false membranes,
as was also an ulceration on the foot, under which this girl had for a
long time suffered. I shall now describe the state in which we
found the back of the child on the 13th of September, being the
ninth day of the disease.

The blistered surface, which at the beginning was only three inches
wide, was now more than six ; it was excessively painful and poured out
an abundant suppuration; it extended upon the back, making irregular
offshoots similar to ivory card-markers (fiches de trictrac) and it was
surrounded with a broad erysipelatous areola, much more marked
below than above and on the sides. The part actually denuded of
epidermis appeared depressed, and was really so in comparison with
the surrounding tumefaction. It was covered with fibrinous super-
posed layers, of a yellowish-white colour, which being thicker in the
centre became thinner towards the circumference. In the middle,
their thickness amounted to two, three, or even four lines, and they
exactly resembled dry pleuritic exudations, which are found in the
cavity of the chest, when resolution has already begun, and the serous
part which had been effused has been almost entirely reabsorbed.
We raised some of these exudations with a very delicate metallic plate
and we saw that they adhered rather strongly to the tissue of the
skin, and that they could not be removed without some difficulty.

The surrounding inflammation presented a singular appearance.
The redness was the more vivid in proportion as it approached nearer
to the excoriated parts. The epidermis, in a multitude of points, was
256 TROUSSEAU ON DIPHTHERITE.

elevated by small effusions of lactescent serosity, so that the skin was
covered. with vesicles, confluent in the vicinity of the wound, and
less and less numerous as they approached the integuments, which
were still healthy. Among the vesicles there were some which ap-
peared to have been formed by the union of several; others which,
whether simple or united together, appeared to have burst; and-in
their place the derma was seen covered with a white membrane
(couénne); these ulcerations were united to other small ones, these
came to join the principal one, and thus the disease crept on by de-
grees. Let me add as a remarkable peculiarity, that near the head
and shoulders, the erysipelatous inflammation hardly extended at all,
and that in these parts we also found very few vesicles.

However, the mother of this child, Josephine Pressoir, being in
the fields on the 30th of August, 1828, that is to say, five days
before her child fell ill, had been seized, at the end of what was
called a cold, with a severe pain in one of her breasts. An inflam-
mation of the cellular tissue of the nipple soon followed, and an
abscess was formed. The pus began to point, and at the apex of
the swelling, the skin was attacked with mortification-in an extent
of about+three lines, and on the 12th of September, the abscess
opened spontaneously. We saw the patient the next day, and the
wound was already surrounded with an erysipelatous circle, and the
edges of the incision were covered with a false membrane, extending
upon the integuments for the space of two or three lines. The child
Pressoir was then at the eighth day of Diphthérite, and she had
not ceased to sleep with her mother during the whole time of her
disease.

At la Blettiére, a farm situated in the commune of Marcilly en
Villette, in the Department of Loiret, five persons died of pharyngo-
tracheal Diphthérite ; Huré, aged ten years, lay in the same room
and the same bed with those who had died, and a slight inflamma-
tion which he had behind his ears, soon became exasperated, the
skin was covered with false membranes, the pellicular inflammation
extended to the whole of the back, and he died in a few days, ex-
hausted by dreadful pain and an excessively abundant suppuration.
M. Regnaud, physician at la Ferté-Saint-Aubin, saw another patient
at Marcilly sink exactly in the same manner, after an attack of cu-
taneous Diphthérite, which at first had taken possession of some
favous ulcerations of the hairy scalp, and then it had extended to
the neck and back as far as the loins. He also communicated to us
CUTANEOUS DIPHTHERITE. 257

the case of a man at Marcilly, in whom the Diphthérite had attacked
the skin of the scrotum, which was previously excoriated.

At le Grand Pied-Blain, situated in the commune of Tremblevif,
and about a quarter of a league south-east from la Ferté-Beauharnois, *
twelve persons were attacked with Malignant Angina, and ten died ;
the mother of three of the children who had just died, applied to the
nape of her neck, a precautionary blister, thinking thus to escape the
disease; but in a few days, the surface of the blister and the sur-
rounding parts were dreadfully inflamed, and this unfortunate woman
soon sunk. We were told that the skin of the neck had been at-
tacked with gangrene.

The same thing was observed in a family named Bouzy, in the
hamlet of Les Rois, near Nouan-le-Fuselier. There had already
been some patients in most of the houses of the hamlet, and a little
girl had died in a room immediately near that of Bouzy. A young
man, named Cauqui, aged nineteen, slept in the same part of the
house which was occupied by Bouzy and his wife and child; he
contracted Malignant Angina, and immediately Bouzy, being alarmed,
applied a blister to both arms of his child, in order (as he said) to
draw away the humour; and almost immediately the blisters were co-
vered with false membranes, the surrounding skin being inflamed ;
and on the fourth day, when we saw the child, the nose was ob-
structed by pellicular exudations ; an extremely fetid serosity flowed
from it, and the pharynx was already beginning to be attacked with
Diphthérite.

At Saint-Loup, in the Department of Loir-et-Cher, twenty-one
persons had been attacked with Diphthérite, and nineteen had died ;
a man named Blaise and his wife had just witnessed the death of
their two children; and they themselves had Malignant Angina at
the time when we went to visit them.. The husband was going on
favourably, under the influence of local treatment, and the state of
his wife, whose larynx had been invaded by the false membrane,
began to excite less apprehension ; but a blister had been placed on
her left arm, which was now in a truly alarming condition. The
surface of the blister was singularly enlarged, it appeared deeply sunk,
and was covered with a pellicular exudation of a blackish-grey
colour; a limpid and very fetid serosity trickled from it, and the
whole arm, the forearm and hand were swollen and of a shining rose
colour. It was impossible not to believe that the surface of the
blister was seized with mortification ; still, by pricking it with a

8
258 TROUSSEAU ON DIPHTHERITE.

pin, we found that below the false membrane the sensibility was
very acute.

We dusted the wound with calomel, and on the next day the
pain and the tumefaction were almost entirely removed; the same
plan was persisted in, and three days after the commencement of the
treatment the wound was entirely cleaned; there was a healthy
suppuration, the false membranes had wholly disappeared, and
nothing remained except a small gangrenous eschar which was de-
tached at the end of twelve or fifteen days.

A child had just died of tracheal Diphthérite in a farm in the de-
partment of the Indre; a medical gentleman, called in too late, was
unable to afford efficient assistance, but he caused some leeches to
be applied to the abdomen of the mother, who complained of pain
in that region ; the bites were soon inflamed, the skin became erysi-
pelatous, and as soon as the epidermis was detached, it was covered
with false membranes of such a fetid smell that they resembled

’ gangrenous eschars.

Francois Miniére, aged forty-five, a labourer of the commune of
Chaumont-sur-Tharonne, in the Department of Loir-et-Cher, had
two children affected with epidemic sore-throat. One died, but the
other was cured by local treatment. In the meantime, the father
himself, who had a slight excoriation at the internal part of the
tarso-phalangeal articulation of one of the great toes, soon felt an
acute pain in this part. The skin became erysipelatous and was
deprived of its epidermis, and some days afterwards, there existed
a foul ulcer with unequal and thickened edges, surrounded by a con-
siderable tumefaction ; the surface of the wound was covered with a
greyish false membrane which could easily be removed; the glands
of the groin and those of the internal part of the leg were considerably
tumefied. We dusted the wound with about six grains of calomel,
and thirty-six hours afterwards, the surface of the ulcer was dimin-
ished by one-fourth, the pain was less acute, the tumefaction had
disappeared, and there was no more false membrane. We repeated
the treatment and left the calomel with the patient, but he lost it,
and the wound, which in a short time had been reduced to very
small dimensions, afterwards remained for a long time stationary.

A young boy of Marcilly, named Maitre, had had, for some time,
together with his mother, gingival Diphthérite (scorbutie gangrene of
the gums of the old writers); and at last he died on the 19th of
January, 1828, of Diphthérite, which attacked at once the throat
CUTANEOUS DIPHTHERITE, 259

and the hairy scalp. This boy had tinea of the scalp. His brother,
aged thirteen, a cowherd at Colombier, came to Marcilly at the time
when his brother and sister were ill, and a short time after his return
to Colombier, the ulcerations which were on his head became dread-
fully painful, and allowed a large quantity of fetid serosity to trickle
‘out. We received these details from the boy himself, and from the
medical gentleman who attended and cured him.

As young Maitre was, in my opinion, the cause of an epidemic
the more interesting as it: was more circumscribed, I shall insist
with some earnestness upon details of great importance.

The chateau of Louan, which belongs to M. Briolet du Cyran, is
‘situated on a hill which looks over a valley, embellished with mag-
nificent plantations by M. du Cyran; the chateau is surrounded by
streams of spring water. At a short distance on the south-west, are
situated two of the farms built upon the downs, named Colombier
and La Grange. Five or six hundred paces from the chateau, on
the south-east is another farm named Bouchebrant, situated in
a little valley, running from south to north. The chateau of Louan,
Bouchebrant, Colombier, and La Grange, are at some distance from
the towns of Ménestreau, Saint-Cyr, and Marcilly, and are very
distant from the surrounding farms; by their position, therefore,
they are entirely isolated.

M. du Cyran, his wife, two children, and two servants, lived at
Louan; Colombier was occupied by a person named Boulinette, his
wife, two children, and a little cow-boy, namely, young Maitre, who
was just mentioned. A person named Derland, his wife, and two
children, occupied La Grange. At Bouchebrant there was the
farmer, the uncle of Boulinette of Colombier, his wife, five children,
a shepherd, and a carter. 3

We have just seen that young Maitre went to Marcilly, a town
situated a league from Louan, where Malignant Angina had prevailed
for more than a year; he remained there while his mother and
brother were ill, and on returning to Colombier, we found the favous
ulcerations on his head assume, on a sudden, a character of unusual
severity, and soon afterwards Pauline and Laurent Boulinette, who
slept in the same bed with him, became ill. Little Laurent, aged
four years, died first with the symptoms of Croup ; his sister, aged
seven years, died of suffocation the next day, February 20, 1828.
For some days previously, this little girl had the back of her ears,

the hairy scalp, and a part of the nape of the neck inflamed and
82
260. TROUSSEAU ON DIPHTHERITE.

allowing of the oozing of a very large quantity of extremely’ fetid
serosity. Subsequently the mother had her body interspersed with
scabby ulcerations, and we still saw these ulcerations in the month
of August. They began by pustules rather analogous to those of
vaccination, except that they were pointed and not flattened. The
epidermis was broken, and the broken part left a small ulcer which
rapidly increased in size, allowed a considerable quantity of pus
to escape, and cicatrized only with great difficulty.

Still the family of Derland, who lived at La Grange, which was
separated from Colombier only by a courtyard, came continually to
visit their neighbours ; the woman Derland to offer assistance and
consolation, and her children came also as much in order not to
leave their mother, as by the habit which they had of playing with
the children of Boulinette. Pierre and Laurent Derland, aged re-
spectively four years and eighteen mofiths, died of suffocation in their
turn, a few days after their playmates. What struck the parents
most was the closure of the nasal fosse, the tumefaction of the face,
and the inflammation of the scalp.

This closure of the nasal fosse is rather common, especially in
children, who continually apply to their nose their hands impregnated
by the virus which flows from the diphtheritic ulcerations of the
skin. I have observed it several times, and particularly at Nouan-
le-Fuselier, a hamlet of Les Rois, as I have mentioned above, in the
case of a little child on whom two precautionary blisters had been
applied, which were suddenly covered with diphtheritic membranes.
We now return to the family of Boulinette.

I have stated, that Pauline Boulinette had had for a few days some
diphtheritic ulcers on the head, before being attacked with Membra-
nous Angina. She was already very ill when she was taken by her
mother to the farmer of Bouchebrant, her great uncle; she there
passed some time with her relatives, playing with the children, as
much as her suffermgs permitted her. Returning in the evening to
Colombier, she soon died. A few days afterwards, some of the chil-
dren at Bouchebrant took cold in their heads, and among others a little
girl, who had the back of her ears inflamed, soon experienced acute
pain in those parts, and, the affection spreading rapidly, the skin was
excoriated as far as the larynx. In the space of two months the
mother and five children died of Malignant Angina. The farmer
himself and his shepherdess were attacked at the same time with
sore-throat ; but this man told us that he had not felt any uneasiness
CUTANEOUS DIPHTHERITE. 261

on the subject, because having looked at himself by means of a
looking-glass, and having examined the throat of his shepherdess, he
had not found there any white skins as in his wife and children.
After this time, the shepherdess and a young carter had, on several
parts of their body, ulcerations which were healed with great diffi-
culty and were incessantly renewed; and we were able to observe,
in the case of the carter, one of these ulcers still in the recent state.
It was hollowed in a conical form, and filled with a false membrane
white at its circumference and’ greyish in the centre; this exudation
was easily detached at the edges. The skin around the ulcer was red
and painful.

All the facts relating to this epidemic of*Louan are wanting in
details sufficient to indicate the anatomical characters of the diseases
of the skin observed at the same time with Malignant Angina; but
as no physician was called in, we are obliged to rest satisfied with the
imperfect descriptions given by the relations and by Madame Briolet
du Cyran who attended most of the patients.

At Paulmery, near Selles, a little girl contracted Diphthérite ; she
eame back to Les Barres (Indre), a farm situated at the distance of
a league from Paulmery, to see her relations; she soon died, as well
as her two brothers, and the mother who nursed them was seized
with Diphthérite, occupying the side of the neck and all the right
side of the face. This woman did not die; but she was a long time
recovering, and suffered very much pain. When we saw her in the
month of August, she was not yet well.

At Gracay (Indre), a little child, who was still sucking, contracted
Diphtheritic Angina which was prevailing epidemically. The mother
continued to nurse the child until its death, and the breast was soon
afterwards attacked with the specific inflammation, and became
covered with false membranes, the extension of which was prevented
by suitable treatment. -

At Montévrant, a farm situated at the distance of a league anda
half from the town of Chaumont-sur-Tharonne (Loir-et-Cher) several
persons died of Malignant Angina. Julie Thomas, the daughter of
the warder of Chaumont, and servant at Montévrant, began to feel
the first approaches of Diphtheritic Angina, and being alarmed she
went to her father who lived in the town of Chaumont, and she died”
a few days after her arrival. She slept with her mother, aged forty,
and with her little sister Marguerite. Three days after her death,
the mother experienced severe pain in the vulva and in the lower
262 TROUSSEAU ON DIPHTHERITE.

part of theabdomen. The husband examined the affected parts, and
I shall quote his exact words, “I looked,” said he, “and I saw her
nature” (meaning the sexual organs) ‘“‘ which resembled my children’s
throats, and had”also a very bad smell; internally it was grey and
black, and all around it was red.” Five days after complaining of
illness, the woman Thomas died. Scarcely a week had elapsed, when
Marguerite, the second daughter, died also of pharyngo-tracheal
Diphthérite.

A similar case was observed at Méziéres (Loiret). Malignant
Angina broke out in the family of the warder of the chateau, where a
child of six years of age died. A short time afterwards, the four
daughters of a person named Adam, who lived in the court-yard of
the chateau, contracted Diphthérite and died ; one of them aged seven
years, had at the same time the hand, the foot, and the vulva attacked
with pellicular inflammation; she did not die of suffocation, but fell
into a deep state of adynamia which rapidly ended in death. This
case was communicated to us by M. Carrére, physician at Cléry, who
also related the following case. A man named Montigny, who saw
six children in his family sink in succession in the space of a month,
out of seven who had been attacked with Malignant Angina, ex-
perienced himself the first symptoms of Diphtheritic Angina, and at
the same time the prepuce was covered with false membranes.

Dr. Epine, physician of the Royal Military School of La Fléche,
observed an analogous case during the epidemic which prevailed in
that establishment. “The sister Marie,” says he in his Memoir,
“nurse at the school of La Fléche, exhibited at first the most serious
symptoms of Malignant Angina: the disease after having made great
progress on the tonsils, developed itself at the external part of the
rectum. The anus, excessively swollen, painful, and of a livid-
red colour, was covered with diphtheritic pellicles which were de-
tached only in parts and very slowly. After exhibiting for several
days a rather well-marked degree of amendment, she fell into a state
of extreme adynamia, constantly suffering from long fainting-fits,
and she died on the'seventeenth day.

Everyone knows the case of Dr. Bourgeoise, who himself suffered
from symptoms of an exactly analogous character, and who was cured
only with great difficulty.

The family of a person named Gabereau, of La Ferté, Saint-Aubin
(Department of the Loiret), was composed of seven persons; namely,
the wife, an elder girl, aged nine years; a boy, aged seven; a girl,
CUTANEOUS DIPHTHERITE. 263

aged five; and a little boy, aged two years and a half. A female
servant, twenty years old, had a natural child aged fourteen months.

The little girl of seven years, died of pharyngo-tracheal Diphthérite
at the commencement of the epidemic of Saint-Aubin, on the 18th of
December, 1827. The mother and the two elder of her children
had since this time, diseases, according to their own expressions,
which got well on one part of the skin only to reappear upon another.
The boy of two years and a half had obstinate ulcers around his
lips ; his sister of nine years had some between the toes and on the
chin; and those on the chin, we were told, were covered with white
skins,

The eldest boy used to amuse himself by drawing his little brother
Pierre in a wheelbarrow. The part of the thigh of this child which
rested on the edge of the wheelbarrow, was slightly excoriated, and in a
few days, there was a broad and painful wound, the severity of which-
was out of all proportion to the slight cause which had produced it. In
the meantime, Louis Sylvain, aged seven years, died of Croup on the
4th of August, 1828, and seven days afterwards Pierre died also.

A little child named Agathe, daughter of the female servant, was
confided, in the absence of the mother who was going on a journey,
to the care of the woman Gabereau and her eldest daughter, Sylvine ;
and she constantly played with the children of Gabereau, for she re-
mained with them in the same room. On the 4th of August, the
day of the death of Louis Sylvain, it was perceived that the child’s
sexual organs were affected ; and they were immediately shown to M.
Régnaud, physician of La Ferté Saint-Aubin. “TI saw,” he told us,
“some white membranes on the mucous surface of the vulva, and
on the skin of the fold of the thighs, which was excoriated, and I
admit that at first I believed in the existence of syphilis ; and know-
ing that the child was not born in legitimate wedlock, I was the
more confirmed in this view. This opinion made me persuade Agathe,
the mother, to go to Orleans with her child, and to enter into the
Hotel-Dieu of that city. .

We then obtained, in connexion with M. Bémnaud: the most ac-
curate particulars in our power as to the condition of the mother,
Agathe, and we were convinced that she had not syphilis. Besides,
for fourteen months after the child was born, she and her mother
had enjoyed perfect health; and since the first fault which she had
committed, and in the hope of contracting an advantageous marriage,
Agathe’s conduct had been most irreproachable.
264 TROUSSEAU ON DIPHTHERITE.

The mother and the child, then, came to the Hétel-Dieu at Orleans.
M. Duverney, the surgeon of this establishment, examined the infant,
and being struck with the singular appearance of the external parts
of generation, and, moreover, not knowing the antecedents, he de-
clared that he found no syphilitic affection, and he pronounced this
opinion in opposition to that of the hospital pupils around him who,
examined the patient with him. Still the case seemed to him em-
barrassing, and he deferred pronouncing a definitive opinion until
the next day; and on the second examination, he could not yet re-
cognise the characters of syphilis, and declared that if it was a species
of that disease, he had never seen it under such a form.

I write in some detail of the uncertainty felt by so experienced a
surgeon, in order to show that-this inflammation of the vulva and
of the skin of the fold of the thighs presented an unusual appearance.
M. Duverney, who himself related the circumstance to us, remembered
very well that it was the existence of the false membranes which pre-
vented him from believing that the case was one of syphilis; and
now that his attention was directed to the point, he remembered that
the state of this little child’s vulva was similar to that of the mucous
membrane of the pharynx in children attacked with Diphtheritic
Angina. ;

However, Agathe remained two days in the Hospital and then
returned to Saint-Aubin; and her child died from the continuance of
the disease, fourteen days after the attack.

CoROLLARIES.

These facts being established, it is necessary to endeavour to show
that the affections of the skin and of the mucous tissue of which I
have been writing, are of a nature identical with those which had
their seat on the mucous membrane of the larynx and of the back
of the mouth. Let us examine at first the most simple facts.

A little girl is attacked with pharyngeal Diphthérite; a blister
is applied, and on the next day the excoriated surface is covered with
false membranes, the thickness of which soon becomes very cousider-
able, and which rapidly extend, beg accompanied by dreadful pain
and avery abundant suppuration. Is this the ordinary course of a
blister P Certamly not. If the surface of a wound caused by
cantharides is covered with false membranes, it is where the action.
CUTANEOUS DIPHTHERITE. 265

of the irritating cause has been long and energetically continued ;
but even in this case, we do not see the phlegmasia extend-
ing from point to point, and rapidly attacking the parts which have
not been at all in contact with the cantharides. If, however, this
were an isolated case, we should hesitate to draw any conclusions
from it ; but it is repeated in all localities and in all epidemics which
we have seen; at Chaumont-sur-Tharonne, at Saint-Loup, at Trem-
blevif, at Gragay ; and, besides, all the physicians have made the
same observation at Rebrechein, Loury, Marigny, Orleans, Saint-Cyr,
aud Cléry. M. Bretonneau had already expressly pointed it out in
several manuscript Memoirs which he has allowed me to inspect. We,
therefore, arrive at this experimental result; that when Malignant
Angina exists in any person, the application of blisters is often fol-
lowed by the most disastrous consequences, that the skin becomes
inflamed, covered with pellicular exudations, and gangrenous. Be-
sides, in the same communes and in the same houses, where the
irritation produced on the skin by cantharides is at present so
dangerous, blisters had previously been employed without the slightest
inconvenience, and we could always easily calculate the local effects
of this treatment.

What is the cause, then, of the difference now observed? Is it the dif-
ference of treatment? Certainly no one will believe it tobe so. Is it
the difference of the atmospheric constitution? If this were the true
cause, why do two adjoining villages and two contiguous houses pre-
sent such different phenomena? For while in the house of Josephine
Pressoir, which is situated at the northern extremity of Nouan-le-
Fuselier, the application of a blister was followed by symptoms
similar to those observed at Les Rois, situated at the southern
extremity; why was nothing of the kind seen in the intermediate
houses? Why, when the symptoms were so common in the
village of Marcilly, were they not observed at MénestreauP Be-
sides, the atmospheric causes are the same, the medicines are the
same, the physician is the same, and yet the results are different.
This variety, therefore, is not due to the physician, nor to the medicine,
nor to the atmospheric conditions; let us then look for the absent
cause in these who do not experience any extraordinary phenomenon ;
and for the presen¢ one, on the other hand, in the midst of those
who are struck suddenly with an unusual calamity. This cause is
necessarily pharyngeal Diphthérite; since this disease is the only
particular circumstance which can be recognised in those whose blis-
266 TROUSSEAU ON DIPHTHERITE.

ters also present peculiar appearances. This becomes still more
evident when we find the disease of the skin exhibiting the anatomi-
cal characters, the progress, and the tendency to spread from point to
point which are altogether analogous to what is observed in the
phlegmasia of the back of the mouth. In fact, just as the diphthe-
ritic inflammation of the throat attacks at first both the tonsils, then
the pharynx, and then at last the larynx and the bronchial divisions ;
so does the inflammation produced in the same patient by the influ-
ence of a blister, rapidly seize upon the back and the shoulders,
and becomes a speedy cause of death, if remedies are not applied
before the pain or the abundance of the suppuratjon has exhausted
the vital powers, and before the cutaneous tissue has mortified.

But we can conceive how the. action of cantharides may, under
certain circumstances, produce serious symptoms; and although it
does not appear to me reasonable to attribute the effects above de-
scribed to this cause, I think, nevertheless, that some doubts may
still remain in the minds of certain physicians. In order to remove
these doubts I shall now examine the facts under another point of
view.

It very frequently happens that those who are engaged in agri-
cultural pursuits, give themselves slight wounds, such as cuts,
punctures, and excoriations. Ulcers are common among the peasantry’;
tinea of the scalp is also a very common disease, and those coarse
persons who regard this disgusting complaint as a means of purifica-
tion, do all they can to keep up what they call the gourmes* of
their children, or at least they do nothing to cure them. To speak
of more simple affections, it is seldom that children do not occa-
sionally suffer from excoriations behind their ears, in the fold of the
thighs, &c.

All ‘these affections are so trifling that they never attract the
attention of the peasantry; and it will be readily admitted, that a
man may practise for a long time in the country without once seeing
them lead directly to a fatal termination. Then suddenly, in certain
villages, these very mild cutaneous diseases assume such a severe
character that death is the consequence, but a singular circumstance
strikes us from the first. This is, that out of ten villages, ten houses,
ten hamlets, there are half of them where nothing similar is observed,

* A word signifying mumps or glanders, but to which no correct corre-
sponding English name can be given.—(Ep.)
CUTANEOUS DIPHTHERITE. 267

and yet these villages, houses, and hamlets are pretty nearly in the
same locality. Thus in the town of Marcilly, in Villette, the
slighest excoriations sometimes become the causes of such severe
symptoms as to induce death; but nothing similar is observed at
Ménestreau, Saint-Cyr, or Vouzon ; symptoms of the same kind pre-
sent themselves at Chaumont-sur-Tharonne and Ivoy, but Neung,
and La Ferté-Beauharnois are exempt from them.

Besides this, some houses remain healthy in the midst of an in-
fected town; this is what we have seen at Marcilly, at La Ferte
Saint-Aubin, and at Chaumont; others are infected in the midst of
a village, where, up to a certain time, all are healthy ; and this fact
was observed at Neung, Nouan-le-Fuselier, and at Mennetou-sur-
Cher. On the other hand we find isolated farms, all the inhabitants
of which are ill; as at Colombier, La Grange, and Bouchebrant ; and
others where all persons enjoy excellent health.

This difference in the health of the inhabitants of one village and
one farm, had struck even persons who were unconnected with our
profession. Madame Briolet du Cyran, who lives in the chateau of
Louan, is very benevolent, and over the whole country enjoys a
well-deserved reputation in the treatment of evils (mau), and in
this denomination are comprised all kinds of sores—from ulcers to
the smallest wounds. She told us, and we shall repeat her expres-
sions :— That for the last eighteen months or two years, the
humours of the people of Marcilly were changed, and that their evils
were much more difficult to cure ; that the cerate which she had em-
ployed for fifteen years with the greatest success, now envenomed the
_ Wounds, and she was able to cure them only with Saturnine extract.”
It must be remarked as a very important peculiarity, that in the town
of Ménestreau, near Marcilly, nothing similar was observed, and that
no one had sore-throat at Ménestreau. Let me add that in the farms .
we visited, the different sores and wounds exhibited no unusual
severity except when some one in the house was suffering from or
had suffered from Malignant Angina, or rather what the peasants
called Le Chancre. In another. Memoir, I may return to this last
affection, which is nothing else than Diphthérite of the gums.

If we now examine the causes of these differences, we shall remark
that it is only in the locality where some one is dying of Malignant
Angina that wounds assume suddenly a character of severity which
they did not before present ; shalt we not then be forcibly led to this
conclusion, that the introduction of Diphthérite into a house is the
268 TROUSSEAU ON DIPHTHERITE.

only cause of these new symptoms? Is it possible not to see her

the relations of causes and effects? But there can remain no doubt
when the existence of the false membranes can be ascertained with
facility, and when the anatomical characters of the cutaneous phleg-
masia are the same as those of the inflammation of the back of the
mouth and of the larynx.

If then it is no longer possible to doubt that the affection which
seizes the skin of persons attacked with Malignant Angina is of a
diphtheritic nature, we are equally obliged to admit that the persons
who are in relation with those who have at once the epidemic sore-
throat and Diphthérite of the skin, or either of these affections, also
present cutaneous inflammations of an identical nature, although in
them the Angina has not developed itself. For in the first place, the
blisters which are applied to their bodies are equally covered with
false membranes, and may even cause death. In the second place,
the slightest inflammations of the skin assume in such persons the
serious character which we have remarked in others, and the conse-
quences are no less terrible. Lastly, to complete the parallel, we
find cutaneous Diphthérite commencing in a house, propagating
Malignant Angina in that house, in the same manner as the pellicular
Angina, when it has taken the initiative, becomes the cause of
cutaneous Diphtherite.
BOUCHUT.
CAUSES. 271

BOUCHUT ON CROUP.*

(DIPHTHERITE OF BRETONNEAU.,)

THE name of Croup is givento the disease of the larynx in which the
inflamed mucous membrane is covered by a fibrinous layer of new
matter, called false membrane.

3 Cavszs.

Croup is an affection which is much mote common in cold and
moist climates than in countries where the climate is temperate ;
it is a disease which especially affects the populations of the north of
Europe. It is developed particularly in children, and in boys rather
than in girls. It is observed in new-born children, and in children
at the breast, and examples of this kind have been related by Billard,
Dewees, and Trousseau. I have met with this disease in a child
eight days old. M. Scoutteten saw it in his own child, aged six
weeks. Still it is more frequent at the period of life comprised be-
tween two and eight or ten years. .

Although Croup is to be considered as a disease of infancy, it
must not be supposed that adults are exempt from its attacks. It
has been met with im young persons of eighteen to twenty years old,
and even in old subjects in their seventy-second year. M. Trousseau
has also observed it in persons of rather advanced years. He has
himself, in a case of this disease, performed tracheotomy upon a
woman who had attained her fortieth year.

Croup generally attacks the same individual only once; still, Home,
Vieusseux, Albers, and Jurime, quote some remarkable cases of re-

* Traité Pratique des Maladies des Nouveaux nés et des Enfans a la
Mamelle. 1852.

-
272 BOUCHUT ON CROUP.

lapse. M. Paul Guersant has seen a very curious example of
relapse, and has himself operated twice on the same child, at an in-
terval of two years. _

It is an epidemic affection. This character is difficult to be deter-
mined in Paris, where the greater number of our facts are disseminated,
and lost to an individual physician who, in his own practice, perceives
only a portion of the picture of the public health. There is in that
city no general epidemic ; there are only partial epidemics, developed
in one quarter, in one house, or in an Hospital devoted to children.
It must also be admitted that these epidemics are very rare, for there
has never been more than one at the Hépital des Enfans in Paris,
and then it was not clearly marked. The epidemic character is par-
ticularly revealed in small localities. It is impossible to mistake it
when we are observing it in the provinces and the country districts,
where nothing escapes attention, and where we can closely follow
the ravages which are caused by this disease upon the population.

Croup, then, is an epidemic affection. Jt generally presents itself in
the sporadic form, and it is thus that we usually observe it in Paris. Its
contagious nature is far from being demonstrated ; still, we must not
resolve this question in the negative, as Croup often succeeds Mem-
branous Angina, the contagion of which latter disease is no longer a
matter of doubt in the minds of physicians, for it has been demon-
strated in the most positive manner by the observations of Bretonneau
and Trousseau. It is, therefore, possible that Croup, which, in its
nature, very much resembles Membranous Angina, may, like it, be
communicated by contagion. I say it is possible, for in the present
state of science, we cannot express ourselves in a more positive
manner. It is consequently advisable to separate children affected
with Croup from other children who have not yet experienced any

attack.

PatHoLocicaL ANATOMY.

The presence of a false membrane on the surface of the mucous
membrane of the larynx, is the fundamental anatomical character of
the disease. Without this new product, Croup does not exist.

The false membranes present themselves under the form of thin
elastic layers, of a whitish-grey colour, and rather tough consistence.
They adhere more or less firmly to the mucous membrane ; they are
exclusively formed of fibrine; their form and extent are variable.
SYMPTOMS. 273

They occupy, in some subjects, the tonsils and the upper part of the
larynx, without penetrating into its interior. In others, this organ
is at the same time affected. In some cases they exist only in the
larynx; and in a small number of children they extend into the
trachea and into the bronchi as far as their smallest divisions.

They form, in the mouth, more or less extensive patches; they
often cover the epiglottis like the finger of a glove. In the larynx,
in the trachea, and in the bronchi, they form tubes which it is possible
to remove entire. I have collected several of these false membranes;
their dimensions are exactly those of the cavities in which they were
contained. Those which come from the bronchi perfectly represent
all the divisions of these tubes. Some have been found infinitely
divided like bronchial tubes and forming an excessively loose hair-
like mass of a very remarkable character.

Their upper surface is smooth and covered with plastic mucous
matters. Their lower surface which corresponds to the mucous
membrane is unequal and is scattered with very numerous red points,
which are very well described by M. Blache in his Memoir on
Croup.

These false membranes are all insoluble in cold water and even in
hot water. The sulphuric, nitric, and hydrochloric acids harden
these productions, and they also shrivel and detach them. Liquid
ammonia, and alkaline solutions dissolve them and convert them into
a transparent and diffluent mucus. It is important not to forget
these characters, which will be found useful to bear in mind in treat-
ing the disease.

The mucous membrane is thickened, and sometimes slightly
softened: its epithelium has disappeared; its surface is unequal,
eroded, and covered with a series of reddish points, which correspond
to the red spots placed on the inferior surface of the false mem-
branes.

Symptoms.

Croup presentsin its progress three periods, which it is almost
always possible to distinguish.

First period.—It is rather difficult to distinguish this period in
children at the breast. Thus, the shiverings and the uneasy
feelings which are observed in subjects in the second infancy pass
unperceived in those who are in the first. But in the absence of

T
274 BOUCHUT ON CROUP.

these signs, there are others more important, the study of which
ought not to be neglected. Young children who are affected with
this disease have some uneasy feelings, and a little fever; they have
sore-throat, their voice is hoarse and they cough pooudinally:

The cough and the hoarseness are two signs of extreme importance.
As soon as they are observed, the lower part of the mouth ought to
be examined ; the pharynx presents a more or less intense redness,
and on the tonsils false membranes are seen already formed. Some-
times we observe, at this period, an abundant nasal flux and false
membranes in the nostrils. On the body where there exists a wound,
or a blister, for example, its surface is often covered by a production
of the same nature.

The duration of this period is sometimes difficult to establish, for
the parents do not always perceive the commencement of the sym-
ptoms, and they are found to hesitate when they are questioned on
these points. In general this period lasts from four to five days, but
this limitation is by no means constant. There are circumstances in
which it has lasted only twenty-four hours.

Second period.—The symptoms of the second period are increase
of fever and of the general disturbance of the economy; dry cough,
returning by paroxysms which are at first slight and afterwards exces-
sively painful, followed by efforts of vomiting and even by the rejection
of matters in which there are false membranes ; hoarse and sibilous
cough, feebleness and sibilous character of the voice, difficulty of
respiration, and more or less anxiety.

The cough presents characters which deserve to be studied ina
special manner. It is hoarse, dull, and followed by a strange, and, as
it were, metallic sibilation. Its tone is very extraordinary, and re-
sembles a little the noise made by young chickens when they are trying
to crow. Much more generally, the cough is hoarse like the voice,
and often, like it, it is stifled or extinguished. __

When the cough is accompanied by expectoration (which is not
the case in young children), or when it is followed by vomiting, it is
necessary to examine the rejected matters. We may find in them
some false membranes, the form of which it may be useful to examine
when it is necessary to establish the seat of Croup. Thus, when
we find the false membranes tubulated, we may judge of the seat of
their formation by their dimensions. We may very easily recognise
the membranous tubes of the trachea, and those of the second, third,
and fourth orders of bronchial divisions.
SYMPTOMS. 275

The respiration is then more frequent than in the ordinary state ;
mucous and sibilant rhonchi are developed in the chest ; and these are
the only auscultatory phenomena which are observed at this period.
The disturbances of the respiratory functions are especially external.
They are betrayed by dyspncea, the dull colour of the face, the
anxiety of the countenance, and by the gestures and the attitude of
the child.

The skin of the face is pale, and its hue slightly bluish, the eyes
are sunk, and the lips are of a reddish-brown colour, indicating
venous congestion of the head. The dyspnoea supervenes by fits,
often after an effort of coughing; extreme anxiety is depicted on
the face; the child makes gestures to be placed in a sitting posture,
and he springs up into that postyre when his strength permits him ;
suffocation threatens him for a moment, and then these symptoms
disappear, and tranquillity rapidly returns.

This period is generally rather ‘short, and lasts from twenty-four
hours to two or three days. Then comes what is called the third
stage of Croup, the stage of struggling against asphyxia which
threatens to destroy the patient, and perhaps is about to do so.

Third period.—In the third period the cough and the voice are
altogether extinct; respiration is accompanied by a well-marked sibi-
lation which is heard ata distance; it is very painful, for all the
inspiratory muscles are in action; thus the muscles of the nose, of
the neck, of the abdomen, and the diaphragm contract energetically ;
the child appears overwhelmed by the disease; his face is
bluish, his pupils contracted, his eyes hollow, his lips cyanosed,
and his head remains thrown backwards. This state of depression
is, however, disturbed by violent fits of suffocation. In the midst
of sleep, after a fit of coughing, the respiration is embarrassed, the
face becomes blue, the looks restless and suppliant, and the child
raises himself forcibly carrying his hands to his neck before falling
into the arms of the persons around him.

Tf the termination of the disease is to be favourable, the symptoms
gradually lose their intensity. We observe a pradual decrease of the
preceding symptoms, respiration becomes more easy, and sibilation
no longer accompanies the respiratory movements, The fits
of suffocation disappear. The cough becomes less frequent and
more moist, and it gradually loses the character of hoarseness which
at first it presented. However, this modification, as well as the alter-

ation of the voice, still lasts a long time after the cure of the
T 2
276 ‘ BOUCHUT ON CROUP.

disease. At the time when the respiratory functions are restored, the
circulation becomes regular, the pulse resumes its ordinary character,
and the skin of the face and of oe rest of the body, recovers its
natural white colour.

Proaress.

The progress of Croup may be traced by the type which we have
just indicated. The disease begins in the back of the throat before
it extends to the larynx and the bronchi; it is a true Membranous
Angina becoming transformed into Croup. When we carefully ob-
serve children at the commencement of the disease, such is almost
always the case. Still, some well-observed, but very rare facts,
demonstrate that Croup may commence at once in the larynx and
bronchi. In these cases, the first period, such as we have
described it, is altogether wanting; and the disturbances of the
respiratory functions characterize the first appearance of the
disease.

Croup, then, generally presents three periods, when the disease
commences in the back of the mouth and extends into the air-
passages ; it presents only two when it begins in the larynx and the
bronchi.

It would be erroneous to believe that the false membranes ought
actually to be developed over the whole continuity of the air-passages.
This is fortunately not the case ; for although these accidental pro-
ductions, developed at first in the mouth, are always formed on the
epiglottis and on the borders of the aperture of the larynx, yet they
may not, perhaps, penetrate more deeply. The disease is then much
less severe. Its symptoms are in other respects the same as in the
cases where the development of the false membranes is much more
considerable, and when they extend as far as the bronchi.

The progress of Croup is almost always regular ; the symptoms suc-
ceed, in general, in the order which we have indicated; however,
there are sometimes rather well-marked remissions, which present
themselves towards the end of the second period. It may happen at
this time that some efforts of cough and vomiting carry away a great
portion of the plastic exudations which obstructed the larynx. Tran-
quillity then returns, but it is not of long duration. The false
membranes are again formed, although they are thinner than at first,
and the symptoms of dyspnoea are presented afresh. Thus, we
COMPLICATIONS. 277

observe in some children, two or three remissions of this kind, pro-
duced by the detachment of the false membranes, and their imme-
diate replacement by others.

Some authors have undoubtedly mistaken the nature of these
remissions, for there are some, and Jurine among the number, who
have admitted the existence of intermittent Croups. I do not think
that we ought to consider Croup with false membranes as an inter-
mittent affection. As soon as these exudations are established, a
certam number of symptoms make their appearance which are due
totheir influence, and which last as long.as themselves. We can consider
as intermittent only theCroups of former days, that is to say, the Croups
without false membranes, and the cases of false Croup and stridulous
laryngitis. These are truly intermittent; they return in well-
marked paroxysms, as we shall mention hereafter. In fact, wherever
there is a complete intermission of the symptoms, there can be no
true pseudo-membranous Croup.

CoMPLICATIONS.

Croup is almost always combined with Membranous Angina ; it
commences with this affection, as we may be convinced by observing
the back of the throat at the commencement of the disease. This
complication rapidly disappears, the false membranes of the mouth
fall off, and.if we examine children when the disease has been esta-
blished for some days, the buccal mucous membrane may appear quite
healthy. We may then believe that the Croup has commenced in
the larynx. This would probably not have been’ the ¢ase, if the
mouth had been examined on the first day of the invasion of the
symptoms,

Membranous Coryza sometimes .co-exists with Croup; this is a
complication of extreme importance in children at the breast. Tt
must be opposed by the most energetic means. The children can no
longer suck nor drink, for while they exercise suction at the breast
or the breast-glass, they breathe through the nose, and, in such a case,
this part is obstructed by the false membranes. As soon as the
children wish to suck, they are suffocated, and are obliged to leave
the breast in order to breathe more freely.

Sometimes oesophagitis and pseudo-membranous gastritis are
found ; but these complications are very rare.
278 BOUCHUT ON CROUP.

The most frequent and most dangerous complication of the disease
now under discussion, is lobular pneumonia. This observation has
been made by MM. Blache, Guersant and Trousseau, and has been
confirmed by all the physicians who have studied Croup. Pneumonia,
in the state of bronchitis in the first period, takes its own peculiar
character only towards the end of the second; 3 it is almost con-
stantly followed by a fatal termination.

We meet with lobular discrete pneumonia and confluent pneu-
monia. In some children it exists concurrently with a capillary
pseudo-membranous bronchitis.’ In this case the disease is beyond

. all the resources of medicine.

Croup has sometimes been observed in combination with hooping-
cough, phthisis, eruptive fever, &c. Among these diseases, only
scarlatina has a direct connexion with Croup. It is, as is well
known, pretty frequently accompanied by Membranous Angina, and
then there is everything to fear from the manifestation of Croup.

Diaenosis.

The diagnosis of Croup sometimes presents difficulties, for there
are other diseases of the larynx which are accompanied by symptoms
somewhat similar to those which it presents.

In simple laryngitis, the cough and the cry are hoarse, but we do not
observe the hoarse, feeble, and sibilant cough of Croup ; the respira-
tion is not accelerated, and there are no fits of suffocation as in that
disease.

The symptoms of oedematous laryngitis, or of edema of the glottis,
are more nearly allied to those of Croup. The cough is equall
hoarse and sibilant, the respiration is painful, and suffocation is im-
minent, but the fundamental character of Croup does not exist.
There is no expectoration of false membrane. This product does
not exist in the back ofthe mouth. Still, as it isnot always possible to
be sure of its non-existence, an error may be easily committed, and we
are liable to mistake these diseases for one another. We must, there-
fore, take notice of the progress of the symptoms, which is much more
rapid in cedema of the glottis than in Croup. There are besides few
chances of misapprehension ; for, as we have already said, cedema of
the glottis is a very rare affection in children. The mistake can never
be prejudicial to the patient ; for in both cases the medical treatment
¢

DIAGNOSIS. 279:

is the same; there is only one resource against asphyxia, namely, —
opening the trachea.

It is more difficult to distinguish Croup from pseudo-membranous
tracheitis. Their anatomical characters are the same; there may be in
both cases expectoration of false membranes ; but as M. Guersant re-
marks, the symptoms observed in these two states are essentially dis-
tinct :— Pseudo-membranous tracheitis does not present any of the
signs of the first period ‘of Croup ; it commences with a more or less
intense fever, and a dry, sharp cough, which causes a more or less
tearing pain ; the voice is low, but it is not extinguished as in Croup ;
the respiration is not sibilant; it is evident that the larynx is free. .
In the second period, the cough becomes more moist ; the respiration,
although difficult and rhonchous after the fits of cough, and between
the fits, presents nothing which can be compared to the dry and
metallic rhonchi of Croup, and to the paroxysms of croupal. suffoca-
tion. In the third period of this disease, the difficulty of respiration
increases, and after some violent fits of coughing, the patients throw
‘up membranous, ribbon-shaped shreds, of greater or less dimensions.
Then they become convalescent, if there is not at the same time an
attack of bronchitis or pneumonia, which is the cause of the prolonga-
tion of the symptoms.” —(Dict. de Méd., t. IX.)

‘The disease which has been most frequently confounded with
Croup and which has given rise to mistakes which are fatal in their
results, is false Croup or stridulous laryngitis. It is important to
establish a precise distinction between these two affections which
require entirely different therapeutical appliances. M. Guersant has
contributed more than anyone else to clear up this subject which
remained so long confused and obscure.

Stridulous laryngitis is accompanied, like Croup, with a dry,
hoarse, sibilous, and more or less sonorous cough. The difficulty of
breathing is extreme; the child appears as if about to perish of
suffocation ; still the larynx is free, and there cannot be any expec-
toration of false membranes. The phenomena which are observed
are purely nervous, they soon subside, and their progress is altogether
peculiar. They appear suddenly and ina very high degree of intensity
in subjects who are otherwise in good health or slightly affected with
cold. They manifest themselves in the middle of the night. The
paroxysm lasts about two hours, and is reproduced on the following
two or three nights in succession; but it becomes gradually more
feeble, and at last it disappears.
280 BOUCHUT ON CROUP.

. Croup presents nothing like this; for the symptoms increase gra-
dually, and suffocation presents itself only at the end of several days.
The fits appear by day as well as by night ; and they are reproduced
as long as the false membranes inclosed in the larynx are not thrown
up. Far from diminishing gradually, they become, on the contrary,
more alarming every moment, and they terminate by carrying off the
patient.

It will be observed, that there exists a rather close analogy between
the manifestations of these two diseases; between the cough, the
dyspnoea and the suffocation; but the similitude is only apparent.
When we carefully watch the progress of these symptoms, their
character is changed, and the interpretation which may be drawn
from them is necessarily changed likewise. This progress is so
different that it appears to me difficult henceforth to confound Croup
with false Croup, and pseudo-membranous laryngitis with stridulous

laryngitis.
PrRoenosis.

Croup is an affection of a very serious character which always en-
-dangers life. It is a disease difficult to overcome or to arrest in its
course. It is very often fatal. Nevertheless, we must establish
some distinctions according to the seat and the extent of the altera-
tions. When the false membranes developed in the mouth exist
only upon the epiglottis and at the superior opening of the larynx,
the disease may be cured by means of suitable treatment. It is
still the same when they do not pass beyond the limits of the larynx.
But if these products are extended to the trachea and the bronchi,
Croup is almost inevitably fatal.

The complications of this disease add still more to the seriousness
of the prognosis. Pseudo-membranous coryza, in children at the
breast, ‘is a very serious affection, as we have already shown, because
it exposes them to die of starvation. Lobular pneumonia may increase
the dyspnoea, and if the obstacle in the larynx is not of a nature to
produce fits of suffocation, the difficulty of breathing which accom-
panies the pulmonary inflammation does not fail to excite them.
In this case, if the child did not sink from the closure of the larynx,
it would die in consequence of the disease of the lungs.
TREATMENT. 281

TREATMENT.

The treatment of Croup has been advantageously modified in the
present century in consequence of the researches of two able physi-
cians, MM. Bretonneau and Trousseau. It is divided into two parts,
one medical and the other surgical. Formerly the first alone was
in favour; in the present day the second is definitively accepted, and
we are indebted for it to the two physicians whom I have just men-
tioned. ;

Blood-letting, revulsives, alteratives, emetics, and sternutatories,
form the basis of the medical treatment. Local medications and
tracheotomy belong to the surgical part of the treatment.

Before examining the value of these different methods, it will be
useful to understand the end which we propose to ourselves to fulfil
in putting them in practice. The due comprehension of the indica-
tions forms the basis of our therapeutics, which would otherwise be
only a blind and dangerous empiricism.

It is necessary to moderate the inflammation of the mucous mem-
brane of the larynx, and to destroy the specific character of this in-
flammation by blood-letting, revulsives, and alteratives. Tartarized
antimony, employed as an emetic, also contributes to this result ; but
it has, like sternutatories, a different action. It acts as a cnechanteal
remedy, and by the efforts which it occasions, it excites the expulsion
of the false membranes which are impeding respiration.

By means of local applications we may hope to favour the rapid
detachment of the false membranes, and when we are unable to
succeed in this object, and suffocation is imminent, tracheotomy then
becomes serviceable. It is a method of delay, by means of which we
may for a time save the lives of the little patients, even if we fail in
arriving at their definitive cure.

Blood-letting —A. period once existed when nothing was thought
more efficacious for subduing the specific inflammation which exists
in Croup, than the abstraction of blood. Experience has remarkably
contradicted this view, and it has been found that blood-letting does
not succeed in this instance as in ordinary inflammations. It is
useful only in strong and vigorous children, when the reaction is very
intense, and when, from the commencement, the breathing is found
to be so embarrassed that suffocation is immment. It is in general
dangerous with children at the breast, who are far from exhibiting
282 BOUCHUT ON CROUP.

the same strength of constitution. However, if it should be thought
necessary to have recourse to this measure, it is preferable to employ
bleeding at the arm rather than local depletion of blood. The latter
method has the great inconvenience of exciting the little patients,
who are frightened by the leeches, and are agitated to a dangerous
degree. The internal spasm which they suffer is, moreover, injurious
to the respiratory functions, and more rapidly induces asphyxia.
Moreover, in order to apply leeches, the children must be laid on their
backs, with their heads thrown backwards, a position which in itself
is sufficient to occasion suffocation. Lastly, the neck is the region
of the child’s body where it is most difficult to stop the bleeding from
the leech-bites. It cannot be compressed in this disease, without
danger of obstructing still more the entrance of air into the chest.
The leeches then allow blood to flow in abundance; and the results
are an anemic state of a very serious nature, and sometimes even
fainting followed by death.

We must, therefore, employ the greatest caution in taking blood
from children at the breast who are attacked with Croup. Bleeding
at the arm is preferable to bleeding by leeches. If, however, the
latter method is decided upon, care must be taken to proportion the
loss of blood to the strength and the age of the patients. Three
or four leeches ought to be sufficient, and it is better to repeat
them than to endanger life by an application of too great a
number.

Revulsives.—The employment of blisters on the neck and on the
different parts of the body does not produce such favourable results
as might be expected. Besides the uncertainty of their action, they
expose the patient to great danger. The wound which they make is
often covered by a false membrane, similar to that of the larynx,
which may extend to a great distance, constituting a second disease,
and one very difficult to manage. Thus, as the utility of blisters’
canhot compensate for such an inconvenience, it is advisable, I think,
to. banish them from the therapeutics of Croup. They may be of
service in exceptional cases, pneumonia for instance; but they are
employed less against the affection of the larynx than against the
complication.

Alteratives.—Alterative treatment has been especially employed
with the object of modifying the organism and, at the same time, the
nature of the diphtheritic phlegmasia. M. ‘Bretonneau has sanctioned
the employment of this method by numerous observations, and
TREATMENT. 283

MM. Trousseau, Guersant, Blache, and the majority of physicians have
derived much advantage from its use.

Mercury, sulphuret of potash, and sulphate of copper have been
successively employed; the first of these medicines is the most useful
of all. Mercurial frictions are usually resorted to on the upper part

_of the chest, the axille, the internal surface of the arms and the
thighs, and calomel is given internally. The frictions ought to be
employed night and morning, and calomel administered, in children
at the breast, in the dose of one, three, or four grams in the day.
This medicine promotes the expectoration and the rejection
of the false membranes. The cough is diminished and loses its
Special character in proportion as the difficulty of breathing ceases.

In children subjected to this treatment, there are copious alvine
evacuations and a discharge from the gums which is salutary when
it is not carried too far. As soon as the motions are too abundant,
the use of the mercurials must be discontinued, so as to avoid
throwing the patient into an excessive state of prostration. Saliva-
tion is excited with difficulty in children at the breast. When it
exists, it may be judged that the mercurial poisoning is very intense,
and we must interrupt the use of the medicines to avoid the superven-
tion of very serious symptoms such as gangrene of the mouth and
necrosis of the maxillary bones, which affections have been observed
by M. Bretonneau.

The internal use of sulphuret of potash has also been recommended
in the dose of twelve to fourteen grains each day, and sulphate
of copper in the dose of four grains in two portions, with an in-
terval of ten minutes, in a spoonful of syrup of gum; but these
methods require their efficacy to be established by new observations.
I shall not allude to them further, for it is useless to vary our thera-
peutical agents, when we cannot substitute more evidently useful
medicines for those which are already known. Mercury i is the best
of the alteratives with which we are acquainted, and it is impossible
to replace it by any other drug.

Emetics—Emetic treatment promotes the rejection of the false
membranes when they are ready to be detached, and assists in the
expulsion of the mucous matters which fill the larynx. This kind of
treatment is most usefully employed in the management of Croup.
Besides, one of the substances which is generally administered,
namely, tartarized antimony, produces a double effect. It acts asa
mechanical agent, as we have just said, and it has afterwards a well-
284 BOUCHUT ON CROUP.

marked alterative action; it modifies the nature of the blood, and
promotes the softening and the removal of the false membranes.

The emetics which may be given to children attacked with Croup
are ipecacuanha and tartarized antimony. The latter deserves
more confidence than the former. Ipecacuanha is given to children
at the breast in the dose of five or six grains, which may be
repeated in the same day. As to tartarized antimony, a draught
should be formed containing two or three grains of this substance,
and it should be taken in teaspoonfuls at a time, every half
hour, till it produces vomiting. It may be suspended at the third
vomiting, and it may be recommenced during the day, if necessary.
In general we must not fear to employ this method energetically, for
it can be useful only in this manner. If the tartarized antimony
produces too copious alvine evacuations, with a sensible alteration of.
the countenance, its employment ought to be immediately discon-
tinued.

Sternutatories.—Irritating fumigations with vinegar, and the
insufflation of snuff into the nostrils, have been employed against
Croup as mechanical agents for promoting the expulsion of the
false membranes. They can produce advantageous results only
when these accidental productions are floating and ready to be de-
tached. This may be considered the case when the character of
the respiration assumes a valve-like sound; when the cough is moist
and mucous, and when there is a tracheal gurgling, indicating the
presence of bronchial mucous matters.

Local Treatment.—In our local treatment, we make use of the
information acquired on the chemical composition of the false mem-
branes. We employ for their destruction the substances which have
the property of dissolving them, or detaching them by causing them
to shrink. Alkalies dissolve them, and acids shrivel them powerfully.

Cauterization by acids is the best method to employ. Weak
hydrochloric and nitric acids are usually applied ; or nitrate of silver in
the proportion of two drachms and-a-half to eight drachms of distilled
water. Itis necessary to use a small fine sponge, firmly fixed at the end
of a rod of whalebone, curved in a hook-shaped form; when the
sponge is soaked, it is gently squeezed and applied to the pharynx
and upon the glottis, so that some drops of the caustic liquid may
penetrate into the larynx.

This operation is exceedingly disagreeable to the child; it leaves
a very unpleasant taste in the mouth, and it induces violent efforts of
TREATMENT. 285

vomiting, which are very painful but salutary. It must be per-
formed at the commencement of the disease, if false membranes are
observed on the pharynx, and it must be repeated twice a day at
least, as long as these products exist on the surface of the mucous
membrane.

Although the cauterization of the back of the mouth and of the
upper part of the larynx is advantageous, it has also its inconveni-
ences which ought to be known in order to be avoided. Immediate
suffocation may be the consequence, if the sponge has been left too
long on the glottis, and if too great a quantity of liquid has penetrated
into the larynx. This accident is a very serious one, for it may
cause death, or at least may give rise to the necessity of immediately
performing tracheotomy. It may be avoided by the most simple
precautions; thus the cauterization ought to be made rapidly, and
the whalebone should be withdrawn from the mouth before the efforts
of vomiting are in full activity. On the other hand, the sponge
ought to be lightly squeezed, and should contain only a small quantity
of liquid, so as not to fill the larynx or the cesophagus, as I once saw
done by an inexperienced manipulator. In such a manner we improve,
as far as possible, this important medication of Croup, and we do not
endanger its success by imprudence and thoughtlessness.

‘ The different methods of treatment of which we have just spoken
are never employed exclusively. Each of them presents great advan-
tages when we know the proper use of them, and we must combine
their action in order to derive from them all the success which we
desire. The following are the results of my experience in this respect.

Three children fully attacked with Croup, were treated at the same
time by emetics and cauterizations; one of them at the Hépital Neckar,
under the care of M. Trousseau; the two others in the town. All
three were cured; but it must be stated, that in the application of
the remedies we took such precautions as were very favourable to the
result. ?

These patients were visited every five hours. At the commence-
ment. of the attack, the back of the mouth and the upper aperture of
the larynx were cauterized with nitrate of silver, and the operation
was repeated every day, three or four times in the twenty-four hours,
until the disappearance of the false membranes of the pharynx. At
the same time,.we gave also tartarized antimony during the day, at
one or two intervals, until vomiting was produced. The false
membranes were rejected from the mouth. The cough which was
286 BOUCHUT ON CROUP.

entirely inaudible, became gradually stronger, more moist, and
less hoarse. The voice by degrees resumed its intensity, and the
functions, disturbed for a time, recovered their natural state. It
appears evident to me, that these three children escaped death only
by the judicious employment of the two kinds of medication combined.
This result deserves to be recorded. It would have the greatest
value if, as may be hoped, other observations should be added in its
support.

Tracheotomy.—When all the preceding means have failed, and the
disease, becoming every day more serious, has produced that state
approaching asphyxia, in which a fit of suffocation may involve the
death of the child, there is no more time for hesitation, and we must
open artificially a new passage for the external air; we must, in fact,
practise tracheotomy.

This operation is not new. It was formerly put in practice
in the case of patients suffocated by different forms of Angina and
by Croup; but it had been abandoned. In our own time it has
again come into favour, thanks to the perseverance of MM. Breton-
neau and Trousseau. These physicians have rendered a true service
to humanity and science, for tracheotomy is, in fact, the only resource
in the last period of Croup.

The operation is performed with facility as will be seen hereafter ;
it presents no danger in itself, and if it does not succeed more fre-
quently, it is because the cases in which it is employed are really
beyond the resources of art. Thus tracheotomy has the greatest
chance of success when it is performed ona child suffocated by Croup
of the larynx; it has much less chance when the false membranes
descend into the trachea; and it may be said that there is no chance
at all when these false membranes extend as far as the bronchi.

Still, as the precise seat of Croup is ascertained with difficulty,
we must, in every case, at the period of asphyxia, and unless there
are serious complications, decide upon performing the operation.
Immediately after tracheotomy, the respiratory functions are reés-
tablished, and we observe the fits of suffocation disappear, at least
for a time. The children revive; some resume their amusements
and appear to enjoy an unexpected degree of health. Unhappily
this condition does not always persist in a definitive manner; the
symptoms of asphyxia reappear, and death is the consequence.

In any case tracheotomy uniformly results in the prolongation of
the life of the patients. Such a resource is not to be despised, for
TREATMENT. 287

in this period of respite, the false membranes of the larynx and
trachea may be thrown up, and the inflammation of the mucous
membranes may be dissipated.

Tracheotomy is, therefore, the ultimatum of the therapeutics of
Croup. ‘The physician ought always to be ready to operate, under
such circumstances, when the fits of suffocation are multiplied, and
when asphyxia is imminent.

The following are the rules to be observed in the performance of
the operation. M. Trousseau has laid them down in a very precise
manner, in a chapter of the work of MM. Rilliet and Barthez, and
still more recently in an article in the Union Medicale. He explains
himself in the following terms on this point :—

“When we have determined to practise the operation, ought we
to perform tracheotomy or laryngo-tracheotomy ?

“ Those who especially advocate simplicity in an operation, prefer
laryngo-tracheotomy, and they base their practice upon the following
considerations :—

“Fewer parts are concerned; very few veins are found; the air-
tube is more superficial, an inestimable advantage in children whose
neck is thick and short. We never run the risk of wounding the
innominata artery or the common carotid of the left side, which in
certain abnormal conditions, crosses the trachea. ‘These considera-
tions are not without some value.

“T confess that the operation is more easy ; but as to the imme-
diate dangers of tracheotomy compared with those of laryngo-bron-
chotomy, I cannot very well make the comparison, for having per-
formed the operation of opening the trachea a hundred and twenty-
one times, I have never had any immediate mischances to deplore, ©
except in an adult who died of syncope at the moment when I made
the section of the skin. It may have happened to me, undoubtedly,
to meet with some arterial anomaly ; butas I have always taken care
to operate very slowly, and not to give a single cut with the bistoury
without being safely guided by my finger and my eye, I am persuaded
that I should avoid the left carotid, even if it sprang from the in-
nominate trunk and crossed the upper part of the trachea. As to
the innominata, I have had it several times under the edge of my
bistoury ; but by inclining my section to the left, and in separating
all the tissues with my finger and the hooked forceps (erigne), I have
terminated these operations which are apparently so dangerous, with-
out fear and without untoward accidents. ‘The surgeons who boast
288 BOUCHUT ON CROUP.

of performing the operation with wonderful celerity, and who boldly
plunge the bistoury into the trachea to divide it from below upwards,
as soon as they have terminated the incision of the skin, may conclude
by deploring their imprudent and useless rapidity, when they find
under the edge of the knife, some vessels which it is easy to avoid if
they have more regard to operating safely than to operating quickly.

“By the side of the above-mentioned advantages of laryngo-
tracheotomy, which have no very great value, let us endeavour to
place its inconveniences.

“In the case of Croup, the introduction of a canula, which is to
remain in the wound, is an indispensable condition. This canula
ought to be of considerable size; it should remain in the aperture
at least six days and sometimes fifty. The canula, besides, is fixed
below the thyroid cartilage, through the crico-thyroid membrane,
and between the lips of the divided cricoid cartilage. At the point
of contact of the canula there arises a violent inflammation from the
purulent infiltration which, at the time of the tracheotomy, almost
constantly induces denudation and necrosis of the cartilages which
are adjacent to the lips of the wound in the trachea. What happens
in the cartilages of the trachea will happen in the cricoid and thyroid
cartilages; and that which, in the trachea, cannot entail any kind of
accident, because the elimination of the necrosed products takes
place easily and without appreciable contraction of the air-passage,
will become, on the contrary, in the larynx itself, the cause of the
most serious complications ; for, when the Croup is cured, it will then
be necessary to cure the necrosis of the cricoid and thyroid cartilages.
Besides, in this part, the enucleation of the necrosed portions is ac-
companied with chronic inflammation and suppuration; and it is to
be feared either that the skeleton of the larynx may remain ever
afterwards distorted, or that the tumefaction of the laryngeal mucous
membrane may cause orthopneic symptoms as serious as those of
Croup, or that at least the voice may remain ever afterwards im-
paired.

“These considerations alone would be sufficient for the rejection
of laryngotomy in the case of Croup. There is still another, which,
although having less value, no less deserves to be placed in the balance;
it is, that by tracheotomy we open the air-tube much lower down,
and in a point which the false membranes have not yet reached, or at
least which they will reach later than the larynx; so that in opening
the trachea we have more chances of being able, by opportune
TRACHEOTOMY. 289

treatment, to prevent the extension of the disease into the
bronchi.”

(Here M. Trousseau describes and figures the instruments used in
the operation.)

“The child is laid upon the mattress ; the cushion is placed under
the neck and shoulders, so that the head is thrown well backwards
and the trachea projects. If the cushion is only under the neck, the
little patient, at the first stroke of the bistoury, draws the chin near
the sternum, and tends to slip downwards, and the trachea sinks, and
shortens itself so much that it is sometimes difficult to reach it. I
have many times.seen an extremely laborious operation become
simplified in a moment, merely by placing the cushion under the
shoulders at the same time as under the neck.

“ Before making the incision in the skin, I trace, with a burnt cork
or a little ink, a line, which passes under the lower part of the thy-
roid cartilage to the superior notch of the sternum. In this manner
the incision of the skin is made in a straight direction, and the
course of the bistoury is the better secured during the rest of the
operation. This little precaution, which surgeons may regard as
superfluous, is very useful for unskilful physicians like myself, and
I cannot tell how many times I have had reason to be grateful for
having observed it.

“The operator being placed on the right of the patient, if he
uses the right hand, makes a fold of the skin, one side of
which he confides to the assistant who is opposite to him, and he
cuts this fold in its whole thickness, following the line’ previously
traced. : :

“ He then cuts upon the median line, and separates the pairs of
the muscles, either with the blade of the bistoury, or, what is better,
with a grooved director, taking care to separate with the hooked
forceps those of the left side, while he himself, with another pair of
forceps, separates those of the right. He then meets with a rather thick
layer of cellular tissue, the plexus of the thyroid veins, and the bridge
which unites together the two lobes of the thyroid body. Up‘to this
time, the operation presents no difficulty and demands no particular
care ; but. now some circumstances present themselves which require
a little more attention. The veins of the thyroid plexuses most fre-
quently pass almost parallel to the axis of the body; and with some
attention we may succeed in not cutting them, although cutting lightly

U
290 BOUCHUT ON CROUP.

the cellular tissue which unites them, and separating them with the
hooked forceps. When they completely cross the trachea, which
sometimes happens, they may be tied on both sides before cutting
the part which cannot be avoided, and then the incision is made
between the two ligatures. Ihave never yet tied the veins in a child ;
but I can understand why an inexperienced operator should wish not
to cut any large veins, for the violence of the hemorrhage may dis-
turb him and make him act with too much precipitation. If, however,
a large vein has been cut, do not be afraid, place one finger in the
inferior angle of the wound and another in the superior angle;
sponge, and wait, and generally before a minute has elapsed, the flow
of blood will be reduced to a very small quantity.

“Tf the bridge of the thyroid body presents itself under your
bistoury, never hesitate to cut it through the middle; you will gene-
rally havea jet of arterial blood as large as a thread which ceases
after some seconds; and by this section you will have remarkably
facilitated the operation.

« Then continue the incision in the median line after introducing
the index finger of your left hand in order to assure yourself that
you are in front of the trachea and not on the side of this tube ; do not
make a cut with the bistoury unless you have sponged the part
previously ; always separate with the hook all the parts you have
cut, and you will thus arrive at the cartilages of the trachea, which
you will recognise by their white colour and their hardness. Do
not yet be in a hurry to cut into the air-passage; lay bare three or
four rings, suspend the operation for a moment, and place within
your reach, and in some measure under your hand, the blunt-headed
bistoury, the dilator, and the canula. When all these are prepared,
carefully sponge the bottom of the wound and the trachea, and make
a very small puncture in the trachea with the point of your bistoury.-
As soon as you have heard the hissing sound of the air, put the in-
dex finger of the left hand on the passage which you have just
made, take your blunt-headed bistoury, and plunging it into the
trachea, cut upwards and downwards, so as to make an opening at
least half an inch long. Do not be alarmed at the introduction of a
little blood into the trachea and at the noise made by the air, the
mucus, and the false membranes escaping by the incision; intro-
duce your dilator, open the wound in the trachea, take the canula in
the left hand, make it pass between the two open branches of the
dilator, and when you hear the air passing through the canula, re-
TRACHEOTOMY. 291

move the dilator, make the child sit down, tie the strings of the
canula behind the neck, and the operation is finished.

“The little hemorrhage which may still exist is arrested; a
violent cough expels the blood and the mucous matters which may
be present in the bronchi, and the respiration is soon calmly
established.

“ Surgeons may find all these details very puerile. Physicians who
have not yet performed tracheotomy, and also those who have already
performed it, will, perhaps, thank me for having entered into these
particulars.

“ But this operation, which is so simple in the child, is very labo-
rious in the adult. In the latter case it is necessary to tie the cut
vessels, from the fear of sometimes seeing hemorrhage continue after
tracheotomy ; in the adult also, we must never open the trachea unless
the bleeding is arrested. In eleven operations for tracheotomy
which I have performed on the adult for chronic affections of the
larynx, I have several times had occasion to repent most seriously of
not having taken the most minute precautions. I have, however,
never tied any vessels, but twice I met with serious hamorrhages
which were prolonged after tracheotomy, and which I had much
difficulty in arresting. If I were obliged again to perform this opera-
tion under similar circumstances, I should not hesitate to tie
all the great vessels which might pour out blood, and I would not
open the trachea until I was perfectly secure from hemor-
rhage.

* Accidents during the operation.—The accidents which occur
during the operation are:—Hemorrhage. We have just remarked
how rare hemorrhage is, and how little severity it exhibits. If it
had happened that we had divided a great number of thyroid veins
and the blood was flowing in streams, it would be essential to fix the
trachea between the ulnar border of the index finger and the
radial border of the middle finger, passed down as far as the verte-
bral column, and to divide the trachea freely and rapidly from below
upwards, and then to introduce the dilator at the same moment ;
thus hemorrhage would be arrested. I do not speak of such hemor-
rhage as might result from the section of a thyroid artery, or even from
a wound of the brachio-cephalic trunk ; in such a case it would be evi-
dently necessary, in order to save the life of the patient, to tie the vessels
before terminating the operation. I do not know whether this mis-
fortune has ever happened ; but I have several times felt the trunk

U2
292 BOUCHUT ON CROUP.

of the innominata beating under my fore-finger, and I should, un-
doubtedly, have wounded the vessel if I had directed my bistoury
incautiously into the inferior commissure of the wound.

“T have seen a patient die of convulsions during the operation ;
this was a man fifty-two years of age, on whom I operated at the
Hotel Dieu for a laryngeal affection which induced extreme suffoca-
tion. The patient, in place of being laid in the recumbent posture,
was seated in an arm-chair, which was a great error on my part. I had
scarcely cut the skin when an epileptiform convulsion occurred. I
was imprudent enough to continue, and before I had reached the
deep cervical aponeuroses, a second convulsion ensued which was
immediately followed by death. I placed the patient in bed; I cut
into the trachea; I introduced a canula; but the divided vessels
allowed the blood which had not been expelled, to flow into the
trachea, and nothing revived the patient, who had been perhaps the
victim of my inexperience.

“T have several times seen asphyxia supervene, and respiration cease
during the operation; in these cases the patient was in a state of
apparent death. I terminated the operation as quickly as possible and
introduced the canula; then having placed the patient on his side if
any blood flowed into the trachea, and on the back in the opposite
circumstances, I made, on the abdomen and the chest, alternate
pressure to drive the air from the chest and to bring it back again,
and thus all my patients were restored to life.

«Syncope is an accident which is far more common. It manifests
itself generally immediately after the operation, at the moment when,
the respiration becoming free, the cerebral congestion suddenly ceases :
I once saw it last for nearly an hour; but it was never fatal. I con-
tent myself by dropping cool water on the face, and also throwing
a few drops into the trachea, while mopping out that tube
rather briskly; and at the same time I make the patient lie
down.

“As to the introduction of blood into the trachea, on which much
stress has been laid, I have never seen this occurrence lead to any
serious results, provided we make use immediately of a dilator to
keep the lips of the trachea wide open, or rather if by any means we can
succeed in immediately introducing a wide canula ; for if, after having
incised the trachea, the surgeon gropes about and cannot introduce
the canula, during each movement of inspiration the blood is sucked
TRACHEOTOMY. 293

into the trachea; and as the air cannot penetrate there at the same
time, an almost immediate asphyxia may be the consequence ; added
to which, the hemorrhage may continue, because the respiration
remains still embarrassed.

“ But if, on the contrary, the dilator holds the wound in the trachea
open, the air penetrates with facility, rejects powerfully the small
quantity of blood which has been introduced, and the return of the
normal respiration causing the. hemorrhage to cease, the introduction
of blood no longer takes place; and if, by chance, some little blood
still flows trickling into the bronchi, the patient can generally get rid
of it without assistance, and a little sponging is sufficient to assist
in this expulsion, which is not very difficult.

“The respiration generally becomes very easy immediately after
the operation. If it remains embarrassed, it is because some clots of
blood, or some false membranes are filling up the principal bronchi.
When there are some clots of blood, it is sufficient, while the trachea
is kept open by means of the dilator, or even after the introduction of
the canula, to instil once or twice some drops of cold water into the
bronchi.

‘When there are false membranes in the trachea, it is proper to
leave the dilator in the wound until the removal of these foreign
bodies, the expulsion of which is likewise promoted by some instil-
lations of cold water into the bronchi. Sometimes in spite of this
proceeding, the false membranes remain fixed by the roots which
they have thrown out in the lung, even when their upper part is de-
tached and floating. In this case, we must try to seize them with
the forceps, between the lips of the wound, and exercise upon them
a very slight degree of traction which is generally sufficient to remove
them.

“The wound is covered with a layer of waxed plaister, pierced with
a hole for the passage of the canula, and a double canula is afterwards
introduced and firmly fixed by means of its two strings tied together
behind the neck. When the operation is finished, the neck of the
child is enveloped in a cravat, in such a manner that the expired
air is partly taken back, preserving its warmth and especially its
humidity. From this arrangement it results that the mucus of
the trachea and of the bronchi no longer hardens, that the expec-
toration is easy, and that the injections and the sponging are never
necessary.
294 BOUCHUT ON CROUP.

“Every time that the respiration appears to be embarrassed, and
even without any such embarrassment, it is necessary, about every three
hours, to withdraw the internal canula in order to clean it, and then put
it back immediately in its place. ‘The wound is sometimes covered
with false membranes, and as soon as they present themselves they
ought to be strongly cauterized night and morning with hydrochloric
acid.

“‘ When, about the fourth or fifth day, the disease appears to be
advancing towards a favourable termination, we must not be afraid to
allow the canula to be a little obstructed, in order that the air, in
making an effort against the larynx, may displace the mucous matters
and the false membranes, and may force for itself a passage through
this organ. We may thus measure tolerably well the degree of

‘permeability of the larynx. This is the more important, as the
capital precept in tracheotomy is to withdraw the canula as soon as
possible.

* As soon as the canula is removed, the edges of the wound are
brought together by adhesive plaister. This dressing, which is re-
newed two or three times a day, is sufficient in the greater number
of cases. A few days are generally sufficient for the wound in the
trachea to close completely, and then there remains only the solution of
continuity of the deep tissues and of the skin, which soon cicatrizes
and leaves a scar which is not.very unsightly,

“Tn one case only was I able to remove the canula definitively at
the end of four days; sometimes from the sixth to the eighth;
generally from the tenth to the thirteenth ; once on the forty-second
day; and also once on the fifty-third day. When no untoward cir-
cumstance occurs, the passage of the larynx is re-established from the
fourth to the thirteenth day. I have not yet seen in a single case
an air-fistula remain after tracheotomy.”

Of the treatment after the operation.—Formerly, M. Trousseau,
hike M. Bretonneau, performed tracheotomy only in order to inject
caustic solutions into the trachea and the larynx, for the purpose of
detaching the false membranes and removing them by the aid of
brushes (écowvillons). At present, M. Trousseau has renounced this
practice which he considers dangerous, and he contents himself with
only cauterizing the edges of the wound if they are covered with false
membranes, or the interior of the mouth if these products still exist
upon the tonsils,
LOCAL TREATMENT. 295

He also places the children in a well-ventilated room, at a. mild
temperature, with their necks surrounded with some network or a
loose woollen cravat, and an assistant withdraws the canula every two
or three hours in order to clean it.

“ After the operation, children drink and eat with extreme facility.
This facility generally remains for four or five days, but then it is
perceived that there is something rather amiss in their mode of swal-
lowing. Every time that they drink, a convulsive cough ensues, and
some drops of drink are seen to spout forth through the canula.
This occurrence is generally observed for five, ten, or even fifteen
days, especially when the. children drink quickly. It even persists
when the canula is removed, and the wound in the neck is exactly
closed. Most commonly the quantity of liquid which thus passes
through the larynx is inconsiderable, and causes only a slight incon-
venience ; but sometimes almost the whole of the drink enters into
the trachea and the bronchi, causing severe inflammatory symptoms,
and the children then refuse anything whatever.

“T make it almost an invariable rule, when this accident happens,
to deprive the children of drink, and to give them thick soups and
particularly vermicelli, macaroni boiled in milk or made into soup,
but removing the milk and the soup; fish, meat lightly boiled, in
rather large pieces; and thus I avoid untoward symptoms such as I
have mentioned. Then they swallow solid food, and with their
strength the facility of deglutition is restored, and soon the children
are able to drink, provided they do so slowly.”

The local medication of M. Bretonneau, which M. Trousseau
appears at present to abandon, ought to be employed only in the
following manner :—

“Tf the child is vigorous, and has energetically expelled the false
membranes contained in the air-passages, and if, after the operation,
the respiration is very easy, then before introducing the canula, we
instil into the trachea, at two or three intervals, fifteen or twenty drops
of a solution made with twenty-four grains of nitrate of silver to seven
drachms and a half of distilled water. This instillation is repeated four
times the first day, three times the second and third day, once or twice
the fourth day ; and then it is discontinued.

“ Concurrently with this treatment, we pass into the trachea a
kind of brush (écouvil/on) made with a very small. sponge fixed at
the extremity of an extremely flexible piece of whalebone and dipped
296 BOUCHUT ON CROUP.

in a concentrated solution, of fifteen grains of nitrate of silver in a
drachm and a half of distilled water,

“We may be satisfied with this last method if we have reason to
suppose that the larynx alone has been attacked. The cauterization
by means of the sponge ought to be performed as long and as often
as the instillations of the cleansing solutions.

“Tnstillations of water and the spongings (¢cowvillonnements) still
hold an important place in the treatment. If the cough is moist, and
the expectoration is easy, there will be no necessity for instilling
the water. Under the contrary circumstances, we may instil, once
or twice in an hour, eight or ten drops of tepid water, which will
mix with the mucous matters, will soften them, and favour their
ejection.

“Tt will be always necessary to instil water after having applied
to the trachea some solution of nitrate of silver, in order to divide
the mucous matters which may have been coagulated and to facili-
tate expectoration. The instillations of water ought to be per-
formed several times in the hour; when the respiration is frequent
and serratic, that is to say, imitating the noise of a saw cutting a stone,
it will be necessary to practise them after each sponging.

“Tt will be necessary to sponge (écowvillonner,) every time that the
canula or the trachea appear obstructed. The sponging will be ren-
dered more efficacious by a previous instillation of water. If we
hear in the trachea a valve-like sound or a peculiar hissing noise
which gives us reason to suppose that there are some false membranes
floating about, it is necessary to sponge at several intervals until the
false membranes are detached and expelled. The sponging will never
be more efficacious than when it is practised at the moment when
the canula has just been removed, and when the lips of the wound
in the trachea are held open by means of the dilator. The sponging
is the more necessary in proportion as the symptoms which follow
the operation are more severe. It never causes any untoward
results; it is always followed by a much greater calmness of respi-
ration, even when the children are in their last moments, and
when the sponge draws away neither mucous matters nor false
membranes.”

Although the success of tracheotomy is not very striking, yet the
results are such as ought to encourage its adoption by a physician
placed in charge of an infant half asphyxiated by Croup. On the one
APHORISMS. 297

hand, M. Bretonneau, in twenty operations, saved six children ; out of
one hundred and sixty, I have saved forty-five. M. Leclerc of Tours,
who has adopted the same treatment, reckons one favourable case in
two operations. M.Velpeau has cured two children in ten. M. Pétel of
Cateau Cambresis, who has followed the same system, has performed
successfully three operations out of six which were operated upon.
Thus out of one hundred and ninety-eight cases of tracheotomy we
reckon fifty-seven cases of success; that is to say rather more than
a fourth.

APHORISMS.

Croup exists from the time when fibrinous false membranes have
been effused on the mucous membrane of the larynx.

A veiled, hoarse, dull cough, followed by a metallic hissing sound,
and accompanied with fever and gasping, reveals the presence of
Croup.

In Croup, the feeble cough and voice, joined to noisy, rasping,
serratic respiration, announce the fits of asphyxia and death.

Croup, arrived at the period of fits of suffocation, is fatal.

There are cases of Croup which get well, and others which are
cured.

Croup ought to be treated by repeated emetics, alternating with
doses of calomel.

A case of Croup which has arrived at the period of fits of suffo-
cation, when death appears to be approaching, ought to be imme-
diately treated by tracheotomy.
EMPIS.,
DEFINITION OF DIPHTHERITE. 301

EMPIS ON DIPHTHERITE.

ResEARCHES ON DIPHTHERITE, FOUNDED UPON AN EipIDEMIC OF THIS
DISEASE OBSERVED AT THE Hoprrat NEckEr, In 1848.
By G. 8. Empis.

(Archives Générales de Médecine, 1850.)

 

DipHtHERite (6vfOepa, membrane, pellicle,) is the term by which
M. Bretonneau, in 1826, described an affection which, although far
from being new, had, up to that timeabeen mentioned by noso-
graphers under denominations almost as varied as the different parts
of the body where it may develop itself. Since the excellent works
of M.Bretonneau upon this disease, the result of his researches has been
to establish and demonstrate the unity of nature in an affection of
which the morbid lesions are very different in relation to their situation
on the body, but only different in situation; and in consequence, it
appears that under the influence of an erroneous interpretation of
the descriptions given by the celebrated physician of the Hospital
of Tours, most physicians have learned to apply the epithet diphthe-
ritie to every pseudo-membranous production, whatever may be, in
other respects, its characters and nature.

Tf in a child at the breast, affected with enteritis, the mucous mem-
brane of the mouth is seen covered with a whitish pseudo-membranous
layer, itis Diphthérite! A phthisical patient, in the last stage of ma-
rasmus and emaciation, exhibits as the last complication an eruption of
muguet on the tongue and the mucous membrane of the mouth, and
it is Diphthérite! If ina patient attacked with Scarlatina the specific
cause of the bucco-pharyngeal inflammation is seen to produce a
plastic and pseudo-membranous exudation, it is still Diphtherite! I
shall not pursue further the enumeration of all the exudations to which
we every day hear the denomination of Diphthérite applied.

Having had occasion to observe an epidemic of Diphthérite last
302; EMPIS ON DIPHTHERITE.

year, at the Hépital Necker, I have profited by this. circumstance to
study thoroughly the pseudo-membranous exudations which are pe-
culiar to this disease, and I have been enabled to convince myself
that they possess characters sufficiently marked to prevent us from
confounding them with the exudations peculiar to other diseases.

I do not give, in this Memoir, a particular description of the
different forms presented by Diphthérite in relation to the localiza-
tion of its products on the different parts of the body; for to study,
in all their details, Croup, Membranous Angina, the Diphthérite of
wounds, &c., would be to write a complete Treatise on this disease,
and this is not my object. I purpose only to study Diphthérite in
general, and as it has presented itself to my notice in the epidemic
which I have been enabled to observe.

I shall therefore treat the subject in the following order :—

1. The pathological anatomy and physiology of Diphthérite, endea-
vouring to describe clearly the characters of the false membrane
peculiar to the disease.

2. I shall offer a few reniarks on the general state of health under
which the false membranes are developed.

3. I shall treat of the diagnosis and draw a parallel between the
different pseudo-membranous exudations observed in different diseases
distinct from Diphthérite.

4, I shall glance at the progress of Diphthérite, and at its pre-
sumed causes. ,

5. Lastly, I shall offer some observations upon the prognosis and
treatment of the disease.

Diphthérite is a specific disease, characterized anatomically by the
development of a perfectly specific pseudo-membranous exudation
on the mucous or cutaneous surfaces.

I shall not, bhke~some authors, take upon myself to criticise the
denomination given to this disease: by M. Bretonneau; it was indis-
pensable to find a new word which might be applied to the same
affection, whatever might be, in other respects, its localization in the
economy ; this word was Diphthérite. If it presents the serious in-
convenience of being capable of application to affections of a totally
different nature from that of the disease which it ought to designate,
it has, at least in the present day, this advantage, namely, that it has
been current in science for the last twenty-five years, and by that
very circumstance, requires no longer to be created.
DEVELOPMENT OF DIPHTHERITE. 303

“ PaTHoOLOGICAL Awatomy AND PHystoLocy or D1ipHTHERIts.

The study. of the false membranes which constitute the patho-
gnomonic character of the disease, ought in the first place to engage
our attention. The differences which exist between the false mem-
branes developed on the mucous and cutaneous tissues, are not
sufficiently marked to prevent us from giving one general description
of this exudation.

The evolution of the diphtheritic pseudo-membrane may be divided
into three periods; first, the period of development, second, the
period of complete formation, and third, the period of decline and
cicatrization.

1. Period of Development.—tIt is often difficult to discover the
first modifications presented by a part which is covered with the
diphtheritic membrane, and to ascertain by observation the phenomena
which precede the specific exudation. The reason is to be found in
the extreme rapidity with which the muco-serous liquid covering a
wound or an inflamed portion of mucous membrane, suddenly
changes its character in order to be converted into a pseudo-membrane.
Still, when I have been warned by the appearance, in a patient, of
some points of Diphthérite and have suspected the repetition of this
formidable affection on other points previously excoriated or inflamed,
I have observed that the exudation of a sero-mucous, transparent,
slightly viscous, and ropy liquid, preceded the appearance of the
pellicle on the affected part. This serous liquid is sometimes very
abundant, and in some cases there would even be, in the vicinity of
a part already covered with pellicular exudations, a kind of sub-epi-
dermic exudation, sufficiently considerable to raise the epidermis under
the form of phlyctens, by the rupture of which the dermis, being
exposed, soon becomes covered with the false membrane. Th’s
mode of development was very evident in one of the children whose
case fell under my observation, and an analogous case is related by
M. Trousseau in his Memoir on Cutaneous Diphthérite. But I shall
return to that subject when treating of the methods by which the
disease is propagated, and it is sufficient at present to state that the
presence of this liquid appears to me always to precede the develop-
ment of the false membranes, which are only an ulterior modification
of it.

In fact, this liquid when once exuded, rapidly acquires more
304 EMPIS ON DIPHTHERITE.

density and cohesion, and adheres, so to speak, more intimately to
the surface which secretes it. It soon presents, at different points
of its surface, little spots which are less transparent and gela-
tiniform, soon assuming. a yellowish tint, and which, at the com-
mencement of their appearance, being isolated from one another,
although imperfectly circumscribed from the rest of the liquid from
which they emanate, yet terminate after a time by uniting and being
confused together. By these means a kind of pellicle is formed,
still very delicate and having little cohesion, which I regard as the
first stage of the false membrane, or, if such a view should be pre-
ferred, which is in reality only the pseudo-membrane itself at the
period when it has just begun to form.

In fact, a sero-mucous liquid, perhaps of a specific nature, is
exuded on the surface of a raw part, and by a kind of coagulation
of this liquid the wound is covered with its first pellicle.

2. Period of maturity.—If this pellicle is studied in its fully
formed state, it will be found that it is the more thick in pro-
portion as we pass from the centre to the circumference of the:
surface which it invests. It is slightly opaque, so as to conceal the
condition of the part which it covers, and it presents, during the
whole period of its extension, some limits which are often made more
appreciable by a border of a rather vivid colour which circumscribes
it, than by the sudden cessation of its substance. This first pellicle
may still be removed rather easily from the surface of the affected
tissues ; but in consequence of its slight cohesion and its want of thick-
ness, it is rather difficult to obtain large strips of it. The dissecting-
forceps which are generally used for this purpose, tear away between
their points some little, membranous, very narrow fragments, which are
separated from the rest of the pellicle under the influence of a slight
degree of traction.

The removal of this rudimentary membrane is generally effected
without occasioning the bleeding of the wound, as may readily be
supposed. In fact, the deep surface of this pellicle is still immersed
in the serous matter which is exhaled on the surface of the wound, and
which is found intermediate between this surface and the diphtheritic
exudation; then gradually the serous exudation just described,
still continuing to be poured out, is superadded to the internal
surface of the pellicle, is incorporated with it, and increases its thick-
ness and density. By these means, at the end of a short time, the
primitive pellicle is found transformed into a true membrane (couénne),
STAGES OF DIPHTHERITE. 305

covering the whole of the wound, presenting a yellowish tint, and
perhaps acquiring some amount of thickness. Its cohesive power is
then considerable, and its adhesion to the subjacent parts is very
strong ; it becomes rather difficult to separate it from them without
producing a small flow of blood at the surface, the hemorrhage being
due to the erosion of the superficial vascular network, either by the
instrument employed, or by the mere act of tearing away the mem-
brane which is strongly attached to the vascular tissues.

In certain cases, this pseudo-membrane, when once developed,
appears to remain for some time nearly stationary; it seems only
to extend superficially, and to invade the surrounding parts by de-
grees; it is, besides, circumscribed by a rose-red border, which
remains during the whole period of its extension; in other circum-
stances, there is a highly exaggerated force of production. As
soon as one pellicle is formed, another replaces it by forming itself
below it, and raises the first, which it passes beyond by its superficial
extension; the second pellicle is soon in its turn raised by a third,
and so on in succession, so as to give rise, on the surface of the
wound, to an accumulation of membranous matter, having a stratified
arrangement, in which each plastic layer is imbricated one over the
other, like the tiles on a roof. When a large quantity of serous
liquid is joined to: this great activity of production, the former soaks
and softens the concreted parts, which adhere to one another, putrefy,
become greyish or blackish, exhale a very fetid smell, and then put
on pretty closely the appearance, at first sight, of a gangrenous affec-
tion.

This phenomenon is especially very remarkable on the mucous
membranes, the deep situation of which favours the accumulation of
the membranous production. Thus, in the throat, between the
tonsils, and, above all, in the vulva, between the labia and the an-
terior part of the walls of the vagina, we find remarkable ex-
amples of Diphthérite simulating gangrene.

A child in the ward Sainte-Julie, gave us the opportunity of care-
fully studying this singular phenomenon, which is clearly distinguished
from gangrene by the preservation of vitality in the tissues covered by
these putrefied membranes. In fact, the child in question died of
the disease, and we were enabled, at the autopsy, to ascertain that
the gangrenous appearance was ‘solely due to the presence in the
vulva of a large quantity of pseudo-membranes accumulated upon one
another and partly decomposed. We were able to remove them with

x
306 EMPIS ON DIPHTHERITE.

facility from the mucous surface, which, being exposed, exhibited
itself quite free from any trace of mortification. The epithelium was
alone destroyed, and the vascular network was very much injected.
It is by no means surprising that an analogous phenomenon, taking
place in the throat, may have deceived some very intelligent prac-
titioners, and that cases of Membranous Angina of this kind may
have been confounded with Gangrenous Angina, which is not a
common affection.

When the diphtheritic pseudo-membrane has acquired its entire deve-
lopment, and ceases to extend superficially, the circumference which up
to that time had always been thinner than its centre, and was always
limited by a well-marked red border, increases in thickness, invades:
the border which formerly circumscribed it, and even appears to pass
beyond it into the surrounding healthy tissue. This is its stationary
condition, if indeed it is permitted to us to regard as stationary any
condition of the economy, which is always in activity, even when its
activity is not manifested to us by any. outward signs. But whatever
may be the case, the diphtheritic patch preserves the same appear-
ance for a period of very variable duration, and during this apparent
repose, the work of cicatrization is being prepared.

8. Period of decline and cicatrization.—\ have already remarked
that during the few days which precede the shrinking of the false
membrane (cotienne) the latter becomes thicker on its edges,
which sometimes slightly encroach upon the healthy tissue. Ifwe
then atiempt to detach and remove this pseudo-membrane with a
pair of forceps, by seizing it at one of the points of its circumference,
we find that these points adhere much less than before to the subja-
cent surface, and that the adhesion is the stronger in proportion as
we advance from the circumference towards the centre. This is
because a process of reparation and cicatrization has been established
from the healthy towards the diseased parts, and by degrees is
bringing back the latter to the healthy condition. In proportion
as this process is accomplished, the diameter of the membranous
patch contracts, and, what is a remarkable circumstance, the thick-
ness of the membrane diminishes also: it appears that a kind of
resorption is taking place on its internal surface, and that the points
last formed are the first to disappear. We never see the membrane
disappear all at once, leaving a cicatrized surface in its place, and
consequently detaching itself like a crust or an eschar; on the
contrary, it is by a continuous physiological process that the pellicle
CUTANEOUS DIPHTHERITE. 307

diminishes in thickness in proportion as the edges of the wound are
cicatrized. If, however, by local and energetic treatment, the exuding
surface is modified, the complete disappearance of the membrane may
be effected, and nothing will be left except an excoriated or granular
surface, which is ready to be covered with a healthy suppuration.
I have several times been enabled to ascertain these facts in wounds
attacked by Diphthérite against which energetic cauterizations had
been employed.

Or THE SEAT OF DIPHTHERITE.

Up to the present time, I have considered the false membrane only
in a general manner, without establishing any distinction relative to
the different tissues on which I have observed it. In the epidemic
of the Hépital Necker, this disease presented itself sometimes on the
cutaneous tegument, sometimes upon the mucous membranes, and
often it has simultaneously affected both these tissues. It is, there-
fore, advisable to examine the tissues attacked by Diphthérite, and to
inquire, in the cases of the patients, whether the course which the
false membrane has taken, has presented any difference in relation to
its seat.

I shall first examine it on the skin and on the mucous mem-
branes.

1. Cutaneous Diphthérite.—All the parts of the external surface of
the body may become the seat of the pseudo-membranous exudation,
but an essential condition of its development is the absence of
epidermis ; thus we almost always see cutaneous Diphthérite exhibit-
ing itself only on excoriated and inflamed surfaces, or upon wounds
in a state of suppuration. We see it pretty frequently developed in
children in regions where, as at the fold of the thigh, the skin, by
excess of stoutness, is found in almost permanent contact with itself,
and thus assumes the most perfect analogy with the mucous integu-
ment. In fact, in very fat children we often find in positions where
the natural folds of the skin are exaggerated by the development of
the subjacent cellulo-adipose tissue, modifications of the external
tegumentary surface which considerably resemble the mucous mem-
branes in appearance; for as in them, the epidermis, under the cir-
cumstances mentioned, becomes exceedingly delicate, and is often even
completely destroyed, while an accidental secretion of a sero-mucous

product lubricates the surfaces which are in contact, and seems, bya
x2

~
308 EMPIS ON DIPHTHERITE.

wise provision of nature, to put an obstacle to their adhesion. These
then are frequently the points which, in children exposed to contract
the disease, are the first to be covered with diphtheritic pellicles,
There is no other part of the skin which is specially predisposed to
become the seat of the exudation, the essential condition of which is
the absence of the epidermis. The reason why we see Diphthérite
most frequently commence in children round the mouth, on the upper
lip, below the nares, or behind the ears, is because these points, more
than any others, are frequently excoriated in consequence of erup-
tive diseases, or of coryza, and often from want of cleanliness.

The existence of a suppurating wound may also become the origin
of the membranous exudation, which, under these circumstances
constitutes a most formidable complication. I shall have occa-
sion, in the course of this Memoir, to refer to some of the facts
related by M. Robert, in his Memoir on the Diphthérite of Wounds,
in which he appears to me to have completely understood the very
specific nature of the disease which I am describing.

‘Whatever may be, in other respects, the seat of cutaneous Diph-
thérite, the evolution of the pseudo-membrane runs through its
periods on the skin, as I have remarked in my general description.

It is particularly under these circumstances that we can properly
understand the first period of the development of the exudation, and
that we are enabled to observe the serous exudation preceding and
accompanying the formation of the false membrane, which, as I have
stated, appears to be developed by the coagulation of the exuded
liquid.

It is also in cases of cutaneous Diphthérite that MM. Bretonneau,
Trousseau and Robert have particularly observed, around the place
of the exudation, an erysipelatous redness and swelling attacking the
edges of the wound, and the epidermis sometimes rising up by the
presence of the serous exudation, so as to form little phlyctens, by
the rupture of which the dermis, being exposed, soon becomes covered
by false membrane ; but when the latter is once developed, it does’
not differ from the false membrane of the mucous'tissue. Being of
a yellowish-white tint, glistening and moist at its surface, it adheres
firmly to the tissues which it invests, and tends always to increase
superficially, until, by properly directed treatment, the secretion
changes its nature. We then find the wound assuming progressively
a better appearance, and tending towards cicatrization by means of
a healthy suppuration, for the mode of cicatrization which I have
DIPHTHERITE OF THE MUCOUS MEMBRANES. 309

pointed out, taking place from the circumference towards the centre,
is particularly observed in the Diphthérite of the mucous membranes,
in which the reproduction of the epidermis appears much more
active than upon the cutaneous dermis. M. Robert, in his work on
The Diphthérite of Wounds, affirms that the diphtheritic pellicle can
never be organized at the surface of a wound and assist in its cica-
trization, and that this is one of the remarkable characters which
separates this specific exudation from certain simply plastic exudations,
such as we often see formed on the surface of blisters, and which,
being susceptible of organization, assist in the cicatrization of the
denuded surface rather than oppose any obstacle to the process.

2 Diphthérite of the Mucous Membranes.—I have never found
any remarkable difference between Diphthérite developed on the
mucous tissues and cutaneous Diphthérite ; the presence of a previous
irritation of the mucous membrane is one of the conditions which
chiefly dispose this tissue to become the seat of the diphtheritic
exudation.

It is often difficult to ascertain upon a mucous membrane whether
a serous exudation precedes the appearance of the pseudo-membrane,
because the presence of the natural secretion, proper to this tissue,
constantly lubricates its surface. Such is at least the case on the
mucous membrane of the mouth, which is always in contact with
the product of its secretion and with the saliva. Still, if we consider
the abundance of the muco-serous secretion which is found in the
trachea and bronchi of a child attacked with Croup; if we observe
that this fluid also flows from the nostrils, in the cases where
Diphthérite occupies the anterior part of the nasal fosse, as I
have seen in several cases, and if we recollect the accumulation of
this fetid serosity softening and putrefying the false membranes de-
veloped on the mucous membrane of the vulva and vagina, as I
have ascertained ;—then it must be admitted that the phenomena,
which attend the development of the false membranes on the
surface of the mucous membranes, are very little different from those
which I have described in the formation of cutaneous Diphthérite.

It is particularly on the false membranes produced on the mucous
membrane of the mouth that I have been enabled to study thoroughly
the mode of cicatrization of the diphtheritic surfaces; that I have
easily seen the colour of the red border limiting the exudation, gra-
dually lose its intensity in proportion as the edges of the false mem-
brane are, as it were, raised by the cicatrization; and that I have

.
310 EMPIS ON DIPHTHERITE.

observed this gradual diminution in the thickness of the false mem-
brane, which seems to disappear by a kind of insensible absorption
of its deepest parts, or by a molecular destruction of the superficial
parts. The adhesion of the pellicle to the tissues which secrete it
has appeared to me a constant phenomenon. There is, however, a fact
which has struck me, and which cannot have escaped those who have
made numerous post-mortem examinations of children who have died
of Croup, during the first days of the attack, namely, that when we
examine the interior of the trachea and the bronchi of a child affected
with laryngeal Diphthérite, we meet with a quantity, often consider-
able, of a serous mucus and of small, very delicate pellicles, some of
which are bathed in this liquid without adhering to the mucous mem-
brane, while others adhere to the latter by one of their surfaces. If
we remove these pellicles from the internal surface of the trachea or the
bronchi, we ascertain that they adhere very slightly to the mucous
membrane placed below them, and that the latter, scarcely at all
irritated, frequently presents no trace of erosion.

The existence of this fact, does not perhaps imply a contradiction
to what I have before advanced relative to the adhesion of the false
meimbranes to the excoriated tissues.

In fact, I have often observed, in children who had just undergone
the operation for tracheotomy, and in whom a tracheal canula had
been adjusted, that there flowed through the latter a considerable
quantity of a liquid similar to that which is met with in the trachea
and the bronchi on opening a body, and that some very delicate
pellicles were expelled with this liquid. Then at the end of a few
hours, whatever care might be taken to clear the canula, the instru-
ment was seen to be lined with a layer of whitish exudations, the
thickness of which continually increased; these exudations were
evidently nothing more than the result of the coagulation of the
liquid, with which the walls of the canula were constantly covered.
We therefore asked ourselves whether the presence of this same
liquid in the air-tube might not, by its coagulation, give rise to the
existence of these small pellicles on the surface of the mucous mem-
brane, even although it was still healthy. Whatever may be the
truth, the mucous membrane of the trachea is the only part where
we have observed pellicles adherent to a mucous membrane, without
the latter having been more or less denuded of its epithelium. On
whatever other part I may have had occasion to study Diphthérite,
whether on the mucous membrane of the lips, the tongue, the pharynx,
GENERAL PATHOLOGY. 311

the nasal fossee, the vulva, &c., the mucous basement membrane was
found in immediate contact with the false membrane, and the epi-
thelium no longer existed.

The difference between cutaneous Diphthérite and Diphthérite of
the mucous membranes, is then very small in an anatomical point of
view ;. for in both cases we see the false membranes passing through
the same phases and presenting the same characters. We therefore
justly regard these false membranes as the pathognomonic character
of the disease, and consider that we are authorized to describe them
in a general manner. One fact which is rather remarkable in relation
to the seat of Diphthérite is this, namely, that all the parts which
are completely removed from the contact of the air are preserved from
the invasion of the disease. Thus, we very frequently see the mem-
branous affection occupying the lower part of the throat, and the
posterior wall of the pharynx, and spreading gradually to the larynx
and the deeper parts of the air-tube; but I have never seen ¢rue
Diphthérite propagating itself by continuity into the cesophagus and
the parts of the digestive canal which are withdrawn from the in-
fluence of the air. Thus, in several children under my observation,
I have seen Diphthérite commencing on the upper lip, or in the
’ nasal fossee, extending from the posterior part of the latter to the
pharynx, and from the pharynx to the air-passages, without at all
extending into the esophagus. The same occurrence is not observed
in the exudations of muguet, which, unlike those of Diphthérite, have
a great tendency to extend into the digestive tube, while they do not
propagate themselves into the respiratory organs.

May the preseuce of the air, then, exert, in these circumstances,
some influence which escapes our notice P

GrneRaL PatHoLocy or DIPHTHERITE.

Membranous Croup, when once formed, is an affection of a most
serious nature from its situation independently of its nature, and
the symptoms which accompany it place the life of the patient in
imminent danger. The physician is so"much engaged in observing
the suffocation of his patient and its mechanical cause, that all his
attention is directed to this point, and he sees only strangulation and
asphyxia, and thinks only of the means of destroying or eluding the
obstacle in the wind-pipe. It is, therefore, evident that,in such a case
312 EMPIS ON DIPHTHERITE.

surgical indications would carry more weight than medical ones, and
if the case presents itself in a child who has been previously healthy,
and apart from all epidemic influences, and if the patient has
not exhibited a rapid and almost simultaneous propagation of
Diphthérite, the latter will probably be considered as a wholly local
affection, and its most important character, namely, the property-
which it has of being generalized in the economy like the diseases
totius substantia, will run a great risk of being misunderstood.

Even supposing the child to be attacked with a well-marked
Diphtheritic diathesis, and to be destined from the first to experience
all the local determinations of this affection, and that we see its
products generalizing themselves on all the surfaces which are sus-
ceptible of its influence, and if the first manifestation of this morbid
disposition has exhibited itself at the entrance of the respiratory
passages, then a sudden death will probably cut short the
diphtheritic phlegmasiz which would otherwise have been ulte-
riorly produced. If, therefore, from such a fearful local symptom,
any one should pretend to recognise the diphtheritic disease, he
would act like a botanist who should describe a vegetable, such as
wheat for example, by delineating this plant in the state of a blade
of grass broken by the storm. To comprehend this proposition
correctly, it must be known, moreover, that the tendency of Diphthé-
rite to repeat itself in the different parts of the economy goes on
augmenting, up to acertain limit, with the number of cutaneous or
mucous surfaces already attacked.

It is certain, therefore, that at a distance from the sources of epi-
demics and from the Hospitals, the cases of Sporadic Diphthérite
which the practitioner in the large towns may observe in his private
practice, can scarcely furnish materials for a general history of the
disease such as M. Bretonneau has written. His predecessors in this
labour, as Huxham, Fothergill, Marteau de Grandvilliers, Samuel
Bard, and Lepecq de la Cléture, had already collected their valuable
observations under circumstances the most appropriate for bringing
into notice the general characters of what they then called Malignant
Angina, and Gangrenous Sore-throat ; and in their descriptions they
have attached as much importance to the general and specific condition
of the patients as to the local symptoms.

It is also under the epidemic type that I have been able to study
Diphthérite, and to convince myself that, like all disseminated
phlegmasiz, this affection presupposes a general morbid condition or
GENERAL PATHOLOGY. 313

a peculiar diathesis, generating and interweaving together inflamma-
tions which are different in their seat, extent, intensity, duration and
number, but identical in their nature.

In fact, it cannot be denied that inflammations which are
spontaneously or successively developed in an individual, in a
limited space of time, and having common generic characters, are
the expression of an affection which is single in its origin, and
consequently of a well-marked pathological nature.

From this general character, therefore, it may be affirmed that such
inflammations are not simple ; and that almost always in their pro-
gress, duration, products, and general symptoms, and by the consti-
tutional morbid condition of the subjects in whom they are observed,
they reveal the presence of a special pathological element, intimately
united with inflammation in its species, but differing from it essen-
tially, or in other words, in its proper nature. Hence, therefore, the
word Diphthérite, equivalent to diphtheritic inflammation, which
perfectly expresses the double character of the disease of which I am
now endeavouring to present a general sketch.

From the circumstance that Diphthérite is a phlegmasia, it should
at first present the phenomena which are common to every inflam-
mation; and this is, in fact, consistent with my observations, and
all my cases testify to the truth of this view. I shall not insist
uponit. What interests us is much less the common generic character
than the specific difference. It must be known, however, that we
can only study the one by means of the other, that is to say, the
specific element only by means of the inflammatory element, and the
specific characters being only manifested in and by the characters of the
genus. It must not, then, be imagined that a diphtheritic phlegmasia
is formed of a pure or waspecific inflammation, and then of a specific
alteration without inflammation, which are, in some manner, placed
in juxtaposition. :

This separation is merely an artifice of the imagination, a useful
abstraction by which we isolate two elements which are very distinct
in their nature, while taking care never to forget that in the diphthe-
ritic phlegmasia, these two factors are inseparably united together.

I maintain that these two elements, the inflammatory and pseudo-
membranous, are perfectly distinct in their nature, although very
intimately associated in the diphtheritic phlegmasia. I shall be very
probably asked, what proof exists of this distinction in their na-
ture, and consequently of this possibility of a distinct existence and
314 EMPIS ON DIPHTHERITE.

manifestation, since I confess that I never observed one of these
characters without the other in the epidemic which I witnessed.

To this I shall reply in the first instance, that as to what consti-
tutes inflammation in general, its existence, independently of the
production of false membranes, has no need to be demonstrated. It

-is in every one’s power to determine artificially a simple inflamma-
tion; but it is in the power of no one to impress the diphtheritic
character upon this lesion from external causes !

As to the morbid disposition by which the pseudo-membranous
exudations are produced, I think that we are unable to identify it
with the inflammatory diathesis: and as to the act itself, as well as
the product of this morbid formation, who would venture to assert
that it does not differ, like one species from another species, from the
act and from the product of a simple and healthy inflammation, to
make use of the correct expression of Hunter? If we were to con-
clude from the fact that the false membrane could not be formed
without inflammation, that therefore these two things are not distinct
in themselves, and that the inflammation is the cause of this species
of morbid secretion, we should confuse all our ideas, and destroy our
nosology. An inflammation may be the most favourable, and the
most common condition of the production of the diphtheritic false
membranes, without at the same time being the cause of them.
This cause consists in a special morbid property, manifested by an
inflammation on which it impresses its special characters; but in
itself it is altogether independent of this inflammation.

Whatever the truth may be, and without stepping beyond the
limits of clinical observation, we may assert the following proposition ;
that in Diphthérite there is no relation between the intensity of the
inflammation and the intensity, the abundance, and the rapidity of the
formation of the false membranes. It is even certain that the force
of the pseudo-membranous secretion, or the diphtheritic diathesis is
in an inverse yatio to the intensity of the inflammatory diathesis,
and the simple activity of the inflammation, and that the produc-
tion of the false membranes is the more easy and the more abundant,
in proportion as the phlogistic element is /ess marked. If we
examine plethoric children at the onset of Diphthérite, we shall be
able to find a pretty exact proportion between the common element
of the disease and its specific element, and we can remark between
these two facts a relation so exact, that we shall be led, if not to
identify them, at least to connect them together like an effect with its
GENERAL PATHOLOGY. 315

direct cause; but if we observe the disease in children who have
reached the last stage of the diphtheritic cachexia, or in whom the
pseudo-membranous diathesis is so intense that it seems hardly to
require any other condition than its own force to be able to manifest
itself, then we shall see the false membranes formed suddenly and
spread indefinitely under the influence of the least mucous or cu-
taneous irritation, so as to convince the most incredulous persons
that, in such subjects, the irritation has only been the mere
occasion, and not the cause, of the development of the false
membranes.

In the purulent fever of the wounded, and in that of puerperal
women, is it not the same case with the pus? Does not this morbid
product exhibit itself in so little proportion to the inflammation that
we may be allowed to ask ourselves if the inflammation is essentially
necessary to the formation of pus?

Hence we must conclude that, speaking nosologically, Diphthérite
is a phlegmasia, considered in relation to the study of the morbid
elements and the formation of diseases, the types of which serve to
construct nosologies ; and that it results from the intimate association
or the fusion of two factors which are very distinct and susceptible
of being perfectly separated by clinical analysis.

Thave written somewhat at large upon this question, because it
is the foundation of the idea of the specific nature of Diphthérite,
and is the point which I am chiefly endeavouring to establish, for the
prognosis and the treatment are intimately associated with it.

Is it possible that this existence of a specific local element, pro-
duced by a diathesis, is not otherwise confirmed by the general
symptoms of Diphthérite? How can we recognise the general state
accompanying healthy inflammations, and exhibiting itself in a simple
inflammatory fever, febris inflammatoria simplex vel genuina, in the
general symptoms of an epidemic Diphthérite? If we appeal to the
epidemic type rather than the sporadic, it is because at the time when
the diphtheritic diathesis is at its maximum, the general symptoms
which reveal it are better characterized ; ‘and first, the prodromata
are longer than in the pure phlegmasie, then the fever is never so
intense, nor the reaction of the circulatory apparatus so energetic,
the heat so intense, or the skin so much injected and so red. All
these symptoms have a character of mildness and slowness; the
children do not appear to be seriously ill; the functional disturbances
are less alarming, because the morbid activity is not so violent ; the
316 EMPIS ON DIPHTHERITE.

tissues are a little flabby; the tint of the countenance often pale ;
‘the pulse small, and more or less frequent, as in all the Anginz of a
malignant character (the contrary being the case in simple inflamma-
tory Angina) ; lastly, and this is a striking point, there is always a
swelling of the sub-maxillary glands accompanying, and most fre-
quently preceding, the appearance of the false membrane, and not only
of the false membrane, but of the pharyngeal phlegmasia. We then ob-
serve, and in a still more constant manner, what happens in the same
region before the development of erysipelas of the face. Who will
venture to allege that this last inflammation is simple, healthy, and not
special? On the contrary, it is certain that it exhibits many striking
points of analogy with Diphthérite; and the same is the case with
Angeioleucitis. These affections, if not of the same species, are at
least of the same genus. Is this leading circumstance of the exist-
ence of a general state preceding the local lesions in Diphthérite, and
appearing to control them, sufficient to make us wnclassify this
disease and transfer it from the phlegmasie into the pyrexie? I
think not, or at least, if some modification ought to be introduced
into nosology on this point, it appears to me that Diphthérite, in-
stead of passing from the phlegmasiz into the fevers, ought rather
to be ranged among those acute diseases which participate of the
nature of both, and which some pathologists propose to designate
under the hybrid name of febri-phlegmasia. It would be found by
the side of erysipelas and many non-virulent and non-contagious
eruptive fevers, in the rigorous acceptation of such a term, as impetigo,
pemphigus, erythema nodosum, certain cases of herpes, and of spon-
taneous Angeioleucitis, &.

At present, if we glance at the symptomatological picture of Diph-
thérite, we find that the individuals who are attacked by it, pass from
health to disease by an intermediate state which from the first presents
some peculiarity and may enable us to foresee the specific affection
which is in preparation. Thus, certain prodromata always precede
the appearance of the false membranes; the subjects attacked by
Diphtheritic Angina have always, before the appearance of the pseudo-
membrane, felt a certain degree of uneasiness, loss of appetite, “a
slightly febrile condition, difficulty in swallowing, tumefaction of the
lymphatic glands, &c. very one has observed that Croup, before
manifesting itself, is announced by uneasiness, cough, hoarseness,
often by Angina, &c. I have been enabled to confirm the fact indicated
by M. Robert, that wounds before being invested with the diphthe-
GENERAL PATHOLOGY. 317

ritic pellicle, change their aspect, become more painful, and furnish
a less abundant and thinner suppuration.

In young children, I have always met with the following prodro-
mata, setting aside the local phenomena which I have just pointed out
and which are connected with the localization of the morbid product,
namely :—a slight degree of excitement ; the child was agitated, lost
its playfulness, and became fretful; there was sleeplessness, deficient
appetite, the child sometimes refusing all kinds of nourishment, and
even its mother’s breast-milk; the skin became rather hotter than
usual, and the pulse was slightly accelerated. These prodromata
were then succeeded by other symptoms which were more significant,
but entirely relating to the seat of the lesions.

These general prodromata, which do not appear to furnish any
characters or signs of one acute disease rather than another, after-
wards acquire, however, some degree of importance on the appear-
ance of the different phenomena relating to the seat of the exudation,
and they may then even become serious signs in the diagnosis.
Croup, for example, is almost always preceded by two or three days of
uneasiness and the existence of the prodromata which I have pointed
out, before it manifests itself by the threatening train of symptoms
which are peculiar to it. On the other hand, Stridulous Laryngitis
or false Croup, most frequently takes children suddenly. by surprise,
while they are in perfect health, and without the appearance of any
of the prodromata announcing the approaching attack. This absence
of prodromata may then become an important sign, and may facilitate
the diagnosis in cases where the other symptoms peculiar to each of
these affections might not be sufficient indications ; but the previous
and concomitant swelling of the cervical glands is, in particular, a
leading differential character.

I cannot enter here into the description of the symptoms which
are peculiar to each of the varieties of Diphthérite in respect to its seat,
for such a course would make me deviate from my object, which is the
study of the disease in general. But the great peculiarity presented
by Diphthérite as a general disease, is a certain progress and dura-
tion, and we are called upon to study the modes of generalization of
its products in the economy. This is the most interesting point of
view which it presents as a general disease, for it is precisely that
which makes it one.

Let us now examine the different parts of this question.
318 EMPIS ON DIPHTHERITE. a)

Proecress oF DiIPHTHERITE.

After what I have observed, in the general description of the
diphtheritic exudation, upon the part which it attacks, I have but
little to add upon the progress of the local lesion. -I have described
the stages which it passes through, and I think it would be super-
fluous to expatiate anew upon this point.

But independently of the progress made by the false membrane
on the tissue which exudes it, we have to consider the general pro-
gress of the morbid state under the influence of which the exudation
is developed on the different parts of the economy. Let me explain
myself. The greater number of the simple eruptive fevers are cha-
racterized anatomically by a special eruption which attacks the sur-
face of the body in one and the same outbreak. Smallpox, for
instance, presents a general eruption of which every small consti-
tuent papular point is subject to the same evolution, and every one
runs through its phases in pretty nearly the same period of time ;
and when the desiccation has become general, we never see a second
eruption developing itself by a fresh outbreak on the surface of the
body. There is indeed sometimes, in varioloid (a modification of
variola), a certain irregularity in the general progress of the eruption ;
all the pustules do not appear at the same time, each of them runs
singly through the phases of its evolution, and some are already in a
state of desiccation, while others which have appeared more recently,
have not yet acquired their entire development. But this is an
exception, and in the simple eruptive fevers, as variola, rubeola, scarla-
tina, when the eruption has terminated, however confluent or discrete
it may have been, we never apprehend a fresh appearance of the
disease. Let it be understood that I am not now speaking of the
possibility of relapses, which are quite another affair. ;

On the contrary, there are morbid conditions with a chronic pro-
gress, the anatomical manifestations of which take place at irregular
intervals. It is sufficient to quote syphilis or scrofula as instances
without entering into more details. Well, Diphthérite is one of the
intermediate states between those, the progress of which is acute and
rapid, and those which last a certain time, so that repetitions of the
morbid manifestation take place in the same individual at rather
irregular intervals.
PROGRESS OF DIPHTHERITE. 319

Let me say a few words on this generalization of Diphthérite and
of its modes of appearance.

I have already called attention to this tendency of the exudation to
extend in surface and to spread gradually to the parts which surround
the spots’ first affected.

M. Bretonneau has particularly noticed that the depending parts
are those which are most rapidly attacked by the exudation, and he
has explained this fact by the presence of the special liquid which
exudes from the diphtheritic surface, and which, under the influence
of the natural laws of gravitation, tends continually to flow over
the parts situated below the seat of those first affected; this is
unquestionably one of the frequent modes of extension of Diph-
thérite by way of continuity. However, it does not always happen
that the most depending parts are attacked by Diphthérite, for we
sometimes see the exudation extending by way of continuity from
the inferior to the superior parts. Thus Diphthérite commencing
on the upper lip may ascend towards the nostrils, and gradually
invest all the inside of the nasal fosse and ultimately extend to the
pharynx and larynx.

But there is another very remarkable mode in which the disease is
propagated, and this consists in the reappearance of the exudation on
regions which are more or less distant from each other; thus when
an individual presents a point affected with Diphthérite, we must
always be apprehensive that this formidable exudation will establish
itself on other parts, and as the air-passage is almost a favourite.seat
of Diphthérite, we must always, in the circumstances indicated, appre-
hend that the mucous membrane of the larynx may be covered with
pseudo-membranes, giving rise to the terrible affection called Croup.

In an individual attacked with Diphthérite, all the parts of the
surface of the body which are inflamed, excoriated, or in a state of
suppuration, become almost constantly, if not always, the seat of the
exudation. If blisters are applied, their surfaces habitually become
covered with pseudo-membranes, and in this case the false membrane
assumes all the characters of the diphtheritic exudation, and no longer
resembles those pseudo-membranes which are often observed on the
surface of certain blisters, and which have no relation with the dis-
ease I am now describing.

In children who have undergone the operation of tracheotomy,
and when the lips of the wound are not yet cicatrized, we very often
see Diphthérite develop itself, but then it is only an extension of
320 EMPIS ON DIPHTHERITE.

the disease by way of continuity, for the serous liquid which exudes
from the trachea by the canula, or between the latter and the wound,
will sufficiently explain the circumstance.

How long, then, will an individual who has had a patch of Diphthérite,
remain liable to a reappearance of the exudation on other parts,
and for how long a time ought we to fear the supervention of Croup P
This question, the solution of which would be to fix the duration of
the general state under the influence of which the false membranes
develop themselves, is very difficult to answer; for it frequently
happens that a child affected with Diphthérite in a limited part, will
recover rapidly under the influence of energetic local treatment, and
that subsequently no new appearance of the exudation may supervene,
while at other times we observe, that a patch of Diphthérite is almost
completely cured, when suddenly the exudation is renewed with
violence upon another part of the body, and at very irregular inter-
vals of time.

Thus I have seen, in a child, that Diphthérite began on the point
of the tongue, ran through its stages on that part, and disappeared on
the thirteenth day after a complete cicatrization of the affected part.
Then, on the fourteenth day, and when by the disappearance of this
local lesion, it might have been supposed that the child was
thenceforward out of danger, the mucous membrane of the larynx
became the seat of a reappearance of the membranous exudation, and
the patient was carried off by Croup. Such examples are frequent.
At other times, the Diphthérite generalizes itself with great rapidity,
and we see it, in the space of two days, occupying several excoriated
parts of the face, the interior of the nasal fosse, the folds of the
groin, the vulva, and lastly the larynx. Sometimes Diphthérite re-
mains localized in one spot for a long time, without producing many
symptoms, and without any ulterior appearance manifesting itself on
other parts. Thus, in one of the children under my care, Diphthérite
remained twenty-seven days localized on the same region, and ter-
minated by disappearing without its being repeated on other parts.

It therefore does not appear possible to be able rigorously to fix
the duration of this disease. ‘Let me state, however, that the per-
sistence of several characters of the general state and even of only
one, which sometimes happens, should always make the practitioner
apprehensive, even when, for several days, all the diphtheritic points
have disappeared. In treating further on the prognosis of this dis-
ease, I shall have occasion to return to the consideration of some
DIAGNOSIS. 321

of the symptoms, which appear to me necessary to be most gene-
rally considered, as signs of the persistence of the diathesis in an
individual, or of his predisposition to the repetition of the exudations.

Diaenosis or DrearnErite.

The diagnosis of Diphthérite is generally easy to be established,
and the confusion which may prevail on this subject in the minds of
some physicians, arises from the great latitude which they allow them-
selves in comprising, as connected with the disease now under con-
sideration, the greater part of the pseudo-membranous exudations
which are developed in different diseases.

If the reader recollects the characters I have assigned to the
true diphtheritic product, namely, the appearance, on a mucous
membrane or an excoriated surface, of a yellowish-white pellicle,
rather dense, rapidly augmenting in thickness, ready to be renewed
when it is detached from the tissue which exudes it, strongly adherent
to this tissue, and having a great propensity to extend superficially
by progressive invasion from the first limits of the exudation;—
if he considers the remarkable change induced in the general state of
the patient by the appearance of this disease, one of the fatal pro-
perties of which is to determine the repetition of the same exudation
on all the parts which are excoriated or in a state of suppuration ;—
if, lastly, he will consider the absence of the symptoms which cha-
racterize other affections, and which, in relation to Diphthérite, are
negative signs, he will then be readily able to distinguish this disease
from every other which may resemble it in the presence of a pseudo-
membranous production.

But, as several of these exudations are still, in the present day,
confounded with Diphthérite, it is advisable to describe their most
prominent distinctive characters.

Let us see, in the first place, if Muguet, on the nature of which
so many opinions have prevailed and still prevail, can be regarded as
a form of Diphthérite.

1. Muguet presents itself in the form of a multitude of small white
points, at first distinctly separated from each other, but which,
in proportion as they become more numerous, touch one another
and are accumulated together so as to form a continuous, whitish
layer, which invests all the inflamed mucous membrane, and thus
constitutes a pseudo-membrane; this is’ the case in confluent Mu-

¥
322 EMPIS ON DIPHTHERITE.

guet. If we endeavour to detach this false membrane with a pair
of forceps, we find that is difficult to obtain strips of it, because
each of the points, the accumulation of which on the mucous mem-
brane has given the appearance of a false membrane, adheres too
slightly to the others to enable us to obtain strips, at whatever period
we may make the trial; but if, with a fine compress, we lightly
wipe the part covered with Muguet, we easily remove all the whitish
layer, and we uncover the mucous membrane, which is red and in-
flamed, but by no means raw. ‘This operation, which I have many
times performed, has never caused the flow of the least drop of
blood, because the adhesion of the Muguet to the mucous mem-
brane is inconsiderable, and is never so close to the detmis as in
Diphthérite. In the latter, as I have already explained, there is a
great force of cohesion; and true membranes are formed, which
are superposed upon one another when their thickness has attained a
certain degree. Their colour is yellowish, and the adhesion to the
tissues.is such that we are rarely able to detach them without causing
the raw part, covered by them, to bleed in some measure.

2. Muguet especially affects the buccal mucous membrane, and
never extends into the larynx or trachea; there has hitherto been
no example of Muguet extending to the respiratory passages and pro-
ducing Croup, but it often extends to the pharynx and the digestive
canal. The diphtheritic product, on the contrary, has the greatest
tendency to propagate itself over the mucous membrane of the air-
passages, where its presence constitutes Croup, and it perhaps never
reaches the digestive canal below the pharynx.

3. The appearance of Muguet is always preceded by a general in-

ammation of the mucous membrane of the mouth, characterized by
a general redness and a very acute sensibility which, in young children
at the breast, presents an obstacle to sucking. The appearance of
Diphthérite is preceded only by a very circumscribed irritation of the
parts of the mucous membrane which are completely covered by the
pellicle.

4. Muguet is never preceded by the serous exudation which is the
forerunner of the pseudo-membrane of Diphthérite ; but it appears on
the mucous membrane when still covered with its epithelium or at
least not excoriated. Diphthérite is never developed above the
epidermis, and it always adheres to raw parts.‘ I have formerly
pointed out the only case in which I found remnants of exudation on
a mucous membrane which was still unaffected,
DIAGNOSIS. 323

The microscope which, as a method of exploration, has already ren-
dered important services to science, may also serve to determine several
points in the study of pseudo-membranous exudations. I shall termi-
nate the section on diagnosis by a succinct statement of my researches
on this subject, and I shall briefly sum up the result. But before
entering upon this microscopical examination of the different pseudo-
membranes, and determining how far this mode of explanation may be
useful in the solution of the question I am now discussing, it will be
expedient to take a rapid view of the semeiological aspect of these
different exudations, and to determine the circumstances which ought
to cause their rejection from the nosological scheme of Diphthérite.

Scarlatinal Angina, which is so frequently accompanied with a
pseudo-membranous exudation, is one of those diseases to which
practitioners most willingly accord the epithet of diphtheritic. These
two affections, however, differ totally from one another; the exuda-
tion is not the same in an anatomical point of view, and the assem-
blage of phenomena accompanying each, make of them two very
distinct diseases. The mode of development and formation of
the scarlatinal membrane does not resemble that of Diphthérite ;
it would rather present an analogy with that of Muguet. This
pseudo-membrane appears simultaneously on both tonsils; the
mucous membrane covering these glands, being uniformly red and
inflamed, is studded with a multitude of small white points, the
aspect of which is rather similar to that of Muguet; and these
little points, which become very confluent, soon unite together and
become superposed on one another, giving rise to a continuous
whitish layer, covering both tonsils and the pillars of the velum

-palati and extending only very rarely to the other parts of the mucous
membrane of the mouth. This pseudo-membrane, the whiteness of
which is more marked than in the diphtheritic membrane, which
assumes a more yellowish tint, differs also from the latter by its less
degree of cohesion, and by a much less intimate adhesion to the
tissues which exude it.

In fact, it is almost impossible to obtain strips of this pseudo-
membrane by seizing a point of it between the blades of a pair of
forceps, for each of the whitish particles which constitute it has so
little cohesion with the others, that they are separated with very great
facility. On the other hand, the adhesion of this matter to the mu-
cous membrane is far from being so considerable as in Diphthérite.
It is rather easy, by scraping the internal surface of the tonsil with the

¥ 2
324 EMPIS ON DIPHTHERITE.

extremity of a spatula, to obtain a sufficient quantity of this matter
to understand its arrangement and to study its microscopical charac-
ters, which I shall hereafter explain. The pseudo-membrane of
Scarlatina does not form a continuous and consistent membrane
similar to that of Diphthérite, and does not present that intimate
adherence to the dermis which is one of the characters of the latter.
Let me add to these anatomical facts, that the pseudo-membrane of
Scarlatina does not possess the invading property of Diphthérite ;
that it remains localized at the point of its development; that it
does not exhibit the unfortunate character possessed by Diphthérite
of generalizing itself by being repeated on all the surfaces which
are excoriated, or in a state of suppuration ; and that lastly, we never
find it extending to the air-passages, where Diphthérite becomes so
suddenly formidable. The authors of the Compendium de Médecine,
however, assert that they are in the possession of the case of a child,
who, at the termination of Scarlatina, was attacked with Croup; but
T am able to show them several cases proving that Croup may also
develop itself at the termination of variola, hooping-cough, and other
diseases besides. The fact attested by these able writers is there-
fore very interesting ; but it appears to me to prove only one point,
namely, that at the termination of Scarlatina, children are in a
general morbid state, not compatible with that under the influence
of which the diphtheritic exudation is developed; for this fact no
more demonstrates the identity in nature of the scarlatinal membrane
with that of Diphthérite, than we are able to prove that this latter
disease is of the same nature as smallpox and hooping-cough, be-
cause it has been consecutive to these two affections.

The distinctive characters of Scarlatinal Membranous Angina and of
Diphtheritic Angina, have been described with so much clearness and
ability by M. Trousseau in a Memoir which he has written on an epi-
demic of Membranous Angina in the Archives Générales de Médecine,
that I think it superfluous to insist further on this part of the diagnosis.

Can the membrane which sometimes covers the whole surface of a
blister be confounded with Diphthérite ?

Here it is indispensable to enter into a little explanation; for this
question may give rise to discussion, for want of being put with suf-
ficient clearness. In fact, blisters may be covered with a fibrinous
membrane which has no relation to Diphthérite ; but they may also
become the seat of this disease. There are, therefore, two kinds of
pseudo-membranes which may be observed on the surface of blisters ;
DIAGNOSIS. 325

one diphtheritic, presenting all the characters I have assigned to cu-
taneous Diphthérite, and particularly remarkable by its extreme degree
of adhesion to the dermis of the skin; the other differing totally from
the latter, and forming a greyish-white membrane, on the surface
of the blister, being, in fact, a continuous membrane, sufficiently
coherent to be removed in large strips, and even sometimes easily de-
tached in a single piece; its thickness varying from one to two
millimetres (about four-fifths ofa line.) The adhesion which it forms
with the denuded dermis is inconsiderable, when it is observed
at a period not very remote from its formation; it is then found, in
detaching this fibrinous membrane from the dermis, that the latter is
more or less inflamed on its surface, and that the projections of the
papillary body are in a slight state of inflammation; but there is not
any trace of ulceration. A little later, if we observe a simple flying
blister, and if the dressings have been made only with cerate, it is
found that this fibrinous layer becomes more compact and more ad-
herent to the dermis ; that it is identified, as it were, with the latter,
and that far from opposing an obstacle to the reproduction of the
epidermis, it appears to assist in its formation. At other times, the
epidermic secretion is formed below it, and when, at the end of a few
days, the blister is completely dry, it is detached from its surface in
the form of scales or irregular fragments, often incorporated with a
little cerate. These certainly are not the characters of Diphthérite!
Do we ever see the latter disease becoming organized, and assisting
or favouring cicatrization ?

M. Robert, in his Memoir on the Diphthérite of Wounds, published
in the Bulletin Thérapeutique, has already drawn attention to this
latter difference distinguishing the diphtheritic membrane from that
of a blister, which he justly regards as a pure and simple plastic ex-
udation, analogous to those which may be formed in the bladder
under the influence of cantharides, several examples of which have
been adduced by M. Morel-Lavallée.

Tt would appear to me to be as much contrary to the truth to consider
the fibrinous exudation, now under consideration, as a form of Diph-
thérite, as it would be erroneous to regard, as belonging to this
disease, the fibrinous membrane which invests the pleura in certain
cases of pleuritic effusion. No one, so far as I am aware, has yet
entertained the idea of referring to serous Diphthérite the fibrinous
coagulation in question, which has the greatest analogy with the in-
flammatory membrane (buffy coat) of the blood.
326 : EMPIS ON DIPHTHERITE.

In many cases of Tonsillar Angina, destitute of any malignity, we
frequently observe, towards the second or third day of the disease,
on the internal surface of one or both tonsils, the appearance of
small, whitish grains, of a sebaceous character, and exhaling
avery fetid odour when they are crushed between the fingers. This
small pathological product, which occupies only a very limited portion
of the tonsils, really differs in too many respects from Diphthérite to
require any further notice.

I have just described the exudations which are sometimes con-
founded with Diphthérite, and it now remains for me to explain the
information which may be obtained by the microscope in the study
of these exudations.

Microscopie characters.—Among the false membranes which, under
the influence of various causes, appear either upon the mucous mem-
branes, or upon the external integument previously denuded of its
epidermis or already occupied by a suppurating wound; or which
appear upon inflamed serous membranes ;—there is one kind of
them which ought from the first to be clearly distinguished from the
others, as it differs entirely from the rest in its microscopical charac-
ters. This: kind comprises the whitish exudations observed very
frequently on the mucous membrane of the mouth, the pharynx, and
the digestive canal, and which are generally designated under the
name of Muguet. When studied by the aid of the microscope,
Muguet presents peculiar characters not met with in any other kind
of pseudo-membranous exudation. It is an organized product, the
position of which in the vegetable kingdom cannot now be contested,
after the researches of MM. Berg and Gruby; and more recently,
a detailed and minute description has been given of it by M. Charles
Robin in his work on the Vegetable Forms growing on living Animals.
(1847.)

M. Gruby regards the vegetable form of Muguet as the analogue of
the Sporotrychium. Whatever it may be, this production is perfectly
characterized by the spores and tubular filaments, so well described
by M. Robin, and which are not met with in any kind of exudation.

To discuss the point, whether the vegetable form of Muguet
can develop itself spontaneously would be to enter into the great
question so often discussed by physiologists, namely, whether
there can or cannot exist in nature such a thing as spontaneous
generation. In fact, Muguet appears as if it ought not to be regarded
as a special disease, nor even as a symptom of a single and identical
DIAGNOSIS. 327

disease. It may exhibit.itself in persons of all ages, of all constitu-
tions, and affected with the most different maladies. Muguet may be
sown upon the tongue of a healthy person (Berg) and may rapidly
bud there. J know an instance in which a child being affected with
Muguet, and suckled. by its mother, communicated it to the woman’s
nipple and the areola of her breast. M. Ch. Robin has informed me
of an interesting experiment; he removed the Muguet from the sur-
face of a mucous membrane, and preserved it in a vessel with a small
quantity of water. Then he was able to ascertain that, bemg thus
separated from the mucous membrane, the Muguet continued to
develop itself according to the laws of its organization, that the
spores continued their evolution, and by a peculiar mechanism of
their organization, induced the formation of tubular filaments. The
work of M. Robin contains besides all the details necessary to be
known in relation to this cryptogamous production, and I should think
it at least superfiuous, in the present state of science to insist upon
its characters.

Vogel, who has described the vegetable form of Muguet, states
that it is found in children and adults, on the false membranes
lining the mouth in Diphthérite. This author has evidently confounded
all the pseudo-membranous exudations under the name of Diphthé-
rite, without regard to their character and nature ; for this vegetable
is met with only in the exudations of Muguet, and not at all in truly
diphtheritic or fibrinous exudations.

As to the other kinds of pseudo-membranes, independently of
the characters recognisable by the physician, and which are related
together as much by their appearance and their seat, as by their
physiology and the conditions of their development, they present
other peculiarities which are only to be determined by microscopical
examination.

The principal exudations of which I now intend to treat are the
following :—1st. The inflammatory coat (buffy coat) of the blood.
Qnd. The pleuritic or serous fibrinous exudation (codienne). 3rd.
The membrane of a blister. 4th. The membrane of Diphthérite.
5th. The membrane of Scarlatinal Angina.

Tf I write a few words on the buffy coat of the blood, a subject
which may perhaps appear foreign to the present discussion, it is
because I regard it as the type of fibrinous coagulation, and because
I have discovered very manifest generic characters connecting it and
the other exudations I have just mentioned. In fact, the micro-
328 EMPIS ON DIPHTHERITE.

scopic study of these different exudations leads to the demonstration
that they all present peculiar characters; and besides, that every
kind is marked by certain anatomical peculiarities according to the
place of its development. But let me observe at once, that these
latter peculiarities are completely in relation to the epithelial cellules
which every exudation brings with it, and the characters of which
vary according to the different regions of the integuments where
they are studied.

Before commencing the characters which are distinctive and
peculiar to each kind of pseudo-membrane, let me briefly point out
the generic characters. 1. A primary character belonging to all the
pseudo-membranous exudations already mentioned (with the excep-
tion, be it understood of Muguet, which I have distinctly separated
from the exudations now under notice) is to present on the field of
the microscope a quantity of small filaments of fibrine interlaced
with one another in different directions, and crossing one another
at acute angles, so as to form a kind of more or less regular
network.

2. A second character, also met with in each of these exuda-
tions, is to present a great number of small, irregularly rounded
corpuscles, forming a series of granular dottings around the fila-
mentous network which I have described, and also occupying the-
spaces left between the interlacements of these fibrinous filaments.
These small corpuscles are found in all pseudo-membranes, but in
very variable number; it is to them that M. Lebert has given the
name of molecular granules, and which resist for rather a long period
the action of acetic acid.

3. A third character, belonging to all these fibrinous exudations,
is that when treated with a drop of tincture of iodine, they imme-
diately assume a very deep-brown colour.

Special characters.—a. Buffy coat of the blood.—In the buffy coat
of the blood we find the common characters which I have just pointed
out. The filaments of fibrine are very manifest, and under the in-
fluence of the tincture of iodine they become of a very dark-brown
colour. But their interlacement is much less close than in the diph-
theritic membrane; so that the kind of network which they form is
much more loose. This at least is what I have been able several
times to observe, when comparing alternately the diphtheritic mem-
brane and the buffy coat of the blood on the field of the microscope.
Molecular granules are found equally in both, but in a quantity gene-
DIAGNOSIS. 329

rally much less considerable than in the other pseudo-membranes.
Other characters which, in addition to these, always enable us to re-
cognise the buffy coat of blood, relate first to the presence of the red
and white globules of the blood; the specific gravity of these latter
being inferior to that of the red globules, they are found in great
number on the adherent surface of the buffy coat after bleeding.
Secondly, two negative characters ought also to be noticed, namely,
the absence of epithelial cellules and of pus globules.

B. Pleuritie false membrane.—This is unquestionably one of the
false membranes which have most analogy with the buffy coat of the
blood; the common characters being so far identical that it would
be superfluous further to insist upon them. We find in this false
membrane, in fact, the fibrinous network which is completely similar
to that of the buffy coat, and the molecular granules exist in it in
great quantity. Still, it will always be easy to ascertain by the mi-
croscope, whether we are examining the buffy coat or a pleuritic false
membrane; for in the latter case, we find a great quantity of pus-
globules which do not exist in the buffy coat seen after bleeding:
and on the other hand, we do not find blood-globules, which are so
abundant in the buffy coat. The pleuritic false membrane is further
characterized by the absence of epithelial cells which we shall find to
exist in the other kinds of false membrane.

c. Membrane of a blistered surface—When studied by the mi-
croscope, the membrane of a blistered surface may be distinguished
from the two preceding false membranes, although their common
characters are almost identical. We find in it the fibrinous network
very well-developed and perhaps more condensed than in the buffy
coat. By the addition of a drop of tincture of iodine, the fibrinous
filaments assume equally a very deep-brown colour. The molecular
granules are very numerous, and just as in the pleuritic false mem-
brane, we find many pus-globules. Still, it may be distinguished
from the latter by the presence of epithelial cellules which are con-
stantly found in it, but which are wanting in the pleuritic exudation ;
while the almost complete absence of the blood-globules will not
allow us’to confound it with the buffy coat of the blood.

p. False membrane of Diphthérite—Here microscopical examina-
tion ceases to afford us much information. The diphtheritic ex-
udations, whatever in other respects may be the place of their
development, present, in a microscopical point of view, the greatest
analogy with the membrane of a blistered surface. We find in them,
330 EMPIS ON DIPHTHERITE.

as common characters, fibrinous filaments which are very abundant
and very closely interlaced together. The molecular granules present
no difference, and exist in both in considerable numbers. We also
find some pus-globules, perhaps in less numbers than in the false
membrane of a blistered surface, but still we do find them; the
difference is no longer anything more than their greater or fewer
numbers, which is always an unsatisfactory microscopical character.

The epithelial cells in the diphtheritic membrane are always very nu-
merous, and they present some peculiar characters according to the
region where they are developed ; but as Diphthérite may present itself
ona great number of parts of the body where we also observe other ex-
udations of a different nature, this microscopical character cannot be
considered sufficiently diagnostic. Jt happens besides, as I have above
stated, that blisters often become the seat of Diphthérite ; and it is par-
ticularly in such circumstances that we are able to judge how inefficient
the microscope becomes In deciding if we have under our notice a simple
fibrinous membrane, such as we so often observe on the surface of
blisters, or if the exudation before us is of a diphtheritic nature. The
microscope, in such a case, is no more useful in elucidating the
question, than it would be in distinguishing a syphilitic pustule from
a variolous or a vaccine pustule.

EB. False membrane of Scarlatinal Angina.—I have endeavoured
in vain, by means of the microscope, to discover some character
which might serve to distinguish the Scarlatinal membrane from the
diphtheritic membrane; in both we find the filamentous network
coloured a deep-brown by tincture of iodine; and in both there
are molecular granules and some pus-globules, and, lastly, epithelial
scales.

We may therefore conclude, from what has preceded, that it is
easy to recognise, by means of the microscope :—

1. The pseudo-membranes of Muguet, which have no character in
common with the other false membranes.

2. The buffy coat of the blood.

8. The pleuritic false membrane; and I may state that it is im-
possible by the aid of the microscope alone to decide whether. we
have under our notice either a simple membrane of a blister, or a
diphtheritic exudation, or lastly, a scarlatinal membrane. :

Now, if from the fact that the examination by the microscope
demonstrates the formation of the false membranes of Diphthérite
from anatomical elements similar to those which enter into the forma-
ETLOLOGY. 331

tion of the false membranes peculiar to other diseases, certain per-
sons would conclude that these different exudations belong to a single
disease, we might object to such a view that the same microscopic
examination would lead them to conclude that the primitive pustule
of syphilis, the pustule of variola, the vaccine pustule, &c., are also
only lesions peculiar to one and the same disease, since the micro-
scope discovers in them only the same identical elements.

The application of micrography to medical studies would become, ~
in my opinion, the most unfortunate method of investigation, if it
should lead to such results. But on the other hand, it is precisely
by establishing and putting in evidence the similarity of the anatomi-
cal elements of many lesions peculiar to different affections, that the
microscope brings out still better all the influence and force of that
guid divinium which presides over the development and the evolu-
tion of diseases, by impressing upon them a certain special seal,
rendering them clearly distinct from_each other, and making from
them so many pathological unities distinct from all other gral
diseases.

Besides, micrography is still in its cradle, and we must not com-
promise the future; let us even hope that the microscope, or some other
method of investigation, will allow us one day to penetrate into the
specific differences of morbid products. All the sensible elements of
diseases will then be known, and what the mind now admits solely
upon the faith of the progress of phenomena, will then be ‘supported
on the most positive and solid data.

-Ertotogy or DripHTHeERTTE.

Of Diphthérite we may make the same remark as we may of most
other diseases, namely, that its etiology remains one of its most
obscure parts. This affection, which is sometimes sporadic, is often
developed in an epidemic manner; but the different authors who
have written upon the disease are as yet unable to discover under
what concurrence of circumstances it appears, and to what influence
its visitations are to be attributed.

‘Attempts have been made by turns to explain the development of
the disease by the influence exercised by moist air, by atmospheric
temperature, or by the unhealthy situation of the localities where it has
raged, but it cannot be said that the investigations made upon these
points have thrown much light upon the subject.
332 EMPIS ON DIPHTHERITE.

M. Trousseau thus expresses himself on this question :—“In
the towns and hamlets in the Department of Loiret, which are
remarkable for their salubrity and for their excellent geographical
position, I saw Diphthérite raging with excessive violence, while some
villages of Sologne, situated in the midst of marshes, remained
exempt from the scourge ; and on the other hand, some hamlets and
towns situated on the banks of ponds were depopulated by the epi-
demic, while others enjoyed a perfect immunity, which was thought
to be attributable to the ordinary salubrity of the place.”

The influence which may be exerted on this affection by bad food
and the different privations entailed by misery, is still surrounded
with much obscurity, and although constitutions which are weakened
and undermined by chronic diseases, have sometimes appeared more
apt than others to contract this formidable disease, yet it is no less
true that we often see it attack persons who are in the most vigorous
health, ;

Tn relation to the question of contagion, we find still more differ-
ence of opinion among nosographers ; but with some it is one of the
most established properties of the disease. ;

Caveant angue pejus parentes $U08 Sitios secum gerere, ubi puerulus
hoc modo infirmatur ; et st in domo ejus continget, statim alios pueros
valetudine fruentes separent (Alaymus). Carnevale and Marcus Au-
relius Severinus also admit its contagious nature; and Francis Nola.
does not much differ from them. Samuel Bard. expressed the fol-
lowing opinion on the Suffocating Angina :—* This disease has ap-
peared to me to be of a contagious nature; every infection proceeds
from some principle received into the economy, and this principle,
whatever it may be, being drawn in by the respiration of a healthy
child, irritates the glands of the throat and the trachea, penetrates
into them, and by so doing, induces a change in their secretion. The
infection, however, in the present case, does not appear to depend so
much upon some general influence of the air as upon the influence
of effluvia transmitted by the breath of infected persons ; which ex-
plains why the disease may attack a whole family without affecting
the adjoining houses.”

M. Bretonneau, whose competency in this matter cannot be dis-.
puted, admits the contagious property of Diphthérite, but in a degree
very much inferior to other diseases.

Other authors, with whom Diphthérite comprises all pseudo-mem-
branous affections, entertain no decided opinion as to its contagious
ETIOLOGY. 333

character. Still, M. Daviot, of Autun, thus expresses himself :—“ I
dare not refuse to it this property which is too readily attributed to
it. When, however, it is complicated with scarlatina or variola, it
-may resemble these diseases, although in a somewhat accessory man-
ner, in their essentially contagious character.” This assertion, in which
everything is confounded by M. Daviot, does not deserve much atten-
tion.

Let me now cast.a rapid glance over the progress of the epidemic,
and the order of succession in which I have observed numerous cases
of Diphthérite during the past year, and let me explain whether, ac-
cording to my own observations, we have any right to admit conta-

- gion as a property of this disease.

It was on the 19th of January, 1848, that a child, aged eighteen
months, and attacked with Croup, was brought from without and
admitted into the Hépital Necker; when, being placed im the Salle
Sainte-Julie, it appeared to become the exciting cause of the de-
velopment of Diphthérite. Now, for more than a year, no child in
the Hospital had been attacked with this dangerous affection, which,
it is important to observe, exhibited itself at this period in several
quarters of Paris, and especially at the Hépital des Enfans, with an
epidemic character. This child, who was lying in the cradle No.
13, died after remaining only twenty-four hours in the ward. Almost
simultaneously, another child, lying in cradle No. 8, and who had
already been a fortnight in the Hospital for hooping-cough, presented
at the point of the tongue an excoriation which soon began to be
covered with the specific membrane, and on the 28th of January, he
presented all the phenomena of Croup, of which he died forty-eight
hours afterwards.

It is rather difficult to admit that this child was the victim of
contagion, for, although in him Croup did not develop itself until
the 28th of January, it is no less true that on the 15th, he pre-
sented a kind of aphthous affection on the tongue, and that already,
at this period, a commencing pellicle covered the excoriated surface.
It is, therefore, quite rational to admit that the child was seized
with Diphthérite under the influence of the same general cause which
. had already developed this affection in the child who was brought
into the Hospital on the 19th of January, and in whom no indication
of contagion could be discovered. The child in cradle No. 8,
presents, however, this interesting point, that Diphthérite, the first
appearance of which was observed in him on the 15th of January,
334 EMPIS ON DIPHTHERITE.

remained for thirteen days localized on the tongue, before attacking
the air-passages. However, on the 22nd of January, a third child
was brought in from without; and for a week he had been attacked
with cutaneous Diphthérite, which appeared in him to have also
originated spontaneously. For the last*two days he had begun to
experience the phenomena of Membranous Angina and Croup; he
remained in the Salle Sainte-Julie, No. 9, for thirty-six hours, and
died after the operation of tracheotomy, on the 24th of January, at
one o’clock in the morning.

The three children above-mentioued, do not, therefore, afford us
any proof of the contagious character of Diphthérite; they even appear

to prove that this affection may have developed itself in them spon-

taneously, or under the. sole influence of the medical constitution ;
and although it cannot be affirmed that contagion, the modifications
of which are so obscure to us, was completely absent, we must at
least admit that its source remains unknown. The following facts
prove, moreover, if not the positive existence, at least the possibility
of the contagion of Diphthérite.

Thus on the 2nd of February, that is to say, fifteen days after the
first appearance of Diphthérite{in the ward, and three days after
the death of the last child attacked with Croup, of whom I have
just spoken, I saw a child, lymg in cradle No. 6, and consequently
separated only by one bed from the cradle of the child who had just
died of Croup three days before, presenting in his own person the
symptoms of this disease, which carried him off in forty-eight hours.

Now this child, who had been in the Hospital since the 11th of
January, convalescent of a varioloid affection, which he had contracted
four months before, in spite of having been vaccinated, retained
a slight bronchial catarrh which latterly had become rather acute.
The child, therefore, had remained fifteen days in circumstances
favourable to the development of Diphthérite by contagion, and he
was the more predisposed to it, because independently of the general
influence then prevailing and to which he must have been exposed,
he presented, besides, an irritation of the mucous membrane of the
air-passages, a condition very favourable to the localization of the
pellicular affection on these parts,

A day afterwards, namely, the 8rd of February, a fifth infant aged
six months, of a good constitution, who had been in the Hospital
since the 6th of January, and who presented at the lower and back
part of the neck a wound suppurating favourably, the result of a
ETIOLOGY. 335

burning by the actual cautery, applied in order. to destroy a san-
guineous tumor in the region indicated :—was attacked with Diph-
thérite ; im fact, the wound which had previously presented a good
appearance and produced a laudable, thick and creamy pus, became
more painful, produced a less abundant and thinner suppuration, and
soon exhibited little whitish and adherent patches which united to-
gether to form a large patch of Diphthérite, having all the characters
which I have indicated in my general description of this affection.
On the same day, the 3rd of February, in the cradle No. 9, of the
same Salle Sainte-Julie, where, on the 24th of January, a child was
lying who died of Croup, and by the side of the cradle No. 8, where
another child had also just died of Croup on the 30th of January,—
there had been for three days a little girl presenting excoriations at
the fold of the thigh and at the umbilicus, but who was otherwise in
good health. On the 3rd of February, these excoriated parts were
attacked by the diphtheritic pseudo-membrane. This last fact, and the
twowhich precede it, appear to me to be of great importance in reference
to the question of contagion. It may be objected, indeed, that I am
now dealing with an affection which has many times raged in an
epidemic manner, and which, at this very period, was exhibiting the
same character, and that it cannot be therefore affirmed that this
coincidence of facts was not the simple result of the general influence
of the medical constitution. Let me, however, be permitted to add,
although without attaching more value to this last fact than it de-
serves, that in the Salle Sainte-Therése, placed immediately above
the Salle Sainte-Julie, there was no child attacked with Diphthérite.
There are yet two more facts which seem to support the opinion
as to the contagious character of the disease. On the 16th of Feb-
ruary, while Diphthérite was attacking the two last children of whom
I have just spoken, a seventh child, lying in cradle No. 5, affected
with syphilitic ulcers, was also attacked by the membranous affection,
and four days afterwards, the 20th of February, an eighth child, lying
in cradle No. 3, was also seized with this disease in the same ward.
The other patients who were subsequently attacked with Diphthérite,
in the Salle Saint-Julie, confirm the epidemic character of this affec-
tion, without affording us evident. proofs of its contagious power.
The same uncertainty prevails as to the cause of the development
of the disease in the Salle Sainte-Cécile, situated in a portion of the
building opposite to that occupied by the Salle Sainte-Julie. It was
on the second of February, that a child who had been six weeks in
336 EMPIS ON DIPHTHERITE.

the Hospital, and was lying in the Salle Sainte-Cécile, in cradle No.
2, experienced the first phenomena of cutaneous Diphthérite, which
subsequently extended to the nasal fosse, the pharynx, and lastly to
the larynx, so that the child died of Croup. I should observe that
some fine days had already succeeded the frosty days of winter, and
that when the first rays of the spring sun invited the nurses to go out
into the courtyards, some means of communication began to be es-
tablished among the patients of the different wards of the Hospital.
It is, therefore, possible that this child, aged eight months, pre-
disposed to the disease as well by the general influence as by
the syphilitic coryza with which he was affected, met with the
efficient cause of Diphthérite in the contact which may have existed
with some other patient of the Salle Sainte-Julie. But I strongly
maintain that these are only possibilities and not certainties. On
the 3rd of April, a child who was lying in cradle No. 8, in the
Salle Sainte-Cécile, was seized with Diphthérite, after a child
who had come from without and was admitted into the same ward
on the 28th of March, died there of Membranous Angina and Croup.
In this case, if the disease had been propagated to the child in No.
3 by the effect of contagion, the incubation must have lasted six days.
It is impossible for me to conclude anything from the result of my
own observations, as to the time which this disease may have
occupied in its incubation, for, as I am induced to think, it must
be admitted that contagion was not altogether wanting as an agent
in propagating the infection. In fact, for two months, Diph-
thérite prevailed constantly in the Salle Sainte-Julie; and the first
children whom I have mentioned as having probably contracted the
disease in the ward under the influence of contagion, may have pre-
sented an incubation at the most of thirteen days, and at the least of
two days. Such a latitude, which becomes still greater in relation
to the children who were subsequently the victims of the disease,
does not permit me to form any definite conclusions on this question.

Inoculation, which, when it gives a positive result, is the most
indisputable proof of the contagious nature of a disease, has not been
repeated by me. When M. Trousseau, some years ago, induced by the
love of science rather than guided by prudence, inoculated himself with
Diphthérite on the tonsils, the result was negative; but can a single
experiment be regarded as conclusive? Do we not daily see cases
of vaccine inoculation turning out unsuccessfully, although success
is obtained in the majority of cases?
PROGNOSIS. 337

Proenosis oF D1patTHerite.

At present, if we glance at the severity of the epidemic,
the progress of which I have observed, we shall find that
Diphthérite is a disease which is always serious, although its
danger is in great part dependent upon the seat of the exuda-
tion.

When Diphthérite has.commenced on the cutaneous integument,
and has first attacked excoriated parts, or those which are in a state
of suppuration, the local disorder which it produces is not generally
so severe that the existence of the patient appears immediately
threatened ; for, by energetic local treatment, the exuding surfaces
have often been speedily modified, and have rapidly proceeded towards
cicatrization. This fact was attested by several of my patients, in
whom Diphthérite, limited to certain parts of the external integument,
rapidly yielded to the action of caustics, and did not again exhi-
bit itself on any other region of the body. Still, when this disease
appears upon a great number of parts at a time, and when it attacks
persons who are already the victims of a serious disease, it may be
followed by a fatal termination, although the false membranes may
not be seated in the organs of respiration. Thus I have seen a
child affected with constitutional syphilis, sink rather rapidly under
the influence of Diphthérite, developed simultaneously on a great
number of parts.

The prognosis of Diphthérite becomes always extremely serious
when this formidable affection is developed in the air-tubes, and in
this case the danger becomes the more imminent in proportion as the
exudation occupies the deeper parts of the air-passages. A child under
my care presented a remarkable example of Diphthérite attacking at
once the ultimate ramifications of the bronchi and rapidly causing
death ; and it may be readily understood why, in such cases, even
when we had recourse to tracheotomy, the operation was useless.
The circumstance which ought always to make us very cautious in
the prognosis of this disease, is the fatal property which it possesses
of being able to reappear on different regions in the same individual
and at uncertain intervals, and of affecting a kind of predilection for
the air-tubes. In fact, whatever may be the first seat of the exuda-
tion, and even when by energetic local treatment we have succeeded

z
338 EMPIS ON DIPHTHERITE.

in favourably modifying the exuding surface, we have not yet com-
pletely protected the patient from the reappearance of the exudation in
the organs of respiration. Thus, several of my patients, in whom
Diphthérite, at its origin, occupied only a very small surface, and
did not appear likely to prove fatal, subsequently fell victims
to the reappearance of this terrible affection in the larynx and
trachea.

Now, independently of the persistence of every local manifestation,
the most important symptoms of the general state of the patient,
and those which ought to cause the most anxiety to the practitioner,
and make him fear the reappearance of the exudation, are, fever, the
cachectic state, and the persistence of painful glandular swellings.
If these three orders of symptoms have remained after the disappear-
ance of the local lesions, we should be apprehensive of the return of
some diphtheritic inflammation, just as in acute articular rheumatism,
if the rheumatic fever continues, we must expect some fresh arthritic,
cardiac, or pleuritic complications.

But it is not necessary that this assemblage of general symptoms
should be so complete in order to testify to the imminent danger of
fresh local lesions; it is sufficient that one of the three should con-
tinue, in order to make us distrustful, and vigilant against a relapse
of the disease. Thus the existence of fever, the diphtheritic cachexia
alone, the still painful swelling of a few lymphatic glands, inde-
pendently of every other sign, will impose on the physician the
necessity of making a careful prognosis, and adopting vigorous thera-
peutical precautions. The frequency and smallness of the pulse, to
the exclusion of every other element of the febrile state, especially if
the child continues pale and of puffy appearance, will afford to the
physician a reason, which is sometimes very cogent, of apprehending
the more or less speedy outbreak of the local manifestations of
Diphthérite.

These remarks, which are as important in a practical point of
view as they are in relation to the general pathology of the disease
now under consideration, will add new weight to what I have already
stated above, concerning the almost chronic progress of Diphthérite,
a disease which is acute in its nature, but which may, in fact, during
its progress, assume some of the characters of chronic diseases. This
peculiarity, namely, its mixed character, will not perhaps be alto-
gether inexplicable, if we observe that the continuation of the
TREATMENT. 339

symptoms and the successive relapses of the local lesions, separated
by intervals during which there is is a persistence of the diphtheritic
cachexia, are more common in weak, ill-nourished, badly-lodged,
miserable children, who are surrounded by unfavourable hygienic
conditions, than among children who are placed in opposite circum-
stances. This is observed especially towards the decline of epidemics.
All these circumstances recall and confirm one of the most incon-
testable and most consoling facts in the general history of Diph-
thérite. We know, in fact, that this disease, besides its epidemic
conditions, rages principally among poor and weak children, living
in unhealthy habitations. Hence may we not be permitted to
hope that the blessings of civilization, by multiplying comforts and
their attendant circumstances, such as the healthiness of dwellings,
the amelioration of the hygiene of food, and the means of protecting
the surface of the body from the influence of atmospheric vicissitudes,
so fertile in producing catarrhal affections, &c., will weaken every
day the predisposing and occasional causes of Diphtherite, and will
gradually reduce it, like many other diseases which were formerly
malignant and epidemic, to a state of sporadicity and benignity, over
which our local methods of treatment will most frequently triumph
when the physician is called in at the commencement of the disease.

On THE TREATMENT OF DIPHTHERITE.

The epidemic which I witnessed was subdued principally by local
treatment; and my observations therefore enable me to judge especially
of this method of medication. The hydrochloric acid, the nitrate of
silver, the acid nitrate of mercury, calomel, and alum, are the agents
which have been most employed as local applications.

T have observed, that under the influence of these caustics, we
could pretty rapidly modify the morbid secretion, and limit the
extension of the Diphthérite to the tissues surrounding the affected
part. But unfortunately Diphthérite, as I have shown, is not alto-
gether a local affection, the persons who are the subjects of it being
the victims of a general condition, under the influence of which the
repetition of the exudation has a great tendency to fix itself upon
points which had not been primarily attacked. Now, the local medi-

cation can act only indirectly upon this general condition. If, as
Z2
340 - EMPIS ON DIPHTHERITE.

experience appears to demonstrate in many cases, a person is the more
predisposed to a repetition of the exudation on different surfaces, in
proportion as he already presents a greater number of diphtheritic
patches, we can understand how by the rapid disappearance of this
morbid secretion, we may diminish, in a given case, the predisposition
of the patient to a repetition of the disease.

But local medication does not afford a complete protection, at
least according to my own observations. Thus in many of my
patients, Diphthérite began with a patch which was often very cir-
cumscribed, and which was vigorously treated by the frequently re-
peated action of caustics. The local application was rapidly followed
by a great amelioration ; the Diphthérite ceased to extend in surface,
and at the end of a few days proceeded towards cicatrization: still,
even when cicatrization was complete, as in many of the patients, we
saw the Diphthérite, at the end of from ten to fifteen days, reappearing
violently in the air-passages and producing death.

To oppose the general condition under the influence of which the
false membranes are developed, and to destroy them when they are
formed, are the two great therapeutical indications to be fulfilled.
The first of these indications unfortunately finds but few auxiliaries
in the pharmacopeias. The specific agents which are capable of
rapidly modifying a general morbid condition, are rare in the domain
of therapeutics, and that which ought to be ‘opposed to Diphthérite
remains still to be discovered.

In the absence of any specific remedy, the physician is reduced to
the treatment of symptoms, which is the only kind of treatment
from which he can expect any favourable results when called upon to
attend cases of Diphthérite.

Blood-letting, which in certain circumstances has appeared to
diminish the inflammatory symptoms often accompanying Diph-
thérite, has generally been banished from the treatment of this disease
by MM. Bretonneau and Trousseau ; these able practitioners having
remarked that under the weakening influence of losses of blood,
patients became more liable to repetitions of the exudation, and that
the temporary relief which resulted from the measure did not com-
pensate for the unfavourable consequences by which it was often
followed.

Calomel, employed both locally and internally, has been often used
among my patients in the Hépital Necker. Its administration pro-
TREATMENT. 341

duces two effects: one, which may be called local, is exerted on the
secretions and determines salivation, which, in certain cases of
pharyngo-laryngeal Diphthérite, may have some favourable influence
over the morbid secretion, and’ over the expulsion of the false mem-
branes ; the other effect is more general, and is exerted aver the whole
organism and the circulation.

Among the patients who were subjected to this treatment, and in
whom the diphtheritic surfaces were at the same time energetically
cauterized, several recovered completely without being attacked by
any subsequent repetition of the exudation; while others, less fortunate,
were not exempt from relapses, in spite of the internal administration
of calomel. It is, therefore, an agent which may be useful, but the
influence of which on the general morbid condition cannot be regarded
as infallible.

When Diphthérite occupies extensive surfaces and remains for a
long time on a patient, his constitution is much weakened and dete-
riorated; and he may even fall into that last condition, called cachectic.
It is especially i in order to prevent and oppose this condition that
we must have recourse to analeptic and tonic remedies, such as suc-
culent food, bark, and iron, which will be employed by the physician
according to the particular indications of each case.

Alum has appeared to me to possess a certain degree of efficacy ;
in some children already affected with cutaneous Diphthérite, hoarse-
ness, cough, and roughness of voice supervened at the end of a
few days, and these children appeared to be imminently in danger of
the attack of Croup, when insufflations of alum in powder, frequently
repeated at the lower part of the throat, caused a rather rapid ces-
sation of all the precursory symptoms of laryngeal Diphthérite,
and the health was completely re-established. I think, therefore,
that when a child is attacked with Diphthérite, and any alarming .
symptoms are manifested in the region of the throat and larynx,
we ought, without waiting any further, to treat the case with
insufflations of powdered alum, which cannot produce any un-
favourable result, and which may, on the contrary, prevent the de-
velopment of the false membranes, by directly modifying the inflamed
surfaces.

I cannot, in this general sketch of Diphthérite, enter into all the
peculiar indications which every variety in the seat of the disease may
present in its treatment, for such a course would lead me beyond
342 EMPIS ON DIPHTHERITE.

the limits which I have prescribed to myself. Let it suffice, there-
fore, to repeat that one of the first indications which present them- .
selves in all the cases where Diphthérite is accessible to the direct
action of medicines, is to endeavour to modify the morbid secretion
by means of caustics, the choice and the application of which, more
or less energetically repeated, will depend upon the special circum-
stances in which each patient is placed.
DAVIOT.
EPIDEMIC PHARYNGEAL DIPHTHERITE. 345

DAVIOT ON DIPHTHERITE.

(Relation Historique d’une Epidémie de Diphthéropathie observée
dans le Département de Saone-et-Loire et de la Niévre, pendant
les années 1841, 1842, 1843, ef 1844, par D. Z. Daviot.
Autun, 1845.)

EPIDEMIC PHARYNGEAL DIPHTHERITE.

As this disease has not exhibited the same severity in all the subjects
who have been attacked by it, we shall recognise three very distinct
stages in its progress and the violence of its symptoms :—

1. In the first stage, the pathological conditions were sometimes
limited to a slight sense of uneasiness in the throat, accompanied
by scarcely any difficulty in deglutition. There was, most commonly,
in addition to these symptoms, a more acute pain in the pharynx,
while the movements of the neck were constrained, and there was
some degree of torticollis. The cervical and sub-maxillary glands
soon became engorged; the face was congested and puffy, with in-
jection and lachrymation of the eyes. On examining the lower part
of the buccal cavity, all or nearly all the parts constituting the
guttural fossee were seen to present a deep rose-red colour in children,
and a more deep-brown one in adults. There was also swelling of one
of the tonsils, more rarely of both, more marked in the inverse pro-
portion to the age; the uvula was almost always tumefied and
relaxed; there was almost habitually coryza; the fever was often
absent or was little felt, and young subjects were able to continue
playing as usual ; in some few cases, a little depression was observed.
In some patients, on the contrary, the general phenomena were either
developed at first, or were very intense from the commencement of
346 DAVIOT ON DIPHTHERITE.

the disease, and therefore caused an apprehension of the most serious
danger. At this period, the disease when suitably treated, lasted,
in certain cases, for several days, but was terminated in other cases
at the end of a few hours.

2. When the disease passed to a more advanced stage, commencing
often on the very day of the invasion, and sometimes a few hours
afterwards, this transition was inaugurated by a very remarkable state,
and one which has not hitherto sufficiently attracted the attention of
practitioners; a circumstance which may be explained by the fact
that the period of commencement is often so short that the medical
attendant seldom observes it. I have constantly remarked, on the
parts which were about to become the seat of the pseudo-membranous
exudation, a fresh transparent coloration, presenting an oedematous
appearance, and similar in tint to a piece of meat blanched by the
action of boiling water. Soon afterwards there were observed upon
the tonsils, the uvula, the velum palati, the posterior surface of the
pharynx, &c., &c.; either solitarily, simultaneously, or progressively,
small vesicular points, formed by partial elevations of the epithelium,
of a shining and whitish appearance, and which, though at first
separated, in general soon become united and confused together, and
then were transformed into patches of a lardaceous, smooth, whitish,
yellowish, or brownish appearance, irregularly circumscribed, more
prominent in the centre, and becoming thin at their edges. Some-
times the primitive patches remained isolated, and appeared to rest
upon a depressed surface. This variety of form which has not yet
been described, has been seen by myself principally upon the tonsils,
which then presented an entirely peculiar appearance. By the side
of these depressed diphtheritic points, these organs preserved their
tumefaction and redness, and their surface became, as it were, an-
fractuous.

Sometimes the uvula was affected on one side only, and curved
upon the diseased side in the form of a hook; sometimes, as M.
Guersant has already stated (Dict. de Méd. Art. Angine Couenneuse),
it was enveloped entirely as in the little finger of a glove.

- With the appearance of the false membranes, the glandular engorge-
ment increased considerably, especially on the side where the tonsil
was more swollen, and the pellicles were more numerous and thicker.
Deglutition was more difficult, but rather in proportion to the volume
of the lymphatic glands, than to the swelling of the tonsils and the
extent of the membranous exudation; and it was never painful in
EPIDEMIC PHARYNGEAL DIPHTHERITE. 347

proportion to the inconvenience which must have existed, a character
which establishes a well-marked line of demarcation between pharyn-
geal Diphthérite and simple Angina. The voice was altered and
became nasal; cough was infrequent or absent altogether ; there was
stoppage of the nose and a flux of serous liquid by the nostrils ; the
patient was abundantly salivated, and voided a semi-transparent fluid
interspersed with large bubbles, pouring out like white of egg and
manifestly albuminous ; liquids were often thrown up and ejected by
the nasal fossee ; the mouth exhaled an odour sui generis, compared
by M. Guersant to that of carious teeth, less perceptible in the child ;
and there was also painful torticollis,

With the local pathognomonic symptoms which we have just de-
scribed, were united some general symptoms dependent on the
direct or sympathetic lesion of many other structures: such as more
considerable swelling, but less deep coloration of the face; more or
less intense febrile reaction, according to the age and strength of the
subjects, and according to the more or less favourable hygienic cir-
cumstances in the midst of which they had been attacked by the
disease ; the pulse was generally frequent, nearly always small and
compressed, even in individuals of a good constitution, which is again
one of the marks of epidemic Diphthérite; cephalalgia more or less
marked ; tongue swollen, covered with a thick and yellowish mucous
coat; rather frequently nausea and vomiting ; and sometimes phlegmo-
nous abscesses were formed at the base of the lower jaw, in the
neighbourhood of the lymphatic glands, or in their tissue. We often
also remarked on different parts of the body, diphtheritic patches,
especially on the lips, around the als of the nose, behind the ears,
around the circumference of the anus, of the vulva, of the nipples,
on the penis, and the hands, and on the blisters which had been ap-
plied upon the patients.

When the disease was about to terminate favourably, the extension
of the false membranes ceased; the latter were then circumscribed
by a red areola, were swelled up, and began to separate, and being
detached in strips, allowed of the oozing of a few drops of blood,
and were then thrown up by the patients together with a frothy
saliva, which was of a viscous consistence, and of a nauseous smell.
These pellicles would be frequently reproduced in a short space of time,
and we were often astonished at the prodigious quantity of decom-
posed matters which was expelled in certain cases. Those of the
second or third formation were more white, thinner and more trans-
348 DAVIOT ON DIPHTHERITE.

parent than those of the first; at last they ceased to be reproduced
after their detachment, or rather, according to the remark of M.
Guersant, instead of being elevated, the primitive exudations adhered
firmly to the mucous surfaces, were always covered by epithelium,
appeared to be absorbed, layer by layer, and to be worn out in some
manner; then soon becoming transparent like gauze, they exhibited
the mucous membrane beneath them, which was generally of a red
tint, but less deep than that of the adjacent parts which had not been
covered by the membranous coat. I may add that when the mem-
branous exudation assumed this condition, which I shall call 4at
couenneuz, it had no tendency to be renewed or propagated, and that
although the action of the local applications was more slow in these
circumstances than in the cases mentioned above, it was nevertheless
an infallible condition of cure.

After the detachment of the diphtheritic exudations, the tonsils
could be seen more or less retracted upon themselves, and sometimes
so constricted that they could be scarcely seen between the arches of
the palate. If the uvula had been totally enveloped by the false
membrane, it was uniformly diminished in size, and its volume often
reduced by three-fourths; if it had not been covered except on one
side by a membranous patch, it remained for a certain time curved
like a hook on this same side. The edge of the velum palati ap-
peared also in some cases, as if it was ulcerated, and had lost a portion
of its tissue. However, this was only an illusion, for, after a careful
examination, no traces of cicatrices nor loss of substance were found.

This retraction of the tissues, clearly depends, as I agree with M.
Roche (Dict. de Méd. et de Chirurg. prat., Paris, 1829, t. II. art.
Angine Cowenneuse, p. 551), on the destruction of the bloody fluid
which had furnished the materials for the formation of the pellicular
exudations. I shall give as proofs of this assertion, both the less
deep colour and the depression of the surfaces which are invested by
the pseudo-membranes.

I have also sometimes found, after the detachment of the pellicles,
small purulent spots in the interior of the tonsils; at other times
these glands have remained in the state of scirrhous induration which
has required their removal.

In proportion as the resolution of the disease took place in the
pharynx, the lymphatic glands diminished in volume and ceased to be
painful ; there was a diminution, and then a complete cessation of all
the general phenomena; lastly, after a variable duration of from six
EPIDEMIC PHARYNGEAL DIPHTHERITE. 349

to twelve days, convalescence was established, but slowly and with
difficulty, and was remarkable for a state of languor which remained
for a long time, by a peculiar paleness of the face, and often by
pustular eruptions (Lethyma Lwuridum) on the limbs, the face, &c.
The voice often remained nasal for a certain period; liquids, and
sometimes food, were rejected through the nostrils, and relapses were
also common. :

3. Lastly, the disease was aggravated and would attain its highest
degree of intensity, sometimes in the space of thirty-six to forty-eight
hours. The tonsils became enormously enlarged, so as to touch one
another, and to form, with the uvula, which was very large itself, a
mechanical obstacle to the introduction of liquids, as well as to the
passage of air. The membranous patches began to thicken, were
very adherent, of a dull yellow-greyish or brownish colour, and invaded
the whole guttural cavity, the nasal fosse, and very often the palatine _
arch: there was considerable tumefaction of the cervical and sub-
maxillary glands, extending sometimes as far as the clavicular regions,
more marked especially at the base of the lower jaw, a circumstance
which gave to the patients a peculiar expression; laborious respira-
tion, accompanied by a more or less noisy guttural rattle; not much
cough, and that not taking place except at the moment of the
introduction of liquids, which, by the difficulty of swallowing, remained
in contact with the opening of the glottis; voice generally feeble ;
discharge by the nostrils of a sanious and fetid fluid; frequent epi-
staxis, sometimes so abundant as to require hemostatic measures ;
mouth always open, and exhaling a gangrenous odour; spitting of a
viscid purulent matter, mixed with membranous flakes, often blackish,
and then presenting altogether the colour and aspect of gangrene ;
lips bleeding and covered with brownish crusts; greater puffiness of
the face ; remarkable lividity of the complexion, a phenomenon which
depends on the obstacle opposed by the embarrassment of the respira-
tion to the return of the blood, and on its accumulation in the
venous system; continual cephalalgia, especially severe in the supra-
orbital and auricular regions ; an expression of weakness and languor,
but never great alteration of the features; constipation either per-
sistent or replaced by a fetid diarrhoea; and fever with irregular
paroxysms. The cutaneous patches which existed in the second stage
of the disease, like those which came on at that time, became brown
and diffused a fetid odour. The pulse soon became thready and
lost its regularity; the extremities were cold; and covered with a
350 DAVIOT ON DIPHTHERITE.

viscid sweat ; there was drowsiness in children, agitation and anxiety
in subjects of a more advanced age. Lastly, the patients after having
presented that paleness of the face, which Laennec calls a semi-
cadaverous phenomenon (Traité de Vauscultation méd. 4° edit.
Paris, 1837, t. 1, p. 888) and without experiencing any disorder
of the intellectual functions, expired, having exhibited all the
symptoms of true asphyxia. The disease sometimes advanced very
rapidly towards a fatal termination, especially when it attacked
cachectic subjects, on whom the false membranes presented a brown
colour from the commencement. Death, in most cases, did not
occur until about from the seventh to the tenth day. The organs of
respiration were seldom attacked by diphtheritic inflammation in the
course of the epidemic, and this complication occurred in an alto-
gether exceptional manner. The extension of the pellicular inflamma-
tion then ceased, and the symptoms of Croup supervened.

There is a mode of termination of Membranous Angina, on which
M. Guersant (op. cit. p.119) has strongly insisted, and which T have
noticed on several occasions. At the time when this affection was
in progress of cure, and at the period when convalescence seemed to
be established, the patients were seized with a consecutive broncho-
pneumonia which was generally double. The supervention of this
formidable complication was very insidious, and the symptoms which
existed were always slightly marked. I observed, in such cases, a

-tather infrequent cough, which was not at all dry or guttural, and
was accompanied with aphonia as in Croupal Diphthérite. There
was an expectoration of scarcely rusty sputa, containing little air, and
presenting some streaks of blood. Percussion and auscultation gave
all the signs of pulmonary engorgement, more or less well-marked ;
there existed intense fever with irregular paroxysms, and the res-
piration seemed habitually less difficult than in ordinary peripneu-
monia. I always found this a fatal complication. Scarlatina and
measles sometimes accompanied the disease, but only rarely in the dis-
tricts of Poil and of Millay, a canton of Luzy. These cutaneous
exanthems impressed a more serious character on the principal disease.
I should have wished, in order to complete this description, to present
it in an essentially scientific form, namely, with the addition of the de-
scription of the post-mortem examinations. Unfortunately, the preju-
dices which are still opposed, in our districts, to the opening of dead
bodies, acted as an obstacle to these investigations.

This defect is, however, comparatively unimportant when we con-
EPIDEMIC PHARYNGEAL DIPHTHERITE. 351

sider the valuable pathological researches with which M. Bretonneau
has interspersed his Memoirs on Diphthérite. These researches are
so accurate and complete that, in my opinion, it would be very
difficult to add to them any new facts worthy of notice.

To what form of pseudo-membranous Angina can our epidemic be
referred ? Let me begin by showing, as briefly as possible, the varie-
ties of Membranous Angina admitted by M. Bretonneau, and adopted.
by more modern writers; and I shall then endeavour to indicate the
points of resemblance which may exist between the disease I am
describing, and the species recognised in nosological science.

1. Common Membranous Angina.—This variety of the disease oc-
curs at other times than those of the epidemic, and has no tendency
to propagate itself from the guttural cavity where it is developed,
towards the more deeply-seated organs. It is not very common, is
generally benignant, and is of short duration. I propose to give to
it the name of Sporapic PuarynceaL DirutHeERits.

2. Scarlatinal Membranous Angina, or that of Fothergill.—This
variety, which is more serious than that just described, generally
shows itself during epidemics of Scarlatina, and like that disease, it
is not propagated into the air-passages. This point of resemblance
is not the only one which connects these two diseases ; indeed, I am
induced to believe they are identical, for they differ from one another
only by the epidemic circumstances which impress a greater or
less intensity upon sporadic diseases in general, and by the na-
ture of the exanthematous affection which produces in the whole
organism, a peculiar modification, under the influence of which the
cutaneous inflammation assumes a greater degree of development.
To maintain a contrary opinion would be to assume that common
typhoid fever, sporadic cholera, &c., are different diseases from ty-
phoid fever, epidemic cholera, &., &c., because these latter may
present an unusual degree of severity. It appears to me, therefore,
that it would be better perhaps to designate the Scarlatinal: Mem-
branous Angina by the name of Epidemic Pharyngeal Diphthérite ;
in the first instance, because several very different kinds of Angina
are met with in combination with Scarlatina (Planchon, Journal de
Vandermonde), and also, because this Angina often accompanies
measles and smallpox; and in the last place, because it may prevail with
all the characters which have been given to it, in the epidemic state,
by authors, and independently of any eruptive fever, as was observed
in our districts.
352 DAVIOT ON DIPHTHERITE.

8. Diphtheritie Angina.—This would differ from the last two va-
rieties by its disposition to attack the air-passages. If, according to
the observations of M. Bretonneau himself, and also to the opinion
formerly expressed by the author of the article on Croup 2 the Dic-
tionnaire de Médecine, Diphtheritic Angina is nothing but common
Croup, which in nearly all cases begins in the pharynx, why should
we assimilate it to two diseases, in which ad/ the phenomena begin
and end in the guttural cavity? Why have we given and preserved for
it a denomination which is not appropriate for pointing out its true
seat? I think, therefore, that it would be most convenient to name
it Croupal or Pharyngo-laryngeal Diphthérite, provided, as I repeat,
that the appearance of the pellicular exudation at the back of the
throat is usually nothing more than the stage of the invasion of
Croup.

We shall not require, I think, to reproduce literal scholastic de-
scriptions in order to arrive at the classification of our epidemic
Angina, and to show that it belongs incontestably to the second
variety. But I say, with the authority to which I so often appeal
upon the great question in which we are occupied (M. Guersant),
that if we admit in these diseases, varieties which are very
distinct, it is impossible not to perceive that the differences which
constitute them are weakened by intermediate shades, sometimes
so imperceptible that the nosological boundaries become almost
abolished between the different forms of pseudo-membranous Angina,
as they often are in smallpox, for example, and in many other
diseases.

I have been able to distinguish, in the course of the epidemic, a
great number of cases which had quite the appearance of sporadic
pharyngeal Diphthérite, and other cases, not less numerous, presenting
all the appearances of the Fothergillian disease, but without any
scarlatinal complication ; in short, I have several times seen croupal
Diphthérite, either originating in the pharynx or terminating in this
organ. Now, although the same cause may induce the different
shades of the diphtheritic disease, some authors would recommend
us to consider these modifications as so many distinct affections. I
am induced to believe that in the present instance, and generally in
all epidemics of the same kind, the seat of the disease and its com-
plications are alone sufficient to establish the line of demarcation, if
we admit any, between the different cases of Angina called pseudo-
membranous.
PRESUMED CAUSES OF THE EPIDEMIC. 353

Presumep CausEs or Tur Hrrpemic.

Shall we be able to discover the determining causes of Diphthérite
in the conditions of the climate of the cantons where it has prevailed,
or in the hygienic state of their population? According to the
general rules which I have laid down in the article on historical
documents, the reply must be in the negative. Shall we find these
causes In certain modifications of the atmosphere? We are com-
pelled to confess that all our hygrometric, thermometric, and
barometrical researches have not explained any better the appearance,
the increase, or the extinction of the epidemic.

Shall we consider with M. Bretonneau (doc. cig. p. 88), and Pro-
fessor Trousseau (Archiv. Gener. de Med. t. XXI.), that contagion
plays the principal part in the propagation of pharyngeal Diphtherite ?
This opinion, already admitted by some writers of the seventeenth
ceutury (Lassis, Malad. Gpid., Paris, 1785, t. I, p. 158; Ozanam,
op. cit. t. III.), would seem, @ priors, to offer a certain amount of pro-
bability, and to remove the doubts attached to the question of the
development of the epidemic of which Iam writing. As for myself,
before 1 witnessed this disease, I had adopted the generally received
theory ; but in the present day, since I have been enabled to verify
all the facts which have presented themselves in support of this view,
I venture to deny the contagious property which is too readily
attributed to it. If, however, it should be complicated with measles,
scarlatina, or smallpox, then it will partake, although in a somewhat
accessory manner, of the essentially contagious nature of those
diseases. Besides, contagion would only explain the propagation
of Diphthérite, and not its origin or its primitive cause. I shall
soon return to this important subject.

In my opinion, pharyngeal Diphthérite must derive its origin from

some agent, which is occult in its nature, but which always deter-
mines pellicular inflammation, and is similar in its effects to certain
chemical substances, as mercurials, chlorine, ammonia, the caustic
alkalies, the ethereal tincture of cautharides, &c., &c., which induce
the same pathological state. Might not the re-agents which demon-
strate the presence of these different bodies assist in discovering in
the atmosphere the nature of the epidemic agent? I appeal to ex-
AA
354 DAVIOT ON DIPHTHERITE,

perience. Let me now add a few words on the nature of epidemic
pharyngeal Diphthérite.

Since the works of S. Bard, who declared the identity of the Angina
called gangrenous, with Croup; (New York, 1771); and the
most recent researches of MM. Bretonneau, Guersant, Deslandes,
(Journal des prog ; des Sciences et Instit. Med., t. 1° p. 102, 1827.
&c.)—we are no longer permitted to.look upon Membranous Angina
as a gangrenous disease. These able observers, particularly the last-
named, have shown in an irrefragable manner, that a gross error had
been committed in taking the pseudo-membranous productions of
the throat for eschars; that the fetid smell of the mouth depends
only upon the putrid decomposition of the pellicular exudations, under
the influence of heat and moisture; and that the different colours
of the false membranes are owing to the blood exhaled by the in-
flamed surfaces, which blood is altered by the concurrence of the
same conditions as those which influence the membranous patches
themselves, and communicates to them the gangrenous aspect by
which they are characterized. These authors have proved by evi-
dence, that Pharyngeal Diphthérite, beg of the same nature as
Croup, which has always been considered as an inflammation, even
by Home, its first historian, ought no longer to be classed among
gangrenous affections.

M. Guersant, however, admits a fact which I have had occa-
sion to verify in the case of a young woman recently confined,
namely, that true gangrene may be met with in conjunction
with the pellicular exudation, but rarely and accidentally (and only
in certain special cases), while we are treating subjects who are of a
bad or very much enfeebled constitution, and especially during epi-
demics of measles, scarlatina, or smallpox, complicated with Malig-
nant Angina, when these eruptive fevers determine in the economy
a particular state which, according to experience, eminently predis-
poses to sphacelus. Under these circumstances, there is always a
loss of substance, and there are evident traces of ulceration which
has succeeded the detachment of the eschars. The patient in my
own case presented, after the exfoliation of the false membranes,
a partial gangrene of the left tonsil with an ulceration of a bad ap-
pearance.

The same author adds that although it is incontestable that
gangrene is sometimes observed in the pharynx, it is only as a
termination of inflammatory Angina, or as a complication of its va-
PRESUMED CAUSES OF THE EPIDEMIC. 355

rieties. Consequently, he does not think that in the present state of
science, we are yet able to recognise a gangrenous Angina, as a dis-

_tinct species, having different characters from all the others and a
course peculiar to itself. MM. Monneret and De Laberge (Com-
pendium de Méd. Prat.) have appealed against this opinion, and have
described anew in their nosological descriptions, an Angina primi-
tively gangrenous in its nature. Nevertheless, in the epidemic
state, we find no authentic reference to this disease in books; and
the chief part of the isolated observations on Gangrenous Angina.
(Guersant, Dict. de Med. 1" edition, p. 379: MM. Barthez et Ril-
liet, Mém. sur quelques points de ? Hist. des Ang. et des Gang. du
Pharynz chez V enfant. 1842) show us that the local disease of the
guttural fosse is always connected with a morbid condition of the
organs of respiration or of the gastro-intestinal tube, or with a typhoid
condition of the system, of which it is only one of the symptoms.
Let me here quote two interesting cases which Dr. Guyton has been
kind enough to communicate to me. I shall, however, have to in-
quire whether the deductions drawn from them by the distinguished
physician of Autun, although conformable in many respects with the
views of the Editors of the Compendium, may not also be reconciled
with the principles advocated by M. Guersant.

“ At eight o’clock in the morning,” says he, “TI was going away
into the country, when I was stopped, on leaving the town, by a
person named Chifflot, a cooper, to see his two sons who had fallen
ill on the same morning. One was about eight years old, and the
other six ; I-recognised in both of them an incipient tonsillar An-
gina; there was redness of the velum and of the pillars of the palate ;
slight tumefaction of the tonsils ; difficult deglutition ; moderate de-
gree of fever; natural countenance; integrity of the intellectual
functions: and in a word, there was a complete absence of every
serious symptom.

“ At five o’clock in the evening, when I returned, I called again at
the house of the patients and I found the eldest child dead and the
youngest in the agonies of death: he died half an hour after my
arrival. Both had the back part of the mouth sphacelated.

“Tt is-impossible to doubt, in these two cases, the existence
of a gangrenous Angina, in all the force of that term. If the
disease had not been such in its intimate nature, it would not
have advanced with such rapidity, and without being preceded by

symptoms indicating the attack of so serious an affection. It is
AA2
356 DAVIOT ON DIPHTHERITE.

certain that the two children were in perfect health on the previous
evening.”

Dr. Guyton will perhaps permit me to hesitate in adopting, with-
out restriction, the corollary which he would deduce from the cases
which have just been related. In fact, if we consult authors who
have written upon the gangrene which is developed upon the mucous
membrane of the digestive organs, MM. Baron (Mém. sur une affect.
gang. dela bouche. Bulletin de la faculté, 1816). Isnard (Dissert. sur
une affect. gang. particul. aux enfants, Paris, 1818). Billard (Zraité
des malad. des enfants, Paris, 8° édit. 1839). Guersant, &., &c.,
aud an observation made by myself, we shall then be easily convinced
that this disease, whenever it is primarily gangrenous, is neither pre-
ceded nor accompanied by a simple inflammation as in the cases re-
corded; that it attacks habitually only cachetic subjects or sickly
persons who are destitute of all vital energy, and that it never pro-
duces, as in the children of Chifflot, such a well-marked general
reaction. The gangrene or anthrax of the digestive passages, so rare
in the pharynx that we are disposed to deny its existence, reveals
itself from the commencement by pathognomonic symptoms, such as
sinking and stupor; and like malignant pustule, it is rather followed
than preceded by the inflammatory state.

I can find, therefore, in the case above cited, and characterized
by the most decided local and general symptoms.of ordinary Angina,
only a phlegmasia having had, dy excess of stimulus, gangrene as its
termination.

According to my own opinion, and I make use of the very expressions
of M. Guyton, if the disease had been, from the commencement,
gangrenous in its intimate nature, it would not have advanced with
such rapidity and without having been preceded by such precursory
phenomena as generally announce the invasion of sphacelus, pro-
perly so called; and I appeal, in confirmation of my views, to the authors
above-named, especially Billard. Now, the two subjects of M. Guyton’ 8
observation enjoyed the most perfect health on the previous evening.

My esteemed friend will excuse this contradiction in consideration
of the importance of the practical consequences, which ought to
follow from theory in this question. In fact, if we consider the disease
of the children of Chifflot and the like, as a primitively Gangrenous
Angina, the indication for the employment of tonics necessarily arises,
and in the circumstances, this kind of medication could only produce,
PRESUMED CAUSES OF THE EPIDEMIC. 357

in my opinion, the most serious results. If, on the contrary, according
to my own view, we see in them only a phlegmasia, threatening, by
the very violence of the irritation, to terminate in gangrene, which
is one of the methods of the termination in every inflammation, we
shall necessarily have recourse to antiphlogistics of the most active
kind, which are the only efficacious barriers we can oppose to this
fatal tendency of the disease. The following is another case
which fell under the notice of M. Gagnard, an old surgeon of the
Hospital of Autun. This gentleman was called to Vaumartin, near
Montcenis, to a family attacked with Angina. Of seven persons
seized on the same day, and nearly at the same hour, six died in four-
and-twenty hours, having their throats entirely sphacelated; the
seventh survived ; this one presented only the symptoms of Aphthous
Angina, with false membrane or couénne.

As this case depends only upon recollection, M. Guyton cannot
guarantee its accuracy; and I shall, therefore, abstain from making
any comment upon it; nevertheless, I am induced to look upon the
disease described as belonging to the pharyngeal or rather to the
pharyngo-laryngeal Diphthérite of an adynamic form, the characters
of which I have elsewhere described. I form this opinion upon the
existence of the false membranes, recognised by the physician only
in the case of the subject who recovered, and by the very fact that
they did not present that brown colour which simulates so com-
pletely the aspect of a true gangrene, and which caused an error of
diagnosis in the case of the patients who died ; 3a very common
error, I may observe, in these latter days.

Nobody, at present, can call in question the inflammatory na-
ture of Epidemic Pharyngeal Diphthérite ; but I agree with many
other physicians, and especially M. Bretonneau, that it is a specific
inflammation; namely, that it offers some peculiar characters which
are not those of ordinary inflammation, and that the existence of
the false membranes, which constitute its essential symptom, is
due rather to the special character of the disease, than to its
intensity.

But the pellicular exudation is not the only distinguishing feature
which exists between simple Angina and pharyngeal Diphthérite.
The latter is not a purely local affection like the former, but it is
found manifestly connected with a morbid state of the whole economy.
This opinion, in fact, has already been offered by the illustrious
358 DAVIOT ON DIPHTHERITE.

Pinel (Nosographie Phys. t. II, p. 256, 1818), and sustained by M.
Deslandes.

I can discover the proof of this proposition in the miasmatic or
epidemic nature of the disease; in the rapidity of its course; in its
severity, which is generally but little proportionate to the apparent
mildness of the local inflammatory phenomena by which it is
accompanied ; in the very remarkable disposition of the cutaneous
ulcerations to take on the diphtheritic and even gangrenous character
in their course, as in typhoid affections; and, finally, I discover this
proof in the length and difficulty of the convalescence,—a general in-
dication of a deep-seated affection of the whole organism. All these
circumstances seem to me sufficient to separate it altogether from
common guttural phlegmasia.

Is Pharyngeal Diphthérite contagious? In support of its imme-
diate and direct transmission, authors have insisted :—

Ist. On the fact that it may exhibit itself at one time on several
members of the same family; but is not this fact, which I have
rather frequently noticed, equally observed in certain epidemics which
are generally considered non-contagious? Here, as in Diphthérite,
is this simultaneous invasion anything else than the result of a simple
analogy of organization and of similar dispositions in individuals
placed in similar hygienic circumstances, and capable of experiencing,
at that very time, the same morbific influences? On the other hand,
the simultaneous attack of the disease upon several subjects belonging
to the same family, is not the general rule; I have observed it quite
as frequently attacking, under the same roof, a certain number of
patients, only at more or less distant intervals, and more usually at
every aggravation of the epidemic, that is to say, at every time when
the epidemic agent (agent epixioique), which had become more active
under a certain influence, began to exert itself afresh and in preference
upon the same idiosyncrasies. Can we, to explain this fact, admit
by any chance that the contagious principle could have six months,
or a year or more of incubation, before its development? This
explanation, which is against all probability, does not require refuta-
tion.

2nd. It has also been alleged that it is to a diréct and immediate
transmission that we ought to attribute different examples of com-
munication, in the cases in which the parents, attendants at ‘hospitals,
and even medical men, like Bourgeois of Paris (Journ. Gén. de
IS DIPHTHERITE CONTAGIOUS? 359

Méd. t. CVI. e¢ CIX.), have contracted the disease, either in attending
upon patients, or in exploring their guttural cavities, because it often
happens, in this examination, that the affected subjects, in coughing,
throw up sputa and shreds of membrane in the face of the observer,
and also cause him to inhale their breath.

I shall reply that, I have seen several times among the poorer
classes, parents sharing the bed of their sick family, and that, in this
prolonged contact, I have never been able to ascertain a single case
of real contagion, which, however, may still appear to occur from the
fact of the family being predisposed to the disease.

I shall also oppose to the views above quoted, the power which
parents have possessed, with few exceptions, of approaching with
impunity the mouths of patients while practising, in the intervals of
my visits, insufflations of powdered alum, a therapeutical application
to which I have constantly had recourse in the treatment of the epi-
demic. Could it be supposed that these persons, for the greater part
of small intellectual powers, would choose the moment of inspiration
to introduce the medicine, with a view to avoid the breath of the
individuals who were affected ?

The epidemic has traversed a great extent of country, and has been
observed by many medical men, of whom no one, so far as I know has
been attacked by it. I myself, in particular, who have been com-
pelled to examine a considerable number of patients in unhealthy
houses, often crowded with inhabitants,—conditions essentially favour-
able to the development of the contagious element, as well as to its
direct propagation ;—I, who for several years have been exposed to
all the circumstances in which Bourgeois and other members of the
profession who have taken the disease were placed ;—I say, that
I have passed through the epidemic without any attack. If it is
objected that my fellow-practitioners and myself were proof against
the contagious principle of Diphtheritic Angina, as any one might
be against that of variola, syphilis, &.; might we not reply, with good
reason, that if we had experienced the epidemic influence, it was be-
cause our organization being identical with that of the patients, we
ought to be subjected to the same morbid consequences ?

If this contagious nature, which is attributed to it in an absolute
manner, really existed, I think that it would have manifested itself
among the strangers who visited the patients, and yet I affirm that it
has not done so.
360 DAVIOT ON DIPHTHERITE.

T have also endeavoured to verify the very important, fact cited by
M. Bretonneau (op. cit.) concerning a student of pharmacy, who,
while still suffering from the consequencés of Malignant Angina,
went to pass a few days in the country, in a house where a short
time afterwards three persons were attacked by the disease, and two
died. This fact, which, in the eyes of the author, appeared an
incontestable example of direct communication, appears to have
assisted powerfully in fixing his opinion in favour of the contagious
property of the pseudo-membranous Angina, and must have helped
in bringing over many persons to his opinion. As for myself, I con-
sider the case to be an exceptional one; and I have never been able,
in spite of my best exertions, to meet with any similar instances.
On the contrary, it would be easy for me to bring forward a great
number of observations, and to quote a multitude of cases offering: a
totally opposite aspect. I shall adduce only three, which, im my
mind, exhibit a striking proof of the non-contagious nature of the
disease.

A family named M—, composed of seven members, of whom six
lived together, were attadked successively or simultaneously; the
seventh, a youth of fifteen, living in service some distance from his
relations, experienced also the epidemic influence without having had
any communication with the rest. He died, and did not communi-
cate the disease in the house where he lived and where there were
four young children.

A family named G—, comprising the father, mother, and three
children, became the Sctinas of pellicular Angina. A nephew who
was a servant at a distant spot, was soon seized with the disease
without having had any contact with his relations. He was ill for
ten days, and the affection did not -show itself in his employers, in
whose house there were a little girl of eight years old, and several
young women.

A family named V—, consisting of three persons, received the
disease simultaneously ; a youth who was a servant soon became
similarly affected, although distant from the paternal home. He
recovered, and notwithstanding his presence, no case of the disease
occurred, although there were three very young children in the
family of his employers.

When such facts have been observed by an unprejudiced mind, it
would require all the enthusiasm which is inspired by an exclusive
IS DIPHTHERITE CONTAGIOUS? 361

system, to prevent our convictions from being powerfully disturbed,
or from doubts, at least, arising in our minds.

Besides, in admitting that it is contagious, it would be necessary,
in explaining, for instance, its appearance in La Tagniére, that there
should have been a transmission from spot to spot from the affected
points towards that commune. Such, however, was not the case, and
Saint-Nizier, which is placed between, presented no case of the disease.

But might not this epidemic have exceptionally put on this cha-
racter which has been attributed to it universally and at all times?
Might there not be, as Sydenham states, in epidemic diseases in gene-
ral, a different nature and constitution at every new outbreak ?
Might it not sometimes assume the property of being transmitted by
contagion, and might not this property sometimes be absent? The
question is not easy to solve.

I shall rest my last argument upon the opinion which is professed
by the majority of the profession on the non-contagious nature of
Croup. But what is Croup, if it is not, as I have already proved, a dis-
ease identical with pellicular Angina in its pathological effects? Then
Croup, when it begins with symptoms peculiar to itself, would not be
contagious, but it might become so when it resulted from the propa-
gation, in the air-passages, of pharyngeal Diphthérite, because some
practitioners have considered the latter as being susceptible of direct
communication! There would have been a flagrant contradiction ;
either we should be obliged to admit, with Starr, Vichmann, Bard,
Lobstein, Cailleau, &c., that Croup, as well as pseudo-membranous
Angina, is contagious ; or like Vieusseux, Jurine, Double, Gardien,
Desruelles, Bricheteau, &c., &c., we must refuse this character to both
diseases.

I repeat the proposition, which seems to me to reconcile conflicting
opinions, that we cannot regard pharyngeal Diphthérite as contagious
when it exists alone and independent of all eruptive fever; but I
think that whenever it is complicated with those eminegtly conta-
gious affections, it may become so, but im an indirect manner.

When, again, we know the fearful destitution which, in the
country, threatens the unfortunate persons who are attacked with
really contagious diseases, I ask if it is desirable to augment, with-
out incontestable proofs, the number of affections (already too great)
which are directly communicated.

T shall not terminate this discussion without relating literally the
362 DAVIOT ON DIPHTHERITE.

conclusions of the contagionist physician who constitutes the greatest
authority in this matter (M. Bretonneau, Joc. cit. p. 85); conclusions
well-calculated to shake the convictions of the most prejudiced
minds :—“ If it were still more positively demonstrated that Diph-
thérite is contagious, it would not be less certain that it is so in a degree
very inferior to other diseases. But on this point, and on the mode
and the conditions of the contagion, much remains to be learned.
I have made some ineffectual attempts to communicate Diphthérite
to animals.”

Pharyngeal Diphthérite, I am induced to believe, is purely and
simply an epidemic disease. Like the affections which assume this
character, it has an origin which is obscure in its development, and
it manifests itself only in localities and in individuals presenting most
affinity for it. Deriving .its source from an alteration in the consti-
tuent elements of the atmosphere, such alteration being unknown in
its essence, but appreciable in its effects, it is propogated by the me-
dium of the air.

Although this last assertion is perfectly demonstrated in the pre-
sent day, I shall quote the very remarkable and decisive fact that a
great number of persons were seized with the epidemic a few days
after their arrival in the infected spots, and without having had com-
munication with any patient.

M. de S—, who had scarcely recovered from an indisposition for
which he had been bled, came to pass some time in a country-house
situated in a district where the Angina seemed to be on the decline.
After a residence of twenty-four hours, M. de S— was attacked by
the disease, though not in an intense degree, but, under the influ-
ence of the prevailing constitution it was prolonged far beyond its
habitual duration, and disappeared only after a change of resi-
dence.

N—, a young mason, who had been living at Lyons for two years,
paid a visit to his family who were settled at Saint-Didier, and no
member of whom was ill. The second day after his arrival the epi-
demic declared itself in him with rather severe symptoms.

I have besides, in conformity with general observation, seen pelli-
cular Angina attacking more particularly children who, by their
constitution, are more exposed to inflammation of the mucous mem-
branes ; it has affected sometimes adults, and more rarely old persons.
For a more ample demonstration, I shall present a comparative table
IS DIPHTHERITE CONTAGIOUS? 363

relating to the age, the sex, and the mortality, in a number of four
hundred and sixty-one patients.

 

SEX. MORTALITY.
—“"_

AGE. c rN

Males. | Females.| Males. | Females.

 

8 months to 5 years| 75 73 5
5 to 10 years - 59 53 13

—

2
iS 0
loto15’ , - -| 46 | 40 2 4
15 to 20, -| 21 | 25 1 2
20 to 30, -| 12 | 20 : 1
30t040 , - -| 11 | 17 ee
40t050 5 - -| 3 5 :
50 to 60 ,, Ell Pass 1

 

227 | 234 21 19

aS
461 40

 

 

 

 

 

 

These statistics demonstrate that the epidemic was more common
from eight months (I have not examined any patient below that age)
up to fifteen years, and more rare in proportion as we ascend the
scale of life. It may also be remarked that, although in the first
fifteen years, it attacks male children by preference, it attaches itself
to the other sex after that epoch ; these results are identical with the
facts collected up to the present time. But I may remark that,
contrary to what has been admitted, Pharyngeal Diphthérite was less
severe at the age of eight months up to five years, and is more fre-
quently fatal, on the contrary, from five to ten years, particularly in
boys ; this circumstance may be explained in the following manner :—

In our parts of the country, it is the custom to send children of
that age to take care of cattle ; they are exposed at that period of life
to all the inclemency of the weather, and are generally of a bad and
deteriorated constitution, which singularly predisposes them to all
epidemic influences, and above all to that of Membranous Angina
which always assumes, in this case, a, more serious character. Out
of four hundred and-sixty-one patients we lost forty, a number which
does not much exceed the ninth part of the subjects attacked, and
yet several died for want of assistance, or were treated too late.

Compared with former statistics, this table gives us a less mortality
364 DAVIOT ON DIPHTHERITE.

than that furnished by the epidemics of the same nature, as is
indicated by the summary given by Ozanam (doc. cit. t. III. p. 279)
embracing thirty-nine epidemics, from 1557 up to 1805, and showing
as the result a loss of eighty patients in one hundred. The propor-
tion of our deaths is also inferior to that presented by the table of
epidemics from 1805 to 1830, made according to the directions of
the Académie Royale de Médecine, and in which we find that death
carried off the fourth of the patients.

In observing that the mortality continually decreases, in great epi-
demics, which, like pharyngeal Diphthérite, depend upon the tem-
perature, the sudden variations, or the other sensible qualities of the
air, have we not a right to hope, if not for their complete disappearance,
at least that they will become less frequent, and will not be much
more destructive than sporadic diseases? This result we shall obtain
by the progress of civilization; by the development of the arts and of
political institutions which are being brought to perfection every day,
so to speak, and will be applied to a much greater number of men; we
shall owe this result, without doubt, to a better organization of labour,
which, in rendering comfort more general, will permit individuals in-
evitably deprived up to the present time of the benefits of hygiene,
to procure for themselves more commodious and healthy dwellings,
more suitable clothes, a more wholesome kind of food, and to be,
therefore, less exposed to external or atmospheric influences.

TREATMENT.

At the period when the Epidemic Pharnygeal Diphthérite invaded
the sphere of my medical practice, I had never observed it except in
the sporadic form, in the wards of Professors Chomel and Bouillaud,
to whose clinical staff I had the honour of being attached.
Knowing, according to the English Hippocrates that a mode of treat-
ment which is beneficial in one epidemic, may in another, although
of the same name, have only negative results (for each popular dis-
ease has its own peculiarity), I have thought it proper to have
recourse to experience, and to consult men of established reputation.
Without stopping at the history of the medical treatment of past
ages, I shall observe that the treatment of Membranous Angina was,
in past times, the object of active controversies. Two entirely opposite
opinions have been offered ; and while some practitioners have insisted
TREATMENT. 365

that the most pressing indication was to subdue the inflammation,
have extolled the antiphlogistic method, and have regarded it as the
only anchor of safety; others considering the destruction of the
pseudo-membranes as the principal indication, have declared asthenic
medication to be dangerous; and have put in practice a totally
opposite method of treatment. A mixed opinion has arisen from
this contrariety, and it must necessarily prevail in the present day.

The modification of the specific nature of the disease by tonics
which destroy the pellicular exudations, and which by a direct, and
immediate action, prevent their formation and return, and the re-
moval of the cause which gives rise to them, that is to say, inflamma-
tion ;—such are the principles which have guided me in the applica-
tion of my therapeutical_measures. If,to the followers of Broussaisism,
T admit that without the aid of modifying topical applications, the
antiphlogistic medication is insufficient, I must also declare to M.
Bretonneau and his followers, that without the help of antiphlo-
gistics, the topical medication has most commonly presented only
uncertain results. These two methods of treatment ought to lend
mutual aid to one another.

ANTIPHLOGISTIC TREATMENT.

General bleeding —This treatment seems to have been much in
use in all the epidemics of Malignant Angina cited by Ozanam,
except in those described by Fothergill (1746), by Richter (1755),

by Bergius (1757), and still it must be remarked that, in these last
epidemics there was concomitant Scarlatina; a disease which, even
when it is isolated, often takes an adynamic form, imperiously re-
quiring the administration of tonics. I quite admit that in this
peculiar complication, and when there is want of vital reaction, we
ought to avoid phlebotomy.

But when we find Huxham (1734), Astruc (1745), Marteau(1755),
&e., &c., having recourse to general bleeding, three, five, and even
seven times in thé same patients, and succeeding in effecting cures
by this powerful treatment, we are led to inquire what fascination
had seized the contemporaries of Pinel, the advocate of the fearful
treatment, called expectant, at a time when physicians absolutely
banished all evacuations of blood in the treatment of this disease
(Nosogr. phil., t. II. p. 248, 1818).

This versatility of the human mind, applied to the science which
366 DAVIOT ON DIPHTHERITE.

ought to be least conjectural, must necessarily astonish and distress
us ; it was a retrograde step...It required all the authority of physio-
logical physicians to destroy the deep roots which had been laid
down in practice by the system of the authors of the Dictionary of
Medical Sciences, a system which offers us only a therapeutical array,
altogether powerless against a disease, the progress of which is some-
times fearfully rapid.

We must come to 1826 to find a treatise, ex professo, on Pharyngeal
Diphthérite (Bricheteau, Précis analytique du Croup et de Pangine
couenneusé, p. 419), in which the author shows himself a partisan of
general bleeding. In his excellent article in the Dictionnaire de
Médecine et de Chirurgic pratique (loc. cit., t. II. p. 557), M. Roche
also advises this treatment; but still influenced, as it would appear,
by a reflection of the thoughts which prevailed in the medical world
before physiologism, he appeals to new attempts, and to new ex-
periments, probably forgetful of the historical facts which I
have above related. MM. Guersant, De Laberge and Monneret
(op. cit., t. 1 p. 67). T. Ridard (Mémoire sur une Epid. d Ang.
pseudo-membraneuse dans le département de Maine-et-Loire, presenté
& 2 Académie de Médecine, 1838), consider phlebotomy as of great
utility in the treatment of this disease. M. Ridard especially prac-
tised with the greatest success, large general evacuations of blood,
although in the epidemic which he had an opportunity of observing
there was a coincidence of Membranous Angina and of Scarlatina,
which circumstance brought into resemblance the epidemics of
former centuries, in the treatment of which epidemics it was thought
proper to avoid depletions of blood.

To all these trustworthy authorities, I shall venture to add my
opinion, which rests upon an experience of more than two years,
and is founded on the examination of a considerable number of
patients, as is indicated by the tables which I have presented.
Speaking generally, the opening of a vein is one of the most energetic
resources in the treatment of epidemic Angina, in cases where the
general reaction is great, the skin hot, and the pulse full and acceler-
ated, in strong and plethoric individuals, and even in subjects of
ten to twelve years of age (below this age local bleedings are sufficient).
Thad constant recourse to it in the first two stages of the disease ;
and abstained from it generally in the third, in consequence of the
prostration of strength and the feeble state of the pulse. I have
TREATMENT. 367

sometimes been able to repeat the general bleeding several times in
the same patients, and always with remarkable success.

Local bleeding. —M. Bretonneau forbids this step in a general
manner; but the opinion of this physician cannot have any absolute
weight in this question, when we know that M. Gendron (Journ.
complém. des Scienc. Méd., t. XXX. p. 269 et suiv., 1828), and-M.
Guimier (Journ. Gén. de Méd., t. CIV. p. 165, 1828), have made very
numerous cures, by this treatment, on the same spot, and in the same
epidemic as the learned physician at Tours. Since then, experience
has sanctioned the use of local bleedings for guttural Diphthérite,
and my own observation confirms not only their utility, but I may
say their indispensability, in young subjects, when the inflamma-
tory redness-and swelling are very well-marked. As in the perform-
ance of general bleeding, I have had recourse to local bleedings only
in the first two stages of the disease. I have made. use of this
treatment even in certain patients whose constitutions seemed weak,
and in whom there was little or no reaction ; and have obtained good
effects from my temerity. Iam led to believe, in fact, that, rela-
tively to its intensity, the inflammation is modelled in general, on
individual constitutions, and that it everywhere and always requires
the antiphlogistic treatment, but appropriated to its degree of acute-
ness, and proportionate to the strength of the patients.

I have adopted, in the employment of local bleedings, a treatment
to which I may be permitted to give a denomination from Professor
Bouillaud, and who has applied it to general bleedings, I mean that of
saignées locales coup sur coup. For instance, every time that the
guttural inflammation was very intense, and when the pseudo-
membranes had a marked tendency to propagate themselves towards
the deeper mucous membranes, I prescribed leeches in less number
than in the case of very abundant but not frequent bleedings, and I
was accustomed to repeat their application every six or eight hours,
in a word, I kept up a flowing of blood till the general reaction had
completely ceased, and there was a positive amelioration in the local
symptoms. ; F

The signal services which have been rendered to me by this modus
faciendi, compel me, as a duty, to announce the result of my expe-
rience, and to recommend the plan to the profession. It is preferable
in my opinion, to bleeding carried out to fainting, a method which
has been favourably mentioned by the Anglo-American physicians,
368 DAVIOT ON DIPHTHERITE.

and in France by many able practitioners, amongst others Professor
Cruveilhier, especially in the treatment of Croup. Too great a loss
of blood involves certain dangers; it throws the patients into a state
of prostration which carries away from the economy its power of
reaction, and no longer allows a recurrence to blood-letting, when,
after the relief generally produced by an evacuation of blood,
carried to syncope, the disease regains the hold which it had lost.

I am led to believe, therefore, that local bleedings, practised one
after another (coup sur coup), taking the pulse as a guide, do not
present this inconvenience. Be this as it may, it ought to be
fully acknowledged in the present day that repeated evacuations of
blood, conjointly with other therapeutical agents of which I shall
presently speak, arrest the course of Pharyngeal Diphthérite quite as
much as that of Croup. I have frequently applied the leeches to the
base of the inferior jaw. I have rarely had occasion to follow the
example of Ribes (em. sur l’Ang. Couénn p. 26, 1818), who had
recourse to local bleeding upon the epigastric region; but I selected
this part by preference when there were manifest signs of gastro-
intestinal irritation. ;

I encouraged the effects of the treatment just indicated, by diluent
drinks, in the first stage, and acidulated drinks in the last two stages ;
by emollient or laxative injections, according to the state of the bowels ;
by emollient poultices around the neck, gargles of the same nature
at the first period, astringent or acidulated at the last; I recom-
mended more or less strict low diet, according to the intensity of the
disease.

When, at the commencement, I recognised the Membranous Angina,
which I shall term adynamic, as manifested by the absence of reaction,
by the rapid progress of the disease, the brownish colour of the
membranous exudations, the gangrenous smell of the mouth, the
smallness of the pulse, the discomposure of the features, and the
general collapse, &c., &c., I avoided all evacuations of blood, in
order to have recourse to a stimulant method of treatment.

Emetics.—Most authors, Ribes, for example, recommend emetics in
the treatment of Diphthérite of the pharynx, as agents in throwing off
the false membranes. As to myself, I think that local treatment leads
more certainly to this result, and I have restricted the employment
of the emetic method to the following cases :—Ist, in very young
patients who cannot spit, and with whom it is always difficult to use
caustics, from the narrowness of their throats. 2nd,where diphtheritic
TREATMENT. 369

inflammation has propagated itself to the air-passages. 8rd and lastly,
im primitive Croup. In these last two cases, emetics in repeated
doses, every five hours, according to the method of Dr. Delarroque
(Bulletin général de Thérapeutique, September, 1840), formed, to-
gether with local bleedings, often repeated, the foundation of my
treatment.

I employed. the emetic piepamationd as follows :—tartar emetic,
eight grains, and infusion of tilia (lime tree), twenty-five drachms ; or,
tartar emetic, eight grains, syrup of ipecacuanha, eight drachms,
water, sixteen drachms,—to take one teaspoonful every ten minutes,
until vomiting takes place.

Purgatives.—I have sometimes used purgatives, and have seen
them, without producing any beneficial effect, augment the disposi-
tion to gastro-intestinal irritation, which showed itself in nearly ali
the patients; and these medicines often caused a diarrhea which
exhausted them more rapidly. Iam consequently induced, notwith-
standing the authority of some distinguished physicians, to condemn
the administration of purgatives, in this disease, not even excepting
the protochloride of mercury, which the physicians on the other side
of the water and in Germany have regarded as a true specific. _

I have not thought it right to try calomel in large doses, as having,
according to the practitioners who recommend it, a direct action,
which, being exercised on the mucous membranes, causes a great
quantity of mucus to flow into them, thus facilitating the separation
and expulsion of the membranous exudations, and even preventing
their formation by giving more fluidity to the secreted matters. I
believe, with Bricheteaux, that by exciting the mucous tissues, we
add. an irritation to that which already exists, and that calomel must
augment the malady instead of destroying it. If this medicine, ad-
ministered even according to the method of M. Guersant, that is to
say, in small doses, but often repeated, namely, a few grains every
hour, sometimes associated with opiate preparations, in order to pre-
vent all purgative effects; if this remedy, I say, exercises the same
action as mercurial frictions, and if these last, by the avowal of M.
‘Bretonneau, who was the first in France to make use of them, are
evidently injurious, I see no motive for preserving in the therapeu-
tical management of the disease which forms the object of this work,
an agent which has theoretically and experimentally been recognised
to be hurtful.

Cutaneous Revulsives.—I have employed, with success, rubefacient

BB
370 DAVIOT ON DIPHTHERITE.

revulsives, such as irritant foot-baths and mustard poultices, pure or
weakened, according to the degree of action which it was desirable
to produce,

Almost all physicians, both ancient and modem, advise revulsive
blisters to be applied upon the sides or the nape of the neck.
Guided by their labours, and placed in circumstances where it was
necessary to use all the resources of therapeutics, I have adopted
this plan, which, in the course of the winter of 1842, appeared to be
useful; but in the following spring, at the time when the atmos-
pheric temperature rose, I was compelled to acknowledge the excel-
lence of the precept given by MM. Guersant and Trousseau, the only
scientific men who reject, on all occasions, the use of blisters in
epidemic Membranous Angina; the first considering them as useless,
the second as hurtful. At the present day, I weigh in the balance
the amount of my own experience, and I assert, that this method of
treatment has not, generally, and under the influence of certain medi-
cal constitutions, any other results, than to become the origin of the
development of cutaneous Diphthérite, and, in this manner, to aug-
ment the evil instead of diminishing it. In witnessing the singular
disposition of these morbid or artificial ulcerations of the skin, to
become covered with membranous patches, it is impossible to mis-
take, in this Membranous Angina, a specific state, and indeed a true
diphtheritic diathesis.

I must add, besides, that blisters, which are, by most practitioners,
employed in Croup, caused, in my hands, the appearance of cutaneous
Diphthérite, in a serious case, in which I was compelled, in spite of
my reluctance, to apply one. This blister, after the disappearance of
the original disease, very nearly destroyed the life of my patient, and
the vesication took a long time to cure.

I think it right to establish this principle, namely, that blistering
revulsives may be of use in sporadic pharyngeal and laryngo-tracheal
Diphthérite, but rarely, perhaps never, when the disease exists in the
epidemic state. I believe, that at the commencement of an epidemic
of this nature, every cautious practitioner ought, before adopting
the use of epispastic agents, to devote himself to a careful experi-
mental use of them. The use of the antimonial pommade has never
been followed by the same evil results; I have made use of it with
advantage in several cases of pharyngo-laryngeal Diphthérite.
TREATMENT. 371

Locat Mepication.

Experience has for a long time dissipated the objections offered
against the employment of this kind of medication, in the treatment
of pseudo-membranous Angina, and local caustics have definitively
acquired, in the domain of science, the high estimation which can
no longer be denied them. As, in following the rules established
by our teachers, I have thought it necessary again to try the va-
rious topical applications which have been recommended at different
times, I shall present, in a brief manner, the results of my own
observations.

Alum.—The action of alum in pharyngeal Diphthérite has been
extolled from the earliest antiquity. It had fallen into oblivion, when
M. Bretonneau, learning from Areteeus of Cappadocia (De causis et
signis acut, et diutur. Morb. lib. IV., cap.9), that in this affection _
the aluminous gargles, and the insufflation of alum, were sufficient to
stop the development of the false membranes, he employed it anew ‘in
1825, with a success which surpassed his expectation. Professor
Trousseau, who, in 1828, received a medical mission for many de-
partments where Diphthérite was raging epidemically, was enabled
to confirm the excellent effects of this treatment. In my hands it
has been of very great assistance to me, and I may thus explain its
use. Alum has a certain efficacy in the first stage of the disease; it
generally prevents the formation of false membranes, but it has always
appeared to be of very little use in the second and more advanced
stage, and @ fortior: in the third.

.As to its mode of application, I have had recourse to the insuffla-
tion-of pulverized alum upon the diseased parts, by the aid of a tube,
and I repeated it every three or four hours, according to the intensity
of the inflammation. In our districts, I instructed the relations to
to perform this operation themselves, and they managed it with
great facility. The cries of the young patients were advantageous
to us, and I profited by them as much as possible, to introduce the

_ topical applications at the moment whén the inspiration took place.
When the insufflation excited coughing, I applied the remedy with a
brush made of hair, using it either in powder, pure, or combined
with gum-arabic, in a very strong solution. Sometimes I used, in
the case of adults, upon whose accuracy I could depend, an alum-

gargle thus prepared:—Common water or mucilaginous decoction,
BB2
372 DAVIOT ON DIPHTHERITE.

sixty-two drachms; rose honey or syrup of mulberries, seven-and-a-
half drachms ; alum, one-and-a-half drachm.

T repeat, that this valuable local application has almost always
succeeded in the first stage of guttural Diphtherite, and often in cases
belonging to the second, characterized by isolated exudations, which
were thin and scarcely adherent. I discarded its employment when
these last were very thick and extensive and strongly adherent; its
effects were then useless.

I shall here notice that I have successfully repeated the experi-
ments of Professor Velpeau (Gazette Médicale, 1837), on the use of
alum at the commencement of cases of simple Angina.

Nitrate of siwer—Since the publication of a very interesting
Memoir which appeared in 1827 (in the Journal Général de Médecine,
t. CIII.—V.) in which M. Girouard, after having established a
detailed parallel between the different therapeutical agents applicable
to the Diphthérite, which is seated upon the mucous membranes,
gives to the nitrate of silver in the liquid state, a well-marked pre-
ference over alum, hydrochloric acid, &c. New trials of it have been
made, and always with remarkable success.

Since the researches of M. Gendron (Gaz. Méd. 1834, p. 560 e¢
seq.) the lapis infernalis is most commonly employed. The use of
this salt is more convenient, and its effect more certain, and I, who
have used it, do not suppose that for the future we shall be able to
dispense with it, unless in the practice of some professional man,
whose sight has undergone the effects of age or whose hand has felt
the trembling of senility, for this manner of applying the nitrate
of silver requires much practice, a firm hand, and an excellent sight,
especially when the false membranes are deeply seated in the pha-
ryngeal cavity.

The following is my mode of proceeding, and it is in conformity
with the precepts laid down by M. Guersant. I place a piece of the
caustic of the length of about an inch, in a silver caustic-holder, or even
in an ordinary pencil-holder of steel or of brass (taking care to take out
the stone after each cauterization, for fear of the chemical decompo-
sition, which renders the stone inert, as has been proved by M.
Chevalier). The caustic is completely fixed, and only a very small
portion projects. After having slightly wetted it, so that it may act
instantaneously, I apply it to the points covered by the false mem-
branes, and even to the surrounding parts. Under the influence of this
contact, the membranous matter becomes of a dull white colour and
friable consistence, and union with the subjacent membrane is quickly
TREATMENT. 373

destroyed. In cauterizing the adjoining tissues, I produce a
modification in their vitality, which offers an obstacle to the spread of
the disease. I repeat this operation three or four times a day, and I
keep this powerful topical remedy for the last two stages of the
epidemic. I have made use of lunar caustic in a great number of
subjects, and twice only has it happened to me to allow a fragment
to fall into the cesophagus. Fortunately, the accident occurred in
children from ten to twelve years old. J immediately hastened to
produce vomiting, by the aid of luke-watm water with tartar emetic,
taken by half glasses at a time, every five minutes, and the patients
soon ejected some bluish-coloured matters, which held the silver
salt in solution.

In one of the cases, the patient after a great many alvine dis-
charges, complained of a violent pain in the epigastric region, and I
thought it proper to administer half a tumblerful of slightly salted
water, in order to decompose the poison, if any small particles should
remain. In very young children, to whom it might be difficult to
give a sufficient quantity of an emetic preparation, it would be best
to put the fingers upon the root of the tongue, so as to induce efforts
of vomiting.

I have also made use of the concentrated solution of nitrate of
silver, in the proportion of one part to five of water. The effects
that I have obtained from it have been less certain than those from
lunar caustic, and towards the end of the epidemic, I have had
recourse to it only in cases where the enormous swelling of the
tonsils no longer allowed the employment of the latter. 1 then
applied this liquid to the guttural cavity with a sponge fixed to a
piece of whalebone, or with a dossil of lint. It is difficult, in general,
to limit the action of caustics, and we are likely to let fall some
drops of a caustic solution, either into the esophagus, or into the
air-passages.

Protochloride of mercury.—\ have insufflated calomel into the
throat of some of my patients, either in a pure state, or mixed with
some powdered sugar, as is recommended by M. Bretonneau. Not
only has the curative action been absent, but the medicine has often
provoked, in young subjects, who do not spit, a violent reaction In
the intestinal canal, or else on the salivary organs. In consequence
of this circumstance, and especially owing to its insolubility, which
must neutralize its topical action, I think that calomel ought to be
completely discarded from the treatment of Diphtheritic Angina,
and reserved, as I shall state farther on, for cutaneous Diphthérite.
374 DAVIOT ON DIPHTHERITE.

Hydrochloric acid—This application, pure or mixed with two or
three parts of rose honey, according to the degree of inflammation,
has been singularly extolled of late years. After numerous trials,
I must declare its efficacy to be less than that of lunar caustic. I
employed it concurrently with alum, in slight cases, or. with liquid
nitrate of silver in the cases in which, as I have said before, the
tumefaction of the tonsils would not permit the introduction of solid
nitrate of silver into the back of the throat.

Chloride of soda.—tI have had recourse to this medicine, either
dissolved in a fifth of its weight of water, as a purifying agent, ac-
cording to M. Guersant, or in the form of gargles, in the proportion
of one drachm to forty drachms of liquid, according to the formula
of M.Roche. This substance has never produced any beneficial result.

Nitrate of mercury.—I place this preparation, for its utility, on
an equality with liquid nitrate of silver and hydrochloric acid.

In serious cases, where it was impossible to have recourse to
cauterization, I injected escharotic liquids into the pharynx, by the
mouth, and sometimes by the nasal fosse, by the aid of the syringe,
the patient having a basin before him.

I was obliged to abstain from trying anew some other pharmaceu-
tical agents, employed at certain periods, in the treatment of epidemic
Membranous Angina, and which have been definitively forbidden.
It is thus, that MM. Guersant and Roche have pronounced a just
anathema against fumigations of ether, ammonia, and chlorine. In
fact, by their irritating nature, these vapours are more adapted to
increase the inflammation, than to destroy or modify it; and is it
not known, besides, that one property of these two last gases, is to
produce Angina with the formation of a false membrane ?

Scarification of the tonsils —This operation, which has been gene-
rally condemned bythe medical men of the seventeenth century, and the
inconvenient results of which were proved by Van Swieten himself, far
from producing the favourable effects which have been attributed to
it by some practitioners, has always appeared to me to aggravate the
disease, and I very soon abandoned the proceeding.

Ablation of the tonsils.—This operation, to which I have only once
been able to have recourse, has, notwithstanding the opposition
which I have encountered, completely succeeded in cases where
asphyxia was imminent.

I consider this operation as a last, but useful resource, when all
rational means have failed. It is only applicable, however, in pha-
ryngeal Diphthérite.
CROUPAL DIPHTHERITE, 375

Tearing away the false membrane—The effects of cauterization
are never more certain than when we are operating on the surfaces
denuded of their pseudo-membranes. I was in the habit of practising
ablation every time that I was able to succeed in the measure
without increasing the local symptoms of inflammation.

Tracheotomy.—I have found everywhere such a repugnance to this
operation, that I have not been permitted to make use of it. I have only
tried to employ it in cases of primitive or consecutive croupal Diph-
thérite.

SOME OBSERVATIONS ON CROUPAL
DIPHTHERITE.

Several cases of Croup have enabled me to observe a peculiar
snoring sound, heard during sleep, and which has not in my opinion
sufficiently attracted attention, since only two practitioners up to the
present day have mentioned its existence, namely, Albers of Bremen,
and M. Marotte. According to the latter author, this snoring sound,
to which Albers gave the name of sonitus crepitans, and which I
propose to call croupal snore (ronflement croupal) is only the exag-
geration of the different sounds caused by the respiratory move-
ments during the waking state, and rendered more intense by the
difficulty of breathing, which is usually greater during sleep. This
sound would be produced in the larynx, and the back of the throat,
and as to its rhythm and intensity, would be regulated by the two
movements of respiration, that is to say, it would be composed of two
alternate sounds, of which one, stronger than the other, corresponds
to the inspiration or expiration, according as either of them is more
noisy and difficult.

According to the same author, this snoring sound sean itself
with two distinct characters; it is dry or moist.. The dryness is ob-
served especially at the commencement of the disease, and when the
inflammatory state predominates; the mozst character, more or less
marked, appears to belong to a more advanced period. It seems to
be due to the passage of the air through the mucus, and the de-
tached pseudo-membranes which obstruct the larynx.

M. Marotte draws the conclusion, that this symptom may furnish
useful characters in the diagnosis, prognosis, and treatment of mem-
branous laryngitis. In fact, the laryngeal sound can only belong to
an affection of the larynx, and must, consequently, concur with other
376 DAVIOT GN DIPHTHERITE.

symptoms in characterizing Croup. If it is dry and metallic, it must
be believed that the inflammatory state continues, and that there is
a tendency to the secretion of plastic matter, whence arises the indi-
cation for depletion by blood-letting. If, on the contrary, it has
become moist and crepitant, it is because the false membranes are
beginning to be detached, and to float freely in the air-tube, a cir-
cumstance which indicates the use of emetics. Lastly, in the first
case the prognosis is evidently more serious than in the second, and
it becomes most favourable, if the snoring sound ceases altogether.

Besides these advantages, we may add, that this symptom may
serve to establish the differential diagnosis between stridulous laryn-
gitis, or pseudo-Croup, and croupal laryngitis, since its existence is
essentially connected with the presence of the pseudo-membranous
exudation. We know that cases of stridulous Angina recover spon-
taneously, and, consequently, under the influence of the most different
methods of treatment; while true Croup is never followed by a
favourable termination “when it is left to the unaided resources of na-
ture; and it even resists, in general, the most skilful methods of
treatment. Now, to apply to pseudo-Croup, which requires only the
treatment applicable to slight colds, the medication necessary for
tracheal Diphthérite, would be to employ therapeutical measures which
are not only useless, but are even likely in themselves to prolong the
duration of the disease. A symptom which would fix a well-defined
line of demarcation between the two kinds of laryngitis, would
enable us to avoid this great inconvenience, and the laryngeal snoring
sound, when it exists, appears to me to fulfil this indication.

I am also convinced that in intense cases of Croup, this pathologi-
cal phenomenon may assist in deciding upon the opportunity for
tracheotomy. The utility of this operation is no longer contested in
the present day, and Professor Trousseau has endeavoured to demon-
strate, by numerous cases, that it has never been followed by such
favourable results as when it has been practised at the earliest possible
period, that is to say, as soon as the exudation was supposed to
exist. In conforming exactly to this precept, we should sometimes
perform the operation on persons who might recover under an ener-
getic plan of treatment, and we should probably furnish some of
those facts which have afforded powerful arguments in favour of
practitioners who are opposed to the early performance of the opera-
tion, when no pellicles have been found in the trachea. Might not the
sonitus crepitans serve as a guide, under these circumstances, by prov-
ing to a certainty the development of the membranous exudation ?
ON EMETICS. 377

ON THE UsE or Emetics.

Jurine, Vieusseux, Albers, Serlo de Crossen, &c., had remarked
that emetics did not always produce vomiting in frequency propor-
tionate to the repetition of the dose; but that, on the contrary, their
action became more and more feeble. In a word, a kind of tolerance
seemed to be established, requiring stronger and more frequently re-
peated doses, in order to obtain results which were sometimes less
marked than at the commencement of the treatment. The same ob-
servation has been lately made by M. Marotte, and I have myself
verified it, and am induced to regard this tolerance as an ordinary
state, as the consequence of the prolonged use of antimonial tartar,
even in small doses, but given at short intervals.

I have often employed the sulphate of copper, peculiarly extolled
by Serlo de Crossen in Croup, and recommended by Dr. Hoffman
(Journal de Hufeland). This medicine does not lose its emetic pro-
perty under the influence of a prolonged administration, but it presents
the inconvenience of producing on the gastro-intestinal mucous
membrane a violent reaction which is never produced by antimonial
tartar, even in the dose of twenty-five to thirty grains in twenty-four
hours.

In the latter periods of the epidemic, I have been convinced that
tolerance might be avoided by the addition of ipecacuan to the anti-
monial tartar. From its too great bulk and. its nauseous and
repulsive smell, ipecacuan is administered with difficulty to children,
and I have, therefore, made use of the following preparations :—
tartrate of antimony, eight grains; brown emetina, fifteen grains ;
water, fifteen drachms; syrup of orange flowers, one drachm; to be
taken in teaspoonfuls at a time, every ten minutes, until vomiting is
produced.

I shall conclude these few observations relating to Croup, by de-
claring the superiority of the method of Dr. Delarroque, namely,
repeated vomiting, considered as a principal agent in the treatment
of confirmed Croup. If membranous laryngitis was considered as
one of the most serious and most frequently fatal diseases until the
publication of the remarks of the physician of the Hépital Necker,
it was owing, it must be confessed, to the fact that the activity and
boldness of the treatment were never proportionate to the rapidity
and intensity of the disease.

The adoption of this energetic treatment must, therefore, hence-
378 DAVIOT ON DIPHTHERITE.

forth impress upon this affection, hitherto so formidable, the characters
of a benignant disease, since M. Delarroque declares that with the
exception of a child, in whom Croup was complicated with meningitis,
and who evidently sunk under the consequences of the latter disease,
he does not recollect a single person whom he has lost, after having
subjected him to the action of the methods which he recommends in
his Memoir, namely, the simultaneous employment (and in the space
of an hour or an hour and a half) of local bleedings, emetics, deriva-
tives, &c.

If I have not met with the same success, I must attribute the cir-
cumstance both to the epidemic nature of the disease, which at that
time was more serious, and to the distance which separated me from
the patients, and prevented me from watching over the treatment ;
and, lastly, to the deplorable negligence of the relations in not
calling me in sufficiently early, that is to say, at the commencement
of the affection.

It is true that croupal Diphthérite showed itself only towards the
end of the epidemic, and continued especially after it. The cases
were isolated, and occurred only in localities which were sometimes
very distant. . The people, too, in our part of the country, who were
well acquainted with Membranous Angina, because it had been gene-
rally prevalent, always mistook primitive Croup for a simple cold,
and the more so as the little patients generally walked and ate, up to
the last stage of the disease. The relatives suspected the danger
only when the asphyxia was imminent. ‘Tracheotomy was itself too
uncertain to allow me to attempt its performance, especially at a
time when a well-marked opposition was shown against the opera-
tion.

CUTANEOUS DIPHTHERITE.

The annals of Medicine inform us that in certain cases of Malignant
Angina, some epidemiographers have remarked different conditions
of morbid appearance on the skin; but little was known on the
subject until 1826, when M. Bretonneau, to whom we owe our
knowledge of the true nature of Membranous Angina, demonstrated,
in an indisputable manner, that Diphthérite exhibited everywhere
the same characters. Professor Trousseau, profiting by the ideas of
the learned physician of Tours, has given us in the Archives Genérales
de Médecine, and in an article in the Repertoire Génér. des Sciences
CUTANEOUS DIPHTHERITE. 379

Med., the most complete picture of this disease when it is established
on the external tegumentary system.

To these facts, I have only to add one which appears to deserve
some attention. M. Trousseau, in the article last mentioned, observes
that he has never seen Diphthérite developed on the skin, unless this
membrane had been previously deprived of its epidermis; unless,
consequently, it presents more or less resemblance to the organization
of the mucous tissue.

Although I am compelled to admit, with this author, that different
wounds, either recent or chronic, herpetic eruptions, blisters, &c.,
often become the exciting causes of the development of cutaneous
Diphthérite, I must also declare that I have most commonly seen it
occur spontaneously. I must even express my astonishment that
this peculiarity which I have so frequently observed, has not struck
the Parisian professor in the course of the epidemic which prevailed
under his inspection.

There is also a point on which I think I ought to insist, in order
to prove, if necessary, the perfect identity existing between pellicular
inflammation of the mucous membranes and cutaneous Diphthérite.
It is the fact that during our epidemic period, under the influence
of the same cause and a similar predisposition, I have seen Diph-
thérite raging simultaneously on several members of the same family,
attacking in one the pharyngeal mucous membrane, in another, the
cutaneous tissue, in another, the respiratory passages, and, lastly, in
another, all those organs at once or successively, and presenting no
other modifications than the symptomatic differences peculiar to each
region. The following are a few examples :—

In the household of Ch—., composed of twelve persons, the disease
exhibited itself on the pharynx in thrée; in the air-passages in only
one ; on the skin in another. Let me here remark, in order to prove
the influence of idiosyncrasies on the invasion or the mode of pro-
pagation of the epidemic, that in this household one portion only
of the family was attacked by it, and that it did not extend to the
others, although all the conditions favouring the contagion existed
among them, such as want of cleanliness, permanent contact with
one another, confined dwellings, &c.

In the family of B—., three patients out of five suffered from
pharyngeal Diphthérite, the fourth from croupal Diphthérite ; in
the fifth case, the disease attacked the air-passages and the skin.

In the household of T—., consisting of thirteen persons, four
experienced attacks of pharyngeal Diphthérite, another suffered. from
380 DAVIOT ON DIPHTHERITE.

croupal Diphthérite, and the last from cutaneous Diphthérite. I must
remark that the eldest brother and his children alone suffered from
the epidemic which spared the other branch. I ask if this fact is
not conclusive in proving the non-contagious character of Diph-
thérite P

In the family of M—., four persons fell victims to Malignant
Angina; the father suffered from an attack of pleuro-pneumonia,
and in him a blister, applied to the thorax, assumed the diphtheritic
character.

The four children of M—. suffered from the epidemic ; two pre-
sented the symptoms of pharyngeal Diphthérite ; the third, those of
buccal Diphtherite, and, lastly, the fourth exhibited the signs of
pellicular inflammation, seated in the pharynx and on the skin.

In the house of J—., containing twelve persons, five contracted
Membranous Angina; and a little girl, after several relapses of the
disease, was attacked with Croup, and died of it without having
presented any trace of membranous exudation in the pharynx.

In the family of F—., five children became ill; in one of them
Diphthérite showed itself on the skin ; in two others, it attacked the
pharynx; in the fourth, it attacked the pharyngeal mucous mem-
brane and the skin at the same time; and the last child was attacked
successively, and at rather distant intervals, with Diphthérite on the
back of the throat, on the skin, and then in the air-passages. The
epidemic element was therefore able, under the control of a deter-
minate organization, to cause the production in the same subjects of
the diphtheritic inflammation on different tissues. Ought not the
same cause to produce the same effects and the same pathological
lesions, modified only by the anatomical structure of the parts and
the varying irritability of the organs P

Let me be allowed once more to enter upon the question of con-
tagion in reference to cutaneous Diphthérite, considered by Professor
Trousseau as a variety of the disease possessing, in the most eminent
degree, the property of being transmitted from a patient to a healthy
subject. Far from adopting this opinion, I shall apply to the cuta-
neous affection the principles which I have laid down in treating of
Membranous Angina, and I must refer to that portion of my work
for an explanation of my views. There is, however, one point on
which I may dilate for a short time.

In establishing the proof of immediate transmission, it has been
asserted that in the affected persons, the diphtheritic product propa-
gated the disease by contact from one part which was affected, to
CUTANEOUS DIPHTHERITE TREATMENT. 381

another part which was unaffected. I reply, that the same fact is
observed in infantile impetigo, which has certainly never been re-
garded as contagious. In my opinion, the diphtheritic diathesis is

- sufficient to explain this successive encroachment of the disease. It
would be difficult indeed to understand the propagation of the disease
by simple contact, since, in the experiment performed by M. Trousseau
on himself, the morbid fluid introduced by inoculation into the
tissues, produced no pathological phenomenon.

For a long time the treatment of cutaneous Diphthérite partook
of the mcomplete views which were entertamed as to its nature.
Although 8. Bard seems to have perceived the true character of the
disease, yet he does not point out any definite methods for its treat-
ment. M. Bretonneau himself, in his excellent monograph, gives
only here and there a few therapeutical rules in reference to this
affection. The only well-considered precepts which science possesses
have been laid down by M. Trousseau. But being founded on facts
collected during the course of a single epidemic, these precepts re-
quired the sanction of experience, and required confirmation by the
study of fresh epidemics. Having been called upon to treat a great
number of persons attacked with cutaneous Diphthérite, I have been

' enabled to make frequent use of the different agents proposed by
M. Trousseau, and to judge of their relative efficacy.

GENERAL TREATMENT.

Antiphlogistics—Depletion of blood.—These are forbidden by M.
Bretonneau; and the Parisian professor (M. Trousseau) declares them
to be altogether useless ; and here let me remark upon the important
fact that cutaneous Diphthérite shows itself only on subjects who
are either cachectic, or who are already suffering under pellicular in-
flammation of the mucous membranes, and consequently weakened
by antiphlogistic treatment, often too energetically employed. The
disease usually assumes an adynamic form, which might induce us to
believe, & priori, that depletion of blood can have only a negative, if
not a positively injurious influence. As for myself, experience has
enabled me to form a positive opinion, for I treated a few of the
most vigorous patients, in whom the general reaction was very well
marked, and found that in some, bleeding produced no other effect
than to weaken them without improving the local affection ; while in
others, in whom leeches were applied in the vicinity of the diphtheritie
382 DAVIOT ON DIPHTHERITE.

ulcerations, the results were still more unsatisfactory. Indeed, in
the latter case, besides the fact that the inflammatory complication
was never subdued, I always found the leech-bites become themselves
the seats of the pellicular exudation. The result of all the faets
which I have been able to collect, is to induce me to reject in all
circumstances, depletion of blood in the treatment of Diphthérite
when it attacks the skin.

Locat TREaTMent.

Emotllients.—With a view of subduing the inflammatory element,
I have had recourse, at the commencement of the epidemic, to
emollient applications; but far from obtaining the slightest favour-
able result from their use, they have, on the contrary, appeared to
me singularly to promote the spread of the disease. I therefore
think that local applications of this kind ought to be proscribed like
the fatty substances, already considered by S. Bard and M. Breton-
neau as being essentially injurious in cutaneous Diphthérite.

Caustics.—I have employed successively, and sometimes concur-
rently, the hydrochloric and hydrosulphuric acids, the nitrates of
mercury and silver, &c., &c. Liquid substances have generally been
inefficacious, but the caustic which has been most serviceable has
undoubtedly been the dapis infernalis.

Catheretics (mild caustics).—Alum, the chlorides of potash, lime,
and especially soda, have been employed by me. The action of alum
has been negative, and the hope which I entertained as to that of
the chlorides has not been realized. The mercurial preparations,
calomel among others, have perfectly answered my expectations.

T have also made use of the white oxide of zinc, which has been
extolled in the treatment of certain herpetic maladies, impetigo, for
example, but I have found no good result from its application.

To sum up my experience, I may state that the rejection of
emollient applications, which, by the relaxation they occasion, favour
the spread of the disease ;—the modification of the membranous in-
flammation by the employment of mercurials ;—and, lastly, the pro-
motion, by means of the dapis infernalis, of the detachment of the
pseudo-membranes, and the substitution of a simple phlegmasia for
one of an unhealthy character ;—are the therapeutical rules which
experience has taught me to follow in cases of Diphthérite of the
skin.
AN ACCOUNT

OF THE

BIBLIOGRAPHY OF DIPHTHERIA,

FROM THE DATE OF

BRETONNEAU’S FIRST ESSAY,.

TO THE PRESENT TIME.

COMPILED BY

JOHN CHATTO,

LIBRARIAN TO THE ROYAL COLLEGE O¥ SURGEONS.
AN ACCOUNT

OF THE

BIBLIOGRAPHY OF DIPHTHERIA, &c.

In constructing this bibliographical appendix, it has been deemed de-
sirable to take the subject up only from the time when M. Bretonneau’s
investigations gave to Diphtheria somewhat the characteristics of a
substantive affection. To have comprised the older literature of the
various forms of sore-throat, which by various writers have been con-
sidered as either allied to, or identical with it, would have required an
amount of space not at the disposal of the compiler, and would have
been to enter upon a debatable territory. Those, however, who wish
to follow up this investigation, will find ample means of doing so pre-
sented them in M. Bretonneau’s Treatise, and in the bibliography
appended by M. Dezeimeris to the article ‘“‘ Angine Couenneuse,” in
the 8rd vol. p. 135, of the 2nd edition of the Dictionnaire de Médecine.
Other references are furnished by M. Deslandes, Dr. Geddings, and
Dr. Fuchs, the titles of whose contributions will be found in the
following pages. The distinctive characters of Croup are so well esta-
blished in this country, that it has only been thought necessary to refer
to it in illustration of its occasional origin in faucial Diphtheria,—a
circumstance that possibly may be more commonly observed ‘in future,
should Diphtheria become naturalized in this country to the extent
in which it has so long prevailed in France.—J. C.

1821-3. Guersant. Dictionnaire de Médecine, Articles “ Angine Couenneuse,” t. ii.
“Croup,” t. vi. and “Stomatite Couenneuse,” t. xix, [This is the first announce-
ment of Bretonneau’s views as contained in his Memoirs read before the Academy,
but not yet published. M. Guersant agrees with him in regarding epidemic
Malignant Angina as a non-gangrenous disease, identical with Croup in its

~ pathological characters, and found combined with it in most epidemics. ]

1823. BourcEorsE. Observation d'une Angine Couenneuse, tendant & prowver que
cette affection est contagieuse, Nouv. Bibliothéque Méd. t. iii. p. 129. [A
paper read at the Acad. de Méd., with the report on it.)

» Bruner. Note sur quelques cas d’ Angine Grave (Couenneuse) qui semblént s'étre
transmis par la contagion, Archives Gén. t. iii. p. 536.

» GosMER. Essai sur la Diphthérite, souvenir des lecons cliniques de Phospice
général de Tours, Thése de Paris, No. 231. [A general description of the
disease as observed at Tours, with three cases.]

x
APPENDIX. 385

1824, DesruELLEs. Obdservations et réflexions sur l’Angine Couenneuse, Bulletin

9

de la Soc. Méd. d’Emulation, p. 161. [Two cases of the sporadic form related
and contrasted with the epidemic Angina, the peculiarities of which are re-
ferred to cerebral complications. ]

Louis. Du Croup considéré chez Vadulte, Arch. Gén. t.iv. pp. 1 and 369;
and Mem. et Rech. Anat. Pathol. 1826, p.203. [In most of the cases here
related the disease commenced in a diphtheritis of the fauces.]

Tapanon. Sur l’Angine Couenneuse Tonsillaire et Pharyngée, Thése de Paris,
No. 118. [Four cases confirmatory of the views of Bretonneau, as stated by
Guersant.] :

1825. GENDRON. Observations sur une Angine Couenneuse, Journal complementaire

du Diction. des Sciences Med. t. xxiii. p. 346. [Account of an epidemic in
Tours. Nitrate of silver and scarification of the tonsils recommended as cura-
tive and preventive treatment.]

, Mackenziz, On the symptoms and cure of Croup, Ed. Med. and Surg. Journ.

vol. xxiii. p. 294. [This paper has been frequently referred to by continental
writers in proof of croup spreading from the tonsils, and as the first recom-
mendation of the use of nitrate of silver in diphtheritis.

1826. Bittarp. De [état actuel de nos connaissances sur le Croup, Arch. Gén,

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a

t. xii. p. 544. [In this article M. Billard submits Bretonneau’s views to criti-
cism; and while he admits that he has established that diphtheritic deposit
has been mistaken for gangrene, he does not admit the specific character of the
pellicular inflammation.]

Bretonneav., Des Inflammations spéciales du tissu muqueux, et en particulier
dela Diphthérite, ou inflammation pelliculaire, connue sous le nom de Croup, d’An-
gine Maligne, a’ Angine Gangréneuse, fc. 8vo. Paris. [Although only published
in 1826, the first two of these Memoirs were read before the Academy of Medicine
in 1821, and noticed by Guersant in the same year.]

BricHEtTEav. Précis analytique du Croup et del Angine Couenneuse. 8v0. Paris,
1826. [While admitting that the two affections may be distinguished, the
author adopts most of Bretonneau’s views.]

Conouiy. Review of Bretonneau on Diphtheritis, Lond. Med. Repository, vol.
xxvi. p. 499. [In an excellent review of M. Bretonneau’s work, an ac-
count is given of the disease as observed by Dr. Conolly at Tours, and of his
practice in treating it by calomel.]

Hamiiton. On a peculiar modification of Sore-throat which occasionally affects
children, Edin. Journal of Med. Science, vol. ii. p. 325. [The sore-throat here
described commenced with diphtheritic deposits on the tonsils, soon followed by
ulceration—this last, in the author’s opinion, distinguishing the disease from
the affection described by Bretonneau. Two terminations were observed, viz.
through the production of croup or, secondly, a sinking of the animal powers—
the latter attributed by the author to the paralyzing effect produced by the ab-
sorbed morbid secretions upon the respiratory nerves. ]

Pretty. Observations on various forms of Croup, London Med. and Phys.
Journ. vol. lv. p. 9. [Refers to cases of croup commencing in the fauces as
not of uncommon occurrence; and believes that these are the cases which fur-
nish examples of the contagion of the disease. ]

Sym. Cases intended to illustrate the contagious nature of Croup, Lond. Med.
and Phys. Journ. vol. lv. p. 14. [Refers to an epidemic of scarlatina not of a
fatal character, except when, as in a number of cases, croup supervened, and
seemed contagious. The affection of the fauces was sometimes very trifling,
but the croup was attributed to inflammatory action extending from them.]

1827. Buaup. De la Diphthérite et de la Laryngo-Tracheite comparées entre elles,

Nouv. Bibliothéque Med. t.ii. p. 5. [An elaborate demonstration of the essen-
tial differences between diphtheritis and croup. ]
cc
386

BIBLIOGRAPHICAL

1827, BRETONNEAU. Notice sur Vemploi d’Alum dans la Diphthérite, Archives Gén. t.

xiii. p. 5. [In this paper Bretonneau defends the nomenclature of the dis-
ease, gives further details on the employment of alum, and enters into a
comparison between diphtheritis and the malignant angina of scarlatina.]

Desianpes. L' Angine Couenneuse et le Croup, considérés sous lerapport de Tétat
local qui les constitues, sont-ils identiques? Journ. des Progrés des Sc. Méd.
t. i. p. 152. [Answered affirmatively. A minute historical review of the sub-
ject of epidemic sore-throat given.]

EMANGARD. Examen critique du Traité dela D. par M. Bretonneau, 8vo.
1827, and Mémoire sur [ Angine Epidémique, ou Diphthérite. 8vo. Paris, 1829.
[A sharp criticism on M. Bretonneau’s views, by one of the ‘ physiological ”*
school, who maintains that the disease is of malarial origin, allied in nature to
typhus, operating through the gastro-enteric membrane—a “ gastro-enteritie
angina.”

FEeRRAND. Del’ Angine Membraneuse, Thése de Paris, No. 234. [Describes a
fatal epidemic, in which the whole 60 cases, almost all being male children,
died as early as the fourth or fifth day. Four narrated in detail.]

Lexur. De la Fausse Membrane dans le Muguet, Arch, Gén. t. xiii, p. 335.
[Contains some interesting researches on false membranes. ]

1828, ABERCROMBIE. Diseases of the Stomach, p. 53. [Reference is here made to

”

y

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>

an epidemic of diphtheritis, which prevailed in Edinburgh in 1826, in which the
danger arose from the extension of the disease to the larynx. Dr. Abercrombie
protests against confounding the disease with croup. ]

Branquin. Sur une Angine Maligne Epidémique, Aun. dela Méd. Physiol. t. xiii.
p- 277. [The prompt use of bleeding is here declared to have saved all out of
three hundred patients attacked, with the exception of fourteen.)

BELDEN. Application of the Nitrate of Silver in Cynanche Maligna. American
Med. Recorder, January. [This has been referred to by some of the French
writers as an early account of the.benefit of nitrate of silver in diphtheritis.]

Fucus. Historische Untersuchungen tiber Angina Maligna und ihr Verhiltniss
zu Scarlach und Croup. 8vo. Wirzburg, 1828. [A historical review of
the epidemics of angina maligna, which he considers as essentially different
from scarlatina maligna, being a typhus identical with the pulpous form of
hospital gangrene. He regards croup as a true angina maligna trachealis,
prevented running through all its stages.]

Genprin. Note sur les differénces de? Angine Couenneuse et du Croup, Journ.
Gén. Méd. t. civ. p. 176, et t. cix. p. 41.

GenpRon (E.) Notes sur l’Angine Couenneuse, et sur les agens therapeutiques
employés dans cette maladig, Journ. Gén. de Méd, t. cv. p. 76; and Journ.
Complém. du Dict. des Sciences Méd. t. xxx. p. 269. [States that he first em-
ployed nitrate of silver in France at the same time as Mackenzie did in Scotland.

He treats the disease by early antiphlogistics, scarifications, and nitrate of
silver.]

GirovaRD. Observations sur les inflammations plastiques de la membrane
muqueuse des fosses nasales, de la bouche, et de larriére-bouche, Jour. Gén. de
Méd. t. ciii. p. 305. [Narrative derived from observation of epidemics.
Nitrate of silver recommended as an application. ]

GuimieR. Mémoire sur une épidémie d'’Angine Maligne, ou Diphthéritique, Jour.

Gén. de Méd. t. civ. p. 165. [Angina terminating in croup is said to give the
best idea of the disease. Nitrate of silver was the chief application. ]

Hortetoup. Observations du Croup chez Padulte, Thése de Paris, No. 53.

[Four interesting cases of croup in the adult, preceded or accompanied by
pharyngeal false membranes. ]

LormEL; Observations de Diphthérite et de Stomacace Gangréneuse. Annales de
la Méd. Physiol. t. xiv. p. 145. [Case related exhibiting the preferability of
antiphlogistic and derivative as compared with topical treatment.]
APPENDIX. 387

1828. Ranqus. Nouveau Traitement des Angines, ou moyen de Pyrothonide, Ann, de

”

la Méd. Physiolog. t. xiii. p. 162. [In epidemics, gargles of pyrothonide are stated
to have exerted a remarkable solvent power upon the false membranes. ]

Risgs, D’une Angine Couenneuse observée 4 Paris en 1818, Rev. Méd. t. v.
p. 43. [Narrative of the disease which attacked nine members of one family.
.The author believes that croup rarely occurs without being preceded by this

angina; and he calls attention to the necessity of a more regular examination of
the throats of children.]

1829. Baron. Rapports, Gaz. des Hép. t. ii. pp. 139 and 168. [Reports to the

?

wy

o

2

Acad. de Med. on accounts given of epidemics by MM. Trousseau, Ramon, and
Gendron, with discussion. ]

~Brinarp. Mém. sur Vemploi du Calomélas dans le traitement du Croup et des An-

gines Pelliculeuses, Arch. Gén. t. xx. p. 491. E

Brovssats (C.). Observations d’Angines Suffocatives guéries par les antiphlo-
gistiques et la laryngotomie, Annal. de la Méd, Physiol. t, xx. p. 140. [Disputes
Bretonneau’s statement of the identity of diphtheritis and gangrenous
angina. ]

DELCAMBRE, BERTRAND, DE L’ HOsDINIERE, and TouRsAINT, Théses de Paris,
Nos. 95, 192, and 208. -[Mere recapitulations of Bretonneau’s views. ]

Genpron (A.). Mém. sur les Angines Couenneuses Epidémiques, Journ. Gén. de
Méd. cix. p. 32. [Regards the disease as synonymous with gangrenous angina,

and employs antiphlogistics and the nitrate of silver in preference to mu-
riatic acid.]

MeEnov. Réflexions pratiques sur la Diphthérite, ou Angine Membraneuse observée ©
en Touraine, Rev. Méd. 1829, t. iii. p. 262, and 1830, t. i. p. 179. [Witnessed
several epidemics of the disease, and was himself the subject of it. Strongly re-
commends mustard poultices externally, and the administration of purgatives
and antimony; but has no faith in local applications.]

Rocz. Dictionnaire de Méd. et Chirurgie pratiques, t. ii, Article Angine
Couenneuse. [He regards the disease as rather of a hemorrhagic than of an
inflammatory character, the pseudo-membrane consisting of decolored fibrine,
the result of circumscribed exudations of blood, deprived of its coloring matter.]

TrovussEau. Mém. sur une épidémie d’Angine Couenneuse Scarlatineuse, Arch.
Gén. t. xxi. p. 541. [Gives an account of scarlatinal angina mistaken for
diphtheritis, and endeavours to lay down the distinctive characters of the two.]

1830. Axison. Clinical Lecture, Lancet, Feb. p. 734, and June, p. 450, [Delivered

33

.
>

9

on a fatal case occurring in an adult at Edinburgh.]

ARCHAMBAULT-REVERDY. Observations d'’Angines, Jour. Univ, des Sciences
Méd. t. Ivii. p. 257. [A well-argued paper objecting to Bretonneau's state-
ments as too indiscriminate both in respect to pathology and treatment, and
protesting against the abuse of local treatment.]

~Conninzav. Note sur une Angine Membraneuse qui parait avoir été communiquée

d'un enfant a un adulte par le moyen dela respiration, Jour. Gén. de Méd, t. cx.
p. 334.

Duaks. Dictionnaire de Méd. et de Chir. pratiques. t. vy. Article Croup.
[Points out the analogies between croup and diphtheritis, without admitting
their identity, with Guersant and Bretonneau.]

Guzrsant. Des Inflammations avec Exsudations Pseudo-membraneuses, Gaz.
des Hép. Nos. 75 et 81. [Clinical Lecture at the Hép. des Enfants.]

Luspine. Precis historique de Vépid. d’Angine Maligne, Plastique, Gangréneus.
(Diphthérite) qui a régné & UEcole royale militaire de la Fléche, Arch. Gén. |
t. xxiii. p. 519.

REGNIER. Angines Couenneuses. Gaz. des Hop. No. 48. [Five cases related
illustrating the insufficiency of antiphlogistic treatment.]
ca
388 BIBLIOGRAPHICAL

1830. Trovsszav. De la Diphthérite Cutanée, Arch. Gén. t. xxiii. p. 383. [Details
of several cases observed during an epidemic, and usually supervening on the
application of blisters. The identity of the disease shewn by pellicular angina.
having been propagated from cutaneous diphtheritis, and vice versd.]

» VeEtPEav. Dela Diphthérite, et du traitement de cette affection au moyen des
topiques, Gaz. Méd. p.11. [A few cases related to shew the superiority of
local treatment by alum or nitrate of silver.]

1831. Broussais. Cours de Pathologie, t. i. Legon 7, p. 325, &e. [Criticism of
Breton neau’s views. ]}
Genpron (A.). Histoire d'une épidémie d’ Angine Couenneuse, avec Rapport par
Kergaradec, Transactions Méd. t. iii, pp. 281, 293, 303. [Account of an
epidemic in the Dep. of Loire-et-Cher, which converted the author to the doc-
trine of contagion. Report to Paris Medical Society, and discussion. ]
Horrmann (J. F.). Angina tonsillaris, $c. mit nachfolgender Lahmung
einiger Sinnesorgane, Rust's Magazin, b. xxxiii. s. 341. [A severe case of
diphtheritis, followed by paralysis of the nerves of the senses, but eventually re-
covering. ]
» PatorEeau. Dissertation sur la Diphthérite Pharngo-laryngienne, Thése de
Paris, No. 167. [A résumé of the chief writings on the subject.]

1832. BricHEreav. Rapport, Gaz. des Hop. p. 427. [Report to the Academy on
M. Miguel’s account of an epidemic, with short discussion. ]
» GIROUARD. Observations sur les Inflammations Plastiques, Transactions Méd.
t. x. p. 173. [Regards the nitrate of silver as one of the best applications. A
communication by M. Authenac in the same volume in confirmation.]

1833. Curyne. Cyclop. of Pract. Med. vol, i. p. 499, article Croup. [Protests
against confounding croup and cynanche maligna together under the name of
diphtheritis.]

Cotuingsav. Mém. sur la Diphthérite,Rev. Méd. t. ii. p. 328. [Believes that
general remedies have been too much neglected for topical ones. The paper
led to a discussion at the Academy, principally on the question of tracheotomy. ]

Constant. Angine Cowenneuse et Angine Pseudo-membraneuse Grave, Gaz.
Méd. 1833, p. 416; 1834, p. 101. [Some cases which occurred under Baude-
locque at the Hép. des Enfants.]

Gewpron (E). Mém. sur l’Angine Couenneuse, Arch. Gén, ser. 2, t. iii.
p. 393 (1833), and Nouvelles Obs. ser. 3, t. vi. p. 328 (1839). [Several cases
related confirmatory of the efficacy of nitrate of silver, as an application. Two
cases of tracheotomy, both fatal.]

Gurrsant. Dictionnaire de Médecine, 2de édition, t. iii. (1833), article Angine
Couenneuse ou Pseudo-membraneuse, and t. ix. (1835), article Croup. [M.
Guersant states, that all his additional observations made during sixteen
years are confirmatory of Bretonneau’s views.]

Lemercier. Note sur une affection catarrhale épidémigue avec Angine Couen-
neuse, Bulletin de Thérap. t. v. p. 261. [During the prevalence of influenza
in the Dep. of Mayenne, a considerable number of persons of both sexes, and
various ages, became the subjects of diphtheritis. Active bleeding, with oxide
of sodium and nitrate of silver as local applications, was adopted.]

Naumann. Ueber die Diphthéritis, Hecker’s Annalen, 1833, und Analekten fur
Kinderkrank. Heft ii. s. 142, und Handbnch der Med. Klin, 1834, b. iv. s. 61.
[A good general and critical account of the disease, but entirely derived from
the French writers.]

1834. Davip. Epidémie de Scarlatine compliquée d’Angine Couennense, Gaz. Méd.
p. 90.

Rivarp. Mém. sur une Epidémie d’Angine Couenneuse, Gaz. Méd. p.273, [An
epidemic occurring in Maine-et-Loire, treated by antiphlogistics and cauteri-
zation.]

.

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APPENDIX. 389

1834. Sauvé. Essai sur la Diphthérite, Thése de Paris, No. 37. [A résumé; and
some cases added, observed during an epidemic in Dep. of Mayenne. ]

»» STOKEs. Clinical Lecture, Lond. Med. and Surg, Jour. vol. iv. p. 197.

1835. Atug. Zwei Fille von Angina Pseudo-membranacea Pharyngea mit todtlichem
Ausgange Oesterr, Med. Jahrb. N. F. b. ix. s. 570.

» Bourceors. Del Angine Plastique dite Maligne ou Gangréneuse, considerée
daprés Vépidémie quia régné dans la Maison Royale de la Legion d’Honneur,
Mém. de l’Acad. Roy. de Méd. t. iv. p. 1. [Epidemic broke out after one of
mumps in a population of 700 females, mostly children. Hydrochloric acid
highly spoken of.]

Fricour and Borgau-Deroince, Théses de Paris, Nos.10 and 191. [M.
Fricout relates the circumstances of an epidemic he witnessed favouring the
views of the contagionists. The other thesis contains nothing original.]

Trousszau. Dictionnaire de Médecine, 2de édition, t. x; Article Diphthérite.
[In this article M. Trousseau chiefly dwells upon the cutaneous form of
diphtheritis.]

TWEEDIE. Cyclop. Pract. Med. vol. iv. p. 176, Article, Diseases of the Throat.
[A good account of the disease given, and the differences between it and croup
pointed out.]

1836. BewnEy. Cases of Malignant Diphtheritis, Dublin Journal of Med. Science,
vol. viii. p. 401. [Three fatal cases are related, one terminating in gangrene ;
the disease believed to be communicated by contagion. ]

»

>

» Bovttiavp. Dictionnaire de Méd, et de Chir. Prat. t. xv. Article, “* Stomatite.”
[The author objects to the specific nature assigned to diphtheritic angina and
stomatitis, as preventing the active and repeated depletion which he has found
useful.]

» RAGUENEAU. Angine Couenneuse, ou Diphthérite observée a Montfaucon. Journ.
de Méd. et de Chir. Prat. Mars. :

1937, Meyver. Rachencroup, Berlin Med. Zeit. p.s. 31, and Dublin Journ. Me
Sc. vol. xii. p. 126. [Four cases of diphtheritis.]

>» RYLAND. Treatise on Diseases and Injuries of the Larynx and Trachea, p.
161. [An interesting chapter on diphthérite, detailing some personal experience
in the disease. ]

» Stokes. Diseases of the Chest, part i. p. 206. [Croup is here distinguished
into primary and secondary, according as the air-passages are primarily or
secondarily engaged, and the distinctive signs are tabulated. ]

1838. BAuMGAERTNER. Winige Bemerkungen iiber den Rachencroup, Ammon’s
Zeitschrift, b. i. s. 50. [Proposes extirpation of a portion of the tonsils. ]

» Rupprus. Bemerkungen tiber Rachencroup, Oppenheims’s Zeitschrift, b. vii. and
Schmidt’s Jahrb. b. xx. s. 211. [The author states that he described diph-
theritis in 1815. He treats it with bleeding and calomel. ]

1839. Asmus. Hin Wort iiber Rachencroup, Berlin Med. Zeit. p. 175. [Relates a
bad case occurring in the person of his own wife, who recovered. ]

Bretonneav. Procédé cathérétique pour le traitement des Diphthérites,

: Journal des Connoissances. Juin. [Describes his mode of applying caustic. ]

>

Briaut anp Appison. Practice of Medicine, Article ‘Cynanche Membra-
nacea, [Treat of diphtheritis chiefly as it is observed in scarlatina. ]

» GeEDpINGs. On Pseudo-membranous Inflammation of the Throat, Amer. Journ.
of Med. Sci. vol. xxiv. p. 73. [A good historical compilation, with references
to the older authors. The author witnessed an epidemic at Charleston, U.S.,
but furnishes no details of it. He found nitrate of silver and muriatic acid very
useful. ]
390 : BIBLIOGRAPHICAL

1839, Heyrewwer. Studien. Article Angina exsudatoria, band ii. {Describes the few
sporadic cases which have occurred in his practice. ]

» Mepiceniscoe—CuIr— THERAPEUTISCHES WORTERSUCH, bandi. (1839), und
suppl.-band (1856). Articles Stoma-typhus und. Rachencroup. [A good
summary of the various means of treatment that have been resorted to.]

1840. Benson. Lecture at the College of Surgeons, Dublin Med. Press, vol. iv. p. 387.
[A good general account. Calomel, with nitrate of silver and mineral acids as
local applications, recommended. }

» Bernpr. Klinische Mittheilungen, and Schmidt's Jabrb. b. xxxvii. s. 251. [An
epidemic occurring at Greisswald, described.]

» Fasre. Dictionnaire des Dictionnaires. Articles Angine Couenneuse, Diph-
thérite, and Stomatite; and supplement Article Diphthérite des Veillards. [This
last is met with in a slight degree as a complication of various diseases, and is
easily relieved by borax.] -

» Symons. Article Angina Membranacea, in Library of Med. vol. iv. p. 48.
[A short résumé.]

1841. Dupnav. Angine Couenneuse guérie chez un sujet agé 59 ans. L’Expérience,
t. viii. p. 1. [A very acute sporadic case treated by bleeding and emetics.]

Kesster. Contagiositdt der pseudo-membranisen Entzunduugen der Schleim-

haut des Mundes, des Rachens, §¢., Berlin Med. Zeit.p. 92. [Relates six cases

in proof of the operation of contagion. ]

+» Maris. Observation de Diphthérie chez un adulte, Arch. Gén. 3 ser. t. x.
p. 342, [The patient, a vigorous subject in robust health, died on the sixth
day.]

» Rivet ayp Barrnez. Mém. sur quelques points de Vhistotre des Angines et

des Gangrénes du Pharynx chez Venfant, Arch. Gén. 3 ser. t. xii: p. 438.

[Cases related in proof of ulceration and gangrene occurring in diphtheritis.]

s
3

» Taupin. Note sur une épidémie de Maux de Gorge in Vanier’s Clinique des Hop.
des Enfants, t. i. p. 86. [Cases observed during an epidemic that prevailed
extensively in Paris, 1841. The author insists upon the importance of ex-
amining the throats of children during an epidemic, whatever may be the
affections they are suffering under.]

1842, Apams. Dublin Journ. Med. Sci. vol. xxi. p. 157. [Some account of an
epidemic prevailing in the Richmond Hospital. ]

Barriger. Maladies de Venfance, t. ii. p. 62.
» Berton. Maladies des Enfants, edit. ii. chap. 2.

» Bouvet. Hist. del épidémie de Croup quia régné al’ Hépital des Enfants de Paris,
Arch. Gén, 3 ser. t. xiii. p. 133. [The author denies the correctness of Breton-
neau’s statement that croup is always an extension of diphtheritic inflamma-
tion of the pharynx, and that gangrenous angina is in fact only diphtheritis.]

», EvANSON AND Maunseiy. Treatise on Diseases of Children, 4th ed. [A
brief account founded on no personal experience. |

GurretiIn. Mém. sur une épidémie d Angine Scarlatineuse. Rapport par M.
Desporres. Bulletin de Acad. de Méd, t. vii. p. 567. [The Reporter ex-
presses his conviction that this epidemic was an example of the_caseiform
variety of pseudo-membranous angina complicated with scarlatina, and in
some cases with typhus. ]

1843, Arnau. Diphthérite Vaginale, Gaz. des Hop. p. 307. [A case related.]

» BEcquEReL. Relation d'une épidémie d'Affections Pseudo-membraneuses et
Gangréneuses gui a régné al’ Hopital des Enfants, Gaz. Méd. Nos. 43, 44, 45,
and 46, [An elaborate history of the epidemic of 1841, comprising cases of
gangrenous angina, of croup following angina, and gangrene of blistered sur-
faces. In the diphtheritis, local cauterization and tonics were employed. ]

7

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>
APPENDIX, 391

1843, Duran. Quelques réflexions sur les Angines, Thése de Paris, No. 3. [Disputes

°

-
=

s

”

Bretonneau’s views as to the identity of diphtheritis and gangrene, as also his
statement that the sole danger consists in its involving the air-passages, while
the general condition of the patient really constitutes the true peril. Relates
some fatal cases observed at the Hépital des Enfants. ]

Gurrratre. De la Diphthérite Buccale. Clinique de Montpellier, December.

Mepicat Timus. vol. vii. p. 165. [Anonymous article * Cynanche Maligna,’
containing some interesting observations. ]

RILET AND Barruez. Maladies des Enfants, ler edit. t. i. pp. 285, 316,
Article Pharyngite Pseudo-membraneuse, or 2de édit. (1853) t.i. p. 242, Article
Angine Pseudo-membraneuse. [They treat ordinary croup and the form which
follows pseudo-membranous angina as identical; but dispute Bretonneau’s
accuracy in confounding diphthérite with gangrenous affections. Thereis scarcely
any additional matter upon the subject in the second edition.]

Simon (Max). Considérations sur l'Angine Gangréneuse et de son traitement,
Bull. de Thérap. t. xxiv. p. 401. [The author agrees with Bretonneau, that
diphtheritis has often presented a false appearance of gangrene, and that
several epidemics af angina maligna have been really examples of diphtheritis.
But he is certain that all authors have not fallen into this error; and that
angina maligna, Fothergill’s angina, and angina gangrenosa, are different
affections from diphtheritis. Cases are related in proof of the reality of the
gangrenous affection.]

TrovussEau. Dela Diphthérite Gingivale et de ses rapporis avee le Croup, Gaz.
des Hép. p. 109. [Clinical lecture on the relations of this to other forms of
diphtheritis, and on its transmission. ]

1844, GuerRsant AND Buac we. Dictionnaire de Méd. 2de édit. t. xxviii. Article

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9

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Stomatite Couenneuse ou Pseudo-membraneuse. [Under this title the
authors comprehend, canker of the mouth, noma, stomacace, the terminations in
ulceration or gangrene being regarded as quite exceptional, and the affection,
in fact, being one of the forms of Bretonneau’s diphthérite. ]

Hater. Arzilicher Bericht iiber das Strafhaus in Wien, Med. Jahrb. des
Oesterr Staates, b. 50, p. 311. [A remarkable case occurring in an adult.]

Hanmann. Uber Rachencroup, Walther und Ammon’s Journal N. F. band 3,
s. 429. [On the occasion of relating a case that occurred in his own practice,
the author presents a very able critical account of what has appeared in
France and Germany upon the subject. |

Haver. Fall von tédilichem Rachencroup. Casper’s Wochensch. p. 817. [Fatal
case in a boy aged thirteen—autopsy. |

JADELOT. Angine Pseudo-membraneuse ou Diphthérite. (Lecon Clinique) Gaz.
des Hop. p. 5.

Jousset. Dela Trachéotomie dans le traitement du Croup, Arch. Gén. s. iv, t.
5, p. 401. [Advocates the operation in extreme cases after trying in vain to
overcome the diphtheritis, which he regards as always preceding croup. Com-
ments on Bretonneau having neglected to notice Bard’s recognition of the
identity of the two affections. |

Lanpssera. Rachencroup oder nicht? Hufeland’s Journ. b. xcvii. s. 3.
[Remarks upon the diagnosis. Question asked, whether the inflamed condition
of the nerves found in a case was an accidental or essential feature—the diph-
theritis being in the latter case a neurophlogosis, as it is considered to be by
Schénlein.]

1845. Dunoan. Ulceration of the Gums occurring in an epidemic form, Dublin Journ.

”

of Med. Science, vol. xxviii. p. 3. [This epidemic was observed at the Dublin
Union Workhouse ; and one of the cases related is an example of diphtheritis. ]
Moranp. Mém. et Obs. Cliniqnes, 8vo. Tours, 1845, and Brit. and For. Med.
Chir. Rev. vol. xxiii. (1847) p. 376. [Eleven cases related. The author speaks
highly of nitrate of silver, and recommends tracheotomy when other means fail.]

.
892

BIBLIOGRAPHICAL

1845, Trousszavu. Diphthérite Gangréneuse Vulvaire, Gaz. des Hop. p. 406. [Clinical

lecture on a case occurring in a child three months old. ]

1846. Conry; Treatise on Diseases of Children, p. 153. [No personal experience

>

stated.]

Daviot. Relation d'une épidémie de Diphthéropathie, Gaz. Méd. p. 178.
[Describes an epidemic at Autun, being the fifth since 1782, occurring without
any local assignable causes. He found bleeding useful in patients older than
ten, and prefers the nitrate of silver as a local application. |

1847, Bovisson. Ophthalmie suraigue avec formation de Pseudo-membranes a la

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surface de la Conjonctive, Annales d’oculistique, t. xvii. p. 100. [The author re-
lates an interesting case of diphtheritis attacking the conjunctiva, which he
believes to be analogous to diphtheritis affecting other parts. The eye was lost.]

Corey. Lancet, November, 1847, p. 576. [Fatal case related at the Westminster
Society, with discussion upon the administration of large doses of calomel. ]

Metuion. Hin binnen 30 Stunde tédtlich verlaufener Rachencroup. Oesterr.
Méd. Wochens, p. 259. [This rapidly terminating sporadic case, occurred
in a girl eleven years of age. ]

MEMOIRES DE L’'ACADEMIE DE MEDECINE, t. xiv. p. 167 (1847) ; t. xviii. p. 168
(1854) 5 t. xix. p. 184 (1855); &. xx. p. 154 (1856) ; t. xxi. p. 103 (1857) ; t.
xxii. p. 90 (1858). [References to the epidemics of diphtheritis contained in
the Academical Reports on Epidemics; but these are meagre in the extreme,
considering the reputed prevalence of the disease, and the organization existing
in France for furnishing accounts of epidemics. The last referred to is by M.
Trousseau, and contains some account of the Boulogne epidemic. ]

Mounixe. Casper’s Wochenschrift, s. 143. [Fatal case, with autopsy. |
Rogsert. Considérations nouvelles sur Pétiologie et le traitement de la Diph-
thérite des Piaies, Bul. de Thérap. t. xxxiii. p. 26. [Here M. Robert describes
a diphtheritic condition of ulcerated surfaces, met with sometimes during epi-
demics of diphtheritis, but oftener independently of these, and chiefly due to
vitiatation of the air from overcrowding. In fact, it is identical in its origin,
its characteristics, and the treatment it requires, with Delpech’s pulpous form
of hospital gangrene. Eisenmann, and other of the German writers, also describe
this form of hospital gangrene as diphtheritis.]

Vircuow. Ueber die Reform der pathologischen und therapeutischen Anschau~
ungen durch die mikroskopischen Untersuchungen, Arch, fiir pathol. Anat. b. i.
s. 253. [The microscopical distinctions laid down of the three varieties of in-
flammation of the mucous membranes, the catarrhal, the croupal, and the
diphtheritic.]

1848. Barot anD Montatier. Del Angine Couenneuse, Théses de Paris, Nos. 34

0

and 205. {No original observations. |

Dunauison. Practice of Medicine, 3rd edit, vol. i. Article Diphtheritic Inflam-
mation of the Pharynx [A short description of the disease, but the author
does not speak of it as if seen in America. ] .

1849. Hein. Luftriéhrenschnitt bei Typhus, Henle und Pfeufer Zeits. b. 7, s. 332.

”

”

[Two fatal cases of diphtheritis, in one of which tracheotomy was performed. ]
Miquet. De la Diphthérite, 8vo. Paris, 1849, and Arch. Gén. s. iv. t. xxi.
p. 502. [Especially recommends calomel and alum in the croupal variety.
Favourable report on this treatment by Guersant, Gaz. des Hép, 1849, p. 533.]

Watsne. Diphtheritic Deposit, Cyclop. of Anat. and Phys., vol. iv., p.
118,

1850. Brox. Epidemie von Croup und Angina Faucium Exsuditiva, Oppenheim’s

”

Zeitschrift, b, xliv.s. 200. [It occurred at Lagstor in Denmark. Emetics
found of use, but cauterization in several cases did more harm than good.]

Bennett (J. R.); Med. Times and Gaz. vol. xxii. p. 418. [A good paper on

the pathology and treatment of the disease, read at the London Med. Soc., and
followed by a short discussion. ]
APPENDIX. 393

1850. Bourgeois. Gazette Med. p. 243. [Report on an account ofan epidemic in

”

»

the department of the Cher, in which calomel and nitrate of silver were the
means employed. ]

Brown (J. D.) on Diphthéritis, Med. Times and Gaz. vol. xxii. p. 670. [The
. first notice of this disease as an epidemic in England. Mercurial treatment
and the application of the nitrate of silver recommended. |

Empis. tude de la Diphthérite d’aprés une épidémie de cette maladie observeé
a Phépital Necker, Arch. Gén. s. iv. t. xxii. pp. 129 et 281.

Froun. De la Diphthérite, Thése de Paris. [A good description of the
disease, illustrated by several cases observed in M. Trousseau’s wards ]

Ramsay. Diphtheritic Inflammation of the Pharynx and Tonsils, Dub. Med.
Press, Aug. 1850, p. 137 (from Phil. Med. Exam.), [General observations ;
but source of experience not stated.]

Rott. Ueber eine Hpidemie der Angina Diphtherea in Drontheim, Oppenheim
Zeitsch. b, xlv. s, 33. [Between 700 and 800 cases occurred, with about fifty
deaths, At pp. 41 and 309 of the same vol. short accounts are given of
epidemics in other parts of Norway.]

WetsH. Diphtheritic Inflammation as it prevailed epidemically in Ohio, in the

years 1847-9, Amer. Jour. of Med. Sci. N.S. vol. xx. p. 276. [A strong solu-
tion of nitrate of silver was found preferable to alum, sulphate of copper, or
diluted muriatic acid.] 7 ,

Wistrann. Diphtheritis Cutanea, Hygiea, vol. xi. No.5; and Schmidt’s Jahrb.

lxx s. 309. [Cutaneous diphtheritis appearing during the progress of a case of
diphtheritis in an adult. ]

1851. Baron. Delemploi de Veau deVichy dans le traitement des Affections Diptheri-

tiques, Gaz. Méd. p. 524. [The first recommendation of alkaline treatment,
since much resorted to in France.]

» CHAVANNE. Epidémie de Diphthérite Gangréneuse des parties genitales observées

”

a0

”

chez les nouvelles accouchées, Thése de Paris, No. 130. [Twenty-six women were
attacked at the Lyons Hospital (whereasimilar epidemic prevailed in 1815), nine-
_teen of the number recovering by the aid of tonic treatment and cauterization.]

LinpEeBoon. Dissert. de Diphtheritide. Groningen.

Morisszav. Paralysie du voile du palais comme cause de nasonnement,
L'Union. Méd. No. 126. [Of five cases of paralysis of the velum, following
diphtheritis, four occurred in adults and yielded to galvanism. The other case
lasted many years. ]

Trovsseau and Lassaus. De la nasonnement et dela paralysie du voile du
palais, L’Union Méd. No. 119. [Paralysis of the soft palate as it occurs in
children, as a sequence of diphthérite. ]

1852, Bonner. Etudes cliniques sur la Diphthérite Laryngo-bronchique chez U Adulte.

L’Union Méd. No. 51. [Two cases of croup in the adult, one being preceded
by false membranes in the fauces. ]

1853. Benrenp. Einige Beobachtungen iiber die entzundlichen, geschwiirzen und

»
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2

.

brandigen Affectionen des Mundes bet Kindern, Jour. fiir Kinder. b. xx.
s. 244. [A review of the distinctive signs of the various affections of the fauces.]

Copnanp. Dictionary of Practical Medicine, Article, Inflammation of the
throat, with plastic exudation. vol. iii. p. 1059 [A critical epitome of the views
of the French writers. ]

GuitLoT. Considérations générales sur U Affection Diphthéritique, L’Union Méd.
No. 45. [Clinical lecture. M.G. regards the disease as a general one, analogous
in its operation to morbid poisons; and distinct in its nature from ordinary croup. ]

Lemarre. De l'emploi du Bicarb, de Soude comme antiphiogistique, Monit. des
Hop. Nos. 83, 84, 85. [Some cases are given, showing the advantages of this
agent in diphtheritis.]
394

BIBLIOGRAPHICAL

1853. Marcuant. Du Croup, nature et diagnostic, L'Union Méd. Nos. 114, 115,

3

116,117. [The author seeks to show that Bretonneau has done much harm by
confounding croup with. diphtheritic angina, and that the latter affection is
really a gangrene. ]

Maziur. Epidémie d’ Angine Membraneuse et Gangréneuse, Gaz. Méd. p. 535.
[Giving an account of a severe epidemic at l'Aigle in the Dept. of the Orme.]
Tuomas. Diphthérite chez une enfant de 11 ans, Gaz. des Hép. p. 191. [Death
suddenly took place from the false membranes, becoming detached from the
velum, obstructing the isthmus faucium.]

VALLEIX. Guide du Médécin Pratique, 3e edition, t. ii. Article, Pharyngite
couenneuse pultacée et gangréneuse. [The subject is here very ably treated.
He believes that Bretonneau, though right in denying the supposed frequency
of gangrene, went into the other extreme. ]

1354. Daga. Del Angine Pseudo-membraneuse et de ' Angine Gangréneuse, Récueil

»
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>

de Mémoires de Méd., &c., Militaires, s.2, t. xiv. p. 141, [An account of the
two varieties of the disease as observed in the military hospitals, and regarded
as blood-diseases. Strong muriatic acid much preferred to nitrate of silver as a
local application.]

Ducios. Réflexions pratiques sur lV Angine Couenneuse, Bulletin de Thérap.
t. xlvii. p. 39. [Two cases related which were solely treated by application
of solid nitrate of silver.]

GrarEreE (A. von.). Uber die Diphtheritische Conjunctivitis, Archiv, fiir
Ophthal. bandi.s. 168. [This affection has been observed to occur epidemi-
cally at Berlin. The author regards it as a general, rather than as a local
disease ; and it is frequently accompanied by diphtheritic inflammation of the
skin, nares, angles of the mouth and blistered surfaces.]

Lesprav. Relation d'une Epidémie Diphthéritique, qui a sevi sur le 75e regiment
d'infanterie a Avignon, Récueil de Mémoires Méd. &c., Militaires, s, 2, t. xiii.
p. 169. [The attack was confined to one regiment of the garrison, consisting
of 1686 persons. These furnishes 200 cases, with twelve deaths. The author
attributes it in some measure to the bad condition of the barracks, but believes
the disease was spread by infection. The prompt use of nitrate of silver formed
the best means of treatment. ]

Maincavtt. Dela Paralysie du voile du Palais ala suite d'Angine, Thése de
Paris, No. 194. [A general account of paralysis of the velum after throat af-
fections, adducing two instances of its following diphtheritis.]

Marcuant. Diagnostic du Croup et d'Angine Gangréneuse, Gaz. de Hép.
p. 33]. [Indicates the points of difference between diphtheritis and croup. A
report on the paper by M. Guersant, Gaz. des Hép. 1855, p. 144.]

Prosco und Pross. Medicinische-Chir. Encylop. Articles Die Diphtherische
und Croupose Angina, Stomatitis and Pharyngitis Diptheritica, [They admit
two varieties of the ordinary angina, the croupal, in which false membranes
are formed, the subjacent surface not being ulcerated, and the diphtheritic, chiefly
distinguished from the croupal by the tendency to ulceration or grangrene.
They do not confound either with ordinary croup.]

Renovarp. De ?Angine Maligne, Revue Méd. t. ii. 1854, p. 592. [In this
case the pharynx, but not the tonsil or velum, was the seat of the false
membranes. |

Santius. Zur Lehre von den Krup, Journal fiir Kinderk, b. xxiii. s. 49. [Two
epidemics of not a very fatal form of diphthérite, which prevailed in Nassau,
one being accompanied by a miliary rash. ]

TroussEau. De l’Angine Maligne, Lettre a Pierre Bretonneau, L’Union
Méd. No. 70. [Written on the occasion of the death of M. Blache’s son from
diphthérite. While still maintaining, that as a general rule, the danger of diph-
sheritis consists in its extension to the air-passages, and that the immense ma-
jority of cases of croup commence with it; he states, that he has of late years
APPENDIX. 395

met with instances of an ataxo-adynamic form of the disease, in which the
patient is carried off independently of any such extension.]

1854. Wxsr. On Diseases of Children, 3rd edit. Lect. 23. [Has never met with the

”

severe idiopathic affection as described by the French authors; but has gene-
rally observed it as a dangerous complication of measles. ]

Wunveruicn. Handbuch der Pathologieund Therapie, 3 Auflage, band 34.s.716,
Article, Pseudo-membranése Stomatopharyngiten. [An able article, but not
derived from German sources. The author considers stomato-pharyngitis : —l,
as simple primary; 2, common secondary, following affections of the mouth,
jaw, &c.; 3, croupal; 4, accompanying scarlatina, variola, or mercurialism ;
5, epidemic stomato-pharyngitis ; 6, aphthous, or cachectic secondary aphtha. |

1855. BAMBERGER. in Virchow’s Handbuch der Pathologie, band vi. abt. 1, s. 1-22.

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.

3

2

a

i

{Bamberger considers inflammation of the mouth and pharynx under the heads
catarrhal andcroupal, dividing the latter into croup of the mouth and pharynx,
and diphtheritis—these being different degrees of the same disease. He gives
a good account of the disease as described by the French, but does not refer
to it as prevailing in Germany.]

BrEsnaRD. Deux observations de trachéotmie pratiquées avec succés dans deux
cas de Croup, ou plutét d’Angine Couenneuse ayant gagné le laryné et le trachée,
Gaz. des Hop. p. 175. ;

BRETONNEAU. Sur les moyens de prévenir le développement et le progrés de la
Diphthérite, Archives Gén. s. 5. t. v. p. 1. and t. vi. p. 257. [Details in-
stances of the transmission of fhe disease by contact. Recommends nitrate of
silver, not only as a means of treatment, but of prevention during the preva-
lence of epidemics. ]

BULLETIN DE THERAPEUTIQUE. t. 48, p. 273. Un mot sur la constitution
médicale, et en particulier sur une épidémie d’ Angines Couenneuses et de Fievres
Typhoides actuellement regnante.

Danvin. Sur le traitement dela Diphthérite par le cautere-Mayor, L’Union
Méd. Nos. 135, 136, and 140. [Application of Mayor's hammer heated by
boiling water with success in fourteen out of seventeen cases, and with less pain
than is caused by Bretonneau’s treatment.]

Fieve. Mémoire sur 0 Angine Couenneuse, 8vo, Paris, 1855. [This Memoir
was produced on the occasion of the epidemic which commenced at Paris in
1855, and which was remarkable for the number of older persons it attacked.
The Memoir is noticed by M. Bousquet, in Gaz. de Hop. 1856, p. 29.]

Gaznrrm pes Hépiraux, 1855, Nos. 44 and 64, and 1856, No. 47. [Observa-
tions on the epidemic of 1855.]

Grisottz. Pathologie Interne, 6e edit. t. i. Article, Angine Pseudo-mem-
braneuse. [A short summary only given, the author maintaining the dis-
tinction between diphtheritis and gangrene of the same parts. ]

Haspen. Observations sur les Maladies qui ont sevi sur ! Arméed' Orient pendant
1855, Gaz. Med. p. 829. [Many cases occurred during the Crimean campaign,
but without assuming an epidemic or devastating form.]

Homoute. De Temploi du Bicarb. de Soude a haute dose dans la Laryngite
Pseudo-membraneuse, L’'Union Med. 1855, pp. 346 & 350; 1856, p. 281.
[Some observations upon the distinction between croup and diphtheritis; and
on the general principles which should guide treatment. ]

Latour. Note sur le traitement de VAngine Diphthéritique, L'Union Méd. No.
74, [Tried alkalies in a case without effect, and strongly advocates free cau-
terization With nitrate of silver. In thesame No., M. Ferranp relates some
cases in proof of the utility of the caustic. ] 4 5
Mancuat ve Carvt. Mémoire sur la nature et le traitement de U Angine Couen-
neuse, L’Union Méd. Nos. 56, 57, 58, 62, & 65. [The author objects to cau-
terization as tending rather to prolong the disease, and maintains the importance
of the general treatment by alkalies, of what may be considered a general disease. ]
396 BIBLIOGRAPHICAL

1855. Marcugt. Observations des Angines Couenneuses traitées sans succés par le
Bicarb, de Soude, L’Union Méd. p. 433. [Relates some cases to show the
inefficiency of soda. He directs attention to the great swelling of the submax-
illary glands which often takes place. ]

» Ovitmont. De l’Angine C considerée plication de la fiévre
typhoide, Rev. Médico-Chir. de Paris, t. xviii. p. 5. [Of six patients who exhi-
bited this complication, five died. Two of these cases are detailed. M. Trousseau
has not met with this complication, which appears at the middle period or
towards the decline of the disease. Report on the paper by M. Anan, L’Union
Méd. 1856, p. 100.]

Ramon. Observation de Diphthérite, suivie de considerations pratiques, Gaz. des
Hop. p. 445. [Fatal case in a child at 10. The author agrees with Breton-
neau as to the identity of croup, and the nonexistence of gangrenous angina. ]

Smite. (A.) Case of Diphtheritis successfully treated by chlorate of Potash,
Dub. Hosp. Gaz. vol. ii. p. 149. :
TroussEAv. Legons Cliniques sur les Angines, Gaz, des Hip. Nos. 86, 89,
100, 104, 109, 115,119. [A series of Lectures commenced on the occasion of
M. Valleix’ death by diphtheritis, in which the whole subject is reviewed in a
masterly manner. |

Vatentin. De l'Angine épidémique, et de son traitement par le Fer Rouge,
L’Union Méd. 1855, p. 419, 1857, p. 606, and 1858, p. 258. [Many cases
treated during epidemics with the best effect by the actual cautery.}

Woop. Practice of Medicine, 4th edit. vol. 1, Article Pseudo-membranous
inflammation of the fauces. [A short article with no statement as to the
prevalence of the disease in America. ]

1856. Baron: Note sur le traitement dela Diphthérite par ' Hau de Vichy et par le
Bicarb. de Soude, Gaz. Méd. Feb. p. 63. [Observations confirmatory of the
advantages he had in 1841, anticipated would be derived from the employment
of alkalies. ]

>, CHassatanac. Sur l Ophthalmie Pseudo b se des nés Annal

d’ Oculistique, t.xxxv. p. 34. [A general account is here given of M. Chassaig-

nac’s views on the purulent ophthalmia of infants, which he regards as a

pseudo-membranous affection, but which, in fact, is an entirely different disease

to the diphtheritic conjunctivitis of Graefe.]

Esert. Zwei Falle von Diphtheritis Vulue, Deutsche Klinik, p. 220. [Two
cases observed at the Children’s Clinic, at the Berlin Charité, one proving
fatal. ]

GuBter. Angine Gangréneuse observée chez une femme, Comptes Rendus de la
Soc. de Biologie, s. ii, t. ii, p. 60. [A specimen exhibited in proof that primary
gangrenous angina may exist independently of diphtheritis or scarlatina, and
unexplained by excess of inflammation. ]

IsamBert. tudes sur Vemploi thérapeutique du Chlorate de Potasse, spécialment
dans les Affections Diphthéritiques, Bull. de Thérap. t. 1. p. 488. [The cases are
few in number, and the chlorate was only useful in those of medium intensity. ]

Lareniez. Emploi du Bicarb. de Soude dans! Angine Couenneuse, Thése de
Paris, 1856. [The author, a pupil of M. Baron, recommends the alkaline
treatment before the disease has extended to the larynx, when it is no longer
of avail. The cases he relates are not very conclusive. |

LxcotntE. Dela teinture d’Iode dans l’Angine Couenneuse, Bullet. de Thérap. t.
1. p. 70. [Three cases are related which were successfully treated by applica-
tion of iodine to the fauces, and of iodized ointment externally. ]

Outmont. Relation d'une épidémie d’Angine Couenneuse quia régné & Uhépital
St. Antoine, en 1855, Arch. Gén. s, 5. t. vii. p. 385. [This epidemic was es-
pecially remarkable by being confined to one ward of the hospital, and by its
complicating some other grave affections, especially typhoid fever, a conjunction
scarcely hitherto mebseed|

 

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APPENDIX. 397

1856. Ozanam. Delefiicacité de Brome dans le traitement des Affections Pseudo-mem-

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braneuses, Comptes Rendus de I’Acad. des Sci. t. xlii. p. 102, and Mon. des Hop.
p. 551. [Based on its successful administration in fourteen cases. The author
recommends bromine or bromide of potassium as almost a specific in pseudo-
membranous affections. ]

Prrron, Zuskouszx1 AnD Borner. Sur le traitement de Diphthérite par les
applications de teinture d'Iode, L’Union Méd. Nos. 58, 70, and 72.

Provo. Notes sur la Diphthérite, Récueil de Mém. de Méd. &c., Militaires,
s. 2. t. xvii. p. 392. [Describes the disease as observed among the troops at
Bona, in Algeria, and relates eight cases. He found the bicarb. of soda to
possess little of its reputed antiplastic power, and preters the free use of muriatic
acid as the best local application. Bleeding was found admissable only in in-
tercurrent inflammatory affections. ]

Roux. Angine Couenneuse guerie par le Chlorate de Potass, Gaz. des Hép. p. 586.
[The nitrate of silver was also used. ] 3

Tarassenxorr. Diphtheritis Epidemica, Med. Zeit. Russlands, p. 92. [An
account of an epidemic observed at Moscow, in 1855.]

1857. ADKINS. On Diphtheritis, Lancet, Dec. p. 653. [As observed in Devon. ]

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Binraaum. Lrlebnisse ausder Kinderprazis, Journal fir Kinderkrank, b. xxix.

s.52. [Describes diphtheritis as a primary and as a secondary affection, the
former very seldom extending, in Westphalia, to the respiratory passages or
nares. He places nrost dependence in cauterization, emetics, and mustard
cataplasms. ]

BuascuKko. Mittheilung iiber eine am hiesige Orte im Jabre, 1854, stattgehabte
Scarlachepidemie mit Diphtheritische Braune, Journal fir Kinderk. b. xxviii. p.
155. [Account of a fatal epidemic of diphtheritic gangrenous scarlatina at
Freywalden. |

BiomrieLp. On the Diphthéritic epidemic, Lancet, Nov. p. 562. [As observed
in Suffolk. ]

Bonnet. Sur une épidémie d Angine Diphthéritique,Cas curieux de transmission
et d'importation de la maladie, L’Union Méd. p. 624. [In evidence of contagion.
Some of the statements controverted by Dupuis, L’Union, 1858, p. 36.]

DesaEnne. Nouvelle observaticn pour servir & Uhistoire des accidents consecutifs
del Angine Couenneuse, L’Union Méd. No. 41. [Relates his own case, in which
the diphtheritis was followed by partial paralysis of the muscles of deglutition. ]

Faure. Des accidents consecutifs de la Diphthérie, L’Uniou Méd. Nos. 15 and
16. [Treats especially of the paralytic symptoms remaining after the diph-
theritis is cured. ] fe
GazettE pEs Hopitaux. Du Chlorate de Potasse dans l Angine Pseudo-mem-
braneuse, pp. 21, 50, 98, 170, 198, 334, 411, 456. [The somewhat conflicting
experience of various practitioners stated.]

Gicor. Etudes cliniques sur le traitement de ? Angine Couenneuse et du Croup,
&vo. Paris. 1857, reviewed in L’Union Méd. 1859, No. 22. [These observations
are founded upon one hundred and thirty cases, thirty-three of which were
cases of croup, a disease the author has never seen unpreceded by angina. He
speaks highly of alkaline treatment, and believes that more harm than good is
done by caustics. ]

Goprrey. Report on cases of Diphtheria or Malignant Sore-throat, Lancet,
Nov. p. 542. [Four cases, occuring in the same house, three proving fatal.
The author recommends iron in the treatment of the disease. ]

Guster. Mémoire sur Angine Maligne Gangréneuse, Arch. Gén. s, 5, t. ix. p.
513. [Although Bretonneau has shown that former writers had comprised
under the term gangrenous, affections really diphtheritic, yet the conclusion
which he and his followers have come to, that primary gangrenous affections
do not occur, is quite unjustifiable. Three cases are related in proof. ]
398 BIBLIOGRAPHICAL

1857. IsamBERT. Des Affections Diphthéritiques, et spécialment de ! Angine Maligne

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observées a4 Paris en 1855; Archives Gén. t. ix. pp. 325, 432. [In this epi-
demic, breach of the mucous surface was often observed. The author divides
the cases that occurred into common angine couenneuse, scarlatinal angine
couennetise, and diphtheritic angine couenneuse. This last exhibited two very,
different types, viz., the croupal diphtheritic angina, in which croup was present
and malignant angina, properly so called, in which death took place from
adynamia, or a peculiar intoxication, without laryngeal affection. This last
type has been observed of late years more frequently in Paris, and especially
in 1855, one of its pathognomic signs being enormous tumefaction of the
glands, Thecroupal variety has not been seen so often as stated by Bretonneau
and his followers; and croup occurs more frequently unpreceded by angina
than they allow.]

James. On Epidemic Diphthéritis, Med. Times and Gaz. vol. xxxvi. p. 587.
[As occurring in Suffolk. ] a

Manizvux. Diphthérite Gangréneuse chez une nouvelle accouchée, transmission
de la mére & enfant, Mon. des Hép. p. 1031. (Slight diphtheritis of tonsil,
diphtheritic ulceration of the nipple, and gangrenous vulvar ulceration. Gan-
grenous ulceration of the infant’s mouth. Both died.]

MeEstIivier, ARAN, AND CHARRIER. Bullet. de Thérap. t. lii. pp. 12, 105, and
503. [Articles on opening the ranine veins, a practice found useful in ordinary
angina, but spoken of as of doubtful advantage in the diphtheritic and malignant
form.]

Mitztart. Coryza Couenneux et Angine Gouenneuse avec Gangréne des Amygdales,
&c., L’Union Méd. p. 464. [An interesting case, with the autopsy. ]

Moorg. Scarlatina Faucium and Pseudo-membranous Pharyngitis, Med. Times
and Gaz. vol. xxxvi. p. 546. [Draws attention to a diphtheritic condition of
the throat, met with during epidemics of scarlatina unaccompanied by rash ;
and suggests that this may prove prophylactic of future attacks of scarlatina. |

PricHaRp. Diphtheritic Conjunctivitis, British Medical Journal, p. 981.
[Mr. Prichard has met with nine or ten examples of this affection, occuring
about the period of the first dentition. Only of late years has he seen the
disease in connexion with scarlatinal diphtheritis. He seems unaware of
Graefe’s observations. ]

Riapy. Med. Times and Gaz. vol. xxxvi. p. 582. [Case of diphtheritis.]

WaRLOMONT AND TESTELIN. Ophthalmie Diphthéritique, Traduction du Traité
des Maladies de l’Oeil par Mackenzie, t. i. p. 778, and Annales d Oculistique, t.
xxxvi, p. 228. [An account of the disease as described by Graefe, of Berlin.]

Watson. Lectures on the Principles and Practice of Medicine, 4th edit. vol. i.
p. 864. [Has only met with two or three cases, and refers to a fatal one in
which tracheotomy was performed. ]

Woopwarp. On Diphtheritis, Lancet, December, p. 654. [Utility of
chlorate of potash in.)

1858. Barry. Diphtheria, or Diphtheritis, Brit. Med. Journ. pp. 599 and 623.

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[Question of nomenclature considered. Some cases detailed. For treatment,
.iron and chlorate of potass, counter-irritation, and application of nitrate of
silver recommended. | .

Brats, On the Structure of the False Membrane in some cases of Diphtheria,
Archives of Méd. No. 3, p. 242. [The microscopical structure detailed. The
author has not met with vegetable parasites. ]

Brtiysen. Lancet, November, p. 513. [A case or two, with some general
remarks. }

Buount. Lancet, November, p. 486. [Some account of the disease as ob-
served at Bagshot. ]
APPENDIX. 399

1858. Boston MEDIcAL JOURNAL, vol. lix. p. 252. Diphtheria in Providence.
[It is stated that diphtheritis has manifested itself at Providence, U.S., with

the same symptoms as in England, the patients dying from exhaustion and
fever, rather than asphyxia. ]

» Bovcnur. D’une Nouvelle Méthode de Traitement de VvAngine Couenneuse.
Comptes Rendus de l’Acad. des Scien. t. xlvii. p. 610, Gaz. des Hop. p. 506,
and L’Union Méd, p. 507. [This consists in amputation of the tonsils, which
the author has performed four times with success. The operation is especially
indicated when the tonsils are enlarged, and will often prevent the extension

of the diphtheritis to the air-passages. False membranes do not form on the
wounded surface. |

» Bovcnor. Del’ Angine Couenneuse et de l Angine Gangréneuse, Gaz. des Hop.
pp. 170 and 186. [A clinical lecture, in which the confounding together
diphtheritis, croup, and gangrenous angina, is protested against. General
rules for treatment are laid down, and glycerine recommended as a local ap-
plication in diphtheritis.]

» Boucuur anv Epis. Resumé d'un Mémoire sur ? Albuminarie dans le Croup et
dans les Maladies Couenneuses, L’Union Méd. No. 132. [Attention is here
called to the frequency with which albuminaria occurs in diphtheric diseases,
it being a symptom of great danger. |

» Bravunp. Lancet, November, p. 566. [Observations on treatment.] |

» Browne (B.) Report on two cases of Diphthérite, Lancet, February, p. 188.
[Observed at Kew, but very superficially detailed. ]

» Brypen. Treatment of Diphthéria, British Med. Journal, p. 927. [Great
success is said to have attended the administration of guaiacum and the local
application of the chloride of sodium. ]

» Cammack. Lancet, October, p. 461. [The author has witnessed an epidemic,
and believes the disease to be herpetic.]

» Camps. Pathology and Treatment of Diphthéritis, Lancet, March, p. 250,
and Med. Times and Gaz. vol. xxxvii. p. 565. [Papers read at the London
Medical and the Epidemeiological Societies. The author believes that three
varieties of sore-throat have prevailed, Bretonneau’s disease, Fothergill’s sore-
throat, and scarlatinal angina. |

Cazin. Bons effets du Suc de Citron et du Suc d’Aildans V Angine Couenneuse,
Bull. de Thérap. t. lv. pp. 327 and 368. [The author states that he has used
a mixture of these substances, both locally and inwardly, during the Boulogne
epidemic, with great advantage. ]

Cuurcuity. Diseases of Children, 2nd edit. p. 498. [A good reswmé of the
opinions of the French writers on the disease, as observed in its primary and
secondary forms ; but no original observations upon the affection.]

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yy CONDIE. Diseases of Children, 5th edit. p. 172. Article Pseudo-membranous, or
Diphtheritic inflammation of the throat. [Refers to the disease chiefly as it is:
met with in the sore-throat of scarlatina ; and does not seem to have had any
personal experience of it as an independent affection. He regards putrid
malignant gangrenous sore-tbroat only as the aggravated form of pseudo-

membranous inflammation, unattended, for the most part, with sloughing or

ulceration. }
4, CowpEtt. On the epidemic Sore-throat, British Med. Journal, pp. 967 and
983. [A classified description of the various forms of this affection met
with of late.]
Dousrc, Note sur le Traitement préventif de l Angine Couenneuse,.Moniteur
des Hép. No. 138. [A case of amputation of the tonsil.]

é i t préventif de V Angine Couenneuse, Gaz. des Hop. Nos. 125,

and 138, This conciste in the adaniatridlen of sulphur, in the belief that
the disease is caused by the oidium.]

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400 BIBLIOGRAPHICAL

1858, Farr. Quarterly Report of Registrar General, No. 37. [Observations on
the name Diphtheria, and on the relations of the disease to bad drainage. ]

Feron. De l'Angine Herpetique et de son Traitement, Bull. de Thérap. t. lv. p.
48], [M. Féron describes a form of herpetic angina attended with the
formation of false membranes, and which corresponds to Bretonneau’s angine
couenneuse commune. It is sometimes mistaken for severe diphtheritis, while it
is usually amenable to very mild means.]

Fourcraup. Diphtheria, a concise Historical and Critical Essay on the late
Pseudo-membranous Sore-throat of California, 1856-7, 8vo. Sacramento, 1858.
[Describes a malignant epidemic which prevailed around the Bay of St.
Francisco, and speaks highly of muriatic acid as an application.]

» Fuiter. Trans. of Pathol. Soc. vol, ix. p. 206. [Fibrinous cast of pharynx
ejected. ]
>» Gay. Membranous Croup, Boston Medical Journal, vol. lix. p. 413. [Two
cases of successful tracheotomy, one of these being an example of well-marked
diphtheritis.]
GazettE pEs Hopiraux, Nos. 36, 39, 42, and 48. [Observations on the
malignant epidemic prevailing in the departments of the Yonne and Céte d'Or,
&e., in 1858.]

» Gxrorax. Lancet, November, p. 619. [Some general observations.]

Gicot and Jopin. Gazette des Hép. pp. 359 and 486. [Observations on the
prochloride of iron given under the idea of the fungous origin of the disease.]

Goprray on Diphthérite. Med. Circular, vol. xii. p. 8. [General description
of the disease, as observed in Jersey, where it is rare. ]

GreEnHow. Case of Diphtheria. Lancet, March, p. 324. [The post-mortem
appearances given.]

Gusizr. Mémoire sur Herpes Guttural (Angine Couenneuse commune). L’Union
Méd. Nos. 2, 3, 5,6, and 7. [The distinction laid down strongly between
malignant angina of septic origin, and common angine couenneuse, which admits
of more active treatment. This last the author believes to be really herpes
of the mucous membrane ; its frequent coincidence with herpes labialis having
already been noticed by others. This herpes may be either primary or may
succeed tonsillitis.]

Goitton. De la guérison del Angine Couenneuse et du Croup par l’insuffiation
du Nitrate d’ Argent pulverisé, Moniteur des Hép. No. 138. [Two cases briefly
related.]

Guu. Lesion of the nerves of the Neck, and of the cervical segments of the
Cord after Faucial Diphthérite, Lancet, July, p. 4. [In this form of the disease,
Dr. Gull believes that death may be produced by asthenia, induced by the injury
done to the nerves through inflammation of the areolar tissue of the neck.]

» Haruey, Med. Times and Gaz. vol. xxxviii. p. 641. [Details to the Pathological
Society—some ineffectual attempts to inoculate animals with diphtheritic exu-
dation. J

Hestop on Diphtheria, and its Treatment, Med. Times and Gaz. vol. xxxvii. p.
552. [The author believes it to be the same disease as that described by
Fothergill and others, and points out its differences from croup. He has derived
great benefit from the application of muriatic acid, and the internal use of
muriated tincture of iron.)

Hinpige on Diphtheritic Conjunctivitis. Dublin Hosp. Gazette, vol. v. p. 278.
[Description of the disease as observed by the author at Graefe’s Clinic,
Berlin. He regards it as contagious.}

Kinesrorp. Lancet, Nov. p. 484. [An excellent paper. The author refers
to the local paralysis which sometimes follows the disease. He recommends
highly supporting and tonic treatment, together with iron and chlorate of
potass, enemata being resorted to as soon as insufficient food is taken.]

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APPENDIX. 401

1858. Lamppen. Lancet, Nov. p. 539. [Recommends the use of chlorate of potash

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with hydrochloric acid, and nitrate of silver as a local application.]

Laycock. Med. Times and Gaz. vol. xxxvii. p. 548, and Lancet, January,
1851. p. 120. [A clinical lecture on diphtheria, with observations on its
supposed origin in oidiwm albicans. ]

Litcurienp. An epidemic of Diphtheritis, sixteen years ago. Lancet, Decem-

“ ber, p. 595. [Believes diphtheritis to be a “masked” scarlet fever, similar to

one before observed at Twickenham.]

McDonatp. On Diphtheria and Scarlatina, Lancet, Nov. p. 538. [Obser-
vations on the relationships of the two diseases. Recommends Bass’ ale and
quinine, with muriatic acid as a local application. ] :

MAcKeEnzIE. On Diphtheritic Ophthalmia. Aunales d’Oculistique, t. xl. p. 30.
[While he has observed as one of the consequences of ophthalmitis (Med. Gaz.
vol. xxxv., p. 594) thé production of false membranes on the conjunctiva
the author denies that there is any special form of ophthalmia which can with
propriety be termed diphtheritic. In the cases related by Mr. PricHarp
he believes the ophthalmia was the result of scarlatina poisoning. Mr.
Wuarron Jonxs also refers to the occasional production of pseudo-mem-
branous inflammation of the conjunctiva. Brit. and For. Med. Rev. vol. xx.
p. 276.]

Maecne. Mémoire sur le Croup des Paupiéres ou Diphthérite Conjonetivale.
Moniteur des Hip. No. 74. [M. Magne states, that in the large practice of
himself and M. Sichel, this affection has only been met with in seven instances
during thirty years. He regards it as a general affection, which is not con-
tagious; and he believes, the cases said to be of frequent occurrence by
Chassaignac and Graefe, are not examples of pseudo-membrane at all, but
consist in mere muco-purulent concretions. However this may be, with regard
to M. Chassaignac’s pseudo-membranous opthalmia of new-born infants, it
certainly does not apply to Graefe’s cases.]

Mavain. Des Eruptions qui compliquent la Diphthérie et de ? Albuminarie
considerée comme symptome de cette Maladie. Moniteur des Hdp. Nos. 130,
131, 132, [The author does not agree with those who believe that there are
eruptions peculiar to this affection. One remarkable contrast between it and
scarlatina, is that while in the former, albuminaria may be observed from the
commencement, in scarlatina itis found usually only at the period of desqua-~
mation, and to a much less extent. He relates fourteen cases of diphtheritis,
and believes that the disease may show itself in two forms, one wherein true
poisoning of the economy takes place, and the other, in which it either
remains localized in the pharynx, or spreads to the respiratory organs, and
kills by asphyxia.]

Mittarp. Note sur [Angine Gangréneuse, Bulletins de la Soc. Anatomique,
8. 2, t. iii. pp. 138 and 165. [A fatal case is related, in which faucial diphthe-
ritis was complicated with well-marked gangrene—a circumstance already
noted. by various authors: and also another fatal case of much rarer occurrence,
viz., of primary gangrenous angina. M. Millard, and M. Axenfeld, the re-
porter upon this paper, give an interesting critical account of the views enter-
tained by thosé who have opposed Bretonneau’s too exclusive conclusions upon
this subject.]

Mitiarp, Sur la Diphthérite généraliseé, Bull. de 1a Soc. Anatom. 8. 2, t. iii.
p. 216. [A case and autopsy related, in which the false membranes occu-
pied the skin, mouth, pharynx, oesophagus, trachea, bronchi, and vulva.]

OpriozoLa. Epidemic of Diphtheritic Angina at Lima. Amer. Journ. of
Med. Sci. vol. caxvi p. 528: [Several epidemics have been observed at Lima
since 1851; the black race resisting the influence, as they do that of yellow

fever.]
DD
402

BIBLIOGRAPHICAL

1858. Pounp. On the varieties of Diphtheritis. Brit. Med. Journ. pp. 251 and 750.

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Prowss. Fatal case of Diphtheritic exudation in Scarlatina Anginosa. Lancet,
April, p. 343.

Rogers. Cases. Brit. Med. Journ. p. 625. [Two cases of diphtheria, in
one of which tracheotomy was performed without success. ]

SanpERson. On Diphtheritis. Lancet, March, p. 324. [Paper read at the-
Harveian Society, and followed by a short discussion. The author believes
that the disease now prevailing is identical with the malignant sore throat of
the older authors, and differs somewhat from the affection described by
Bretonneau.]

Srtirerier. Paralysie suite d’ Angine Couenneuse. Gaz. Hebdomad. t. v. p.107.
[In a communication made to the Med. Soc. of the Dep. of the Seine (and
followed by a short discussion) the author states, that during the last two
years he has met with 160 cases of diphthérite, thirty-three of which proved
fatal, He gives brief notes of three cases of consequent paralysis occurring in
adults. ]

Sempre. Lancet, Oct. p. 424. [Paper read at the London Medical Society,
founded on fatal cases observed at Bagshot. ]

Srernens. Lancet, Nov. p. 512. [Proofs of the infectious nature of diphthe-
ritis adduced, ]

Stizes, On Diptheria, with the results of 350 cases. British Med. Journal, p. 628.
[Speaks well of a concentrated solution of chloride of sodium, as a local appli-
cation, and of the use of the sesqui-chloride of iron.]

Tompson. Diphtheria or Diphthérite. Brit. Med. Journal, p. 449, [Describes
an epidemic at Launceston ; and refers to the relationship of the disease to
scarlatina. ]

L’Union Mepicate, pp. 395, 407, 447, and 526. [Discussion on the treat-
ment of diphtheritis at the Paris Hospital Medical Society. ]

Wave. Observations on Diphlheritis. 8vo. 1856. [History and symptoma-
tology of the disease treated of only, but ably. Albuminaria especially remarked
upon. |

Warp. Cases of Diphthérite. Trans, Pathol. Soc. vol. ix. p. 217. [Six in
number, two being fatal, and one of these complicated with purpura. |

WHITEHEAD. On Angine Couenneuse (Diphthérite), or the Epidemic at Boulogne.
Med. Times and Gaz. vol. xxxvii. p. 560. [Very insufficient details given.]

Wixs. On Diphtheria, and its connexion with a parasitic vegetable fungus
Med. Times and Gaz. vol. xxxviii. p. 354. [Dr. Wilks has met with the iden-
tical fungus, sometimes found in diphtheria, in various other diseases, during
the course of which films are formed in the mouth. ]

Witten. On the treatment of Diphtheria. Med. Times and Gaz. vol, xxxviii.
p. 646. [Treatment as adopted in several cases; but no details given.]

1859. Banus. Clinical Lecture on a fatal case of Diphtheritis. Dublin Hosp. Gaz.

-
=

vol. vi. p. 63.

BERNARD. On Diphtherite, its Nature and Treatment, Brit. Med. Journ. p. 81.
[A general review of the various modes of treatment that have been adopted. ]

Borzanp. Case of Diphtheritis rapidly terminating in Croup, Bost. Med. and
Surg. Journ. vol. Ix. p. 89. [In a child eight years of age. One of the tonsils
was amputated. The croup proved fatal on the third day.]

Bovcuur et Gavx. Observations d’Angine Couenneuse et de Croup avec Albu-

minarie. Gaz. Méd. p. 165. [A fatal case of diphthérite and one of croup
attended with albuminaria.]

Brapury. On the Treatment of Diphtheritis. Med. Circular, vol. xiv. p. 14.
(Caustics and good diet the chief means recommended. ]
APPENDIX. 403

1859. Boxter. Observations on the Nature and Treatment of Diphtheria. Med.

=

°

>

~

»

”

>

”

~
:

Times and Gaz. vol. xxxix. p. 3837. [An interesting paper. The author con-
siders that nitrate of silver has been too indiscriminately applied, and he prefers
treating the disease by exciting diaphoresis by means of hot packing, and by
the application of stimulating liniments. ]

CrarK. Med. Times and Gaz. vol. xxxix, p. 169, [Two cases very briefly detailed.]

Copeman. Essay on the History, Pathology, and Treatment of Diphtheritis. 8vo.
1859. {An account of the disease, chiefly derived from Rilliét and Barthez 3
no personal experience stated. ]

Corrigan. Dublin Hosp. Gaz. vol. vi. p. 49. [A clinical lecture on a fatal
case occurring in an adult.]

Crorr. Lancet, Jan. p. 121. [A case of diphtheria in the adult. The in-
halation of the vapour of strong acetic acid, and external fomentation recom-
mended. ]

Haruny. Lancet, Feb. p. 173. [Observations on the supposed parasitic
origin of diphtheritis. |

Hiturer. Med. Times and Gaz. vol. xxxix. pp. 107 and 159. [A historical
sketch of the disease, and observations on its relationship to scarlatina, and the
confusion between the two diseases that has taken place. ]

Hopson. Chlorine inhalation in Diphtheria. British Med. Jour. p. 22. [A
case related in which the vapour of water mingled with that of solution of
chloride of lime proved of service.]

Hovenron. Dublin Quarterly Journ. vol. xxvii. p. 94. [Four cases of
diphtheritis related, confirmatory of the value of the treatment by iron, muri-
atic acid and stimulant diet, as advocated by Dr. Heslop.]

Hucues. Cases of Diphtheria. Brit. Med. Journ. p. 80. [Two cases related.
the autopsy stated in one.]

Hurcurnson. On the Diphtheritic Nature of ‘so-called Ulcerative Stomatitis,
Medical Times and Gazette, p. 290. [The report contains the details of a
carefully noted case, proving, in the first place, that the ulcers of this form of
stomatitis are covered by diphtheritic pellicles; and, secondly, that’ the local
use of chlorate of potash is efficient to their rapid cure. Mr. Hutchinson
suggests that the chlorate should be tried locally in diphtheria of the fauces, &c.]

Jopin. De la Nature et du Traitment du Croup et des Angines Cowenneuses
Revue Méd. t. i. pp. 22 and 134. [Advocates the fungoid origin of the dis-
ease, and its treatment by the perchloride of iron.]

Lancer, Report onthe History, Progress, Symptoms, and Treatment of Diphthe-
ria, pp. 65—169. [A very good resumé, and contains the only general account
of the recent progress of the disease in England. ]

Lowe. Lancet, March, p. 250. [Observations on the supposed fungoid origin
of the disease.]

Mackinper. Epidemic throat affection, or Diphtheria as it appeared at Gains-
borough in 1857-58. Med. Times and Gaz. vol. xxxix. p. 44. [A paper read
at the Epidemeiological Society, and followed by a discussion ; professes to be
based on 400 cases, one only of which was fatal. See also Sanitary Rev.
vol. iv. pp. 104, 197, 402.]

Mepicat Times, vol. xxxix. p. 113. [A case of tracheotomy in diphtheria,
with autopsy. }

Moncgton. Med. Times and Gaz. vol. xxxix. pp. 93 and 222. [Some account
of an epidemic at Brenchley, with observations-on the nature of the disease.
The author recommends treating it by early and effectual cauterization ‘and
purgatives, giving supporting remedies later. ]

Perry. Turpentine in Diphtheria, Med. Times and Gaz. vol. xxxix. p. 245,
[Turpentine and carbonate of ammonia recommended to be given alternately.]

Dpd2
404 BIBLIOGRAPHICAL APPENDIX.

1859. Ramsxitt. On Local Treatment in a particular form and stage of Diphtheria,
Lancet, February, p. 182. [The author believes that cauterization may do
harm sometimes by inducing swelling of the glands, and should not then be
persevered in, a solution of chloride of lime and infusion of camomile being
substituted.]

» Ranxine. Lecture on Diphtheria, Lancet, pp. 27 and 51. [A good descrip-
tion of the disease, but not stated to be founded on much personal observation. ]

> Rogers. Lancet, January, pp. 92 and 98. [Paper read at the London
Medical Society, the discussion turning chiefly on the fungous origin of the
disease. ]

+ Sitva. Angines Couenneuses et Croup traites avec succés par le perchloruse de
fer intus et extra,Gaz. des Hép. No. 18. [States that at Boulogne he found
a use and external application of perchloride of the iron highly
useful.

»» Stmvan. Ablation des amygdales dans ?Angine Couenneuse, Gaz, des Hop.
No. 3. [A successful case of amputation of the tonsils narrated,]

» Wane. Lancet, February, p. 147. [Observations in relation to the occur-
ence of albuminaria in diphtheritis.]

3» Wintarp. Epidemic Diphtheritis in Albany, N. Y. Boston Med. and Surg.
Journ. vol. 1x. p. 88. [A short account of the epidemic which prevailed in the
City of Albany, in 1858, giving rise to one hundred and sixty-seven deaths.]
INDEX.

Alum, local employment of 168, 341, 371
Anatomica] characters of tracheal diph-
thérite - - - 73
Angina, specific characters of different
kinds of - - - 134

» maligna, same form of phlegmasia
as croup and scorbutic gangrene of

the gums 6, 14, 22, 37
ARETUS, on diphthéritic phlegmasia
28

Bibliographical appendix - ~ 383
Blisters, employment of ~ 102, 369
Bloodletting, inefficacy of - 49, 97
»» general and local, value of - 366

Bovcuur on croup (diphthérite of

BRETONNEAU) - - 271
Cantharides, phenomena of poisoning
by in animals - - 186
CaRNEvaLe, de epidemico strangulatorio
affectu - - - 32
Casgs.
1.—Malignant angina, with post
mortem appearances = - 10
2,—Ditto, ditto - - ill
3.—Ditto, ditto - - 12
4,5, 6.—Croup, with post-mortem
appearances - - 18

7.—Croup, tracheotomy, autopsy 44
8,—Croup, successful employment of
mercury - - -
9.—Croup, inefficacy of blood-letting,
‘autopsy - - - 49
10.—Tracheal Diphthérite, tracheo-
tomy, recovery - - 59
11,—Pharyngeal D., successful treat—
ment by hydrochloric acid - 71

 

Casxs, continued.
12, 18, 14, 15, 16.—Tracheal D.,

death, autopsy - - 73
‘17, 18, 19, 20, 21.— Tracheal D.,
treatment by mercury = 77
22, 23, 24.— Tracheal D., treated
by mercury, all fatal - - 89
25.— Tracheal D., tracheotomy,
autopsy - - - 96
26.—Complication with pneumonia,
. autopsy - - - 98
27, 28.—Tracheal D., autopsy - 100
29, 30, 31.—Tracheitis - - 121
32.—TrachealD. - - - 130

33, 34, 35, 36, 37, 38, 39, 40, 41, 42,
(autopsy) 43, (tracheotomy, autopsy)
_ 44, (tracheotomy, autopsy) 45,
(autopsy), diphthéritic angina 141
Causes of diphthérite 238, 271, 331, 355
Chenusson, epidemic at, in 1826, 139
Chiara, epidemic at, in 1618 - 32
Common membranous angina - 114
Contagion, question .of, 38, 127, 174,
ee 332, 358
Cremona, epidemic at, in 1747. - 35
Croup, (see also Diphthérite)
Gurrsant on (tracheal diphthérite

of BRETONNEAU) - - 207
Stages of ditto ditto. = 213, 273
Terminations of - - 215

Varieties of, 219— complications of,
220, 277 — diagnosis of, 222—
treatment of, 223, 281 —tracheo-
tomy, 227—prophylaxis - 230

Cutaneous diphthérite, 17, 26, 235, 255,
307, 378
406

Davior on diphthérite - 345
Diphthérite, (see also croup)

Diagnosis of, 15, 23, 37, 107, 211,

222, 278, 321, 375

Inoculation, the only miode of trans-

mission - - > =-477

», notthe mode of transmission 210

Post-mortem appearances, 15, 23, 37,

272

(See cases also.)
Phenomena of - - 19, 273, 303
Etymology of - - 20, 178
Specific characters of | - - 24

Contagion of 38, 127, 174, 332, 358
Treatment of, 40, 167, 223, 241, 339,

364
Epidemic - - - 58
Sporadic tracheal - 59, 123
Pharyngeal = - - 71, 345

Duration and mode of termination of
inflammation in - - 138
Means of preventing its development

and progress - - - 173
Nasal - - 196, 20]
Cutaneous, 17, 26, 235, 255, 307,

378
Buccal - - - - 237
Causes of, - 238, 271, 331, 355
Danger of - - - 240
Stages of - 213, 273, 303, 345
Complications of - 220, 277
Progress of - - 276,318
Prognosis of = - - - 280
General pathology of. - 311
Mortality from - - 363

Diseases resembling diphthéritic angina
107

Scarlatinal angina - 109
Common membranous angina - 114
Stridulous angina, (pseudo-croup of

GUERSANT) - - - 115
Tracheitis - - - 121
Membranous or polypus sporadic

angina - - - 123
Sporadic diphthérite  - 59, 123

Dogs, effects of mercury on - 86
»  cantharideson - 186

Ecthyma luridum, during convalescence
349

Eygptian disease, (see Diphthérite)

Emetics, employment of - - 377

 

INDEX.

Empis on diphthérite - - 301

Epidemic diphthérite - 58, 345
Epidemics.

At Chenusson in 1826 - ~ 139

», Chiaia in 1618 - - 32

+ Cremona in 1647 - 35

>» La Ferriére in 1824 - 126

», Hépital Necker in 1848, 301, 333
+ in départment of Saone-et-Loire,

1841-4 - ~ 345
At Tours 1818-20 - 6,25, 54
Fégarite - - 9
Garotillo - - - 31
Gauis!I,
On pseudo-membranous exudation of
air-passages - 4
Gurrsant on Croup, (tracheal diph-
thérite of BRETONNEAU) - 204
Habit, influence of 5 - 189
Herpes labialis - - 1ld
Herrin, M. inoculated with nasal
diphthéria  - - - 181

Historical evidence, analysis of 27, 173
Home (Francis) ‘‘Treatise on Croup”
4

Hydrochloric acid, topical use of, 9, 15,
42, 105, 374

Inflammatory lesions, alterations of
tissue - - - 19
Influence of habit 189
Inoculation the only mode of trans-

mission of diphthérite - 176.
Not the mode of transmission
(TRoUssEAD) - - 240

La Ferriére, epidemic at in 1824 126

LAENNEC.
Anatomical characters of diseases 3
Local treatment, 105, 167, 192, 284,

339, 371

Hydrochloric acid, 9, 15, 42, 105,
374

Alum 168, 341, 371
Nitrate of silver 192, 284, 372
Calomel - - - 373
Nitrate of mercury - - 874
Malignant angina - - 10

Same form of phlegmasia as croup and
scorbutic gangrene of the gums

6, 14, 22, 37

Membranous or polypous sporadic an-
gina - + 123
INDEX.

Mercury, employment of

43, 170

Efficacy in a case of croup - 48
Cases of tracheal diphthérite treated
by - - - 77
Poisonous action of - 84, 89
Effects of, on dogs - 86, 170

Microscopic characters of muguet and
__ other false membranes - 326
Mortality from diphthérite - 363
Mucous tissue
Many inflammatory lesions of, con-
founded together - - 6
Exudation which accompanies them
presents, in itself, remarkable va-

rieties - - - 5
Muguet - - - - 321
Microscopic characters of - 326
Nasal diphthéria - - - 196
Case of in detail - ~ 201
Necker (Hépital) epidemic of diphthérite
in 1848 - - 301, 333

Nitrate of silver, local employment of
: 192, 284, 372
Poisonous action of mercury 84, 89
Post-mortem appearances
(See cases also.)
Practical observations on tracheotomy

94

Prophylaxis against diseases designated
as croup - - - 230
Revulsives - - - 369

Saone-et-Loire, epidemic in the de-
partment of - - 345
Scarlatinal angina, - 109, 323
Scorbutic gangrene of the gums, same
form of phlegmasia as croup and

15, 23, 37”

 

407

Scorsutio GANGRENE, continued,
malignant angina 6, 14, 22, 37,

Phenomena of - - = Ag
Has nothing in common with scurvy
8

Hydrochloric acid, topical treatment
by - - - 9,15
Senega, action of - - - 105
Skin, membranous affection of, accom~
panying angina maligna 17, 26,
235, 255, 307, 378

Specific characters of diphthérite 24
Specific characters of different kinds of
angina - - - 134
Sporadic tracheal diphthérite 59, 123
Stages of diphthérite 213, 273, 303, 345
9

Stomacace> - - -
Stridulous angina (pseudo-croup of
GUERSANT) - ss = - 115
Temperature, value of, in mercurial
treatment - - - 170
Tonsils, removal of - - 374

Tours, epidemic at, from 1818 till 1820

6, 25, 54
Toxemia - - - 173
Tracheitis - - - 121

Tracheotomy 44, 59, 170, 199, 227, 242,
286
Practical observations on 94, 242
Treatment - 40, 167, 223, 241
(See ‘ Cases” also.)
281, 364
TrovussEAUu on diphthérite - 235
Van SwIiETeEn, opinions of - 9
Variola, contagion of, compared with
that of diphthérite - - 174

THE END.

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