: symptom which leads to the calling in of a medical adviser though in some cases the dysphagia is so trivial that the friends or patient do not suspect any throat affection at all, till they are informed of its existence. On inspection of the throat, appearances varying much in degree, though not all in kind, are presented in the slightest cases, i. e. the slightest judged by this particular symptom-though this is no measure whatever of the patient's ultimate, or even immediate, danger—in the slightest cases there may be nothing more than a little enlargement of the tonsils, which are generally of a dull red colour, and studded with whitish specks; the follicles may be dilated, giving rise to the impression that the tonsils are ulcerated; again, the tonsils may be covered with a skin of the same colour as the specks, the mucous membrane immediately continuous with that covered by the white lymph, will, in that case, present the redness and tumor which, in the first instance, appeared in the portions of the tonsils between the specks; or again, the whole mucous membrane of the tonsils, soft palate, back of the pharynx, uvula, hard palate, and even portions of the tongue and cheeks may be covered by thick tenacious film of varying thickness. On removing this, which may oftentimes be done, with a pair of forceps in large patches, so coherent is it, the mucous membrane (to which it is more or less adherent) will be found of a shade varying from dull purple to a fiery red, and tumified; the same observation applies to any part of the mucous membrane which may not have been, in the first instance,, concealed by this white skin. Although the false membrane is white or whitish, it may acquire a dark hue from imbibition of blood or coloured drinks (e. g., black currant tea), and subsequent desiccation. The breath is often described as being slightly foetid or even very offensive, but this phænomenon is by no means universal; it depends probably, sometimes at all events, upon partial decomposition of the lymph or fluids secreted by the mucous membrane, and it is the custom now to pay much attention to the removal of these by topical applications. A red eruption, papular, generally of limited extent, and of very uncertain, but most frequently, short duration, may make its appearance upon some part of the skin about the time that the throat becomes affected, or it may precede the latter, or appear only late in the disease, or often not at all; the pulse quickens when reaction, following the first invasion of the disease, sets in, its rapidity is not usually extreme till near death, and there is rarely any hardness or sharpness about it; the skin is seldom very hot, frequently clammy, or not at all abnormal; the diarrhoea which often attends the onset of the complaint usually stops of itself in twenty-four to forty-eight hours, sometimes, however, it continues till death, and perhaps, more often, stays for a time and recurs some time previous to the fatal event. Persistence or recurrence of the diarrhoea have always been noted as unfavourable omens; the urine is generally pale, rather scanty, but to the eye, normal, occasionally, however, high coloured and loaded with lithates. Soon after, sometimes even before, the invasion of the throat, the absorbent glands of the neck and submaxillary regions become enlarged and painful, and may subsequently suppurate, these glands however, may be only slightly, or not at all, affected; if much enlarged they add greatly to the distress of the patient; at a somewhat later period an acrid, often offensive, sero-sanguineous discharge issues from the nares, the angles of which become ulcerated; these ulcers are sometimes coated with lymph, as are also the raw surfaces of blisters, when these have been applied. A gradual diminution of any or all of the symptoms above described is the indication of a favourable issue. The patient, however, not unfrequently dies when the disease is, apparently, very slight, or when convalescence is well established, or even, seemingly, almost complete. This feature of the complaint it is 'which especially renders it disagreeable to treat and difficult to manage. If the practitioner, aware of this circumstance, endeavours to impress the necessity of great care and caution upon careless parents, in what appears to them a trivial case, he is often supposed to be ignorant, or actuated by unworthy motivesa view which the successful result of his prevision is often believed to corroborate. If, on the contrary, ignorance of the treacherous character of the disease should lead him to speak lightly of the danger, and to give an unguardedly favourable prognosis soon after falsified by a fatal issue, parents not unnaturally infer that the case has been misunderstood, and their child has been carelessly and needlessly sacrificed. In cases which tend steadily to a fatal termination the aspect of the patient becomes more anxious, the pulse feebler and quicker, the exudation continues to be reproduced after removal, a purpuric condition is manifested by spots on the skin, and hæmorrhage, generally from the nares, bowels, or kidneys, the lips and tongue are covered with sordes, symptoms of croup manifest themselves, after which the patient seldom lasts for much more than twenty-four hours, often much less; in infants convulsions often precede death. The croupy symptoms occur finally in almost all fatal cases, whether in the onset they have been slight or severe. Regurgitation of fluids through the nose during attempts at deglutition, is frequently seen in those cases where the throat is much affected. This does not occur at any stated period of the complaint: it is often accompanied by a nasal tone of voice; and these symptoms, or one of them, may persist for a long time after the patient is in other respects well. The duration of this disease is very uncertain: its most fatal period is from the sixth to the eighth day; but even after this time the patient is by no means necessarily secure. He may linger on without much alteration in the symptoms, and finally die several weeks from the commencement of the attack, or the fatal event may occur within a day or two of the first seizure. Diphtheritis, though not confined to children, comparatively seldom attacks adults. It is usually epidemic, and may occur at any period of the year; though spring and autumn seem most favourable to its ravages. Its victims have often been previously in a delicate state of health, though this is by no means constantly the case. When it has invaded a family, it will, unless precautions be taken to separate the sick, run through all the children. Several of them may die, or all may recover; but if one recover, those attacked subsequently seldom die: and this is a very important and useful prognostic. Such is a brief sketch of this disorder, which I shall presently endeavour to fill up by collating the opinions of the many great observers who have left us writings upon this subject. In order to obtain the widest possible basis of facts upon which to found the pathology of this disease, as well as to afford a standard with which we may compare the symptoms I have stated, it is desirable to consult the descriptions of authors who have observed this disorder at different periods and in different places. Advantageous as this method is in all cases, it is infinitely more so when diseases of an epidemic character are concerned; for consistent as the specimens of an epidemic may be with others occurring in the same season, or in the same locality, we well know that at another time, or in another place, variations of the widest range may be seen: "the epidemic constitution," deeply as it impresses itself upon sporadic disorders, is made manifest more especially in those of the zymotic class. Now, a vast number of authors have described from time to time, chiefly during the last three centuries, epidemics of throat affections of an excessively fatal character, to the identity of which however, with diptheritis, two principal objections may be raised. Firstly, that some of them were very similar to scarlet fever; and, secondly, that most of them were described to be attended with sloughing and ulceration of the fauces and the parts thereabouts. Bretonneau witnessed, at Tours, an epidemic sore throat of a most deadly sort, for which he invented the name of "diphthérite." His conclusions upon its nature he published in a volume* (consisting of several independent "Mémoires," previously presented to the French Academy of Medicine), which, ill-arranged as it is, has rendered his own name, as well as that of the seat of his observations, famous in the annals of medicine. His dissections and clinical observation led him to believe that diphtherite was essentially the same disease *Des Inflammations spéciales du Tissu muquex, et en particulier de la Diphtherite, ou Inflammation pelliculaire, connue sous le nom de Croup, d'Angine Maligne, d'Angine Gangreneuse, &c. Par P. Bretonneau. Paris: 1826. 8vo. as scorbutic gangrene of the gums, and croup, and that, besides these, it had no pathological relations; and he strenuously denied that there was any connexion whatever between it and scarlatina. Bretonneau's arguments in support of this position may be stated in his own words. "If the character of the cutaneous eruption which ordinarily accompanies scarlatina anginosa can be easily appreciated, it yet cannot be doubted that the pharyngeal inflammation peculiar to scarlatina exists without being accompanied by the other symptoms of scarlatina. It is especially in such a case that the filmy (couenneuse*) inflammation of the tonsils presents a deceptive resemblance to the pellicular (pelliculaire) inflammation. "Several characteristics, however, aid us in distinguishing between them. In the scarlatinal angina, the superficial ulceration is rather overspread with a filmy (couenneuse) exudation, intimately adherent, than covered with a membranous pellicle. "If an opaque, white, caseiforme secretion does cover the bright redness of the velum palati and the walls of the pharynx, it can be easily wrinkled; and it does not assume either the lichenoid aspect, nor the coherence of a false membrane. "The tonsils are, it is true, the principal seat of the inflammation; but the whole cavity of the fauces, and that of the nostrils, are invaded simultaneously by a vivid redness; and the point of origin of this morbid affection is not, as in the diphtherite, at first limited and circumscribed. Finally, there is a more important differential characteristic of the scarlatinal inflammation of the pharynx: it has not any tendency to propagate itself into the air-tubes." (Op. Cit.; p. 250.) A little farther on he contends against the supposition that scarlatina is ever complicated by croup, and in other parts of his work shows that it is upon this difference between the two diseases that he substantially rests his differential diagnosis. Now, as Bretonneau, in the preceding quotation, limits himself to establishing distinctions between scarlatina without eruption, but with some whitish exudation on the tonsils, and true diphtheritis, it may, I think, fairly be taken for granted that he thinks it needless to elaborate diagnostics between scarlatina with eruption (albeit with a whitish exudation) and diphtheritis-the eruption alone in such a case being sufficient in his eyes to stamp the affection as scarlet fever. The condition of the fauces affords no reliable distinctions between the * I translate "couenneuse" filmy for the purpose of giving greater value to Bretonneau's argument than the dictionary meaning of this word would do-" covered with a skin, sward, or incrustation." To show that the distinction Bretonneau has endeavoured to insinuate between the exudation in diphtherite and that in scarlatina, by applying the term "couenneuse" to the latter, is a mere verbal one, inappreciable even by French authors, I may state that both Roche and Guersant call diphtherite "angine couenneuse." two diseases. In diphtherite, says M. Roche,§ "we see that the base of the tongue, the velum palati, and the uvula, which is ordinarily swelled and pendulous, are of a more or less vivid redness, from pale rose up to the darkest scarlet." (Tome ii, p. 548.) Bretonneau himself admits that there is in diphtherite a bright red margin round each patch of lymph, and that these may, in a few hours, cover the whole of the fauces, and that the mucous membrane underneath these patches is of a similar hue; and even in ordinary scarlet fever, the redness of these parts may vary very considerably in degree. It is also an undoubted fact that the thickness and tenacity of the false membrane may vary exceedingly. He says himself of scarlatina "the couenneuse ulceration of the tonsils presents appearances well calculated to simulate gangrene of the back of the mouth, and the prolonged death-rattle leaves no doubt that the dyspnoea depended upon a mechanical obstruction to the respiration. It is not likely either that Huxham† should mistake a layer of mucus for pieces of the internal membrane of the windpipe (p. 281); or that Fothergill should mistake the false membrane for a thick opaque or ash-coloured slough (p. 237), unless it were pretty thick and tenacious. The exudation in diphtherite varies in thickness very considerably, even according to Bretonneau's own statements. In a family which I attended during this present epidemic, five persons were attacked: in none of these was the faucial membrane extensive or thicker than thin parchment; in two, there was but a slight patch on one tonsil, not sufficiently thick to conceal from view the mucous membrane, and appearing more like a small quantity of apothecaries' honey smeared on the part than anything else. As all these persons were attacked in less than a week, we may presume that they were all affected by the same disease; and as the two who died were found on dissection to have their trachea lined by a consistent false membrane, resembling, as Bard* says (p. 12), "wet shammoy (sic) leather," we may further presume that Bretonneau would admit this disease to have been true diphtherite. The first cases which I saw in this present epidemic, I attended in conjunction with my friend Mr. Clayton. A little girl, who had been staying in a neighbouring town where a malignant throat disease had prevailed, was there seized with it: she was immediately sent home to Birmingham. The false membrane was so thick and tenacious that it could be, and was on several occasions, removed in large portions by means of a pair § Dictionnaire de Médecine et de Chirurgie Pratiques. Paris: 1829. An Essay on Fevers: to which there is now added a Sore Throat. By John Huxham, M.D. Seventh edition. A complete Collection of the Medical and Philosophical London: 1781. 8vo. Dissertation on the Malignant Ulcerous Works of John Fothergill, M.D., F.R.S. * An Inquiry into the Nature, Cause, and Cure of the Angina Suffocativa, or Sore Throat Distemper, as it is commonly called by the Inhabitants of this City and Colony. By Samuel Bard, M.D., and Professor of Medicine in King's College, New York. New York: 1771. 8vo. |