At the time when Bretonneau wrote, science was still under the rule of the doctrines of Broussais. Irritation explained every thing, and there was no disease which was not an inflammation. While protesting against the exclusiveness of that school, and demonstrating that inflammation assumed different and specific features in its course as well as in its products, features which varied, not only with the structure of the tissues upon which it manifested its action, but also with the causes which it recognized, while bringing these profound modifications into the prevailing doctrine, Bretonneau still remained sufficiently attached thereto to make the disease which he described an inflammation and a specific inflammation, to which he gave the name of diphtheritis.

A more extended knowledge of the disease showed that these inflammatory lesions were but the result of a general specific and infectious disease, like the pyrexias, like the virulent affections which, impregnating the whole economy, manifest themselves on the exterior under the form of products of an inflammatory nature. Such are smallpox, syphilis, typhoid fever and the like. This principle having prevailed, the name was changed, and diphtheritis became diphtheria. The legiti macy of this conclusion is self-evident, for it results from all that has been said in the different portions of this work.

Recognizing diphtheria as a general toxic disease, with what disease should it be classed? Is it, properly speaking, a virulent disease, or one of those pyrexias which seems to result from the absorption of a morbific germ by the respiratory passages? It should be placed, according to my notion, with typhoid fever, and especially with scarlatina and variola, with which it offers so many analogies. Like them it appears as benign or malignant, discrete or confluent, and, as with them, the morbid poison is propagated by contagion.

What is to be gained by separating the disease into two? Nothing but confusion. The treatment is about the same, supportive. If we can possibly tell the family it is a case of what the dualist calls the croup, that it is a local trouble, that it is asthenic disease, that it

is non-contagious, all is well and good. But can we? In some of my cases of intubation my friends say that it is a case of croup, and if I can relieve the asphyxia (remember the dualists say this is the only way croup kills) the case will get well. I accidentally wound the lip, the tongue, the pharynx or the tonsil, a true diphtheritic membrane develops on the cite of the wound, and we discover it is a case of diphtheria.

This has occurred more than once-yes, several times.

Now tell me, if you can, what is croup, and what are its symptoms.

The President (Dr. Ouchterlony) of the Louisville Clinical Society was requested to read a paper on the non-identity of membranous croup and diphtheria of the larynx. He asked me to look up the authorities on the other side. The above article is the result. I must acknowledge it has come very near making me a unicist. If there is a difference, it is far from clear in my mind.

LOUISVILLE.

ON THE NON-IDENTITY OF PSEUDO-MEMBRANOUS CROUP AND DIPHTHERIA.*

BY JOHN A. OUCHTERLONY, A. M., M. D. Professor of the Principles and Practice of Medicine and Clinical Medicine in the Medical Department of the University of Louisville, Louisville, Ky.

Croup and diphtheria exhibit certain points of resemblance. Both affecting the upper portion of the respiratory tract, both being characterized by the presence of pseudo-membranous formations, they are both febrile diseases, and in both certain secondary changes in the lungs are prone to occur. Finally, the mortality is so great in both that they must be classed among the most formidable of diseases especially when they occur during the first decade of life.

It is not, then, very strange that they should have been confounded. The name "croup" is derived from the Scotch word which means "strangling," and in Swedish the disease is known as "stryp-sjukan" or "the strangling sickness."

The first description of true membranous croup was published in 1764 by Dr. Francis Home, of Edinborough. Steiner, however, insists that a disease similar to it was described in the works of Hippocrates. In the sixteenth century a disease somewhat resembling it, and characterized by the presence of false mem

*Read before the Louisville Clinical Society, January 10, 1888. For discussion see page 78.

brane, was described by Baillan. In the seventeenth century Villa Real spoke of a "morbus suffocans," which may have been croup. Even in the time of Home and the writer who immediatly succeeded him, Dr. Cheyne, the distinction between this disease and diphtheria was fully recognized. In 1826, when Bretonneau published his first essay and advocated the theory that the two diseases are identical, a controversy began which has not even at this time been settled.

Every one who comes much in contact with these diseases, and who has carefully studied them, must, sooner or later, decide this question for himself. He will be forced to embrace either the belief that the two diseases are distinct in spite of the points of resemblance between them, or that they are identical in spite of the points on which they differ.

While gladly acknowledging the high character, the ability, and experience of those who entertain an opposite belief, and freely admitting that cases may now and then occur in which the line of separation is not to be clearly drawn at the first glance, and in nowise deprecating the practical difficulty encountered in the more or less marked anatomical similarity in certain respects between the pseudomembranous products of the two diseases, yet the evidence appears to me so perfectly convincing that I am forced to conclude that croup and diphtheria are separate and distinct diseases, just as certainly as croupous and catarrhal pneumonia are distinct from one another, and just as absolutely as a simple venereal sore is a different disease from an infecting chancre.

In the following paper, then, my chief object will be to present the facts which appear to necessitate a belief in the non-identity of croup and diphtheria.

On this point Hilton Fagge offers a very striking remark. Having noted that both Home and Cheyne were well acquainted with diphtheria, which under the name of "morbus strangulatorius" and malignant sore throat occurred in their time in its most typical epidemic form, and its points of resemblance to croup, he goes on to say, "I think it worthy of notice that if they should prove to have been wrong in regarding them as distinct, the progress in

medical science will in this instance lead to a result directly opposite to that which it is bringing about in all other cases; for, in regard to every other group of diseases, the more our knowledge advances the more our distinctions and subdivisions multiply."

It is generally conceded, and all writers with whose writings I am familiar agree that diphtheria is a general infectious and contagious disease. Senator, of Berlin, has even recently proposed to give it the name "cynanche contagiosa." Though rarely entirely absent in our larger cities, yet it is emphatically an epidemic disease. Here we observe the first and radical difference between diphtheria and croup, the latter being a simple inflammation, purely local, non-infectious and non-contagious affection.

The symptoms of diphtheria clearly point to toxaemia which often is most virulent and deadly.

In croup, on the other hand, there is no evidence of toxaemia, but the symptoms denote mechanical obstruction.

In diphtheria there is a period of incubation varying from two to eight days, and sometimes of even longer duration. It is shorter when the infectious material has been brought directly from a diseased person into immediate contact with the fauces or a denuded surface, as in the case of the celebrated Valleix, in whom infection was followed by symptoms on the next day, and death ensued in forty-eight hours.

In croup there is no period of incubation, the application of the irritant is quickly followed by manifestations of the disease, as in the cause celebre, quoted by Sir Thomas Watson, of Dr. Gregory's twin children, who, having walked together in the sunshine in a strong wind during the evening, were both seized. with croup during the same night.

Numerous accidental inoculations through diphtheritic material have been followed by a development of the disease in those inoculated. Thus Valleix, Gillite, Blache, Otto Weber, and Seehusen contracted the disease by inflating the lungs, or clearing the tracheotomy tube by suction, and died martyrs of their philanthropic zeal.

Oertel and Trendelenburg inoculated rabbits with diphtheritic matter introduced into the trachea. Hueter, Tomasi, and Oertel inoculated the muscles; Nasiloff and Hueter introduced the matter into the cornea with positive and most striking results.

But no one ever succeeded in introducing croup either by accidental or experimental inoculation in human beings or in the lower animals. On the contrary, a simple trauma has been repeatedly known to produce a membranous croup both in man and animals. (See Guy's Hospital Reports, 1877; Parker, Clinical Transactions, 1875; Riez and Oertel's Experiments on Dogs.)

Both diseases being characterized by the presence of pseudo-membranous formations, observers have naturally sought in these a solution of the question at issue. Those who believe in the identity of the two diseases insist that there are positively no anatomical, chemical, or microscopical distinctions to be observed between these respective pseudo-membranes, while others have been able to find. more or less marked and constant differences between the two.

It must here be noted that, as Flint remarks, croup with its characteristic exudation may occur as a complication of diphtheria. Hence, it is not to be inferred that a false membrane in the larynx or trachea, in a patient with diphtheritic deposit on the tonsils and uvula or pharynx, is of necessity diphtheritic, for it may be simply croupous. Neither would it be philosophical to compare the tracheal pseudo-membrane in such a case with the similar formation in a case of true croup without diphtheria and deduce identity of the two diseases from the identity of structure of the two membranes. Rather should the typical membrane upon the tonsils, uvula or pharynx in diphtheria be compared with a typical fibrinous exudation in the trachea of croup, for in the vast majority of instances diphtheria is confined to the area above the glottis, whereas the cronpous exudation is almost entirely limited to the space below this point.

When such a comparison is made, it will be found that, in spite of a certain degree of

similarity, yet very marked and important differences between the two have been made out. Virchow's distinction between croupous and diphtheritic exudation is fully borne out in typical cases of the two affections. The former being upon the basement membrane, and the latter being interstitial, and involving the deeper and submucous strata, hence the croupous membrane is simply separated, loosened by a vital and non-destructive process, and is often thrown off in large portions, or even as a whole, while the diphtheritic formation is gradually removed by a necrotic process involving more or less ulceration and destruction of tissue.

As to the membranes themselves, the exudation in diphtheria is chiefly made up of granular fibrin, fibrillated fibrin in smaller quantities, large masses of epithelium, which become cloudy, lose their nuclei, and are transformed into a homogeneous mass presenting numerous ramifications. In other words, it is metamorphosed epithelial cells, which form the reticulated membrane; leucocytes, red corpuscles, and numerous forms. of low vegetable organisms are also present. The membrane is firmly adherent to the deeper structures.

In croup the exudation lies upon the basement membrane, whose epithelium is absent. It consists chiefly of fibrillated fibrin, holding in its meshes pus cells; red blood corpuscles; sometimes epithelial cells are present. There is no fibrinous exudation in the deeper

structures.

Vegetable micro-organisms are present in the membranous exudation of both diseases. Their presence in diphtheria led Oertel and others to believe that they constituted the infectious element of that disease. Some of these organisms having been found in croup, this seemed, to those who believe in the identity of the two diseases, to furnish a powerful argument in favor of their view. Which, if any, of the numerous micro-organisms is the contagious element of diphtheria has not yet been ascertained. It is certain that some of them are quite innocuous, for they have not only been found in croup, which is not an inoculable disease, but also in

various other purely catarrhal lesions of the mouth and air-passages. Indeed, it has quite recently been suggested that the infectious principle of diphtheria is a chemical and not an organic agent; but the infectious nature of diphtheria has been completely established, and this implies the entrance and multiplication of pathogenic micro-organisms within the body; and though the special micro-organism which produces diphtheria has not yet been satisfactorily singled out, yet, in the light which modern investigations have shed upon the subject of infectious diseases in general, we are obliged to believe in its existence and confidently expect that it will some day be made out with as much certainty as we now claim for the bacillus tuberculosis.

Loffler* found the micrococci much less constant in diphtheria than the short bacillus to which he attached more importance, but unfortunately it is not invariably present, and besides has been found in the mouth of a child entirely free from diphtheria. That very similar micrococci have been found in both diphtheria and croup can not then be regarded as an argument in favor of the identity of the two diseases.

In diphtheria the starting point of the disease is the point of inoculation. Not so with croup, which can not be inoculated at all.

The site of diphtheritic exudation is most commonly on the tonsils and fauces. Now, if the two diseases were identical, one would naturally expect the diphtheritic process to very often engage the larynx, both by virtue of contiguity and continuity of tissue, but it is a well-known fact that it does not do so. With about two per cent of exceptions the exudation begins in the tonsils, and in epidemics. of diphtheria laryngeal complication has been found most exceptional.

Inadvertently the German writers with whose works I am acquainted admit, theoretically, the existence of a simple fibrinous laryngitis, but practically they appear to regard all such cases as diphtheria. Steiner's very exhaustive article on croup fails to give any

*Mittheilungen aus dem Kaiserlechen Gesund heits Amte, Bd. 2, p. 427.

differential diagnosis between diphtheria and that disease, which in itself is quite significant. Oertel considers the two diseases identical, yet describes a variety which he calls "croupous diphtheria."

Croup is a much more rare disease with us than diphtheria, while it is much more common in more northern regions. In Scotland and England it is much more frequent than in Germany and France, which may account in some measure, at least, for the tendency in these countries to confound the two.

In diphtheria asthenia is early and marked, while in croup the strength is generally well maintained, even up to a very late period.

Both diseases are most frequent in childhood, but diphtheria is also common to all ages, whereas croup is most rarely met with in adults.

Glandular enlargements are present in diphtheria not only in the neck but in other parts, while they are never observed in uncomplicated croup.

Fever is common to both, but is subject to great variation according to idiosyncrasy and epidemic character. One need not, therefore, be surprised that authors materially disagree as to this point.

Whatever the degree of resemblance between the pathological products of the two diseases, there can be no question that essential differences between them exist in regard to etiology and clinical history, and these differences are so great and invariable as to compel us to regard them as entirely distinct morbid conditions.

DIFFERENTIAL DIAGNOSIS.

LOUISVILLE CLINICAL SOCIETY. Stated Meeting January 24, 1888, J. A. Ouchterlony, M. D., President, in the chair.

Dr. Turner Anderson presented a placenta taken from a primiparous woman who was supposed to have gone three weeks over her time for delivery. The organ, though not adherent, was removed with difficulty, and proved to be in a state of calcareous degeneration. The cord leaves the placenta in such a way as to give it the appearance of a battledoor, but is spread out over the surface, and proves to be attached to the entire free margin of the organ.

Dr. I. N. Bloom reported a case of syphilitic orchitis, complicated with hydrocele, in which inunction treatment (up to 3.50 grams daily) effected a cure of both. The hydrocele developed after the orchitis. Patient, a man of thirty-five, had contracted syphilis twelve years before; orchitis began two years ago; hydrocele soon after; both have been cured; time of treatment three months. Asks if others have met with similar cases of hydrocele, as it is directly or secondarily of syphilitic origin?

Dr. S. Brandeis said the case was an interesting one. He did not recall in his experience a case of hydrocele depending directly upon syphilis. He thinks that mechanical irritation of the unusually enlarged testes caused the hydrocele, and that with decrease in size of the former the latter disappeared. The cause being removed, the diseasedis appeared.

Dr. Thomas P. Satterwhite, in commenting upon the preceding, recalled a case of orchitis in his practice which for a time exhibited the clinical features of malignant disease, but which disappeared under specific treatment. Dr. S. then reported the following case: L., a lady of twenty-six years, had four years noticed a nodule in her left breast. This he removed by the knife. After ten months the disease reappeared, when it was again removed under antiseptic precautions. In less than a year the breast again presented nodules, with glandular enlargement in the axilla. He then, with the assistance of Dr. Guntermann, removed the gland and such of the adjacent tissues as were likely to serve as foci for the reproduction of the disease, but preserved the nipple and surrounding skin. This operation was also done antiseptically, and the wound healed without suppuration. The preservation of the nipple lessened to a great degree the deformity that usually follows the operation. Subsequently he was called to remove a few infiltrations, the size of bird-shot, in the neighborhood of the cicatrix, but found no glandular enlargement in the axilla. The speaker mentioned, in passing, a case of cancer of the breast in the person of a woman who several years ago was an inmate of the Louisville City Hospital. The woman was nursing a child at this time, and was anemic. He operated for the removal of the growth, but the hemorrhage was great, and a portion of the breast not diseased was left. Seven hours after the operation profuse hemorrhage occurred, which ceased without ligature. The bleeding vessel was surprisingly small. The wound healed kindly, but the patient was much annoyed by the secretion of milk from the portion of gland left untouched.

Dr. W. O. Roberts said that Thomas was the first to advise the preservation of the nipple in the operations for the removal of mammary neoplasms, but Gross condemned the procedure on the ground that it favored rapid recurrence of the disease. Dr. R. makes a a cart-wheel incision and a clean sweep of every thing down to and sometimes into the pectoral muscle.

Then followed the adjourned discussion on