DIPHTHERIA.

IRVING W. LYON, M. D., Hartford.

As the committee of the State Medical Society on matters of professional interest have by a series of questions directed especial attention to diphtheria, and as this disease now exists in an epidemic form in various portions of this State, the occasion will at least justify a few remarks upon disputed points relating to the etiology, nature, and differential diagnosis of this interesting affection.

The name diphtheria was first given to this disease by Bretonneau, who in 1821 read two celebrated memoirs before the Royal Academy of Medicine, based upon careful observations made during an epidemic which prevailed at Tours from 1818 to 1820. He described diphtheria to be a specific inflammation, characterized by a pellicular exudation; a disease propagated by contagion, and identical in all respects with the putrid sore throat of Fothergill, malignant angina of Huxham, and the membranous croup of Francis Home.

In the historical portion of his second essay, after alluding to passages in Homer and Hippocrates which possibly had reference to diphtheria, Bretonneau established very conclusively that the disease which he had been studying at Tours was the same that Aratæus in Asia Minor had described about one hundred years after Christ under the name of Malum Egyptiacum.

Since the attention of the profession was called to the subject by the publication of Bretonneau's Memoirs, diphtheria has been carefully studied during many epidemics, and though our knowledge of this disease has been greatly increased, and its literature enriched with the labors of the ablest investigators, still it may be truly said, that at no time during the past fifty years have greater interest and activity centered around certain questions relating to its nature and causes than at the present day.

The committee have shown a thorough appreciation of this in

terest by their circular questions, which embrace all the points in dispute, and to which we will now address ourselves in reply.

"Is diphtheria at first a local disease which may at an indefinite time become general?"

Most physicians of the present day believe diphtheria to be a systemic disease from its beginning; with these we shall not disagree. The others, a small but able minority, with Oertel as their leader, declare that diphtheria "begins as a local disease and develops afterwards into a general one;" that "the disease establishes itself at first in one spot, the focus of infection, and thence radiates, as it were, through the body, until by general blood-poisoning, it renders the organism incapable of life." The mucous membrane of the throat is the usual site of the primary or local manifestation of the disease, and this fact is explained by the lodgment here of certain parasites, which are drawn in with the inspired air. According to this view it is the local contact of the parasite, and not blood-poisoning, which causes the first appearance of the membrane. The bacterian theory of disease is thus invoked to explain the supposed local origin of the membranes which are first seen in diphtheria, and because micrococci are constantly found in the substance of these membranes, it is held that they have been transported thither from without, and act as units of contagion.

Let us look for a moment at the present status of the bacterian or germ theory.

In the debate upon "The Germ Theory of Disease," which occurred in the Pathological Society of London, in April and May 1875, (Lancet, Vol. 1, 1875,) Dr. H. Carlton Bastian, professor of pathological anatomy in University College, in a masterly address, pointed out that the present bacterian theory of disease was the logical outcome of two theories; the one, that the contagiousness of certain diseases was analogous to the "property by which one fermenting mass may communicate its state of change to another mass of fermentable material," which doctrine dated as far back as Hippocrates, and had in recent times been termed by Dr. Wm. Farr, "zymosis: " the other, Pasteur's doctrine of fermentation and putrefaction; that these processes, though chemical, were invariably initiated by low organisms. It became therefore an easy matter to combine these two views, and to hold that low organisms were the true contagia, or sole " germs" of the so-called "zymotic diseases."

Dr. Bastian then proceeded to oppose to the germ theory the following facts:

First, that bacteria are not necessary to fermentation and putrefaction as formerly taught by Pasteur, since these two processes may be initiated in their absence, a doctrine which Pasteur himself now admits.

Second, that bacteria may be "introduced into the blood vessels of the lower animals by thousands, without producing any deleterious effects in a large proportion of the cases."

Third, bacteria habitually exist in so many parts of the body, in every human being, and in so many of the lower animals, as to make it almost inconceivable that these organisms can be causes of disease: and “in persons with open wounds bacteria are constantly to be found in contact with such surfaces, especially if the wounds are not well cared for, though the injured person does not necessarily suffer at all in general. health."

Fourth, "the virulence of certain contagious mixtures diminishes in direct proportion to the increase of bacteria therein."

Fifth, "that fresh and actively contagious menstrua lose scarcely any of their contagious or poisonous properties, after they have been subjected for a few minutes, when in the moist state, to a temperature which no living units can be shown to survive (212° F.), or after they have been exposed to the influence of boiling alcohol, which is well known to be equally destructive to all recognized forms of living matter."

Dr. Bastian then developed at length an argument tending to show that bacteria should be regarded as the results, instead of the causes of those diseased processes in which they occur.

The physico-chemical views of Dr. Bastian were ably supported by Dr. Murchison, Dr. Dougall of Glasgow, and others.

Dr. Burdon Sanderson, whose eminence as a pathologist, had given great strength to the germ theory, which he had supported since 1870, as shown by Dr. Bastian, quite surprised the society and his friends, by declaring that although bacteria have an inseparable connection with certain diseases, that their true relation to these morbid processes, whether that of cause or consequence, had not and could not yet be determined; he added,

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Supposing any of us went to Recklinghausen, Virchow, Chauveau, Paget, and asked the question, 'do you believe in the germ theory?' the answer he would certainly get would be, 'I really cannot give you any opinion upon the subject. A great number of observations have been made upon the subject; you must read those observations; then if you wish to pursue it, you must make observations yourselves, and perhaps at a future time, it may be possible to come to a conclusion upon the subject.' But if they were pressed to give an answer to the question, 'do you believe in the germ theory?' I believe all of these eminent men would shrug their shoulders."

In the British Med. Journal, Feb. 26, 1876, Dr. Lionel S. Beale. in criticising some remarks by Prof. Tyndal upon the importance of a better knowledge of the relation of bacteria to disease, says, "The doctrine that contagium consists of bacteria, is opposed to broad and well known facts."

Drs. Thomas E. Satterthwaite and Edward Curtis, of New York, found that the clear liquid, obtained by filtering septic fluids through porous clay, was innocuous; which seemed to confirm the experiments of Burdon Sanderson, and to show that the poison was contained in the granules. Next, with a view to determine whether these granules were bacteria, their spores, or other bodies, septic fluids were subjected to such influences as are known to destroy living germs, viz: a prolonged temperature of 212° F., and boiling alcohol, and then placed under circumstances favorable to the development of bacteria; but in a number of instances no bacteria were developed, although the fluid retained its poisonous properties; which was accepted as evidence that those granules were poisonous which were neither bacteria nor their spores.— Medical Record, Dec. 18, and 25, 1875.

The facts and considerations now adduced in opposition to the germ theory in general, are equally available as objections to the bacterian origin of diphtheria. But before leaving the subject of the local production of this disease by parasites, it will be very pertinent to inquire why these should limit their operations to the tonsils and parts adjacent, while all other portions of the respiratory tract escape in the great majority of instances? Surely these germs as they are swept along over the 1400 to 2000 square feet of respiratory mucous membrane, ought to be able to obtain a foothold, and to produce irritation and inflammation in more than one particular place, unless Oertel, Hueter, and others, have greatly overrated their clinging, boring, and other pernicious properties.

Finally, it appears impossible to explain cases of diphtheria terminating fatally in twenty-four, (Greenhow, page 139) thirty-six, and forty-eight hours (Trousseau, page 497), with little or no membrane in the throat (George Johnson, Lancet, Jan. 16, 1875), upon the bacterian theory, which would seem to require more time for its fatal operation than is thus allowed.

It must therefore be acknowledged that this brilliant theory, though begotten within the temple of science, and fostered by her ablest experts, is yet of too feeble growth to withstand adverse criticism, or to cope with its older rival, the chemical theory.

There are those, however, like Dr. George Johnson, who, while apparently rejecting the germ for the chemical theory, nevertheless maintain that the membranous exudations of diphtheria are of purely local origin. Dr. Johnson (Lancet, Jan. 16, 1876,) says:

"I believe that the poison, whether inhaled with the air or swallowed with water, coming in contact with the mucous membrane of the fauces, or the nostrils, exerts there a local poisonous influence, and that the exudation is a direct result of this purely local action; that in short the diphtheritic poison applied to the mucous membrane, calls out the membranous exudation as the application of cantharides to the skin raises a blister. The history of cases of cutaneous diphtheria affords support to this doctrine. It is a well-known fact that in what we may call a diphtheritic atmosphere, a part of the skin from which the epidermis has been removed by a blister or other abrading agent, may become the seat of diphtheritic exudation. Trousseau, referring to these cases, expresses his belief that an "abraded surface has served as a door of admission for the disease, which for some time remains a local affection." He compares the phenomena with those which occur when a syphilitic local sore is followed by constitutional symptoms."

Next, after describing the dangers of auto-infection from the membranes when once formed, he proceeds to say, that,

"In most cases of diphtheria, there is abundant evidence of blood infection during the progress of the malady, the high temperature, the general constitutional disturbance, and the nervous symptoms and sequelæ, are results, probably of blood-poisoning. There are two distinct modes in which the blood becomes infected in these cases; first, by the direct passage of the inhaled poison through the pulmonary capillaries into the blood; second, by the absorption of the morbid products from the exudation on the mucous membrane through the lymphatics and blood vessels. As there is a class of cases, in which with an abundant local exudation in the throat, the constitutional symptoms are of the mildest character, so there is an opposite class of cases in which constitutional symptoms, the result probably of blood-poisoning, are overwhelming and rapidly fatal, while there is little or no appearance of false membrane upon the surface of the throat."

It will be observed that Dr. Johnson does not state that diphtheria is primarily a local disease, but that its membrane is locally produced, and this by the same poison, which, passing into the blood through the lungs is able to destroy life in a very short time, with little or no appearance of membrane in the throat. But inasmuch as these latter cases are very rare, he seems to attribute little influence to the diphtheritic poison introduced from without, bc