DIPHTHERIA. 270 DIPHTHERIA. throat,' given to the disease by Dr. .lolin Fother- gill, of Ixfndoii, in 174j, renmincd the accepted name in Knglish-spcaking countries till, in 1821, Bretonneuu, of Paris, published his admirable and extensive observations upon the disease and gave it its prc'^ent name. Little advance ■was made in the knowledge of diphtheria after Hretonneau's treatises were put forth until the micro-organism of the disease was isolated. MoRT.LiTY. The control of diphtheria, which has been epidemic in this country since 1S57, is largely due to the early treatment of the disease ■with diphtheria antitoxin, together with system- atic isolation of eases. While occasional clini- cians of experience and ability are found who actively antagonize the theory of, and deny the good results from, the use of antitoxin, the great and overwhelming mass of evidence in its favor continues to increase year by year. The diph- theria conunittee of the Clinical Society of Lon- don published in its report for 1898 the followins; results of inquiry into 1)33 genuine cases of diph- theria: The total mortality in these cases was 19.5 per cent, as opposed to 29. G per cent, in the non-antitoxin control series, compiled before the introduction of antitoxin. In the tracheotomy cases the mortality amounted to 36 per cent., as opposed to 71.6 per cent, in the non-antitoxin series. Buchwald, of Munich, reported 57.72 per cent, of deaths in cases treated without anti- toxin, 28.93 per cent, of those treated with antitoxin. Kriinlein. of Zurich, reported to the Congress of German Surgeons in 1898 upon 1773 cases of diphtheria observed in the clinical hospi- tals of the university from 1881 to 1897. The mortality in the pre-antitoxin period was 39.9 per cent., against 12.5 per cent, in the antitoxin period. In the oj)eration cases (including both tracheotomy and intubation cases), the mortality was C6.1 per cent, under the old ri'^gime, and 35.6 per cent, with antito.xin. In the cases upon which no operation was done, the mortality in the pre-antitoxin period was 14.2 per cent., against 5.6 per cent, under antitoxin. In all the 437 cases occurring in the antitoxin period the Klebs- Lijffler bacillus was demonstrated. Dr. A. .Jacobi, perhaps the most eminent clinical authority on the disease in New York, sums up the facts proved by Kriinlein's statistics, as follows {Tii>cn- tieih Century Practice, vol. xvii.. New York, 1898): "While the morbidity of the whole dis- trict, city and country, remained imaltcred in the antitoxin period, the mortality decreased consid- erably, and principally in the first years of life. While previously to the institution of the anti- toxin treatment one-half of all the cases demand- ed operation, this percentage had fallen to 23.1 per cent, since that time." Dr. TT. M. Biggs con- cludes from extensive experience and many researches made as pathologist of the Health Department of New York City, that "since the introduction of antitoxin treatment the mortality of diphtheria is reduced one-half; its course is shorter and milder; an injection made within the first two days of the disease reduces the mortal- ity to 5 per cent., and the earlier the injection is made the better is the result. Small quanti- ties of concentrated scrum are tolerated by very young infants. If antitoxin is not a specific, it is certainly the best remedy in our possession against diphtheria. The genuine (that is, un- complicated bacillary) cases are more amenable to its favorable infiucncc than mixed infections. It has no secondary effects on the heart, kidneys, or nerves. Heart failure and paralysis, whenever observed, are caused by diphtheria, not by anti- toxin." B.vcfEBiOLOGY ..ND PATHOLOGY. The baciUus which causes diphtheria was discovered in 1883 by Klebs, and in 1884 Lilttler publislu'd the re- sults of his careful study of the bacillus. Houx and Yersin added proof to tlie dependence of diphtheria up<m this bacillus, and the names of the first discoverers have been given to the causa- tive micro-organism. The bacillus is from 2.5 to 3 niicromillinieters long and .about one-lifth as wide. It varies in sha|)e, being straight or slightly curved, with rounded, clubbed, or, more rarely, ])ointcd extremities. One of its most marked peculiarities is that, when treated with Lolller's alkaline methylcneblue solution, it takes an irregular stain, being darker in some parts than in others. This peculiarity is ex- tremely valuable in identifying the organism. Artificially the bacillus may be cultivated on bouillon, agar, or blood serum, but it grows most rapidly and luxuriantly on glucose broth serum ( Lofller's blood scrum mixture) at about body heat. Advantage is taken of this in deter- mining its i>resence in doubtful cases. Tims, if a scraping from the membrane be rubbed over the surface with blood scrum, and the tube con- taining the same be placed in an incubator for from twelve to sixteen hours, the Liifllcr bacillus, if present, so outstrips mo.st other bacilli in growth, that a specimen examined with the mi- croscope shows an almost pure culture of diph- theria bacilli. The bacillus is not motile, does not develop spores (see BArTKEiA), can live for months in the dried condition, but is killed by exposure for ten minutes to 58° C, moist heat. Various other bacteria are often associateil with the Li'ifiier bacillus in diphtheria. Of these, the most common, and at the same time most im- portant, is the fitrcptorocciis pyogenes. This organism is probably responsible for the sup- puration of the glands, for the bronchopneu- monia, and the general infection, Avhich some- times occur during the course of a diphtheria. To the works of U'eigert, Wagner, and Oertel we are indebted for much of our knowledge of the minute changes which take place in the for- mation of the diphtheritic membranes. The diphtheria bacilli or their jwisons fir.rt induce necrosis of the more superficial cells. This is followed by a more extensive coagulation necro- sis, with exudation, the whole forming the well- known false membrane. This membrane is most conmion on the mucous membrane of the tonsils and adjacent parts of the pharynx, but may ex- tend to or involve any portion of the mucoui membrane of the throat, mouth, or nose, .mong the most fatal forms of diphtheria are those in which extensive membranous form;>tion takes place in the nose or in the larynx, the latter sometimes called 'membranois croup.' (See Crocp.) Diphtheritic membranes are occasion- ally found on the conjunctiva, in the external auditory canal, the mucous membrane of the anus and genitals, and on wounds of the skin. Of lesions in other organs, bnmeho-pneumonia is not uncommon, and some cases are aceoiiipanied by acute parenchymatous nejihritis. Of Inter effects, the most common and important is paralysis, a lesion of the nature of a multiple neuritis, due to the poison of the disease. The
