DIPTHERIA.

Lyttelton Times, Volume XI, Issue 680, 14 May 1859, Page 3

DIPTHERIA.

The highly important nature of the subject upon which the following letter treats renders its publication desirable in spite, of its length arid somewhat professional character. It is extracted from the columns of the ' Southern Cross/ to the editor of which paper it is addressed :— To the Editor of the ' Southern Cross.' Sir,—Several deaths* having recently occurred fn Auckland from Diptheria, I have been solicited by several persons to place my ideas of the complaint before the public. I do so the more readily.as I think it might interest some of your readers to understand the nature of this disease, while it might advantage them to know the symptoms attendant i upon the complaint; for, when-these are compre!j hended, and early and judicious remedies applied, ' little is to be apprehended from the disease; but if neglected, and the larynx, or organ of the voice, , participate in the complaint, almost certain death from the spasmodic closure of the glottis is the consequence. : Diptheria, or Diptheritis, as it used to be called, is a complaint that has been long known and described in France. There, it generally occurred in. low and unhealthy districts;' in the crowded, wards ;of the children's hospital;, or in the close and confined parts of the French metropolis : since then it has become general; extending over France, and spreading to England, where it appears to have been extremely fatal last year. It is from the description of French medical men, and especially from the pen of M. Britonneau, that we first hear of this : complaint.- In England it appears not to have been ! recognised till very lately, but last year the increased frequency of the complaint has forced itself I upon the attention of the Medical Profession, and •we find almost every newspaper and periodical I abounding with notices of deaths from this cause. | That Diptheria is more likely .to appear at periods ! when the general condition of the health of the community is disturbed, is well known; when an I atmospheric cause spreads an evident epidemic inI fliience throughout the country. Such may be rej marked at the present moment; for influenza has • been extremely general in Auckland for a long time past, and still influences a considerable portion of community. Although extremely numerous, the cases of influenza are not remarkably intense, ; so that we cannot-recollect any deaths to have been : caused by it, as used to happen a few years since; | still a vitiated zomatic condition of the atmosphere ;is plainly present, which, by poisoning the blood, degrades and debilitates the human system, so as i !to maTce man-more liable to low typhoid complaints —complaints in which the fluids of the body are rendered very susceptible of decomposition. In fact the constitution of man would appear to have considerably changed of late years: it has little of the power and tone necessary to develop acute inflammation. I can remember when it was the fashion to bleed persons three or.four times in the year—when the lancet was absolutely demanded in very many cases, to save the life of the patient. Not so now; we are far more frequently obliged to support the tone and power of our patient's constitution; hence, true active inflammation is far less frequently met with in our day. This change, we apprehend arises in, a great degree from the present vitiated condition of the atmosphere of oiir planet, tending to produce influenza and its kindred complaints : favoured by the condition of the atmosphere; animal and vegetable life appear more susceptible to the attacks of those parasites, both of the animal and vegetable kingdom, that tend to injure and destroy their organization. Thus the grape, the plum, the apple, and all the finer forms and more highly organized varieties of animal and vegetable life, have suffered from this cause.

The'aphis, a winged animal of incalculable powers of reproduction, is destroying our apple trees, our roses, and an infinity of other plants; these puncture the bark, and suck the juices of the plant, so as to destroy it, while the oidium, a vegetable parasite, a niinute fungus, or microscopic cell plant, locates itself on the vegetable structure of the grape or

*Note.—According to the registry of the district* iof. Auckland, the deaths of children, under ten years jof age, during the month ending tlie 11th of April, iwer'e 18, while 54 are the recorded number of the 'same age, in all the Province of Auckland, during 'the year 1858,

plum, pierces its covering, sends its roots into the cellular tissue, absorbs its. juices, arid destroys the texture of the fruit, so that it rots before our eyes. So great has been this scourge in some, of the winegrowing districts, that great misery and want has arisen to the inhabitants" of those countries in consequence. To the microscope we are particularly indebted for the apprehension of these various causes of

disease in the animal and vegetable kingdom. In man we can readily distinguish many such,causes— the itch insect—the insect of the sebaceous follicle— the hydatid—and many others; among the vegetable parasites the " Sarsinti Vehtriculi," which often exists in the stomach to a large, amount—the four varieties of parasitic plants which are the cause of ringworm, as was shown by Gruby. That the thrush of infants is produced by a vegetable parasite can be easily shown; so can many others that produce disease in the animal frame. That an unwholesome condition of the atmosphere has existed in Auckland for some months, must have been observed by all; that the extreme prevalence of easterly winds may have had to do with this condition, is not unlikely; .in all.countries the easterly wind would seem to have an unhealthy tendency. Who does not remember the old couplet, " The wind from the East - Is good for neither man nor beast"? In what, way the prevalency of this easterly wind is the predisposing cause of influenza it is hard to say; but such appears to be the case: while a vitiated condition of bur atmosphere having occurred periodically for ages past might lead us to imagine that our planet, travelling" in space, occasionally meets with causes that tend more particularly to produce it. . Should it be asked how this unhealthy condition of the atmosphere affects the human body, we have but to iremember that the process of respiration requires a certain amount of pure air to produce the necessary and healthy changes in the blood, every time we breathe. If the atmosphere is not pure the blood becomes loaded with extraneous arid foreign matter; it is then the duty of the liver and kidneys to elaborate and remove this from the blood; if these organs are unable to perform the functions perfectly, the blood becomes poisoned, a tendency to irritation or fever manifests itself universally in the frame, and the sudden influence of cold, or change of temperature, determines this cause to operate upon some particular part of the body, producing pain and irritation—say of the frontal sinuses, or in the throat; hence the various symptoms of influenza or cold. ;

Having thus shown that a morbid state of the atmosphere is a cause why the blood, the source of healthy activity in all parts of our frame, becomes vitiated—impure, we may remark that under this morbid influence, the'various divisions of the nervous system are irritated arid debilitated; we can see how the muscular frame suffers, while the whole body and mind feel tlie depressing and degrading influence of this condition; so we can likewise understand that, during such a condition, various parasites are more likely to germinate, and produce their deleterious influences upon the.human body; and we shall be the better able to comprehend the Diptheria, especially when we have considered the symptoms. • . The premonitory symptoms that indicate the approach of Diptheria are often very slight, and insidious; the person has a slight cold, or shows the symptoms of influenza; there is generally. slight febrile disturbance, and that of the remittent or typhoid type—depression of the spirits, and general disorder of the health, such as you would expect from a vitiated'state of the blood. Perhaps the individual has slight soreness of the throat, hoarseness, and cough, attended with occasional croupy sound; you examine the throat, and you find a blush of red upon the arches of the palate, uvula, and tonsils. Now, you may say that the patient has a common cold, attended with a slight attack of croup. The common means will soon relieve these symptoms ; such as a warm' bath and alterative medicines—medicines that tend to remove the poison from the blood. Should theses synrptqm&contihue and in a few days you again examine the throat, you now find the tonsils, uvula, and palate covered with patches of a greyish white membrane, more or . less confluent,>from the size of a pin's head to that of a sixpence: this condition is most marked upon the tonsils, and although the neighbouring parts are of a dark red colour, they are attended with little or no swelling or tumefaction, as would be the case in ulcerated sore tnroat. Now we are warned that a different condition of disease exists, and we call it Diptheria. Still, however, there is little or no danger, while the complaint continues located in the present position; it gives rise to no increase of symptoms; the patient may complaini somewhat of difficulty of swallowing, but I have known persons'have this condition of things present, who scarcely considered themselves sick. By proper means we may remove the false membrane, arid by due attention to the health, cure tlie complaint. Now, too, we can peel off this false membrane with our brush or sponge, and only leave a red surface, which perhaps slightly bleeds: no deep indentation, or rugged excavation, or loss of substance, as though the part had died of' mortification or sloughing.

Heretofore the disease has been confined to the soft palate, but let the larynx, or organ of the voice, become implicated, and a vastly different condition of symptoms are produced. The cough now increases in intensity, the oroupy sound of aspiration during breathing is present to a painful degree, the breathing is quick and the respiration difficult; the countenance becomes swollen, and of a bluish leaden hue. These symptoms sometimes slightly remit, but soon return with increased vehemence—one paroxysm follows the other in quick succession, increased by the least excitement—until the patient becomes exhausted, or sinks, oppressed, from the poisoned condition of the brain.: In this case we do not find the intense inflammatory fever of true croup,, for the patient is generally bathed in a cold perspiration; indicating fear and intense mental excitement. 'A fatal termination may happen without being ushered in by that urgent dyspnoea, or difficulty of breathing,—those violent efforts to obtain air, which attend upon most of the cases of true croup. In some cases the deposit upon the tonsils and fauces is extremely partial; only a few specks may be observed, notwithstanding the larynx is greatly implicated: indeed, I can imagine a case (for I have seen one) in which the false membrane was confined to the larynx, where great difficulty would be experienced in deciding the nature of the complaint. The typhoid type of. the fever, and the character of the epidemic going about, would tend to indicate the nature of the case. In any case, the affection of the throat may be easily overlooked, unless we take sufficient care to have a good view of the fauces, by properly depressing the tongue. In other cases the fauces may be covered with the false membrane, and the disease not extend into the larynx, but descend the gullet, and go down into the stomach, causing great gastric irritation, and constant vomiting, so that the patient sinks from exhaustion. Upon examining the false membrane- under a microscope, we find it to consist of the epithlial covering of the mucous membrane, connected with a large quantity of minute cell formations of a parasitic fungus, not unlike that variety of Oidium found in the Thrush.

The. rationale of these /symptoms of Dyptheria point to certain conditions: first; that the constitutional condition of the individual affected is depressed by the poisoned condition of his blood, as is indicated by the febrile irritation, and symptoms of influenza; secondly, that, instead of the forehead and frontal sinuses being the seat of the catarrhal affection, the throat and fauces are the parts locally influenced by this complaint. The disease may never increase beyond this point* for the powers of the constitution may have sufficient tone, so as to prevent the development of Diptheria, especially when aided by judicious remedial means. But should the sporules or seed of the minute fungus above-mentioned be deposited, they will now find a hot-bed prepared for their germination in the congested tonsil. They will grow; then shall we find the ash-coloured membrane above alluded to. When located upon the tonsils and arches of the palate, these minute fungi appear to cause' little or no irri - tation, but as soon as they take root and grow in the larynx, they become a source of extreme irrita-

tion—-bring on spasm of the glottis,or chink of the windpipe—ami cause death by impeding the respiration, or pro venting the entrance of air into the lungs. To understand the mode by which these minute parasitic plants can cause the production of this false membrane, it is necessai-y to understand the structure of the niucous membrane of the throat. This consists of a basement membrane, supplied with a copious amount of blood-vessels, intended to develop and nourish a large amount of animal cells, formed to cover the outer surface of the mucous membrane, and lie upon it, like the stones in a pavement. These are plainly demonstrated by the microscope; they are so exact and precise in their character that when once seen they cannot be mistaken for anything else. These pavement epithelium, as they are called, are continually shed, and new ones developed; when in a state of health they lie compact, and are not easily removed, but when the part is in a state of irritation, and more blood than usual goes to it, this; cell formation is easily loosened, and readily removed; the basement membrane swells, from the increased quantity of blood, a larger amount of pabulum is supplied to these animal cells, which causes their rapid growth and removal. If at this time the sporule or seed of the vegetable fungus floating in the atmosphere be deposited upon the part, the abundant supply of nourishment makes it germinate, sends its roots down between the animal cells,.draws nourishment from the fluids of the body, grows into a mass, elevating the epithelial cells of the mucous [[membrane, and presenting, to the unassisted eye of the observer, the whitish grey mass which, for not knowing better^ or not employing one of the most useful aids of science, the microscope,-he calls a slough—that is a mortification or death of the part; he has, however, only to take a brush, or sponge, to remove the growth, to find the mucous membrane still whole beneath, continuous, without loss of substance: he merely brushes away the parasitic fungus and loose epithelial covering, the natural defence of the part, and leaves exposed the basement membrane—full of. blood and vascular from irritation, but still whole and continuous.

It is not improbable that this fungus may grow again after it is removed; but such is not likely to happen, unless the epithelial covering of the mucous membrane is reproduced. Then animal and vegetable cells may grow together, when the "white slough " (as it is improperly called) will again appear in the same spot.

This process might goon for a long continuance upon the fauces, in the deep mucous crypt or indentations of the tonsils (where we commonly first observe it) without any great harm to the individual. Indeed, all the mouth and throat may be thickly covered*'with this parasite without any absolute danger. But when the disease spreads to,the larynx, the organ of- the voice, the case becomes quite different—the danger then is imminent. The larynx, |the organ of the voice, situated in the immediate vicinity of these parts, is lined with a muicous membrane, similar in character to that which covers the throat—the delicate basement membrane, supplied t with numerous blood, vessels^ extremely sensitive nerves, and similar animal cells, which constitute its external covering. The throat or gullet being principally intended for the passage of tlie food down into the stomach, comparatively few nerves supply the part with sensibility—the function is mostly of an animal character. 'Not so the larynx; this is most highly endowed with nervous sensibility, is supplied with a multiplicity of nerves of the most exquisite character, constituting the larynx one of. the most highly developed organs of our frame; endowed with attributes.far above the animal creation, it forms a link in the chain that connects man with superior beings. That the larynx is supplied with exquisite sensibility, the wonderful modulations of the human voice can readily attest; while every day life gives evidence of the care with which this part is guarded against the intrusion of foreign bodies into the glottis or chink of the windpipe. Let but a crumb of bread or a drop of water go the wrong way (as it is familiarly termed), when we behold the most violent cough, the most intense efforts are exerted to reject the foreign body. ■ This is loose and easily coughed up; soon the parts become quiet' and composed; but even how the whole frame has experienced.a shock.approaching almost to.strangulation, which is not easily forgotten. Should it Happen that some of the sporules of the fungus drop into this sensitive part, they may germinate on the mucous membrane, and readily grow in the slight vascular excitement of the part produced by the influenza. , Most minute at first, by degrees they increase in size, until the larynx feels the presence of a foreign body. The nervous sensibility of the part is alarmed, and spasmodic closure of the glottis is the consequence. The cause is permanent, the spasm continuous; the volume of air necessary to breathing is prevented from entering the lungs; this closure of the glottis causes a sound we call " croup." Terrible is the condition which prevents the entrance of aii" into the lungs; dreadful is the appearance of the terror and alarm evidenced by the whole frame. The blood soon becomes poisoned, the brain and nervous system oppressed, and death is a necessary result of this asphyxy.

: As the parasite grows, the spasm of the glottis increases, and death must be the inevitable result, unless we can. remove the cause, or find means to admit air into' the lungs. We may attempt to.remove, the parasite from the larynx by means of a sponge attached to a piece'of whalebone ; but from the extreme sensibility of this part, it is almost impossible to reach the various saks and depression ""where the parasite is prone to grow ; hence the difficulty of removing the foreignjaody, saying noth- '. ing of the impediment offered to our attempts'by the rigid closure of the glottis, and the intense irritability of the part. On the mucous membrane of the throat, the presence of the parasite is comparatively harmless ; so it would be in the larynx, did we not require to breath through the glottis ; consequently could we make an opening into the windpipe below the larynx, we should restore the admission of air into the lungs, the croupy sound would' cease, and the danger to the brain and nervous system be obviated for the present; while time would be given to cure the disease. • If such is the case, it is naturally asked why is not an immediate opening made into the windpipe ? When the breathing is quiet and the patient tranquil that is an easy matter ; but when the vast excitement and constant mobility of the part are present— wheii the impediment to the breathing retards the' circulation of the blood, so that the most minute veins are full to bursting, and when a cut would bleed without ceasing—this would complicate the operation so that few surgeons would venture upon it at this time. Mr. Thompson, of London, however, has invented a lancet which can be readily introduced into the windpipe, and when there, its sides can be opened by a screw, so that a tube to breathe through can be passed between the blades, and respiration may go on. This accomplished, if the patient is hot too far gone before the attempt is made, before the brain is irremedibly injured by the poisoned blood, may give us a chance to save life—may give us time to apply our. remedies to the part, and get rid of the parasite ; so that if the patient's constitution has power to rally, we may snatch him from the jaws of one of the most frightful deaths imaginable. I trust that I may be forgiven for thus obtruding my views of this subject in a newspaper ; but the public anxiety to gain some information of this for-: midable disease must plead my excuse. 1 remain, Sir* ■'''■ Your obedient servant, S. J. Stratfoko. Parnell, 9th April, 1859.