LIBRARY NGRESS. i Shelf JMt> UNITED STATES OF AMERICA A TREATISE ON DIPHTHERIA. js BY A. JACOBI, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK J PHYSICIAN TO BELLEVUE, MOUNT SINAI, AND THE GERMAN HOSPITALS, ETC. NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES ST., 1880. -. to « '■"• S3 n o O Q Z < tu ■4-1 S3 to 9i a < . .2 •"S J3 S3 B u < £ to g o w> u Z >• U (A {) s S o flj i • i i d «-■ 5 , O O O S3 bJO > y >► cu n3 ^-, f3 J-l fa u ^ >, ^ $3 ^ s .2 2 05 *i "* in h «j ° B •!-> O S3 £ B ■" -t: fe to 7 4> £ CU* S3 d U l-H CU O S p* h fa Z b .£3 cu « £ S3 . "^ S3 05 "T t7 * to >> 2 +J to S3 to o W CO o 13 > £ - S3 • S3 5 S3 "1 g 3 -S "-C o S S >-. rt o tu O r>, S . . S3 3 O a cu s 3 -J"* a ^ Z - c o c > « ^® O tu — u S3 CU S3 to > CLTJ y3 a, cu CU £ fa CU > > > > »1 i-i to . S£ £ to to **- S3 -1 O H3 CO ►J S3 ,rH o ts P-.'o U U Pm hJ fa .fl ^j to"'— ' " S3 S3 .■a u (3 a, cs w o O " to s > ^ *J CS Ml S3 o e o to ^ B to D O B 1 J3 1 to "b/5 3 tr, to • ^ CU to $3 es S3 ^3 ■u • l-l Cl, a O o .5 o > u — * O &1 >* o u a w u w h-I 5 < * ANATOMICAL APPEARANCES. 1 27 amount in the buccal cavity, very abundant in the walls of the lymph-follicles of the tonsils, and so prominent an ele- ment in the trachea that the fibrous tissue is relatively tri- fling. The influence of the anatomical condition on the diphtheritic process must be very marked. It can easily be demonstrated that where the elastic tissue is present to a large amount, an antagonism to diphtheritic impreg- nation is maintained for a long time, but when it is obliged to yield, there is a corresponding resistance to recovery. It is the pavement-epithelium, according to Wagner, which gives the first foot-hold to diphtheritic membrane. Where it is most abundant, the diphtheritic poison can most easily settle and develop. Thus it is that the tonsils, not from their prominent situation alone, but from the character of their surface also, are favorable to the reception and further development of the infection, and their elastic and connective fibres, when once affected, are apt to harbor the process a long time. Ciliated epithe- lium, on the other hand, is not so liable to be affected. It occupies a higher rank in the scale of animal formation, has a more complex function and a greater power of resistance. The presence of a large number of mucous glands im- pedes, as a rule, by the presence of the normal secretion, an extensive destructive action upon the tissues. The secreted mucus assists in removing epithelial masses, and even fibrinous exudations, from the surface. The tissues themselves do not take an active or prominent part in the process ; the serum of the mucus penetrates the parts which are the seat of morbid deposits, and tends to pre- dispose them toward maceration, and the mucous secre- tion raises mechanically the superjacent deposits from their bed. Thus it is that the deposits in the respiratory portion of the nasal cavities are frequently cast off through the nostrils, probably because they have been produced in excess, and in a similar manner, the membranes that have formed in the trachea are ejected in a semi-solid con- 128 A TREATISE ON DIPHTHERIA. dition through a newly-made tracheotomic outlet. The large number of mucous glands in the larynx and trachea is unquestionably the reason why the lymphatic vessels of the mucous membrane are not influenced by the over- lying loosened masses, and will not absorb ; hence laryng- eal and tracheal diphtheria have decidedly a local char acter, and are so frequently devoid of constitutional symptoms. THE VOCAL CORDS deserve especial notice. They form the borders of the narrowest aperture of the air-passages. Foreign bodies, whether malignant or otherwise, are detained or retained by them. They are covered with pavement epithelium which, as has been remarked, is the principal resting and breeding place of the diphtheritic affection. They have no muciparous follicles, and few or no lymphatic vessels, and therefore if there is any part which is predisposed to diphtheritic infection it is certainly the vocal cords. Where the poison is insufficient for general infection, it is at times capable of still producing local phenomena. Where an epidemic of diphtheria has died out, a local diphtheritic infection can still take place, and individual cases occur now and then with an almost insignificant power of infection. Such occurrences take place for years or decades, and give rise to the so-called sporadic mem- branous croup, in the same way as we have for years heard of an occasional case of sporadic cholera or of a few cases of small-pox. There may not be sufficient infectious material to act on the blood, larynx, or pharynx, but just enough to gain a foothold on the prominent vocal cords with their pavement epithelium. On the other hand, the absence of acinous glands on the vocal cords must serve to a certain degree as a guard against the disease. Dry, atrophic, smooth conditions of the mucous membrane of the fauces likewise tend to ward off an attack of diphtheria. A more or less moist or ANATOMICAL APPEARANCES. 1 29 viscid condition of the surface is necessary in order that the poisonous material may cling thereto. The compara- tive dryness of the vocal cords, however, considered by the side of the perpetually moist and uneven surface of the pharynx, would not appear as favorable to the deposi- tion of foreign infectious elements. Thus there are cer- tain conditions predisposing to, others antagonizing in- fection. They demonstrate, however, why laryngeal croup is more frequent in winter than in summer, in direct proportion to the greater frequency of laryngeal catarrh in winter than in summer. Diphtheritic membranes on the vocal cords are not easily cast off, for there are no sub- jacent muciparous glands whose secretion could wash them away. No general infection can arise from them, for they have no lymphatic vessels which could serve as carriers of the poison ; furthermore, suffocation occurs too early to enable the few neighboring lymphatics to absorb and transport the poison elsewhere, in case the de- posits should finally become macerated. It strikes me that these anatomical and physiological considerations will help to throw light on the question of the mooted difference between "croup" and "diphtheria." The lymphatic and vascular systems must be looked upon as the most influential factors in the development and severity of the general phenomena in diphtheria. The absence of the lymphatics and the paucity of blood-ves- sels explain why diphtheria of the tonsils has so mild a character. The large number and size of, as well as the direct communication of the lymphatic ducts of the Schneiderian mucous membrane with the lymphatic glands of the neck accounts for the dangerous character of diphtheria of the nose. However, the direct infection, i. e., the absorption of the poison into the body, is not always dependent on the lymphatics, for they have occa- sionally neither enough time nor the opportunity to use their power. For instance, in those cases of diphtheria of the nose in which early and slight epistaxes occurred, 9 130 A TREATISE ON DIPHTHERIA. the poison appears to have been absorbed directly into the blood-vessels. Then we fail to observe the ordinary swelling of the neighboring glands of the neck, but the general symptoms are very rapidly developed. Usually, however, infection results through the lymphatics. The fluid contents of the tissues, or such particles or elements as are suspended therein, be they of a gaseous, chemical, or parasitic nature, are conducted to the lymphatic glands whose peripheric fascia propria serves as the first resting- place, for here' the lymphatic vessels subdivide, previous to penetrating the fascia and evacuating their contents into the lymph-spaces of the alveoli of the cortical sub- stance. As is well known, the latter are filled with lymph- corpuscles consisting of coarse, . granular protoplasm. From hence the lymph is carried off by delicate ves- sels into the substance of the glands. Their structure is the same as that of the cortical substance, with the excep- tion that they are less dense because of their containing less connective tissue and more and larger lymph spaces. All the infectious material that had entered the afferent channels and is small enough to be carried onward with the lymph and newly-suspended lymph corpuscles, is now introduced into the uninterrupted lymphatic and vas- cular currents, unless obstructed by a second series of lymphatic glands. All that which is as delicate as the lymph, and not larger in its microscopic proportions, is conveyed without interruption through the fascia propria into the reservoir of the cortical and medullary substances of the glands. There may be two conditions, however, which will serve to impede the current. In the first place, the foreign material may be present in too large an amount to circulate with ease ; the result will be stagna- tion and consequent irritation, either in the fascia propria or in the glandular substance. By pressure, the capillary circulation becomes interfered with, proliferation ensues, the circulating lymph mingles with the white corpuscles from the lymph spaces, and the result is an abscess in the ANATOMICAL .APPEARANCES. 131 intra- or peri-glandular tissue. When this is not the case, the foreign material is retained in the interior of the fas- cias in the connective tissue or in the dilated lymphatic vessels of the cortical substance. Thus fluids injected into the cortical substance have been found collected in the external portions of the glands, where it was im- possible for them to be carried into the circulation. Hence the gland may serve as the receptacle of noxious elements which have circulated in the lymphatic current, with or without danger to the integrity of its tissues. In. this manner a second attack of diphtheria may often find its explanation in the absorption of stowed away poison ; syphilis also, and other poisons, may be stored in the gland, or if their presence prove irritating, give rise to speedy suppuration, and even elimination, provided the abscess be opened sufficiently and early. The glands may swell considerably, though the foreign matter be not present in excess, but of a very irritant character— this will occur where the poison is of a hetero- geneous nature — no matter whether the elements are of a chemical or a parasitic nature. The swelling may be very marked. In infection from cadaveric poison, the axillary glands may become fifty times their normal size, for it is they and not the cubital glands which form the first upward station of the greater number of lymphatic vessels of the fingers. The glands of the neck, too, may in diphtheria become enormously swollen within a few hours. Swelling to a certain degree always results when there has been an irri- tation of the lymphatic system. I have already referred to the irritation produced by a simple nasal or oral catarrh, resulting in a gradual swelling of the neighboring lymphatic glands. It is a positive fact that many a case of so-called scrofula, founded on an indolent swelling of the lymphatic glands, would find a ready explanation in the presence of a chronic nasal catarrh or of superficial erosions of the buccal mucous membrane. If the absorbed 132 A TREATISE ON DIPHTHERIA. material be but little irritating, but in sufficient amount and extending over a longer period, a considerable mass may be taken into the circulation before they can give rise to a local swelling. If the materials are very minute and in moderate amount, they may traverse the lympha- tics for days and even weeks, and finally give rise to general infection rather than to a local disorder. This will ensue when elimination is less rapid than absorption. In this way an infectious poison, whose elements, organic or not, may be ten or twenty times smaller than the lymph-corpuscles — if it be feasible to calculate their size or predict their immediate changes — may stagnate in the smallest blood-vessels, proliferate rapidly, and then travel onward, or give rise to changes in the red blood- cells and leukocytes of the smallest vessels, and lead to de- posits of a purulent, septic, and gangrenous character, and a disintegration of the normal tissues on a large scale, be- fore local symptoms can be diagnosticated. Indeed, we often find that the apparently mildest cases of diphtheria eventually exhibit the most unpleasant symptoms. Sudden collapse and death are usually noticed in the apparently mild cases, and thus we are rarely in a position to say at the outset without hesitation (not even when nothing is perceptible except a circumscribed local diphtheria of the tonsils) that the individual case will prove mild or severe, that it will be short-lived or followed by succes- sive ailments. SUMMARY. The membrane, or the granular infiltration, are charac- teristic of diphtheria. Its contents are, more or less, fibrin, changed epithelium, blood, mucus, and pus. The main changes take place in the pavement epithelium, ac- cording to E. Wagner. The epithelium is as rapidly re- newed as changed. The views of histologists do not, however, agree about the nature or the importance of the epithelial transformations. The doctrine that the diph- ANATOMICAL APPEARANCES. 1 33 theritic process is caused, excited, or aided by bacteria is either sustained or denied by many. The membranes pro- duced by artificial irritation are considered by some iden- tical with, by others to differ from, the genuine diphtheritic product. The former view is held by the foremost clini- cians. Most organs are liable to participate in the diphtheritic process, the blood (thin, black), the heart (granular, fatty, hemorrhagic, thrombotic, endocarditic), the lungs (several forms of inflammation, infarctus, oedema, emphysema), the spleen and sometimes the liver (large, hypersemic, soft), the kidneys (congested, nephritic), the muscles (ecchymo- tic, degenerated, atrophic), the glands (swelled, ecchymo- tic, gangrenous, suppurating), the intestine and other viscera. The, several forms of diphtheria have a peculiar predi- lection for certain organs or part of organs. This pre- dilection depends on the character of the surface and its epithelium. The greater or less amount of elastic tissue, the number or absence of muciparous glands and of lymph vessels, the nature of the epithelium (pavement, ciliated, or fimbriated), determine the character of the membrane in the different locations. Copious secretion of mucus in- duces early maceration. The vocal cords are apt to serve as resting-places for the diphtheritic poison, but constitutional infection is pre- vented by the absence of lymphatics, and rapid maceration by that of muciparous glands. Nasal diphtheria is apt to be very fatal by the immense net of lymphatics in the Schneiderian membrane, or by direct absorption into the superficial blood-vessels. Lymphatic glands swell very considerably, but suppu- rate but rarely. They may serve as depots from which re- absorption and relapses may take place. 134 A TREATISE ON DIPHTHERIA. CHAPTER VII. DIAGNOSIS. The characteristic sign of diphtheria is the membrane, with more or less injection of the surrounding parts. In regard to this more or less injection, I will say that pharyngeal congestion, when it is uniform, may or may not point to imminent diphtheria. When it is local, con- fined to one side mainly, it is either traumatic or diph- theritic. White spots which are easily washed away, or can be removed with a brush, or squeezed out of the fol- licles of the tonsils, into which a probe can be introduced sometimes to the depth of one-half inch, soon announce their true character, either a simple catarrhal secretion or the effects of suppuration. Even though the superficial de- posit contain oidium or leptothrix in considerable numbers, it can easily be removed ; I have only known the totally in- experienced to mistake muguet of the mouth for diphtheria. In the larynx, muguet is, moreover, very rare indeed, and always circumscribed, mainly on the true vocal cords. The gray discoloration of superficial follicular ulcerations, as observed in the ordinary form of stomatitis follicularis, can hardly fail to be recognized. Such patches are very numerous in the fauces and on the lips and cheeks, never on the gums, except in ulcerous stomatitis which is not follicular. They are accompanied, too, by vesicles con- taining more or less serum, which have not yet ruptured. It must be remembered, however, that the mucous mem- brane, when deprived of its superficial covering, is liable during an epidemic of diphtheria to become infected, like every other wound. I have seen cases in which stomati- tis and diphtheria existed side by side, the latter having DIAGNOSIS. 135 invaded the exposed surfaces resulting from the former. The examination of the entire throat is not always easy. Very young children vomit frequently and persistently before the whole surface is exposed to view, and not in- frequently, repeated examination with the spatula is ab- solutely necessary. In general, however, the slight attempts at vomiting suffice to cause a great part of the swollen posterior portion of the tonsil to revolve into view. I have heard that the pale surface of old hyper- plastic tonsils has been mistaken for diphtheria ; I merely mention this fact to stigmatize so gross an error. When a discoloration happens to be the result of a deposited flake of mucous, a drink of water will remove it. Fever is not always a prominent symptom ; in fact at times it is necessary to take the rectal temperature in order to discover an elevation ; as a rule, simple diphthe- ria of the tonsils is accompanied by very little fever. Still there are plenty of exceptions. But the differences of temperature are not more striking than in most other infectious diseases, whose either mild or severe invasion may offer an obstacle to immediate diagnosis. As the height of the fever does not absolutely determine or even indicate the character of the subsequent course of the disease, but little importance is to be attached to the tem- perature, unless there be a very marked elevation. A sudden rise frequently occurs with lymphadenitis. High fever in the beginning may render the diagnosis difficult or postpone it. A girl of fifteen years, who had suffered from intermittent fever a great deal previously, was taken sick with a chill, with flushed face and throat after, and a temperature of 106 . This attack also was referred to the influence of malaria poisoning, the single at- tacks of which had generally lasted from twelve to sixteen hours. The next morning her temperature was still 104 . The diagnosis of malaria was dropped. There was a slight patch on one of her tonsils. That very evening her temperature was still the same, and some little albumen in 136 A TREATISE ON DIPHTHERIA. her urine. A great deal of albumen the day after, and the third day but little albumen, copious urine, and a tem- perature of ioo%° (rectum). The absence of lymphadenitis does not nullify the diagnosis of diphtheria, for when the tonsils are affected by the disease, there is frequently little or no swelling of the neighboring glands. The swelling of the glands en- ables us to locate the affection in a mucous membrane richly endowed with lymphatic vessels. It is very marked when the nose is affected. A few hours' duration of nasal diphtheria suffices for the development of a severe lymphadenitis, especially at the angles of the jaw. When the latter condition is found to exist, the throat should be examined with the idea of finding a membrane extending upward ; nasal diphtheria is very liable to com- plicate an affection of the uvula and arches of the palate. The membrane cannot well be seen by looking through the nostrils ; highly serviceable for this purpose is a very short, broad rhinoscope reaching upward to the bony structure of the nose. However, nasal diph- theria may frequently be diagnosticated some days be- fore the membrane becomes visible, by the rapid develop- ment of lymphadenitis ; this may be done even where the sweetish, musty odor of certain forms of diphtheria is ab- sent. Yet nasal diphtheria may occur without much lymphadenitis ; as, for instance, when the blood-vessels are very numerous and superficial, and thereby give rise to slight hemorrhages at the very beginning of the sickness. In such cases the lymphatic vessels are little, if at all, required to transmit the poison, the open blood-vessels replacing them in the function of absorbing. Naturally there are cases in which an ocular examination is not im- mediately or even at any time satisfactory. In the jour- nals we read of brilliant results of rhinoscopic and laryngoscopic examination ; in practice we see but few ; the patients are less inclined or in the proper condition to submit thereto, than the observer. This holds good DIAGNOSIS. 137 especially for the dyspnoea accompanying laryngeal diph- theria where the diagnosis may be doubtful, when no membrane can be detected in the fauces ; even if mem- brane be observed there, symptoms of suffocation may still arise from a laryngeal stenosis independent of mem- branous deposits in the larynx. If aphonia and difficulty of both inspiration and expiration be present at the same time, there is certainly membranous occlusion. If aphonia appear late, or even toward the very last, and only inspir- ation be impeded while expiration is comparatively free, there is an cedematous saturation of the ary-epiglottidean folds and its copious sub-mucous tissue, and consequently of the posterior attachment of the vocal cords. Such a condi- tion is not at all uncommon — whereas, a general oedema glottidis in connection with diphtheria is of exceedingly rare occurrence — and has forced me to tracheotomize many times ; but again, a comprehension of the true condition, where it occured in not very severe cases, has on several occasions enabled me to avoid an operation. This local oedema may sometimes be detected by palpation in the region of the swollen posterior wall of the pharynx. One of the diagnostic symptoms of membranous laryn- gitis, believed in and referred to by Kronlein, does not exist, viz., the swelling of lymphatic glands, which in his opinion is pathognomonic. Not only is that not the case, but what I said above of the absence or scarcity of lymphatics and muciparous glands of the vocal cords and their neighborhood renders the absence of lymphatic swellings a necessity, provided the latter do not depend on complicating diphtheria in other localities. In uncom- plicated diphtheritic laryngitis I expect no lymphadenitis. The character of the laryngeal membrane does not depend at all on the condition of the pharynx. The latter may have membranes of any description or consistency, without be- ing able to determine the condition of the larynx. I lay stress on this fact because no less a writer than Kronlein believes that where there is but little or no membrane 138 A TREATISE ON DIPHTHERIA. in the pharynx, that in the larynx is rather loose and movable. One of the pathognomonic symptoms of diphtheritic laryngitis, " membranous croup," is the relative absence of fever. Catarrhal laryngitis, pseudo-croup, is a feverish disease. A sudden attack of " croup " with high temper- ature — provided there is no pharyngeal or other diph- theria present — yields a good prognosis ; without much fever, a very doubtful one. If I had but words strong enough to impress that fact upon the minds of my readers, for this is the very diagnostic point against which most sins are committed. A boy of four years, F. M., in the practice of Dr. Teller, had in December, 1877, an attack of tonsillar diphtheria with very little fever ; after a few days, his diphtheria being better, fever set in (io4°-io5°) with hoarseness and some stenosis. It proved a temporary affair of short duration (catarrhal laryngitis), of which he soon got well. On January 3d, 1878, moderate laryngeal stenosis, hoarseness ; supra-clavicular and diaphragmatic exertion not great ; inspiration a little prolonged, with al- most a normal pulse ; a slight diphtheritic spot on lower lip, and the end of the tongue, and a temperature (rectal) of 101 . Diagnosis: membranous laryngitis, which was verified by the experience of the following days and necessitated tracheotomy. Another boy, three and a half years old, H., a patient of Dr. Obbarius, exhibited at 6.30 p.m., on November 2d, 1877, the following symptoms : Slight redness of fauces, hoarse- ness, difficulty of both inspiration and expiration, pulse rather normal. No elevation of temperature. Diagnosis : laryngeal diphtheria (" membranous croup "). At 2 A.M., November 3d, tracheotomy had to be performed hurriedly, while the temperature was 99^ (rectal), pulse 96 imme- diately after the operation, which produced quantities of false membrane. Membranous deposits inside the larynx are characterized by the above symptoms ; also the paralysis of the vocal DIAGNOSIS. 139 cords produced by ary-epiglottic oedema, posteriorly, by the symptoms enumerated above. Now and then there is a com- plication of both, now and then the symptoms are not well pronounced. Sometimes, when there are membranes on the tonsils, it may be of importance to watch the posterior aspect of the pharynx. When it is not swelled, not cede- matous, the stenosis is probably of a membranous char- acter. When it is cedematous, the probability is in favor of oedema about the insertion of the vocal cords. L. Fleischmann has placed the principal real or alleged symptoms of " croup " and diphtheria side by side in the following manner : Croup. Not contagious. True pseudo-membrane lying on the surface of the mucous membrane, from which it can be removed. Most in children. Most frequently affects the mu- cous membrane of the air- passages. Paralysis never occurs. No infection of the blood, with corresponding symp- toms depending thereon. Swelling of the glands, but al- most never suppuration of fcetid character. Begins as a catarrh that follows immediately after infection. Diphtheria. Contagious. Never a true croup-membrane, but deposits consisting of degenerated and exfoliated epithelium, fungi, and detri- tus. Occurs alike at all ages. " Multilocular invasion" fre- quently, the fauces, nose, genitals, intestines, and the skin being affected simulta- neously. Even in mild cases severe ner- vous disturbances. Infection of the blood and fat- ty degeneration of the striped muscular tissue, es- pecially that of the heart. Suppuration of the glands of frequent occurrence. Has a period of incubation and prodromi. 140 A TREATISE ON DIPHTHERIA. Croup. Croup may run its course with- out diphtheria. Not inoculable. Diphtheria. Diphtheria may run its course without croup, and invade other parts beside mucous membranes. Inoculable. J. Solis Cohen likewise tabulates the clinical differences between the two in a concise form, after acknowledging that there is no actual anatomical distinction between croup and diphtheria, either in the morbid products or the subjacent mucous membrane. His parallel is as fol- lows : Croup. Not specific in its origin. Never contagious. Not inoculable. Not adynamic. Usually sporadic. Rarely attacks adults. Always accompanied by an exudation. Only fatal by physical obstruc- tion to respiration. No weikening of the heart's action. Pulse frequently strong and hard. Respiration accelerated in pro- portion to the pulse, rarely less than i : 4. Rarely albumen in the urine. No secondary paralysis. Tolerates antiphlogistics. Rarely occurs more than once in the same person. Diphtheria. Specific. Frequently contagious. Inoculable. Adynamic. Generally endemic or epi- demic. Frequently attacks adults. Occasionally no exudation oc- curs. Often fatal without the least impediment to respiration. Marked weakening of heart's action. Pulse never strong and hard, even though rapid and full. Respiration not accelerated, usually less than 1 : 4. Albumen frequently present in the urine. Secondary paralysis frequent. Does not tolerate antiphlogis- tics. Frequent relapses. DIAGNOSIS. 141 I gladly devote some space to these attempts at simpli- fication and explanation, in order to demonstrate to the reader the errors or exaggerations contained therein. To discuss the individual points separately would certainly be superfluous, after the consideration of the subject in which the reader has thus far accompanied me. These tabulated comparisons are not even convenient. Aside from the positive errors which they contain, hardly a single case of either " croup " or " diphtheria " could be appropriately placed beneath either head. Conditions which are de- pendent upon each other and which even clinically blend into each other continually, of which one indeed (croup) is recognized at last as a purely clinical term (unless the term croup be only applied to pseudo-membranous steno- sis), cannot be arbitrarily tabulated. To the above differential symptoms, Lyon (Trans. Conn. St. Med. Soc.) adds the following : Croup. Diphtheria. Pseudo-membranes of the skin Pssudo-membranes of the skin never observed. occasionally observed. Generally in cold weather. Is little influenced by weather or season. The larynx the principal seat The principal seat of the dis- of the disease. ease above the larynx. The first distinction does not exist, as any one knows who observed croup beyond its suffocative symptoms. Tracheotomy wounds, though carefully joined, fre- quently become diphtheritic within twenty-four hours, and from thence I have seen an extension of the process to the skin, and anywhere. Its author himself dulls the edge of the second distinction by his " generally " and "little," and in his anxiety for localization, he has in the third distinction simply reiterated that which has been assumed as a matter of convenience, namely, the designa- tion, by the term " croup," of the pseudo-membranous de- posits in the larynx, which give rise to stenosis. But, 142 A TREATISE ON DIPHTHERIA. this is not a polemic book, and I therefore refer my read- ers to former pages. PRIMARY DIPHTHERIA OF THE TRACHEA AND ASCENDING CROUP does not occur frequently, yet it can be diagnosticated, and actual observation on the living and dead contradicts flatly the opinion of many writers whose opportunities may have been limited. Quite lately (Klebs, Handb. d. Pathol. Anat, VII., p. 283, 1880), Hans Eppinger risks the statement that "croup and diphtheria occur also in the trachea, but only when descending from the larynx." Without (occasionally with) an affection of the fauces, without general symptoms that would cause a feeling of anxiety to the parents, without more fever than one would expect in the slightest bronchial catarrh, without much dys- pnoea, and after symptoms of aslight bronchial or tracheal catarrh which have lasted a few hours or days, the little suf- ferers are most abruptly attacked by a stenosis of the larynx. Within an hour, or even less time, they become cyanotic ; tracheotomy affords but a slight temporary re- lief or none at all ; and the entire process occupies a very short space of time. Rarely is a large amount of mem- brane found in the larynx, but very much in the trachea and its larger ramifications. The disease began there, and without causing occlusion, because of the large size of the organ, ascended to the larynx, where it gave rise to a far more speedy death than is usually brought about by a descending croup. I have operated perhaps fifteen times in such cases, and no case, from the commencement of urgent symptoms to death, ever lasted more than a day, but many a few hours only. The secondary descending diphtheria of the trachea can only be recognized after tracheotomy has been performed. If an elastic catheter, feather, or probe be passed through the tube, the slightest contact with mucous membrane that is not covered by deposits will give rise to coughing. DIAGNOSIS. 143 In proportion to the depth to which the process has de- scended, with a corresponding deposit of membrane, will this effect become less noticeable. By degrees the irrita- tion may be applied one or two inches and more below the inferior extremity of the tube, without producing any reflex phenomena. The approach of new symptoms of suffocation (which do not assume the fearfully violent character of laryngeal stenosis) and cyanosis, gradually usher in death which can in no wise be warded off. Al- though the duration of this scene must vary in different cases, yet I can point to a series of cases in which the interval between the performance of tracheotomy (which I undertook at the time deemed most proper by myself, and hence not late) and final death was sixty hours. PNEUMONIA accompanying the general process can be diagnosticated only if the larynx be not much affected. The latter, how- ever, is usually the case, and the laryngeal rales in such a case drown the auscultatory signs of pulmonary inflam- mation ; percussion, too, gives no satisfactory results, as the dulness may be caused as well by collapse of the lung-tissue as by infiltration. The same may be said of bronchitis and acute oedema which may be looked upon as the direct results of rarefaction of the air in the bronchi and alveoli of the lungs. Rapid increase of temperature, together with increased number of respirations, speak for pneumonia. Diphtheria of the vagina, of the CONJUNCTIVA, and of WOUNDS can only then be confounded with a simple puru- lent coating when an ocular examination is the only means at our command ; even then rarely. The same holds true for intestinal diphtheria. Large shreds and cylindri- cal moulds are not always formed of diphtheritic mem- brane, but sometimes of mere mucus compressed into that shape, with little epithelium and almost never with blood. Thus they are seen in chronic catarrh of the colon. In the 144 A TREATISE ON DIPHTHERIA. dysenteric form of intestinal diphtheria the thrown off shreds are generally not large, and easily recognizable together with their accompanying symptoms. THE ERUPTION occurring in the course of diphtheria appears first on the warmer parts of the body, as the chest, neck, and abdomen ; occasionally, however, it covers the entire body, and is distinguished from the scarlatinous eruption in that the latter more frequently appears first on the hips and ex- tremities. Where it covers the entire body at once, in scar- latina, there are more severe general symptoms and higher fever than in diphtheria. In the former, the eruption lasts from five to six days ; in the latter, but a few days. Still mistakes may occur, as the intensity, extent, and dur- ation of the eruption in scarlatina may be very variable. In general, however — and this fact is of value in the diagnosis, to a certain degree — a marked scarlatinous eruption in the earliest period of the disease is accom- panied by a more characteristic erythema of the mouth and throat than in diphtheria, and with less diphtheritic deposits. These will, in scarlatina, appear after a few days as a rule, and not in the beginning. In diphtheria, the characteristic symptoms belonging to the tongue, redness, throwing off of the epithelium, papillar elevations, etc., are not so well marked. At times, however, the character of the desquamation only will decide the nature of the efflorescence. It appears, however, that in some epi- demics diphtheritic eruptions are but seldom observed, while in others they are more frequent. The appearance of ALBUMEN in the urine will serve as a valuable diagnostic point, some- times, between diphtheria and scarlatina. In the latter disease, it is rarely noticed in the first week ; it generally appears about the ninth or tenth day at the earliest, and it may be delayed until the twenty -fifth, even to the thirty- DIAGNOSIS. 145 third in my experience. When it appears in the first week, it not infrequently presents the picture of a danger- ous form of general diffuse nephritis, which is apt to ter- minate lethally. In diphtheria, albumen is pretty sure to appear, if at all, within the first few days, neither the degree of fever nor other general symptoms affording an explanation of its presence. It is frequently found, and in large quantities too, for a day or two, apparently as a symptom of rapid elimination, in cases which set in with a high fever, which lasts but a short time, and gives way to almost complete apyrexia. Gangrene manifests itself in a destruction of the tissues, for instance of the vagina or cornea, and depends some- times on pressure by the impregnated surface ; or it occurs on such privileged localities as are adapted, from their coating of pavement epithelium, for deep inroads of the degenerative process. Still the genuine necrosis of the tissues occurs in other parts of the mouth besides the tonsils, but we must be careful not to declare any thick black briny masses at once to be gangrenous. Not infre- quently they are merely deposits which are easily removed. Genuine gangrenous masses readily bleed, either from the sharp corroded edges or from deep-seated vessels which have been injured. I have but rarely seen dangerous hemorrhages from grangrenous portions of the neck, and not many deaths therefrom. EPISTAXIS is not infrequently a formidable symptom. Its seat can sometimes be estimated by the facility with which, in dif- ferent postures, the blood makes its appearance in the throat. DIPHTHERITIC PARALYSIS exhibits certain peculiarities which facilitate diagnosis. The latter presents no difficulties for the practitioner who has witnessed the entire course of the disease and sees 10 I46 A TREATISE ON DIPHTHERIA. paralysis appear during convalescence. It becomes all the more easy when the soft palate is the first to be at- tacked, and is gradually followed by the implication of other parts. But in those cases where the diphtheritic process was not observed, and the soft palate was not affected or became so only later, the diagnosis will be more difficult, and may even be involved in utter dark- ness. The knowledge of the fact that diphtheria has pre-existed may arouse suspicion and guide the physician to a proper appreciation of the case. But it is necessary carefully to weigh the accompanying circumstances. A migrating paralysis of mixed character, like the diph- theritic, may be either peripheric or central. It is impor- tant to determine this point in the first place. Severe central lesions, whether of diphtheritic or other origin, will invariably present a certain clinical picture. Diffi- culties arise only when the question of multiple lesions of a different character, such as hemorrhages, sclerosis, can be raised at all. The more frequent, if not the constant, form of diphtheritic paralysis is the peripheric ; it runs a precisely opposite course to that which is described by some authors. It is not the assumed regularity, but just the remarkable irregularity and wavering char- acter of the paralysis, together with a capriciousness of the symptoms and of the affected organs or parts thereof, which are especially characteristic of the disease. As a general thing, the paralytic symptoms commence in the soft palate, and pass to the ciliary nerves after (mostly bilaterally). But the reverse may take place. The symptoms, when the patient does not get well soon, may extend over months, or rather, one will be replaced by another. Beside the above mentioned, there may be stra- bismus, general debility of the muscular system, local paralysis, atrophy of single muscles, atrophy of skin, and nutritive disorder with alopecia, disorder of sensibility, not always of a subjective character only, dyspnoea from either degeneration of heart or paralysis of respiratory DIAGNOSIS. 147 muscles, irregular behavior under the influence of faradic (diminished) and galvanic (normal, sometimes increased, diminished after a while) currents. All the time, how- ever, the sphincters are intact (with very rare exceptions) as in the amyotrophic or peripheric paralysis of children. SUMMARY. Diphtheria is characterized by its membrane. The diagnosis from muguet is easy. Complications with folli- cular stomatitis are of occasional occurrence. Follicular inflammation of the tonsils is recognized by its local char- acter, by the ready removal of the deposits, and the easy introduction of a probe into the follicle. The congestion in the diphtheritic pharynx is sometimes less pronounced than in catarrhal pharyngitis. In the latter the hyperae- mia is general, in the former it may be local. Fever is not always high. Sometimes the temperature is even low in very bad septic cases. High temperatures in the beginning are less frequent than, for instance, in scarlatina. Glandular swelling may be absent for many reasons. Nasal diphtheria has much glandular swelling ; may, in some distinct cases, have none at all. Diphtheritic laryngitis has less fever than catarrhal laryngitis, and when uncomplicated shows no glandular swelling. The character of the laryngeal membranes does not depend on the condition of the pharynx. Complete aphonia and uniform difficulty of inspiration and expira- tion indicates membranous obstruction; difficult inspira- tion with easier expiration and but partial hoarseness or almost clear voice indicates the presence of local oedema and consecutive paralysis of the vocal cords. Primary diphtheria of the trachea is difficult to diag- nosticate ; it is likely to exist when after apparently catar- rhal symptoms those of laryngeal stenosis occur very suddenly and fatally. The progress of the diphtheritic process downwards can be watched through the trache- 148 A TREATISE ON DIPHTHERIA. otomy tube and estimated by the absence of irritability of the mucous membrane of the trachea. The diagnosis of pneumonia accompanying laryngeal diphtheria is not impossible. In the other forms of diph- theria it is recognized by its usual symptoms. The cutaneous eruption of diphtheria is usually distinct from scarlatinous eruptions, and the diagnosis easy in most cases. Albuminuria is mostly an early symptom, and dis- appears more readily than in scarlatina. Diphtheritic paralysis is recognized by the previous history of the disease, by the frequency of its starting from the pharynx, its irregular course, its mostly peri- pheric character, and the absence of symptoms belonging to bladder or rectum. It is mostly motory, sometimes sensory or sensitive. PROGNOSIS. 149 CHAPTER VIII. PROGNOSIS. Trousseau once expressed his opinion that diphtheria was more dangerous than cholera, yellow fever, or the plague. He certainly said so under the influence of the impression conveyed by some of the worst septic cases we are apt to meet with. Fortunately the sad picture is greatly overdrawn. I have already, on some previous pages, alluded to the fact that the majority of cases are of a mild type, and that in many a season the ratio of mor- tality is but small. Many a year it was not higher than five per cent of all the cases. Ten per cent is certainly a high rate. Still, as far as each individual case is concerned, there is hardly a disease in which the prognosis is more uncertain than in diphtheria. Before the process has fully run its course, it is unjustifiable to consider the favorable termination secured ; even when it is completed, a relapse may occur, which again casts obscurity over the entire question. The general character of individual epidemics, now mild, now severe, permits, it is true, to rely to a certain extent on probabilities, but the physician will often enough be deceived, and more frequently, too, in mild than in bad cases. There is a certain class of cases in which the prognosis is absolutely unfavorable ; there is another class in which it appears favorable, and yet dangerous symptoms and a fatal termination ensue. In general, the prognosis is favorable when the affected surface is of small extent, and where such parts are the seat of disease as have little communication with the lymphatic system. To the latter class belongs simple diphtheria of the tonsils. Marked glandular swelling, 150 A TREATISE ON DIPHTHERIA. particularly if arising suddenly, is always an uncomfortable sign, and calls for the utmost caution, especially if the region of the angles of the jaw be speedily and markedly infiltrated. This, as we have seen, is particularly apt to occur with nasal diphtheria, whether developed primarily, accompanied by a thin foetid discharge, or, as is more com- monly the case, secondarily from an affection of the pharynx and palate in the continuity of tissue. With the appropriate local disinfection, it is neither so absolutely dangerous as Oertel depicts it, nor so assuredly fatal as Roger but a few years ago taught in his clinique, or Kohts appears to believe (Gerhardt, Handb. d. Kinderkr., III., 2, p. 20, 1878), yet it is ever doubtful. With energetic treatment, most cases will get well. Diphtheria of wounds, complicating diphtheria of the pharynx, is always an unpleasant sign ; that of the mouth and angles of the mouth, associating itself with a previously existing diphtheria, having an indolent course, and producing rather a deep impregnation of the tissues than a thick deposit, presents very disagreeable symptoms. Diphtheria of the larynx, whether it be of primary origin or the result of extension from the fauces, is nearly always fatal. In severe epidemics the mortality is 95 per cent. Tracheotomy, too, saves but few of those who take the disease at such a time. In fifty consecutive tracheoto- mies, from 1872 to 1874, I did not see one recovery. In the last few years, I have seen few good results. In average epidemics, tracheotomy will save 20 per cent. A pulse of 140 to 160, and high fever immediately after the operation, render the prognosis bad ; so does absence of complete relief after the operation. An almost normal temperature the day after the operation is an agreeable symptom, but does not exclude a downward extension of the diphtheritic process, and hence cannot be looked upon as assuring a favorable prognosis. A marked elevation of temperature occurs with a renewed attack of diphthe- ria, or a rapidly-appearing pneumonia, and is an unfavor- able symptom. A dry character of the respiratory mur- PROGNOSIS. 151 mur, some time after tracheotomy, indicates the approach of death from descent of the membrane, within from twelve to twenty-four hours j* cyanosis likewise, whatever be its degree of intensity. Diphtheria of the trachea, which ascends to the larynx, is positively fatal. It has a rapid course, and tracheotomy only postpones the end for a little while if at all. The general health and strength of the little sufferer have no influence whatever. Thick, solid deposits need not of themselves render the prognosis so unfavorable as do septic and gangrenous forms. Even in the nose they are not of as serious import as the thin, putrid discharge. I have seen recovery ensue in cases where I was obliged to bore through the oc- cluded nasal cavities with probes and spoons. Foetid, putrid discharges are unfavorable, but in no wise fatal; conscientious disinfection accomplishes a great deal. Slight epistaxes indicate the possibility of rapid and un- doubted absorption through the blood-vessels ; but here, too, the final result depends on whether the disinfection be equally rapid and thorough. The same holds true for the sweetish, foetid odor of the breath, whether of the nose or mouth, which, on one hand, demonstrates the sig- nificance of the disease, while, on the other hand, it indi- cates the possibility of infection by the breath. The height of the fever is not in proportion to the dan- ger in the individual cases ; some have a favorable, some an unfavorable termination, without fever of any account. Simple catarrh of the pharynx and larynx frequently begin with a sudden and marked rise of temperature ; * R. W. Parker (Tracheotomy in Laryngeal Diphtheria, London, 1880) says: " The presence of membrane in the trachea in a fatal case of mem- branous laryngitis, after tracheotomy, must be regarded as evidence of the want of due care on the part of the surgeon in charge, just as much as would the presence of a piece of gut in the inguinal canal after herniotomy, or a calculus in the bladder after the operation of lithotomy." I do not hesitate to express my opinion that the gentleman will modify this " somewhat absolute dictum," as he calls it himself, after some more experi- ence. 152 A TREATISE ON DIPHTHERIA. diphtheria in the same parts but rarely. There are cases, however, in which the height of the fever and the depos- ited membranes are in inverse proportion to each other. In these cases, the fever may subside rapidly, owing to a speedy elimination of the poison. Young children only are in danger of death from convulsions, or a rapid tissue degeneration. If the temperature rise suddenly after days of sickness, either a complication or a fatal termina- tion is to be apprehended. Yet, if we except laryngeal and tracheal diphtheria, there are as many deaths with com- paratively low, as with very high temperatures. Whether collapse has resulted rapidly or slowly, the patient dies often with low temperature. Thus a rapid elevation is hardly a more unfavorable sign than a rapid fall. The pulse, too, may be very variable. True, a small, rapid, and irregular pulse is always unpleasant, because it indi- cates a weakening of the cardiac function ; yet, as long as it retains an approximately normal relation to the fre- quency of respiration, a rapid pulse gives no cause for alarm. Moreover, the pulse is not always rapid when the strength gives way. It occasionally becomes slower, and sometimes very slow, and may then become a dangerous symptom. It seems to me highly probable that there is in such cases, as in certain forms of chronic fatty meta- morphosis of the heart, a degeneration of the cardiac gan- glia of the sympathetic. Every complication adds to the danger. Bronchitis and pneumonia are not infrequent ; yet I have seen cases of laryngeal diphtheria recover, in which I had suspected pneumonia before performing tracheotomy, and was en- abled to diagnosticate it after operating. Albuminuria in the early part of a diphtheritic attack (with high fever) is of little significance ; nephritis, later in the course of the disease, partakes of the character of scarlatinous nephritis ; cases of acute diffuse disease are fortunately infrequent, and the remainder are very submissive to treatment. The cases complicated with endocarditis, in my practice, PROGNOSIS. 153 ended fatally. An early implication of the sensorium, not dependent on pressure upon the jugulars by greatly swol- len glands, is an unfavorable symptom. Purpura, with profuse hemorrhages and a livid hue of the skin, is omin- ous ; icteric discoloration, together with marked glandu- lar and periglandular tumefaction, is absolutely fatal. Calimani observed an epidemic in which he lost one hun- dred and fifteen cases out of two hundred. Before the diphtheritic eruption on the integuments took place, he often noticed a cyanotic discoloration and an offensive secretion of the last phalanx of the big toe, sometimes of other toes, or of the middle finger. All of those showing these symptoms died. A case of acute diphtheritic infec- tion with fatal termination, taking its course with the symptoms of pernicious icterus, was but lately recorded by Becker (Berl. klin. Woch., Nos. 30 and 31, 1880). 154 A TREATISE ON DIPHTHERIA. CHAPTER IX. c TREATMENT. GENERAL REMARKS. Every case should be treated on general principles ; thus it is not possible to lay down a routine treatment for every individual case. High fever should be reduced by spong- ing and baths, quinine, and sodium salicylate ; collapse speedily treated, and severe reflex symptoms, as vomiting, etc., checked at once. Whether to employ for this pur- pose ether, wine, cognac, champagne, or coffee, must be decided by the physician in individual cases. The admi- nistration of the remedy, whether by mouth, by injection into the bowels, or subcutaneously, as I have employed cognac, ether, alcohol, and camphor dissolved in ether or alcohol, in some cases with decided and rapid success, must depend on the condition of the organs and on the urgency of the case. At all events, it may be stated that all the above remedies are frequently of no service be- cause they have been administered too late, and in too small doses, and hence we may infer that to obtain the proper results both from external and internal treatment, the remedy must be employed early and often, and in suf- ficient quantity. If I have ever had cause to feel con- tented with the results of treatment in diphtheria, it is owing to the fact that 1 did not lose time. Moreover, the nourishment of the patient is a matter of very great importance, and should not be neglected, and no medicines resorted to which are apt to derange the digestion of the patient. It is true that caution must be exercised in the food administered to febrile patients, but we must bear in TREATMENT. 1 55 mind that, when the lymphatic vessels are kept empty, and no new and proper material is introduced into them, the absorption of locally existing poisonous substances is pro- portionately increased. I dwell particularly on the foregoing remarks for the reason that, in diphtheria, unlike certain diseases having a typical course and those of a simple inflammatory character, expectant treatment should not be indulged in. Oertel's advice, that when neither high fever nor complications are present we should quietly wait, and " act only when new and most alarming symptoms present themselves," is decidedly perilous. A mild invasion does not assure a mild course. Never has a " perhaps superfluous " tonic or stimulant done harm in diphtheria, but many a case had a sad termi- nation because of a sudden change in the character of the disease, putting the bright hopes of the physician to shame. Only the philosopher may be a passive spectator, the physician must be a guardian. When I again read, in the work of the same meritorious author, " that when in exceptional cases, in children and young people, death is imminent, not from suffocative symptoms in the larynx and trachea, but from septic disease and blood-poisoning, it is necessary to resort to powerful stimulants," it strikes me that he is frequently too dilatory with his remedies, and furthermore, that his experience concerning the ter- rible septic form of diphtheria, which is so frequently met with in some epidemics, must have been very limited at that time. In New York, during the past twenty years, for every death from diphtheritic laryngeal stenosis, there have been three from diphtheritic sepsis or exhaustion. To generalize from a few cases or years would be unsatis- factory. But few authors have displayed the unselfish- ness of Krieger, who, in his " Etiological Studies" (Strass- bourg, 1877), had repeated opportunity for observation, yet in his careful essay on the " Predisposition to Catarrh, Croup, and Diphtheritis," refers to the insufficiency of his own observations. 156 A TREATISE ON DIPHTHERIA. When a modern writer (Ripley, Med. Rec, July 31st, 1880) teaches that " diphtheria is a self-limited disease," " which runs its course from a few hours to weeks," and may " end in recovery, according to the character of the epidemic and idiosyncrasy of the patient, even without medicine," he certainly stretches the definition of a self- limited disease to undue proportion, while in regard to spontaneous recovery he states what may be said of any and every disease. His teaching that the only rational plan of treatment of diphtheria is a symptomatic one, is dangerous, because it is apt to seduce into the neglect of preventives, and of the timely resort to medication, to say the least. It is true that the results of no treatment cannot be uniformly successful, but at all events the indi- cations for causal treatment are commencing to be known at last. In that respect we have progressed somewhat be- yond the most thoughtful therapeutics of the disease, as developed in the course of the last century, and so well illus- trated by the " Tentamen medicum inaugurale de cynan- che maligna," by Thomas Wilson, Edinb., 1790. He says, p. 24 : " Cum hactenus nullum inventum est remedium quod contagionem in corpus receptam suffocare possit ; cum medicamenta pleraque quae putredinem corrigere dicuntur, corpus ejusque functiones manifesto roborant; et denique, cum hunc morbum comitantur virium prostra- tio, et, etiam ab initio, summa functionum debilitas, qualis evacuantia omnigena prohibet, indicationem curandi unicam, scil. debilitatis effectibus obviam ire, proponam. Hinc corporis conditioni obviam itur praecipue tonica et stimulantia administrando." (As no remedy has yet been found which can extinguish the contagion after it has been received into the body, as most medicines which have the reputation of correcting putrefaction, are robor- ants for the body and its functions, and lastly, as this disease is attended with great prostration and such debil- ity of functions as to preclude the use of all sorts of evacu- ants, I propose but this one indication for treatment, viz., TREATMENT. 1 57 to meet the effects of debility. This is fulfilled by the administration of mainly tonics and stimulants.) While speaking of stimulants, I will say a lew words in regard to the dose to be given. There is more danger in diphtheria from giving too little than too much. When the pulse begins to be small and frequent, they must be administered at once. A three-year-old child can com- fortably take thirty to one hundred and fifty grammes of cognac, or one to five grammes of carbonate of ammonia, or a gramme of musk or camphor in twenty-four hours. In the septic form especially, the intoxicating action of alcohol is out of the question, the pulse becomes stronger and slower, and the patient enjoys rest. In those cases in which the pulse is slow, together with a weak heart's action, the dose can hardly be too large. The fear of a bold administration of stimulants will vanish, as does that of the use of large doses of opium in peritonitis, of quinine in pneumonia, or of iodide of potassium in meningitis or syphilis. 1 know that cases of young children with gen- eral sepsis commenced immediately to improve when their one hundred grammes of brandy was increased to four hundred in a day. The remarks I have made in reference to the general treatment of diphtheria naturally render superfluous a discussion of the value of abstraction of blood. To be sure, it could only be a question of local bleeding. For nobody would dare to resort to jugular venesection, as our predecessors did in the last century. It may be safely asserted of the latter that it has no influence on the pro- cess, but frequently increases the local swelling and makes the patient more anaemic. There is no case in which a resort to it would not be criminal. I can distinctly recall the time when bleeding and calomel formed the ground- work of the treatment. Until the year 1862, the death rate in Rupert, Vermont, from diphtheria was ninety per cent, according to the reports of the local physicians, and particularly of my pupil, Dr. Guild, who at that time 158 A TREATISE ON DIPHTHERIA. finished his studies in New York and commenced practis- ing. When, in the same epidemic, bleeding and calomel were replaced by stimulants and iron, with the chlorate of potassium, ninety per cent recovered. That attention must be paid to the general condition, mainly during a retarded convalescence from previous sickness, is self-evident. Any complications, too, must be subjected to early treatment. Diarrhea must be men- tioned among these ; it reduces the patient's strength very quickly ; likewise, the early appearing nephritis which may suddenly end life. One important axiom must be borne in mind, namely, that prevention is more easy than cure. I do not refer simply to the removal of the healthy members of the family beyond the danger of infection, or to the isolation of the patient. If the latter becomes necessary, the first in- dication is his removal to the top floor of the house. There are, in addition, however, certain prophylactic measures which will prove valuable in the hands of every o-ood physician. It is necessary under all circumstances that the mouth and pharynx of every child be constantly kept in a healthy condition. Eruptions of the scalp must be treated at once, and glandular swellings of the neck caused to disappear. But lately some cases of laryn- geal diphtheria have been traced directly to the pres- ence of suppurating bronchial glands, with or without perforation (Weigert, in Virch. Arch., Vol. jj, p. 294, 1879). The same rule applies to nasal and pharyn- geal catarrhs, the treatment of which should be be- gun in warm seasons, when general or local remedies yield better results. Enlarged tonsils should be resected, or, where that cannot be done, scraped out with Simon's spoon, at a time when no diphtheritic epidemic is raging. It is important that this take place at a time when, even though sporadic cases of diphtheria occur, the danger of infection is not great ; for, during the height of an epi- demic, every wound will give rise to general or local in- TREATMENT. 1 59 fectlon. This holds true for wounds of any part of the bod}', as well as of the mouth. I therefore avoid an oper- ation at such a time, provided it can be postponed. In this connection 1 shall speak of a remedy which I class among the prophylactic agents, namely the chlorate of potassium, or the chlorate of sodium. I cannot say that I rely on either of these remedies as curative agents in diphtheria, and yet I employ them in almost every case. The reason lies in the fact that the chlorate is useful in most cases of stomatitis, and thereby acts as a preventive. There are very few cases of diphtheria which do not exhibit larger surfaces of either pharyngitis or stomatitis than of diphtheritic membrane. There are also a number of cases of stomatitis and pharyngitis, during every epi- demic of diphtheria, which must be referred to the epi- demic, sometimes as kindred diseases, and sometimes as introductory stages only, which, however, do not, or do not yet, show the characteristic symptoms of the disease. When, in i86o(Amer. Med. Times, Aug. nth and 18th), I wrote my first paper on diphtheria, I based it upon two hundred genuine cases, and at the same time enumerated one hundred and eighty-five cases of pharyngitis, which I considered to be brought on by epidemic influences, but which, the membrane being absent, could not be classified as bona fida cases of diphtheria. Such cases of pharyngitis and stomatitis, no matter whether influenced by an epidemic or not, furnish an indication for the use of chlorate of potassium. They will get well with this treatment alone. The cases of genuine diphtheria, complicated with a great deal of sto- matitis and pharyngitis, also indicate the use of chlorate of potassium ; not as a remedy for the diphtheria, but as a remedy for the accompanying catarrhal condition in the neighborhood of the diphtheritic exudation. For, it is a fact that, as long as the parts in the neighborhood of the diphtheritic exudation are in a healthy condition, there is but little danger of the disease spreading over the sur- l6o A TREATISE ON DIPHTHERIA. face. Whenever the neighboring surface is affected with catarrh, or inflammation, or injured, so that the epithelium is loose or thrown off, the diphtheritic exudation will spread within a very short time. Thus chlorate of potassium or sodium, the latter of which is more soluble and more easily digested than the former, will act as a preventive rather than as a curative remedy. Therefore it is that common cases of pharyngeal diphtheria will recover under this treatment alone, nothing else being required. The cases of diphtheria in which the exudation is lim- ited to the tonsils are by no means dangerous, for the lymphatic communication between the tonsils and the rest of the body is none at all, or very trifling. Thus no absorption into the circulation can take place from a ton- sillar diphtheritis alone. The surrounding stomatitis and pharyngitis will be favorably influenced by the administra- tion of chlorate of potassium or sodium, and thus the entire disease will run a favorable course, inasmuch as the ton- sillar exudation will be removed within three or six days. The surrounding portions of the mouth and fauces, mean- while, having been put into a tolerably healthy condition, the danger is passed. These are the cases which have given its reputation to chlorate of potassium as a remedy for diphtheria. The dose of chlorate of potassium for a child two or three years old should not be larger than half a drachm (2 grammes) in twenty-four hours. A baby of one year or less should not take more than one scruple (ij^ grammes) a day. The dose for an adult should not be more than a drachm and one-half, or at most two drachms (6 or 8 grammes), in the course of twenty-four hours. The effect of the chlorate of potassium is partly a gen- eral and partly a local one. The general effect may be obtained by the use of occa- sional larger doses ; but it is better not to strain the elim- inating powers of the system. The local effect, however, cannot be obtained with occasional doses, but only by TREATMENT. l6l doses so frequently repeated that the remedy is in almost constant contact with the diseased surface. Thus the doses, to produce the local effect, should be very small, but frequently administered. It is better that the daily quantity of twenty grains should be given in fifty or sixty doses than in eight or ten ; that is, the solution should be weak, and a drachm or half a drachm of such solution can be given every hour or every half-hour, or every fifteen or twenty minutes, care being taken that no water is given soon after the remedy has been administered, for obvious reasons. I have referred to these facts with so much emphasis, because of late an attempt has been made to introduce chlorate of potassium as the main remedy in bad cases of diphtheria, and, what is worse, in large doses. It is Seeligmuller especially who has recommended chlo- rate of potassium for that purpose in a saturated solution. Sachse also looks upon a saturated solution of chlorate of potassium as a panacea, inasmuch as he did " not lose a case out of one hundred/' except those, as he says, " which were hopeless at the beginning." A young colleague in our State also recommends chlorate of potassium (six drachms daily) as his sheet anchor in diphtheria (Louis Weigert, M.D., Hospit. Gaz., Jan. 16th, 1879). Seeligmuller administers a solution of one in twenty. Of this, he gives children of three years and over a table- spoonful every hour at first — doses which amount to half an ounce in twenty-four hours ; afterward every two or three hours. To children a little younger, he gives half a tablespoonful, and continues the treatment day and night. He insists upon the necessity of not adding any syrup to the solution, and also of not allowing the patient to drink within a short time after the administration of the rem- edy. In his opinion, the internal treatment suffices ; still he advises that the solution should be used as a wash, a gargle, and also should be snuffed. He says that the bad odor and fever, under that treat- 11 1 62 A TREATISE ON DIPHTHERIA. ment, disappear within a very short time. The number of cases which he first reported as treated successfully in this manner was fifteen. At the same time, he gave milk, broth, egg, and a small quantity of Tokay wine. These cases were published a number of years ago. Since that time he has modified his opinion to a certain extent. He says that chlorate of potassium may prove injurious, because of the possibility of the potassium acting upon the heart ; and that, when it does, the heart's action becomes either more or less frequent, and may be intermittent. On the other hand, he directs attention to the fact that diphtheria itself will act upon the heart in a similar way ; and, as soon as such symptoms occur, quinine, coffee, and wine are recommended. Digestion may also be interfered with by chlorate of potassium, inasmuch as when acute gastric catarrh is pres- ent the remedy is not well tolerated. In such cases, smaller quantities must be given, or the drug must be dis- continued altogether. In consequence of meeting with these drawbacks, he insists upon the above method of ad- ministering the remedy only during the first twenty-four or thirty-six hours. This modification he began particularly after a few of his patients died with a sensation of burning and soreness. I have reported his practice so extensively, because 1 mean to raise my voice against it for the reason of its dan- gerousness. As early as i860, 1 advised strongly against the use of large doses of chlorate of potassium, but the translation of the paper I then published in the American Medical Times, which was printed in the Journal fiir Kinderkrank- heiten, in 1861, was so defective that I am not astonished at my warning having been overlooked on the European side of the Atlantic. The treatment is dangerous because of the largeness of the doses of the chlorate of potassium administered. Seeligmiiller himself reports a case of a boy six years TREATMENT. 1 63 of age, who died within a very short time under the chlo- rate-of-potassium treatment, the main symptoms being copious greenish discharges, obstinate vomiting, and col- lapse. The kidneys were not examined after death, but the symptoms and the resemblance of these cases to a number of others of equal nature and result, prove them to be cases of nephritis depending upon over-doses of chlorate of potassium. Lacombe had under observation a man who took one ounce of potassium chlorate, intending to take an ounce of the sulphate of magnesium. The man died in convulsions, after having purged very freely, and the cause of death was regarded as excessive diarrhcea. The probability is, that it was a case of nephritis. Isambert, in his first reports upon the effects of chlorate of potassium, published more than twenty years ago, found among its effects increased diuresis, a sensation of heaviness and dragging in the lumbar region, such as is found after the administration of large doses of nitrate of potassium. Ferris reports a case of death from cyanosis, with absence of pulse, within a period of thirty-six hours after a table- spoonful of the chlorate of potassium was taken. He found the ventricles of the heart empty and con- tracted, while the auricles were distended with dark blood. The kidneys were not examined. When I myself, nearly twenty years ago, took single half-ounce and six-drachm doses of chlorate of potassium, I had a sensation of heaviness and dragging in the lumbar region, and increased renal secretion. I did not examine for albumen. The case of Dr. Fountain, of Davenport, Iowa, occur- ring at the very same time, is first mentioned by Alfred Stille (Therap. and Mat. Med., 2d ed., 1874, p. 922). He experimented upon himself, taking an ounce of the chlorate of potassium, and died in a week of nephritis (and enteritis).* * Alfred Stille publishes a letter of Dr. John M. Adler, of Davenport, Iowa. 164 A TREATISE ON DIPHTHERIA. A case of death from chlorate of potassium, occurring in the practice of Dr. Krackowizer, I reported some years ago. It was that of a young lady who was told to use a solution of one ounce of chlorate of potassium as a mouth- wash and gargle. Instead of that, she swallowed the whole of the solution, and within three days died of neph- ritis. I have also, before this, referred to one of my own cases ; it was that of a man of thirty-odd years, who was told to use internally ten drachms of the chlorate of sodium, within six days. Instead of that, he took the entire quantity who was Dr. Fountain's friend and medical attendant. According to that letter (Stille's text makes it an ounce, and I know from my intercourse with Dr. Fountain that he took half an ounce previously), Fountain took half an ounce in a goblet of warm water at 8 A.M., on March 22d, 1861 ; free diuresis fol- lowed during the course of the day ; it ceased entirely at 4 p.m. He looked fatigued and was pale, but ate heartily at 7 p.m. ; was attacked with purg- ing, vomiting, and cramps after 8 p.m. ; was in dangerous collapse at 9.30, with vomiting and purging, with intense pain and cramps, skin cold, with the hue of a person nearly asphyxiated. He rallied, but retained an exceedingly dusky appearance of the skin. Between 6 and 8 A.M. the following day, he voided about two ounces of black-colored urine. After this, there was no secretion from the kidneys. " When he called my attention to the urine, he remarked that he feared the chlorate had seriously injured his kidneys." Immedi- ately after, the choleraic symptoms returned, with profound collapse, but he rallied again ; the purging ceased, and there was no further evacuation from the bowels during the six subsequent days of intense suffering. Vomiting and intense pain were incessant. He died just one week from the time of taking the chlorate. " The autopsy revealed a general intense inflammation of the entire alimentary tract, from the stomach to the rectum ; portions of the mucous membranes were destroyed, hanging in ragged shreds and patches, as if the intestine had been macerated a long time in a strong alkaline solution. The mucous membrane of the bladder gave a similar appearance. The bladder was empty. There were crystals of the chlorate in the pelvis of the kidneys, and a large bulk of extravasated urine (apparently) " (?) "under the capsule of one kidney." There is no mention made of the anatomical condition of the kidney, but there were two "ounces of bloody urine, and no more for six days," though the patient rallied after that second relapse also. There was general hypersemia and even ulcerations of the gastro-intestinal tract, whether primary or the result of the pertinacious vomiting and (in the beginning) purg- ing, is another question. It is seen in the violent gastro-intestinal symptoms of nephritis. TREATMENT. 1 65 within six hours. Within twenty-four hours he suffered from diffuse nephritis. What little urine he passed was smoke-colored, and afterwards black. It contained a large percentage of albumen, blood, hyaline and granular casts. Then there was complete suppression. There was vomit- ing and diarrhoea, headaches and coma. He died on the fourth day, and the post-mortem examination exhibited acute diffuse nephritis. Dr. J. Lewis Smith, in a meeting in which the above statements of mine were referred to, reports a case of a child three or four years of age (see Medical Record, p. 397, 1878), who took three drachms of the chlorate of potassium in one day. After that only a few drops of bloody urine were discharged, and the child died at the end of twenty-four hours. In the same number of the same journal Dr. Hall reports a case of a child under one year of age, who took one drachm of the chlorate of potassium in a single night, with exactly the same symptoms and the same results. Conrad Kuster(D. Zeitsch. f. prakt. Med., 1877, No. 33), for no other purpose but to prove the essential identity of the punctated, maculated, membranaceous, croupous, and nephritic forms of diphtheria — similarly to most writers since Bard, Bretonneau, and myself amongst many — re- ports the following cases : A young woman of twenty, vigorous and blooming. Mild angina. Small, white specks on tonsils. Feels pretty well. A strong solution of chlorate of potassium for gargling and internal administration. No doses, however, reported. The doctor found her dying at daybreak the following morning. Relatives said that vomiting and diarrhoea commenced in the evening, but that they all slept and were awakened in the morning by the labored breathing of the patient. No post-mortem examination was made ; urine was not obtained. There was no dropsy, but the skin exhibited a peculiar dusky hue. A man of thirty, in vigorous health. Trifling macu- l66 A TREATISE ON DIPHTHERIA. lated diphtheritic angina. Strong- solution of chlorate of potassium as a gargle, and internally lime-water, besides. The tonsils cleared rapidly, but some malaise all the time. Urine albuminous. The doctor learned that the urine was peculiarly black on the third or fourth day. Gradual improvement, but urine albuminous a year and a half after. A boy of three years, in good health ; very mild, punc- tated, diphtheritic angina. Two other children had diph- theria seriously half a year previously, one of which died of laryngeal diphtheria. Gargle and administration of a strong solution of chlorate of potassium. Next day the doctor was notified the child was dying, and had passed black urine. So it was. The urine was black, a little greenish hue, moderately albuminous, the surface bluish white, the child dying. A good deal of vomiting. No dropsy. No post-mortem. A girl of four, also robust and vigorous. Mild angina, some trifling whitish marks, hardly visible in the tonsils. Gargles and administration of chlorate of potassium in strong solution. Appears nearly well both locally and gen- erally, within two days, but in the afternoon very sud- denly: vomiting, yawning, apathy, bluish-white complexion, accelerated and compressible pulse, skin cool. In the evening some urine, black with greenish hue, albuminous, contained hematine. On the following days, the color be- came more normal, and albumen less. On the fifth day, the danger was over, but the pulse remained frequent a long time. No dropsy. A slight return of albumen on the sixteenth day. Now Dr. Kiister claims all of these cases as acute neph- ritis, and adds verbatim : " There is here a peculiar resem- blance to renal irritation from carbolic acid poisoning. One is reminded of a medicinal poisoning, and would pre- sume its presence if carbolic acid had been used for external application. In my cases, the substance irritating the kidneys could be none but the chlorate of potassium. How- TREATMENT. 1 67 ever, as this effect of chlorate of potassium has not been observed, as nephritis in diphtheria is, besides, nothing unusual, the latter must be claimed as the cause of the accidents." Kuster's facts are correct, his theory is not. His cases were mild, all of them tonsillar, no general symptoms, no adenitis ; in fact there is no, or very little danger, in consequence of the absence of lymph-vessel communi- cation between the tonsils and the rest of the body. Two of his four cases terminated fatally in a very short time ; two barely escaped. The same symptoms, the same nature of the disease in all. The cases seemed to the author like so many of poisoning by medication, and so they were. Unfortunately the author, otherwise known as careful, earnest, and conscientious, reports do doses, but in every case he speaks of strong solutions of chlorate of potassium, which appear to have been used rather indifferently or indiscriminately. Whoever has fol- lowed my remarks, and compares my own cases with his, will not hesitate to look upon his cases as such of acute nephritis brought on by excessive doses of chlorate of potassium. After all the previous remarks, the practical point I wish to make is this, that chlorate of potassium is by no means an indifferent remedy ; that it can prove, and has proved, dangerous and fatal in a number of instances, pro- ducing one of the most dangerous diseases — acute nephritis. We are not very careful in regard to the doses of alkalies in general, but in regard to the chlorate we ought to be very particular. The more so as the drug, from its well- known either authentic or alleged effects, has risen, or descended, into the ranks of popular medicines. Chlorate of potassium or sodium is used perhaps more than any other drug I am aware of. Its doses in domestic administration are not weighed but estimated ; it is not bought by the drachm or ounce, but the ten or twenty cents worth. It is given indiscriminately to young and old, for days or even weeks, for the public are more given to taking hold of a l68 A TREATISE ON DIPHTHERIA. remedy than to heed warnings. Besides, it has appeared to me that acute nephritis is a much more frequent occurrence now than it was twenty years ago. Chronic nephritis is certainly met with much oftener than formerly, and I know that many a death certificate ought to bear the inscription of nephritis instead of meningitis, convulsions, or acute pulmonary oedema. Why is that? Partly, assuredly, be- cause for twenty years past diphtheria has given rise to numerous cases of nephritis ; partly, however, I am afraid, because of the recklessness with which chlorate of potas- sium has become a popular remedy. In this respect the medical profession has done nothing to check its quackish use. For, with the exception of Alfred Stille, who knew Fountain's case and the destruct- ive powers of chlorate of potassium — it appears, however, that not the kidneys but the intestines were suspected — almost nobody has suspected it. Still, Isambert noticed, after large doses of the drug, increased elimination of urine, and after doses of twenty grammes a sensation of heaviness and pain in the renal region, without any other disorder. Buchheim (Arzneimittellehre, 1859), ^ is true, speaks of the irritation of the mucous membrane of the urinary tract, with frequent desire to micturate, and even of inflammation of the bladder and hematuria resulting from the use of the chlorate, as well as of the nitrate of potassium. Edlefsen, on the other hand, declares the remedy perfectly harmless (D. Arch. f. klin. Med., XIX., P- 97). In connection with a paper of mine on this subject (Med. Record, 1879, March 15th), which he quotes, F. Marchand (iiber d. gift. Wirkung des Kali chloricum in grosseren Dosen, Sitzgsber. d. Naturforschenden Ges. zu Halle, Feb. 8th, '79, and Virch. Arch., vol. yj) has also observed in- toxication by potassium chlorate. Death ensued either suddenly, or after some days. In the former cases, the blood was brown, but no changes took place in the organs ; in the latter, an affection of the kidneys resulted in the emission TREATMENT. 1 69 of a urine loaded with decomposed blood-cells and de- pended on obstruction of renal capillaries by the changed blood-corpuscles. Experiments made on dogs, which con- sisted in potassium chlorate being either administered in- ternally or thrown into the abdominal cavity, had the same effect. Blood taken from time to time proved an increasing discoloration of the same ; it resembled the changes tak- ing place in blood after severe burns of the surface. When death did not occur suddenly, the urine changed after twelve or twenty -four hours. Spectroscopic examination of such blood yielded the character of methasmoglobin (the same changes which take place when blood is mixed with potassium chlorate). Finally, E. Baginski,* referring to my own and Mar- chand's communications, reports four clinical observations of a nature similar to that of my own cases. I have no doubt but that the number of unfortunate cases of the kind will increase unless my warning be heeded. My views concerning the treatment of diphtheria are based on the principles laid down in the discussion of the pathology of this disease. Although diphtheria is, after all, a constitutional disorder, yet it frequently has a local in- ception ; in other words, the infection enters into the gen- eral system at a certain circumscribed locality. In many cases, this locality is the same, namely, the fauces. From this stand-point, constitutional diphtheria may be com- pared to the septic absorption occurring in wounds and in the puerperal condition, and for that reason we shall be obliged to rely principally on the method of treatment that is most serviceable in diseases of wounds, and puer- peral fever after delivery, to wit : local disinfection. While, however, we may congratulate ourselves on a posi- tive knowledge of the effects of disinfecting agents upon accessible putrid fluids, we have no proofs of our ability to * Ueber toxische Wirkungen des Kali chloricum, Arch. f. Kinderheilkunde, 1880, p. 100. 170 A TREATISE ON DIPHTHERIA. disinfect the blood in the living body. True, we may claim that we possess remedies which enable the body to resist the action of the poison, but we cannot yet assert that we have at our command remedies which, when absorbed into the blood, are able to destroy the poisonous elements contained therein. It is possible that salicylic acid forms an exception ; yet concentrated salicylic acid, when mixed with diphtheritic scrapings from the tongue, did not destroy the infectious qualities thereof. Besides, it ought not to be overlooked that salicylic acid, when introduced into the system by internal administration, forms at once salicylates ; mainly sodium salicylate, which is not a disinfectant. Moreover, if the pathological process in question, and pathological processes in general, were the result of bac- teria, and bacteria only (or, according to the botanist Naegeli, organized substance of some kind), the therapeu- tics would necessarily consist in destroying these bac- teria, these organized substances. But, when we read of the assurance with which antiseptic medicines are recom- mended for internal administration, we are certainly entitled to our share of astonishment. It is a well-known fact that the most thorough mixture of antiseptic with putrid material is required to destroy bacteria, but with the most child-like faith do we send our liquids down into other people's stomachs, expecting every antiseptic drop to look out for its duty. It is expected to be absorbed, and being swept into the circulation, to find its way to the " nests " of micrococci stowed away in gangrenous tissue out of reach of vascular or lymphatic circulation, to fall upon the enemies of tissue and mankind and commence their deadly combat. It is also expected that a fraction of a grain of sodium benzoate atomized down into a pul- monary abscess swarming with bacteria should have the same effect; while in the bottle and in the test-tube, we know that a thorough shaking with a well-known and large pro- TREATMENT. 171 portion of antiseptic admixture is required for a satisfac- tory effect. N. C. Scharrenbroich's and Appert's (Virch. Arch., 61, p. 364) observations on the effect of quinine are, for the time being, of not much importance for practical medi- cine. It is true that leukocytes become dark and seem- ingly granulated in a solution of neutral muriate of qui- nine. 1 : 200-1 : 2000, and that amoeboid movements are imperceptible afterwards. It is also true that doses of 3T0T or 4 0*0 °^ tne we ight. of the body of a frog render both emigration and marginal position of leukocytes impossible, and that the above-mentioned changes will take place; and further, that pulse and circulation are very much retarded. But such doses cannot be employed in practising on the human being, and the full effect of the drug cannot, therefore, be obtained, provided that the doses required in men are in any way proportionate to those in the frog. Even though they be much smaller, like those calculated by Binz, they would be too large to be administered. Prevention, after all, is but in part the business of the physician. It is mostly that of the individual, or the com- plex of individuals, viz., town, state, nation. Those sick with diphtheria must be isolated, though the case appear ever so mild, and if possible, the other children sent out of the house altogether. If that be impossible, let them remain outside the house, in open air, as long as feasible, with open bed-room windows during the night, in the most distant part of the house, and let their throats be examined every day. The watching eye of a father or mother will discover deviations from the norm, so that the physician can be notified. Let the temperatures of the well children be taken once a day, in the rectum. Ten minutes of a mother's time are well paid by the discovery of a slight anomaly, which may require the presence of the physician. Happily, there are many mothers who keep and value a self-registering thermometer as an important 172 A TREATISE ON DIPHTHERIA. addition to their household articles. The attendant upon a case of diphtheria must not get in contact with the rest of the family, particularly the children, for the poison may be carried, though the carrier remain well, or appar- ently well. Unnecessary petting of the patient on the part of the well ought to be avoided, kissing forbidden, the bed-clothing and linen to be changed often, and disin- fected, the air cool and often changed. The well, or apparently well children of a family that has diphtheria at home, must not go to school nor to church. The former necessity is beginning to be recog- nized by the authorities and teachers, and also in conse- quence of partially enforced habit by parents, the latter will be resisted longer. Schools ought to be closed en- tirely when a number of cases have occurred. Even when the school children have not been affected to a great extent, but a diphtheria epidemic has commenced in earnest, it will be better to close the schools for a time. If that be not advisable, the teacher ought to be taught to examine throats, and directed to examine every child's throat in the morning, and return home every one barely suspicious. In times of an epidemic, every public place, theatre, ball-room, dining-hall, tavern, ought to be treated like a hospital. Where there is a large conflux of people, there are certainly many who carry the disease with them. Disinfection must be enforced by the authorities in regular intervals. Public vehicles must be treated in the same manner. That it should be so when a case of small-pox has happened to be carried in such, appears quite natural. Hardly a livery stable keeper would be found who would not be anxious to destroy the possibility of infection in any of his coaches. He must learn that diphtheria is, or may be, as dangerous a passenger as vari- ola. And what is valid in the case of a poor hack, is more so in that of railroad cars, whether emigrant or Pullman. They ought to be thoroughly disinfected in times of an TREATMENT. 1 73 epidemic, in regular intervals, for the high roads of travel have always been those of epidemic diseases, and railroad officers and their families have often been the first victims of the imported scourge. Can that be accomplished ? Will not railroad companies resist a plan of regular dis- infections because of its expensiveness ? Will there not be an outcry against this despotic violation of the rights of the citizen, the independence of the money bag? Cer- tainly there will be. But there was also, when muni- cipal authorities commenced to compel parents to keep their children at home when they had contagious diseases in the family, and when a small-pox patient was arrested be- cause of endangering the passengers in a public vehicle. In such cases, it is not society that tyrannizes the individ- ual; it is the individual that endangers society. And society begins at last, even in America, to believe in the rights of the commonwealth, and not in the rights of the democratic person only. The establishment of State and National Boards of Health proves that the narrow- hearted theories of the strict constructionists have not only disappeared from our politics, but also from the con- science and intellect of society. The sick-room must be kept cool, the windows kept open — more or less — in the night, the floor frequently washed, the linen soaked at once, the excrements removed. Dead bodies ought to be kept moist, for infectious material, chemical or otherwise, will spread more easily when dry. Attendants must not talk unnecessarily over the mouth or diphtheritic wounds of the patient, and will do well to carry a little dry loose cotton — to be changed often — in each of the nostrils, for it prevents the transport of infec- tion from septic material to such as would be considered exposed under ordinary circumstances (Wernich in F. Cohn's Beitr., III., 1859, P- ll S)- A very urgent and important mode of prevention consists in disinfection. Its requirements may be stated as of a double nature. Those who still believe in bacteria as the causes and 174 A TREATISE ON DIPHTHERIA. main representatives of infectious diseases do not consider disinfection complete unless the disinfectants used have succeeded in destroying the vitality of bacteria. Now, about the same time experiments have been made in both hemispheres, the results of which are singularly unanim- ous. Thus Schotte and Gartner, under the orders of the Surgeon-General of the German Navy, publish a report with experiments on the question, how much carbolic acid or how much sulphurous acid is required for the destruc- tion of bacteria (" Zur Todtung des kleinsten Lebens "),* with the following result, viz., that a sure disinfection can- not be accomplished on board ships by the evaporation of carbolic acid or by burning sulphur, because of the large quantities required for that end, but that there is a fair hope to find a substance which, when in solution, is capable of surely destroying bacteria in watery solutions or in garments. And George M. Sternberg, U. S. A., in his ex- periments with disinfectants, made at the request of the National Board of Health (Bull. No. 47, May 22d, 1880), comes to the following conclusions, viz., that the amount of pure carbolic acid required to destroy the vitality of bacteria is equal to about seventeen pounds in a room twelve feet square and twelve feet high (capacity 1728 cubic feet) and to fulfil the conditions oi the experiments on a large scale it would be necessary to scatter this amount over the floor of a room having these dimensions, and to suspend articles to be disinfected near the floor for at least six hours, care being taken that all apertures are closed, so that the fumes of the acid may not escape. Another experiment (No. 43 in the series) shows that four times this amount (sixty-eight pounds) of " crude " acid placed upon the floor of a room of the same size would not destroy the vitality of bacteria exposed in the room for six hours. These experiments show that the popular idea, shared, perhaps, by some physicians, that an odor * D. Viertelj. f. offentl. Gesundheitspflege, 1880, XII., p. 337. TREATMENT. 175 of carbolic acid in the sick-room, or in a foul privy, is evidence that the place is disinfected, is entirely fallacious, and, in fact, that the use of this agent as a powerful disin- fectant is impracticable, because of the expense of the pure acid and the enormous quantity required to produce the desired result. The warning is appropriate, and when it will be heeded, much carelessness will be avoided, and much danger averted. But, perhaps, the case is not so bad, after all, as we might conclude from the results of the observations of the medical men engaged in the above experiments. The uniformity of their results proves almost to a cer- tainty that they are quite correct in regard to bacteria, but those who do not see in bacteria the cause and essence of all infectious diseases, especially diphtheria, will look to disinfection as their safeguard, without fearing to be baffled in their practical efforts to avert disease. Two hundred years ago, when the first infusoria were dis- covered, they were also accused of being the cause of in- fectious diseases. They were met with the thunder of cannons ; but when that refused to be effective, it was at- tempted to bewitch the infusoria with music. A pound of pure carbolic acid to a hundred cubic feet looks very much like the cannon ball, but has the advantage, accord- ing to Sternberg, of being effective ; may be that what the National Board of Health has recommended to us, in the shape of their Circular No. 1,* is also more effective than the music of old. I cannot do better than to copy it from Bulletin No. 10, September 6th, 1879. Instructions for disinfection. Disinfection is the destruction of the poisons of infec- tious and contagious diseases. Deodorizers, or substances which destory smells, are * Signed by George F. Baker, Phila. ; C. F. Chandler, New York ; Henry Draper, New York ; Edward G. Janeway, New York ; Ira Remsen, Balti- more ; S. O. Vander Poel Albany. 176 A TREATISE ON DIPHTHERIA. not necessarily disinfectants, and disinfectants do not necessarily have an odor. Disinfection cannot compensate for want of cleanliness nor of ventilation. I. Disinfectants to be employed. 1. Roll-sulphur (brimstone) for fumigation. 2. Sulphate of iron (copperas) dissolved in water in the proportion of one and a half pounds to the gallon ; for soil, sewers, etc. 3. Sulphate of zinc and common salt, dissolved together in water in the proportion of four ounces sulphate and two ounces salt to the gallon ; for clothing, bed-linen, etc. Note. — Carbolic acid is not included in the above list for the following reasons : It is very difficult to determine the quality of the commercial ar- ticle, and the purchaser can never be certain of securing it of proper strength ; it is expensive when of good quality, and experience has shown that it must be employed in comparatively large quantities to be of any use ; it is liable by its strong odor to give a false sense of security. II. How to use disinfectants. 1. In the sick-room. — The most available agents are fresh air and cleanliness. The clothing, towels, bed-linen, etc., should, on removal from the patient, and before they are taken from the room, be placed in a pail or tub of the zinc solution, boiling-hot if possible. All discharges should either be received in vessels con- taining copperas solution, or. when this is impracticable, should be immediately covered with copperas solution. All vessels used about the patient should be cleansed with the same solution. Unnecessary furniture — especially that which is stuffed — carpets and hangings, should, when possible, be re- moved from the room at the outset ; otherwise, they should remain for subsequent fumigation and treatment. 2. Fumigation with sulphur is the only practical method for disinfecting the house. For this purpose the rooms to be disinfected must be vacated. Heavy clothing, blankets, bedding, and other articles which cannot be treated with zinc solution, should be opened and exposed TREATMENT. 1 77 during fumigation, as directed below. Close the rooms as tightly as possible, place the sulphur in iron pans sup- ported upon bricks placed in wash-tubs containing a little water, set it on fire by hot coals or with the aid of a spoon- ful of alcohol, and allow the room to remain closed for twenty-four hours. For a room about ten feet square, at least two pounds of sulphur should be used ; for larger rooms, proportionately increased quantities. 3. Premises. — Cellars, yards, stables, gutters, privies, cesspools, water-closets, drains, sewers, etc., should be frequently and liberally treated with copperas solution. The copperas solution is easily prepared by hanging a basket containing about sixty pounds of copperas in a barrel of water. 4. Body and bed-clothing, etc. — It is best to burn all articles which have been in contact with persons sick with contagious or infectious diseases. Articles too valuable to be destroyed should be treated as follows : A. Cotton, linen, flannel, blankets, etc., should be treated with the boiling hot zinc solution ; introduce piece by piece ; secure thorough wetting, and boil for at least half an hour. B. Heavy woollen clothing, silks, furs, stuffed bed- covers, beds, and other articles which cannot be treated with the zinc solution, should be hung in the room during fumigation, their surfaces thoroughly exposed, and pockets turned inside out. Afterwards, they should be hung in the open air, beaten, and shaken. Pillows, beds, stuffed mattresses, upholstered furniture, etc., should be cut open, the contents spread out and thoroughly fumigated. Car- pets are best fumigated on the floor, but should after- wards be removed to the open air and thoroughly beaten. 5. Corpses should be thoroughly washed with a zinc solution of double strength ; should then be wrapped in a sheet wet with the zinc solution, and buried at once. Metallic, metal-lined, or air-tight coffins should be used 12 I78 A TREATISE ON DIPHTHERIA. when possible, certainly when the body is to be trans- ported for any considerable distance. SPECIAL TREATMENT. The local remedies may be conveniently divided into three classes. The first includes those which dissolve the pseudo-membrane, and thereby afford an opportunity to remove it ; the second, those which appropriately mod- ify the surface from which the membrane has been re- moved, or the membrane itself ; the third, the real anti- septic agents which are credited with being- able both to bring- about chemical changes and to destroy parasitic organisms, and which are, therefore, believed to be ap- propriate by those who consider diphtheria either due to a chemical poison or to the presence and rapid proliferation of bacteria. It is mostly when the pseudo-membrane has its seat in the larynx that it is highly important to dissolve it as rapidly as possible. Of the vast number of remedies that have been recommended for this purpose, but four have held their ground up to the present day, to wit : Lime- water, glycerine, lactic acid, and steam. INHALATIONS OF STEAM. Quite remarkable effects have been expected of, and claimed for, them. It is true that pseudo-membranes, like everything else, become softened by the warm vapors. It is also probable that steam increases the secretion of the mucous glands, and thereby possibly loosens the overlying membranes and favors their removal, but it must not be forgotten that it also softens the healthy tissues, and that this change in character enables the poison, whatever be its nature, to penetrate more deeply into them. These two hypotheses must be kept in mind when, in any case, the question of the employment of steam arises. Steam for the purpose of softening the tissues and of provoking the secretion of mucus and suppuration has TREATMENT. 1 79 been used to a considerable extent ; in fact, in England and America it constitutes an important part of the treatment of diphtheria of the larynx. The patient must inhale it directly from a vessel, or in a tent which is more or less closed, or breathe the atmosphere of the room after it has been saturated therewith. For the latter purpose, water is kept constantly boiling, or lime slaked, or red-hot stones put in water from time to time. The results from this procedure in diphtheria of the larynx have not always been pleasant. I have repeat- edly had the joy of seeing children, with croup, become less cyanotic after their removal from an atmosphere of vapor, and I can readily see that pure atmospheric air would be more agreeable and wholesome to a child with stenosis of the larynx than an atmosphere laden with steam. Of course, this remark does not apply to cases of pseudo- croup and bronchitis, which are generally benefited by a warm, moist atmosphere. In pharyngeal diphtheria I anticipate but little from the softening and suppuration- producing properties of steam. Whoever has noticed the obstinacy with which diphtheritic membranes and infiltra- tions resist all treatment, for days, and even beyond a week, will hardly attribute the recovery from a mild and favorable case of diphtheria of the tonsils, and of light pharyngeal diphtheria, to moist air. Those, however, who deem it judicious to employ steam as a vehicle for carbolic acid, salicylic acid, chloride of sodium, chlorate of potassium, or lime, had best resort to the atomizer for applying these remedies. It can be used without trouble ; most children are sufficiently intelligent to allow a spray of nebulized solution to be directed upon the fauces and larynx every ten or fifteen minutes, in case of necessity. On the other hand — and again I emphasize the fact, that I know of no specifics for diphtheria, and recommend no uniform treatment for all persons, and all cases — I have seen cases of fibrinous bronchitis getting well, when I had every reason to attribute the recovery to the persistent l8o A TREATISE ON DIPHTHERIA. use of steam. As in the case of croup I have detailed in another place, the child was kept in steam and turpentine vapor more than four days, so I have seen Dr. F. Zinsser lock up a baby in a small bath-room, with one window, and let the hot water run persistently, for days, fill the room so as to produce a constant fog, and make every per- son in the room dripping. The result was highly gratify- ing ; the baby got well ; and so did another, whom I had the good fortune to benefit by my experience in that case. Again, I insist, steam will improve, steam will impair. Ars longa. Individualizing is a great art. In regard to the steam therapeutics it is, however, not so difficult. Its object is to soften, but principally to increase the secre- tion from the mucous membrane, and thereby throw off the superjacent membrane. This can be done to advan- tage only where there is a natural tendency to it, that is, where there are a great many muciparous follicles under a cylindrical or fimbriated epithelium. This is the con- dition on part of the pharynx, but not on the tonsils, in a small portion of the larynx, in the trachea and bronchi, not on the vocal cords. Wherever there is pavement epi- thelium on the normal surface, and where the membrane is imbedded into the tissue, steam can hardly be expected to do good. In the other cases it will. Thus the locality of the diphtheritic process determines to a great extent whether steam is indicated or not. If it be used, the necessity of a full supply of atmospheric air must not be disregarded. Steam, with an over-heated room and with- out pure air, is liable to be as injurious as steam in pure air is beneficial in a number of cases. There can be no better proof for the necessity of indi- vidualizing, and the impossibility of treating all cases alike, than the fact that many will do well under steam treat- ment, and others are certainly injured by it. We ought not to be surprised at the repetition of the same old expe- rience that, when two do the same thing, it may not be the same thing. Two means as well patients as doctors. TREATMENT. l8l The object for which steam is inhaled is to soften and remove membranes. When that can be accomplished without reducing the required amount of oxygen, all is well ; when, however, respiration is annoyed or interfered with, the contra-indication to steam is as clear as its indi- cation is in more favorable cases. Nor is this different in cases of obstinate pneumonia, where steam may be either beneficial or injurious, according to circumstances. WATER may be made serviceable in quite a different manner. Its effect, when taken in large quantities, under normal or abnormal circumstances, on the skin is a matter of daily experience. Copious perspiration is its immediate result. The very same effect is produced on all integuments and amongst the mucous membranes, principally on those of the respiratory and digestive organs. It is particularly plain when water is drunk during a nasal catarrh, when the discharge increases immediately ; while, on the other hand, abstinence from drinking reduces the secretion. Much drinking moistens the mucous membranes, rhonchi become looser and moister, and the aim of raising and macerating membranes, if not reached, is certainly ren- dered more accessible. While one is done, however, the other need not be omitted, and a judicious combination of the methods of supplying the muciparous glands with plenty of fluid suggests itself readily to the thoughtful practitioner in the appropriate cases. Besides profes- sional hydropathists, I know of but one (C. Rauchfuss, in C. Gerhardt's Handb. d. Kinderkr., III., 2, 1878) who fav- ors the plentiful use of water, either by itself, from 100- 200 grammes (3 to 6 ounces) every hour, or oftener, or mixed in alcoholic beverages, warm punch, etc. COLD WATER, AND COLD IN GENERAL, are useful in different ways. Severe inflammatory symp- toms, in diphtheria and other affections, such as redness 1 82 A TREATISE ON DIPHTHERIA. of the throat, great pain, swelling of the glands, require cold applications, either an ice-bag or ice-cold cloths, well pressed out and frequently changed. They must, however, be placed where they can do most good ; in laryngeal diphtheria around the neck, in pharyngeal diph- theria and glandular swelling over the affected part. Therefore, the flannel cloth which covers the whole of the application must be tied over the head, and not behind. When ice-bags are used, care is to be taken lest they should be too large ; if so, they will not affect the desired spot at all. Small pieces of ice frequently swallowed are greatly relished by the patient; water-ices in small quan- tities will render the same service ; ice-cream, in half-tea- spoon or teaspoon doses every five or ten minutes, adds to the necessary nutriment. When the fever is high, and the surface hot, sponging with tepid or cold water, or water and alcohol, will mitigate both. For the cold bath or the cold partial pack (trunk and upper part of thighs), the general indications hold good. As a rule, 1 favor the latter. For many cases have such a tendency to debility and collapse that sometimes the circulation of the surface of the body is badly interfered with by cold bathing. Therefore, a contra-indication to cold bathing must be found at once in cold feet, either before or after a bath. When, unfor- tunately, the feet do not recover their normal temperature in a very short time, they ought to be warmed artificially, and the cold bath not repeated. In such cases, the cold pack, however, is still indicated. A linen or cotton cloth, large enough to cover the trunk and half of the thighs, is dipped in cold water, well pressed out, and the body of the patient wrapped tightly in it. The arms remain outside, the whole body is then wrapped up in a blan- ket, the feet may be warmed meanwhile when neces- sary, and the cold pack repeated as often as required to reduce the temperature, viz., once every five minutes, every half-hour, every hour. The contra-indications to the use of cold have in part TREATMENT. 1 83 been alluded to. Very young infants bear it but to a limited extent. The beginning of recovery contra-indicates it, unless for some local cause, for instance, an inflamed gland. Extensive use of cold water or ice is also forbid- den when there is no fever, where there is perhaps an abnormally low temperature, where we have to deal with the septic or gangrenous form of diphtheria, where the vitality is low, and the mucous membranes pale or even cyanotic. In such cases, on the contrary, while unlimited internal stimulation is required, the hot bath, or hot pack, and hot injections into the bowels will be found beneficial. LIME-WATER, GLYCERINE, AND LACTIC ACID decidedly dissolve the membranes, but whether there is sufficient time in most cases to produce a curative effect is another matter. Concerning lime-water and glycerine, I have employed a combination of equal parts of both. In cases of diphtheria in children of three or four years and over, I think that my favorable results were owing to assiduous cleansing of the throat and nose. In vastly more than one hundred cases after the completion of tracheotomy, I have employed the same combination, re- duced to a spray by means of the atomizer, and directed into the opening in the trachea, but must confess that my results left much to be wished for. Particularly in the last few years, in which the prevailing epidemic of diph- theria hardly ever intermitted, my results from tracheot- omy have been very unsatisfactory, because, amongst other measures undertaken for the same purpose, the spray of lime-water and glycerine was not of the least service in preventing the descent of the process into the bronchi. Long ago I have begun to rely less implicitly upon lime- water, where a local action upon the larynx and trachea is called for, owing to its instantaneous conversion into car- bonate of lime.* * Dr. Billington takes exception to my remarks on the inefficiency of lime- water made before the New York Academy of Medicine, on the occasion of 1 84 A TREATISE ON DIPHTHERIA. lactic ACID, too, dissolved in from ten to twenty-five parts of water, has yielded no better results in my hands. I can cite but one case, that of a boy of five years, who, under the constant spray of lactic acid into the throat, and as far as possible into the air-passages, recovered from an attack of croup after a number of days, although trache- otomy had not been performed. A similar success has been communicated to me by Dr. Wm. Chamberlain. Those cases of tracheotomy which I subsequently treated with a spray of lactic acid did not terminate more favorably than those in which lime-water and glycerine were employed. I have not been able to convince myself of the locally solvent action of PEPSIN. With NEURIN I have no experience. It was both externally and internally first used by Winiwarter, and is recommended because of its being an alkaline antifermentative, while all other the doctor's reading a detailed account of forty cases of diphtheria. In an open letter to the Editor of the Medical Record, over his name and ad- dress, he says it occurred to him that the question might be answered by a very simple experiment. He says : " I was permitted, by a patient who has an unusually patent and tolerant threat, to hold a bit of red litmus paper at the end of a wire, and protected from the action of the saliva by coils of wire, well back in the pharynx, the patient being instructed to breathe naturally. I then, with the atomizer -which I use in treating diphtheria, and in exactly the same manner, threw the spray of lime-water into the throat. In fifteen seconds the red litmus paper was turned blue — this change occurring quite as rapidly and as completely as when the same experiment is performed in the outer atmosphere. In other words, it was not appreciably modified by the breath. Again, litmus paper moistened with lime-water can be held in the breath for some minutes before its blueness is perceptibly affected by it. This experiment seems to me to show that lime-water spray reaches the fauces and pharynx as lime-water, and does not immediately thereafter cease to be lime- water. When spray thrown into the throat by this method enters the larynx, it does so by being drawn in thither by the inspired breath which is compara- tively free from carbonic acid, and it therefore reaches the walls of the larynx as lime-water, and then continues to be lime-water for a certain length of time." So the red litmus paper, while dry, was not easily affected by the carbonic acid of the breath? Why should it, when no chemical text-book makes a statement to the contrary? And the red litmus paper was turned blue by cov- ering it with lime-water — indeed! Litmus paper owes its very existence TREATMENT. 1 85 antiseptics are acid, and, therefore, must undergo changes before they can be admitted to the circulation. It is claimed that the foetid odor disappears readily, and that membranes are dissolved more easily by its three-per-cent solution than other dissolvents. C. Edel recommended (Med. Rec, Jan. 19th, 1878) the treatment of diphtheria by TURPENTINE INHALATIONS. Fifteen drops of oil of turpentine are inhaled from a com- mon inhalation apparatus, which is placed at a distance of three inches from the mouth of the patient, for a period of ten minutes every hour. He claims recoveries in from twelve to forty-eight hours. Taube (Deutsche Z. f. prakt. Med., 1878, No. 36) also uses oil of turpentine, but, as far and reputation to the fact that it is so very sensitive, and shows the effect of either acid or alkali so readily, and in the most minute quantities. Let us remember that the atomizing apparatus with each pressure sprays about i-500th of a grain of lime ; that, therefore, it takes hours to send a grain of lime into the throat ; that, however, a membrane has to lie immersed in lime-water for hours before it shows signs of maceration ; that lime-water introduced into the trachea even, through the tracheotomy tube, does not dissolve membranes to any satisfactory degree — though they be only deposited upon, and not (as on the tonsils and parts of the larynx) into the tissue ; and though in the trachea the mucus of thousands of glands readily aids in mac- erating ; and though in the opened trachea the lime-water certainly reaches the membrane, which is not so certain in regard to pharyngeal or even laryn- geal membranes when you atomize into the mouth and pharynx. And as the doctor relies on experiments, he can add one which he made when he. was quite young. Let him blow into as much as half a pint of lime-water (containing about four grains of lime), and the whole of that lime will be a turbid cloud of carbonate after a very few expirations. Here is another experiment : Let the doctor dip blue litmus paper into moistened carbonate of lime, or a solution of sodium carbonate, or even bicar- bonate, and his blue litmus paper will behave exactly as it does in his patient's throat, to wit, it will remain blue ; which is not remarkable at all ; and then let him breathe upon the litmus paper moistened with calcium carbonate ever so long, and it will remain blue. Should it not? In his experiments on his patient's throat nothing is proved except that the newly formed calcium car- bonate secures the blue color to his litmus paper for some time. That is all, and requires no proof. 1 86 A TREATISE ON DIPHTHERIA. as the effect of the latter is concerned, it cannot be appre- ciated, as his treatment is not a uniform one. For he adds two or three daily injections into the tonsils of a three-per-cent solution of carbolic acid, one or two tea- spoons of claret every hour, ice externally, two or three warm baths daily, with cold shower, milk, egg, infus. digi- tal. 0.5:80.0, with ac. benzoic 1.0, etc. His dose of oil of turpentine is like that of Edel ; in order to avoid local irritation, he oils the face and covers the eyes with a bandage ; he reports that he never saw renal or cerebral disorders following its administration. For years I was in the habit of using turpentine, either the oil or the rectified spirits, as an inhalation in bad cases of pneumonia, where hepatization was very extensive,, and expectoration and resolution did not commence, with very good result in children and adults. The vapors of turpentine are so volatile and penetrating (and certainlv the procedure of Taube so disagreeable to the patient, if it be permitted at all by children) that the usual method of inhaling from an apparatus appeared to me to be very superfluous. I allow the patient to remain in his bed, and keep water boiling constantly on an alcohol lamp, on the stove, or over the gas. A tablespoonful of spir. rect. or ol. terebinth., more or less, is poured on the water, care being taken that nothing is spilled in the fire. Thus the room is constantly filled with a penetrating odor of turpentine, which is not at all disagreeable, even when in great con- centration. The effects are very satisfactory indeed. Where circumstances allowed or required it, I raised a tent over the bed, large enough not to give inconvenience to the patient, and to admit either the whole apparatus or the tube containing the mixed vapor of water and turpen- tine. This plan I followed also in the case of laryngeal diphtheria of a girl of two years, in the children's service of the Mount Sinai Hospital. The baby was in a room of her own, with a nurse. A tent was raised over the bed. Four days and nights was she exposed to the water and TREATMENT. 1 87 turpentine treatment, awake or asleep ; not only she, but also the nurse, whose presence under the tent was insisted upon by the patient whenever she was awake. It ought to be stated that the case was not (or was not allowed to become ?) a very serious one. It was serious enough to be diagnosticable, to produce hoarseness, aphonia, dyspnoea, and to render the perception of pulmonary murmurs impos- sible ; but there never was cyanosis with the exception of a slight hue on the upper lip. She got well, with no other treatment but my iron and pot. chlor. solution. As a practical addition, I may say that the nurse did not suffer much more than she would have done after the same time passed in a close room, and in constant attendance upon an exacting and whimsical patient. AMMONIUM CHLORIDE, muriate of ammonia, may sometimes be used to advantage for its softening and liquefying effects. Its internal admin- istration in bronchial and tracheo-laryngeal catarrh is so old that it has several times been obsolete. Of late, more stimulant effects have been attributed to it than it actu- ally possesses. But its liquefying action, in cases where the secretion of mucus is defective, and expectoration slow and viscid, is undoubted. Thus it proves valuable in many cases of simple catarrh, both when administered internally and inhaled. The latter mode of inhalation I have often resorted to, and believe that its macerating influence has been of service to me in cases of laryngeal diphtheria. Half a teaspoonful of the pure salt is spread on the stove, or burned over alcohol or gas. It evaporates immediately and fills the room, or the tent, with a white cloud, which, when dense, excites coughing. But it does not irritate to any uncomfortable degree, and the process may be repeated in an interval of an hour or more. HYDRARGYRUM has been used in all and any children's diseases. When I 1 88 A TREATISE ON DIPHTHERIA. was young, I seldom saw a prescription for a child without some little or much mercury on it. That, therefore, it should be given in diphtheria is not surprising ; that, how- ever, it should be given in a septic or gangrenous form is almost incredible ; that it should be recommended as a panacea in all classes and forms of diphtheria shows that common sense and sound judgment does not always pre- vail in the treatment of a disease where individualizing is of the utmost importance. If there be any specific in the world, mercury is not it ; not even in syphilis. However, not all cases of diphtheria are septic or gangrenous ; and not all cases occur during an epidemic ; nor are all the cases occurring during an epidemic of the same type. Some have the well-pronounced character of a local dis- ease, either on the tonsils or in the larynx. The cases of sporadic croup met with in the intervals between epidem- ics yield no constitional symptoms, and assume more the nature of an active inflammatory disease, very much like the sporadic cases of fibrinous tracheo-bronchitis. These are the cases in which mercury deserves to have friends, apologists, and even eulogists. Amongst them I shall not mention any of the old-time practitioners, who may have been led to the regular use of mercurial preparations in large doses by the very fact of their cases assuming the merely inflammatory character, but a few with a deserv- edly fair fame, and taking a high rank in the modern pro- fession. I shall mention Oppolzer, Bartels, Senator, and Rauchfuss, the two latter of whom are alive and still active ; but again insist on the fact that they use mercu- rials in membranous croup for its liquefying and melting effect. Of these, however, after long experience, Bartels discarded it; Oppolzer used calomel and iodide of potas- sium ; Senator, calomel and antimony ; Rauchfuss, calomel with oxysulphuret of antimony, blue ointment, and hypo- dermic injections of the corrosive chloride. In regard to the action of mercurial remedies, I am no longer so skeptic as I was a quarter of a century ago. For TREATMENT. 1 89 a dozen years I hardly ever prescribed mercury, suppos- ing that the harm it might do could be avoided by substi- tuting other medicines, and that its effect, except in syphilis, could be obtained by other means. I admit that the expe- rience of many subseqent years has changed my views to a certain extent. I know that in chronic inflammatory troubles which I considered incurable in former times, a good many favorable results have been due, at my hands, to the protracted influence of mercurials ; thus, for in- stance, in chronic inflammations of the nervous centres, particularly the spinal cord. I also know that when the constitutional effect of mercury could be obtained speed- ily, cases of fibrinous tracheo-bronchitis got well in an unexpected manner. To accomplish that, it is neces- sary to give small doses very frequently. Calomel, 0.5- 0.75 (grs. viij.-xij.), divided into thirty or forty doses, of which one is taken every half-hour, is apt to yield a con- stitutional effect very soon. Such doses, with minute doses, a milligramme or more (gr. -gL-), of tartar emetic, or ten or twenty times that amount of oxysulphuret of antimony, have served me well in fibrinous tracheo-bron- chitis. But the mucous membrane of the trachea and bronchi is more apt to submit to such liquefying and mac- erating treatment than the vocal cords. The latter have no muciparous glands like the former, in which they are very copious. And while the tracheal membrane is apt to be thrown out of a tracheal incision at once, though of more recent date, the pseudo-membrane of the vocal cords takes from six days to sixteen or more for com- plete removal. Still, a certain effect may even here be accomplished, for maceration does not depend only on the normal mucus of the muciparous glands, but on the total secretion of the surface, which will be in constant contact with the whole respiratory tract. Thus, either on theoretical principles, or on the ground of actual expe- rience, men of learning and judgment nave used mercury in such cases as I detailed above, with a certain conn- 190 A TREATISE ON DIPTHERIA. dence. The actual benefit derived therefrom cannot have been great, for the mortality from croup has nowhere been encouraging. Nor is it an enjoyable proof of its efficacy that Bartels is known to have lost confidence in it in his ripest old age, either for its general unsatisfac- toriness, or for the reason that the general character of all the cases in the epidemics of his later years changed the nature of his cases from the inflammatory to the septic type. If ever mercury is expected to do any good in these cases of suffocation by membrane, it must be made to act promptly. That is what the blue ointment does not. In its place I recommend the oleate, of which ten or twelve drops may be rubbed into the skin, along the inside of the fore- arms or thighs (or anywhere, when their surface becomes irritated) every hour or two hours. Or refracted doses will be useful, such as given above ; or hypodermic injec- tions of corrosive bichloride in one-half (or one) per cent solution in distilled water, four or five drops from four to six times a day, or more, either by itself or in combination with the extensive use of the oleate, or calomel internally. The hypodermic injections act very promptly and favor- ably, as I repeatedly convinced myself; for instance, in those cases of hereditary syphilis, which, from the pres- ence of volar or palmar pemphigus and general cutaneous eruptions at birth, yield, as a rule, an almost fatal prog- nosis under ordinary circumstances, and with the ordinary treatment. ASTRINGENTS. It seems to me a fact worthy of notice that the pure astringents, as alum, tannin, and nitrate of silver, which are so extensively employed in the treatment of the simple pharyngeal catarrh, appear to have been given up, to a greater or less extent, by most practitioners, where an exudative process exists. Oertel raises an objection to the employment of astringents, on the ground that, by TREATMENT. 191 hindering the detachment of the membranes, they are more likely to prevent suppuration, and thereby facilitate the impregnation of the tissues with poisonous elements. Whether this theory be correet or not, I assume that it is based on an experience which agrees with my own, as a result of which I am opposed to the employment of pure astringents. The remedy, however, which, for a number of years, has been employed by physicians, and which, furthermore, belongs to the group of astringents, is the CHLORIDE OF IRON. This substance was first used in diphtheria because an analogy was supposed to exist between the latter disease and erysipelas, in which the remedy had proved of great utility. It was introduced into France by Velpeau, into England in 1851 by Hamilton Bell in the treatment of erysipelas, and employed, not merely locally, but also internally. It has been used in diphtheria in France, by Gigot, since 1848, and in the following year by Crichton, in Scotland. Richardson, in the year 1865, published a report of two hundred and twenty cases of diphtheria in Melbourne, extending over a period of seven years, which he had treated without exception, since 1861, with large doses of the chloride of iron in combination with chlorate of potassium administered in the form of powder. There were eighteen deaths, constituting 8.2 per cent of the en- tire number of cases, in other words, a mortality but little greater than that from measles, as observed by himself and many others. Since that time, British and American journals have teemed with the reports of good results fol- lowing the administration of the chloride of iron, and in a monograph which appeared a few years ago, Schaller maintains that the diluted chloride of iron is superior to all other remedies in the treatment of diphtheria. I have used the chloride of iron in very many cases of diphtheria. In my essay on the latter disease, in i860, I spoke of its effectiveness after observing a large number of cases of the disease in 1858, 1859, an d i860. 192 A TREATISE ON DIPHTHERIA. In the administration of the chloride of iron it must by no means be forgotten that small doses at long intervals are out of the question. I have not the least doubt but that the failure of the remedy may be attributed in most cases to the fact that the doses were too small and administered too seldom. Steiner thought himself in duty bound to refute Schaller's statement concerning the efficacy of the remedy after employing it for four chil- dren. He administered hourly a teaspoonful of a mixture containing five to eight drops of the tincture of the chlo- ride of iron in three ounces. In addition, a mixture con- taining thirty drops in sixty grammes was applied locally three or four times daily. The youngest two, one a child of three years, died in consequence of an extension of the process to the larynx, the other two recovered. These experiments were decidedly incomplete and therefore gave an unsatisfactory result. A dose of five to fifteen drops every ten or fifteen minutes, half hour, or hour, is indispensable for a proper estimation of its effects. Gargles are not of much service, for the simple reason that they do not come into sufficient contact with the affected parts, and reach at the utmost to the anterior pillars of the soft palate. A direct application of the remedy to the mucous membrane of the pharynx may also be desisted from, thereby avoiding any irritation, the in- ternal administration at short intervals causing the pharynx to be sufficiently influenced by local contact with the remedy. It must, of course, not be expected that the chloride will remove the membrane, but it can frequently be seen to reduce the hypersemia and swelling, and pre- vent the reproduction of exuded material. Now, as re- gards the power of coagulating albuminous substances which is possessed by astringents, a considerable difference between these various agents can be demonstrated. A solution of tannin brings about a cloud-like flocculus, car- bolic acid the same, but it requires to accomplish that effect about half a minute ; alum, a viscid coagulated mass which TREATMENT. 193 sinks to the bottom of the test-tube without increase of its bulk by further deposits ; creasote, added drop by drop, forms isolated coagula, each one of which sinks separately to the bottom and increases in size. Perchloride of iron produces a coagulum several lines in thickness and sinks slowly to the bottom, while the fluid above remains clear (M. Putnam Jacobi). When we expose the subcutaneous veins in a living rabbit and touch them with a drop of solution of the chloride, no effects will be apparent for more than a minute. At the end of that time, the calibre of the veins becomes decidedly diminished ; on the other hand, a drop of creasote similarly applied gives rise to coagulation which at once obliterates the veins by compression. The effect in the latter case is purely mechanical. The former indi- cates that the chloride exerts a decided influence on the vital contractility of the blood-vessels. This increased contractility certainly assists in diminishing the rapidity of absorption of putrid fluids through the blood-vessels, which constitutes the principal source of danger from the disease. It cannot yet be positively asserted that the chloride of iron exerts a direct effect on the lymphatic vessels. Naturally this was claimed, when the remedy was trans- ferred from its therapeutic effects in erysipelas with the accompanying inflammation of the lymphatic vessels of the skin, to the treatment of diphtheria. Although we know of no direct compression of the lymphatic vessels due to the action of the chloride, yet it may be assumed that perhaps the compression of the blood-vessels exerts a similar influence upon the neighboring lymphatics. In consequence of this there would be an impediment to the absorption and further development of poisonous sub- stances in the lymph. The chloride, like the sulphate of iron, is a tolerably powerful disinfecting agent. All astrin- gents act more or less as disinfectants, and some of the best disinfecting agents, as creasote, are powerful astrin- 13 194 A TREATISE ON DIPHTHERIA. gents. .Mundy employed iron in the treatment of wounds, and Beale claims that it is a powerful antiseptic, especially when combined with glycerine. He explains its action on the ground of its limiting the growth of the bioplasm and hence checking the rapid necrobiosis. It is as efficacious in checking the movements of micrococci and bacteria as in coagulating albuminous ferments, so that its action may be explained to suit the existing theories concerning diph- theria. As the result of experiments with disinfecting agents, which were undertaken in London, it was found that 2.27 litres (half a gallon) of chloride of iron sufficed to disinfect 30,000 litres (6,600 gallons) of polluted water, 1.36 kilogramme (3 lbs. avoirdupois) of chloride of lime, and 36.35 lbs. of lime being necessary to produce the same re- sult. The chloride of iron long had a place in Chevallier's list of disinfectants, and is placed by Herbert Baker by the side of other mineral salts to which he attributes the power of destroying chemical poisons. The internal administration of the chloride of iron, moreover, is undoubtedly as important as its local appli- cation, even though the theory of its absorption, and of its action after absorption, be still involved in obscurity. It has been claimed that the chloride is decomposed immediately after it has been introduced, and that the muri- atic acid alone enters the circulation, but the urine has just as little revealed the presence of free muriatic acid as of the salt. There is reason to believe that the chloride of iron is absorbed with remarkable rapidity by the stomach directly, and that the re-appearance of the iron in the faeces may be explained by an elimination of the remedy by the intestinal glands. Moreover, Quincke has found that when the chloride of iron is rapidly introduced di- rectly into the veins of animals, emboli form in the pulmon- ary vessels ; but when the drug is so slowly injected that its entrance into the blood may correspond with the period required by the stomach for absorption, only very minute precipitates will form and be taken up by the white blood- TREATMENT. 195 corpuscles. If this observation be correct, it may go very far toward explaining the action of the chloride of iron in septic diseases, which are accompanied by an exalted activity of the lymphatic vessels, and an increase of the white blood-corpuscles. Furthermore, Saase has in so far modified the general opinion concerning the influence of the iron and the obliteration of the blood that he attributes to the ferreous salts the power of converting oxygen into ozone. They share this power with the blood-globules exclusively, and could hence, to a certain degree, sup- ply a deficiency of the latter. Pokrowsky, too, has shown that iron increases the process of oxydation in the body by demonstrating that in health there is a elevation of tem- perature and an increase of the percentage of urea in the urine, during its administration. In anaemic persons, to whom iron has been given for the purpose of increasing the amount of blood, the above phenomena may be observed before this object is accomplished. Thus iron appears to replace the blood-corpuscles to a certain extent. Now, in infectious disorders of the blood, when the red gobules are perpetually menaced with destruction, it seems plausi- ble that the preparations of iron should exert an antiseptic action. Finally it has been found that of all the preparations of iron, the chloride possessed the power of stimulating the nervous system. Possibly this effect may be traced to an increase of the arterial pressure in the nerve-centres. It has been said that this effect has been vividly illustrated in certain forms of chlorosis. If this be true, iron would be all the more indicated in diphtheria, since it would act as a prophylactic against a series of nervous phenomena that so frequently present themselves, both during and subsequently to, the diphtheritic process. CARBOLIC ACID has long held a prominent position in the group of disin- fecting agents. It is an established fact that, in solutions I96 A TREATISE ON DIPHTHERIA. of the proper strength, it checks putrefaction, destroys bacteria, and suspends the movements of the white blood- globules. It is true we cannot infer from this that diph- theria depends on the presence of living germs which, in a state of health, exist in large numbers in almost all the organs of the body, the more so as an immense quantity of the disinfectant is shown above to be required for that purpose ; but carbolic acid exerts a powerful influence on the vitality of all living elements, and, hence, too, on rapidly proliferating epithelium which constitutes a part of the diphtheritic membrane. It has been experimentally proven that carbolic acid destroys the efficacy of vaccine virus ; in a similar manner, probably, it lays low the diphtheritic poison. I employ it both locally and inter- nally, the latter in frequently repeated doses — every ten or fifteen minutes to one hour — dissolved in water, with or without the addition of glycerine or alcohol, adminis- tering from one-half to two grammes (eight grains to half a drachm) in twenty-four hours. For gargles, mouth-washes, and nasal injections, I resort to solutions of one-half to two per cent. Rothe also has seen excellent results from the use of carbolic acid, and it forms an important part of many recipes highly recommended by contributors to medical journals. In the degree of dilution in which he has employed it, the results have probably been similar to mine with the use of more concentrated solutions, for he too describes the contraction and shrinking, though not the crumbling of the membrane which I have frequently seen to occur in a short space of time. He combines the remedy with iodine, for external applications, in the fol- lowing proportion: Carbolic acid and alcohol, each 2 parts ; water, 10 ; tincture of iodine, 1 part. SALICYLIC ACID, of late, has been highly praised as a disinfecting agent. Its action is tolerably well understood, but continued observation and clinical experience will tend to cool TREATMENT. I97 the ardent enthusiasm with which salicylic acid has been praised. I have not had favorable results from the local employment of salicylic acid. In rather concen- trated solutions (1 : 30-50) and in weaker strength (1 : 200- 300) its action was alike undeserving of praise. In the more concentrated form it acts as a caustic ; the only effect that I could perceive from the milder solution was a diminution or total disappearance of the foul odor from nose and throat, but 1 cannot testify to a more rapid de- tachment of membrane, or to a more speedy termination of the disease under its use. Its failure to produce good results seems to me to be in direct proportion to the ex- tent and thickness of the membrane. Its salts are no dis- infectants, but antifebriles, and salts are at once formed in the stomach when it is given internally. Where there was high fever accompanied by a very moderate exuda- tion, I had reason to be satisfied with the effects of the drug administered internally. I have reference to cases in which the general symptoms are more prominent than the local ones, where the latter may even be absent, and to which, as long as twenty years ago, I applied the term of diphtheritic fever. One of my first cases on which I tried the salicylate of sodium was that of a boy of four years, who for days had a slight exudative deposit, a marked swelling of the glands of the neck, and a temperature of nearly 106 F., without showing any signs of improve- ment. The prognosis was rather unfavorable, or, to place it in the best light, very doubtful. Under the adminis- tration of 4-5 grammes (3-4 scruples) of salicylic acid, combined with 3 grammes (2]4 scruples) of bicarbonate of sodium daily, the boy recovered. My experience was similar in many other cases. In many, on suspending the remedy, the temperature would rise, but sank again as soon as it was resumed. For this reason I recommend the use of sodium salicylate as an antifebrile agent in a severe attack of diphtheritic fever, while I am not at liberty to speak favorably of the local action of salicylic I98 A TREATISE ON DIPHTHERIA. acid on parts covered with membranous deposits.* When- ever it is administered, however, it ought not to be forgot- ten that serious brain troubles, collapse, and irregular and paralytic breathing may follow its administration. It ought not to be used without careful watching, and the cotemporaneous free use of alcoholic stimulants. As regards the antiseptic action of the usual doses of QUININE, it can be hardly considered as brought about otherwise than by actual contact with the membrane, and not per- chance after absorption into the blood. Binz found, as the result of experiments with solutions of pure quinine vary- ing from one part in a hundred to one in a thousand, that the latter sufficed to prevent the development of bacteria in fluids capable of undergoing putrefaction ; but even estimated thus, a patient with eighteen pounds of blood would require one hundred and thirty-eight grains of quinine circulating therein in order to satisfy the condi- tions of Binz's experiment. If Binz considers two grammes (half a drachm) of quinine per day sufficient for an indi- vidual weighing one hundred and twenty pounds, his cal- culation is founded on experiments with dogs, in which * In regard to the effects of sodium salicylate, P. A. Blanchier made a num ber of experiments in Vulpian's laboratory (Recherches exper. sur Taction physiol. du salicylate de soude, Paris, 1879). His conclusions are as follows : It requires rather large doses to exhibit an effect. In the commencement it stimulates, and afterwards paralyzes the central nervous system to such a degree as to destroy the functions of the gray substance. By its effect on the nervous centres, and especially the medulla oblongata, it increases secretions, produces vomiting, and disorders the gastro-intestinal tract, and destroys life by paralyzing respiration and circulation. It has no influence on the peri- pheric, sensitive, or motory nerves, but paralyzes the sympathetic ganglionic cells in general, and the intracardial ones particularly. In very large doses it affects the glandular cells as well, as also, histochemically, the muscular tissue, though it cannot claim to be a muscle poison. Its therapeutical success in articular rheumatism is attributed to its local modification of the inflamed tis- sues of the joints, an attempt rather at an explanation than a lucid and intelli- gible illustration of its effect. TREATMENT. 199 septicaemia was avoided by the injection of quinine. It is also necessary to bear in mind that Binz makes a distinction with regard to the preparations of quinine employed. He warns against the use of the bisulphate as being the most inactive. No matter which preparations are used — I pre- fer the muriate — I have come to look upon quinia as of no great service in reducing the temperature in infectious fevers. The main indication for its use can only be found in inflammatory fevers. When it is given, however, salicy- late of sodium may be added for a short time to obtain a speedier effect. My position in regard to the question whether the local manifestation of the disease, or local origin of the disease, should be treated with caustics, is at once determined by the fact whether in individual cases I consider the membrane the symptom of a general disor- der, or the cause of the disease. In the former case less can be accomplished than in the latter, supposing that the destruction of the morbid products can be accomplished at all. The matter is not by any means simple, for even though the membrane be but the result of a general pro- cess, yet the presence of membrane or of an infiltration acts in turn locally, by influencing the lymphatic system, by injuring the blood-vessels, and by contaminating the air, so that, what was an effect now becomes a cause. Therefore there is, at all events, a theoretical indication to destroy existing membranes, and thus render them innocu- ous. But in practice we often meet with either im- possibilities or contra-indications. Most of the caustics act only superficially ; this is especially the case with NITRATE OF SILVER. POTASSA and other deliquescent salts, as also CHROMIC ACID may at once be excluded because of their proving dan- 200 A TREATISE ON DIPHTHERIA. gerous to the neighborhood. In my experience, concen- trated mineral acids penetrated no deeper than nitrate of silver ; for the quantity at each application must only be small. Indeed it is far easier to recommend than to carry out the cauterizing process. Few patients have enough self-control to permit a thorough application of the remedy, and rarely does it succeed so happily that a satisfactory effect is obtained, while at the same time — and that is of paramount importance — no injury is caused to the surrounding parts. Inasmuch as I so forcibly insist on the importance of keeping the oral mucous membrane as healthy as possible, and even for that reason alone look with favor upon the treatment by chlorate of potassium or sodium, I should certainly take great care not to cause wounds or erosions on which the diphtheritic process could at once take root. I consider it wrong to cauterize a membrane or infiltration unless I am sure of being able to do it thoroughly, and at the same time to limit the action of the remedy to the diseased surface. I prefer, above all other remedies for cauterization, a mixture of equal parts of carbolic acid and glycerine or the concentrated acid alone. I have occasionally seen good results therefrom. The local action is at all events satisfactory if it can be restricted. The membrane crumbles and drops off in small fragments. Where the oral or pharyngeal space is small and the patient unruly, I confine myself to frequent disinfection of the diseased parts with weak solutions of carbolic acid, by way of the mouth or nose. I never use force to compel a child to submit to a cauterizing process in the throat, when I mean to limit the effect of a caustic. Dr. A. Had- den recommends to me the local application of the liquor subsulphatis ferri. He states that in his opinion some of his tracheotomized patients recovered in consequence of the local effect it had on the tracheal membranes. My experience with bromine, administered internally at short intervals, in order to TREATMENT. 201 combine local with general treatment, and employed in numerous cases in several epidemics, does not redound to its credit. To apply bromine in substance, or slightly diluted, to the affected parts, as I have seen others do, and have myself done in hospital gangrene, is here entirely out of the question. Therefore, solutions only are admissible, as recommended by Ozanam, Schiitz, Rapp, and others. I have given the remedy in one-half per cent solu- tion with bromide of potassium every half-hour or oftener, without being edified regarding the local or general effects. In a number of cases, I have preferably given the bromide in statu nascente by mixing chlorine water with a solution of bromide of potassium. It is a more agreeable mode of administering the remedy, although the effects are not in- tensified thereby. In this connection, however, I should feel remiss of fulfilling my whole duty if I did not refer to the favorable effects, claimed by as deserved a colleague as Prof. Wm. H. Thompson, for bromine both locally and internally. While in a number of cases I have carefully followed his plan of treatment, 1 cannot say that my expectations were fulfilled. Still, his convictions are so strong, and his field of observation so large, that I gladly avail myself of his permission to detail his treatment in his own words, as contained in the following letter of his : New York, Aug. 21st, 1880. Prof. A. Jacobi: Dear Doctor : — ... I will simply give my reasons for relying on bromine in diphtheria as follows : I have been led long ago, by experience as I fancied, to prefer the haloid disinfectants, i. e., chlorine, bromine, iodine, and sulphur, to the carbolic acid class, i. e., quinine, salicin, carbolic acid, camphor, the spices, etc., against the septic changes which the specific communicable acute diseases cause in the system. On the other hand, for in- fection by decomposed pus, etc., the carbolic acid group is superior to the haloids. Those conditions, however, 202 A TREATISE ON DIPHTHERIA. which are more or less similar in their symptomatology, with low petechial or gangrenous manifestations, common in bad cases of measles, scarlatina, variola, typhus, and some cases of dysentery, as well as markedly in diphtheria ; in all such I regard the chlorine and bromine class far more effective. Of all members of this latter group of antiseptics, I have found bromine the most active and the best borne when administered according to the directions to be mentioned. It can be taken internally in relatively larger doses than any disinfectant with which I am acquainted, and from the entire absence of effect upon the nervous system (which cannot be predicated of any of the carbolic acid family, not even of quinine) it acts on the body purely as an antiseptic. Hence I have employed it for eighteen years in the treatment of diphtheria to the exclusion of all other remedies, and until I note very different results from it than has been the case in my own practice, I shall use no other remedy whatever. The benefits I would claim to result from its proper ad- ministration in diphtheria are these : i. When applied locally, it promptly arrests fetor by arresting directly the gangrenous process, and thus lessens risk from absorption. 2. It acts as an anti-putrefactive likewise in the fluids of the body generally, i. e., blood, interstitial circulation, and secretions, owing to its high rate of diffusibility, equal to sodium chloride itself. 3. It locally destroys the communicable property of the discharges, shown by the immunity of attendants from any sore throat, when it is used, and from its checking the spread of the disease in the locality. No claim can be adduced for it as an antidote, so-called, to the diphtheritic agent, except that I believe it can wholly destroy its germs when they are locally developed previous to general infection. When reproduction through- out the body has occurred, or when the contiguous TREATMENT. 203 lymphatic glands are extensively infiltrated, its action is then simply that of an internal antiseptic, and as such, I think, has no superior. When called to a case, I order two solutions to be used ; the first of equal parts of Lawrence Smith's solutio bromini and glycerine, applied with a hair pencil to the membrane, as gently as possible. Sometimes I use the solution full strength. The brush should be washed at once in water, and does not last more than one day, owing to the action of the bromine on hair. If, however, the membrane be very extensive and the parts much swollen, or difficult to reach, I resort instead to douching with a Davidson syringe, using half a drachm to one drachm of the solution to the pint of warm water. By beginning gently with the stream directed against the buccal mucous membrane, the child soon becomes accustomed to the cur- rent and allows it then to play against the deeper parts. Internally I order from six to twelve drops of the solu- tion to half-ounce of sweetened water, every hour, two, or three hours according to the urgency of the case, and continuously ; no other medicine being taken until the disappearance of the membrane ; when the case may then be treated on general principles. For convencience' sake I frequently order the preparation : 3 Smith's sol., 3 i. ; Aq., 3 i. ; teaspoon in tablespoon of well sweetened water. It should be swallowed promptly, for the disagreeableness of bromine is due much more to its fumes than to its taste, and patients soon learn to take it readily. The only in- convenience which I have seen from it has been in some a slight looseness of the bowels, which may be readily con- trolled by a small dose of paregoric. It is well borne by the stomach, as I have repeatedly seen it retained when solutions of quinine, or tr. ferri were uniformly rejected. The only diet recommended is cold milk and lime-water. As to the amount which may be taken with impunity, I once saw, in consultation with Dr. Chauveau, of Houston street, an infant of fourteen months, whose case seemed 204 A TREATISE ON DIPHTHERIA. hopeless from laryngeal extension of the membrane, but for three days it took twelve drops of Smith's solution, equivalent to two drops and a half of pure bromine, every hour unintermittingly, and finally recovered without an untoward symptom. The most convenient way of making Smith's solution is: take two ounces of a saturated solution of potass, bromid. in water, add to this, very slowly, in a bottle and with constant shaking, one ounce of bromine. It is better to add a part and then let it stand a while before adding the rest ; then fill up gradually, and with constant shaking, with water till it measures four ounces. This solution should be complete and without sediment. Dose, as above stated, six to twelve drops in well sweetened water. But it should not be ordered in a mixture with either glycerin or sugar, for it is soon changed by these agents into a color- less compound which is certainly inefficacious. For daily use I order it as above stated, dissolved in different strengths in simple water, and if not exposed to too strong light, it keeps for several days. Yours sincerely, W. H. Thomson. Finally, I reproduce (from Prag. Med. Woch., No. 10, 1880) an abstract of the treatment which J. Schiitz recom- mends. It is a bromine treatment, similar to that which he eulogized ten years ago, and which, amended by what I cannot help believing doubtful practice, he applied to twenty-eight cases with, as he states, satisfactory results. As soon as a deposit is visible in the throat, the finger is covered with a piece of linen cloth, moistened with water, and the membrane rubbed off.* When it is but partly removed, the process is repeated. " Patients felt better immediately, were cheerful, fever diminished, appe- tite increased, and sleep was no longer disturbed." After *Also E. J. Bonsdorff (Hygeia, No. 4, 1879, Med. Rec, Sept. 20th) takes the responsibility of mechanical removal, by all means possible, of the exuda- tion and mortified tissue, and touches the surface with nitrate of silver, twice daily " if necessary." TREATMENT. 205 the membranes were rubbed off, he made two or three injec- tions of a solution of bromine and potass, bromid., aa i , in 200 parts of water, or of pure water. That forcible removal of membranes must be repeated two to three times daily. The injections are to be repeated hourly. " Advanced chil- dren take a great pleasure in making the injections them- selves." (?) " The parts injured during the rubbing-off process remain mostly intact." (?) When there are obstin- ate membranes, they ought to be moistened with bromine solution five or six times daily. Cold applications round the neck are not required. Glandular swellings require pot. iodid. ointment (1 14), the size of a pea, three times daily. (?) "The patient is isolated. As a matter of pre- caution, after recovery, the bedding is aired, and it is left to the attendant to resort to any kind of disinfec- tion." (!) Jaeger (Corr.-Bl. f. Schweizer Aerzte, 1877, No. 5) uses iodide of bromine, potass, brom., aa 0.3-0.5 ; aq. destil., 150.0 (gr. v.-viij. in water § v.), |— 1 teasp. hourly or half-hourly for inhalation. Ice in addition. Netolitzky (Prag. Med. Woch., 1879, J une 2 3d), potass, brom., bromin., aa 0.05- 1.0; 150-200 (gr. i.-iss. in § v.-vi.) to be inhaled from a sponge for five or ten minutes every hour. Prince (St. Louis M. J., 1877, July 18th) prefers, also for inhalation, iodin., 0.06; potass, iod., 0.25 (gr. i.-iv.), in a mild solution. OZONE has but recently been recommended again, this time by Ph. Jochheim (Darmstadt, 1880). It is developed in a Richardson's apparatus, with two tightly-fitting corks and a funnel, by slowly (drop by drop) adding concentrated chemically pure sulphuric acid, 30.0 ( 1 i.), to potassium hypermanganate, 30.0. Ozone is developed while hyper- manganic acid and manganese hyperoxyde are formed, and expelled by a common syringe balloon, the tube of which enters the apparatus by the perforated cork. Potassium iodide paper has to turn purple or bluish-black by it. An 206 A TREATISE ON DIPHTHERIA. inhalation of three or five minutes every hour or two is considered sufficient. Still he does not neglect other treatment. Locally he uses a two or three per cent solution of potassium hyper- manganate as a gargle, mouth-wash, or application ; internally quinia muriate, 0.03-0.12 (gr. ss.-ij.), in honey or wafer, every two hours. Steam is used besides, and as a disinfectant, potass, hypermang., 50.0, in water, 300.0 (1 :6), mixed slowly in a china vessel with pure concentrated sulphuric acid, slowly heated. BORIC ACID has been used and eulogized by Wertheimber as a gargle, in a solution of 10 : 300 or 250, which is to be used every hour, with the exception of the nights, where the intervals may become longer. If gargling be inconvenient or re- sisted, the solution is injected, or the nasal douche resorted to. M. Vogel (Allg. Med. Centr. Z., Nos. 99 and 100, 1876), brushes the throat arid gargles with ac. bor. 4-6 : 180, every hour in the commencement. My own experience is not gratifying ; it is true that I gave up the remedy after I had used it in a dozen cases, but my results did not appear to encourage me. J. T. Lewis (Brit. Med. Jour., Jan. nth, 1879) recom- mends sulphurous acid in water as a gargle, in combina- tion with plenty of plain food and also stimulants. Concentrated solutions of boric acid have been highly praised in diphtheritic conjunctivitis. It is to be applied hourly. In accordance with Graham's experiments, made in Prof. Klebs' laboratory, which appeared to show that a certain proportion of SODIUM BENZOATE prevented the vegetation of the diphtheritic contagion, L. Letzerich (Berl. klin. Woch., Feb. 17th, 1879) adminis- tered sodium benzoate in twenty-eight cases, part of which TREATMENT. 207 were serious. Of these twenty-eight, but one died, and that was a case of laryngeal diphtheria. The child had suffered from croup before, and retained a great tendency to laryngeal disorders. Infants of a year or under, took one-half tablespoonful hourly of the following mixture : 1$ Sod. benz 5.0 (3iv.) Aq. destill., Aq. menth. pip aa40.o(|i. 3 iij.) Syr. cort. aur 10. o ( 3 iiss.) Children of from 1-3 years took 7.0-8.0 daily ( 3 ij.) children of 3-7 years, 8.0-10.0 (.3 iiss) ; and those over 7, sod.' benz. 10.0-15.0 (3iij-?ss.). Adults took 15.0-25.0 ( I ss.-3 vi.) daily. A disagreeable effect was not noticed. Twice or three times daily, or in bad cases every three hours, sodium benzoate was thrown or blown upon the diphtheritic deposits. Older children would also gargle with a solution of 10.0 : 200.0. In all cases the fever de- creased within twenty -four or thirty-six hours. Amongst the first who tried sodium benzoate exten- sively was Demrae (Annual Rep., 1878). His doses were, for the age of 3-6 months, 2.5 daily (3)ij.); 7-12 months, 5.0 (3iv.); 1-2 years, 7.5 (3ij.); 3-7 years, 12.0-15.0 ( 3 iij.-l ss.). In no case did he see an injurious effect. Beside the internal administration, he blew the drug into the throat every two or four hours. When the pro- cess was a very rapid one, with large tumefaction of the neck and glands, he also made subcutaneous injections of sodium benzoate (1:2) into the subcutaneous tissue and also into the tonsils. Besides, the trunk was treated with cold packs, and sometimes cold bathing was resorted to when the temperature was above 102 ; in septic cases also alcohol 5.0-75.0 (3iv.- § iiss.) daily. His mortality of twenty-two per cent he claims as favorable, though it does not impress me as such. To lose six cases out of twenty- seven is a result no practitioner is apt to rejoice over. Still he insists upon the following points as reliable con- clusions : 1st. That sodium benzoate is a reliable antizy- 208 A TREATISE ON DIPHTHERIA. motic in both internal and external administration. 2d. By its local application both as a powder and in solution it increases the secretion of the mucous membranes and favors the removal of diphtheritic deposits. 3d. Even large doses do not reduce the temperature to any great extent. 4th. The contraction of the heart becomes more intense, the beats less frequent, and the secretion of urine more copious. 5th. It does not influence either nephritis or albuminuria. In regard to its effects as a medicinal agent, I never ex- pected much. The parasitic school of pathologists have been remarkably hasty in their literary productions, as is well known. The journals of the last ten years are flooded with superficial observations, insufficient experiments, and immature conclusions. " Preliminary communications " of any length, and long articles, at the close of which the very writer says that his experiments prove nothing (compare, for instance, Miflet in F. Cohn's Beitr., III., 1879), abound. Thus journalism, and mainly in regard to those branches which boast of being exact, has become rather flimsy and flighty. The worst feature of this tendency in medical literature consists in the fact that the men who have to rely on their senses mostly, in their special investigations — mostly microscopical — finally rely on their own senses only. When they see benzoate of so- dium destroying bacteria in a glass vessel, they not only take it for granted that bacteria are the infectious disease, but also that the human organism will permit of the same action on the part of the antiseptic medicine as the glass vessel. Thus benzoate of sodium is sent into the stomach, or into a pulmonary cavity, under orders to do the same thing it does in the laboratory. The drug has, in conse- quence, had a short life, after having been extolled in a very limited time by microscopists, Russian diplomats, and the public in general. Clinicians tried it, but have soon learned not to trust it much. I believed I saw some favor- able result in puerperal diseases, at first, but do not feel TREATMENT. 209 convinced in regard to them at all. As an anti-diphthe- ritic, or even as an anti-febrile remedy, it cannot be trusted. Fr. Mosler's general principles in regard to the treat- ment of diphtheria are those of all sound practitioners. Thus he avoids depletion, antiphlogistics, and emetics, particularly antimony, and prescribes nutritive food and medicines. As a local application he employs oil of turpen- tine in inhalation, after having given up carbolic and salicylic acids, and potass, hypermanganate, because of bronchial irritation resulting from their use. After he obtained a favorable result from the use of OLEUM EUCALYPTI E FOLIIS (not ol. eucalypti australis, which is lower in price) in a case of echinococcus of the lungs, he also employed it in diphtheria. His strongest formula is as follows : 1$ 01. eucal. e fol 5-o(3iv.) Spir. vini rectif. 25.0 ( 3 vi.) Aq. destill 170.0 ( § vi.) M. For ten inhalations, one every hour or one and one- half hours. The professor hopes that no bronchial irritation will result from these inhalations, but admits that it may. His own cases are not numerous, and his confidence is not great. As in every disease which, at least in certain instances, presents great and insurmountable difficulties, so too in diphtheria, the pharmacopoeia has been ransacked for remedies. Long before the time of Roger and Barbosa, SULPHUR had been used. The insufflation of the drug at first gave rise to coughing and vomiting, and in the end proved dis- agreeable and futile. Still, Stuart (Practit., April, 1879) recommends it again. THE BALSAMICA, copaiba and cubeb, have been recommended for internal 14 210 A TREATISE ON DIPHTHERIA. administration, mainly by the French. Trideau's treatment of the inflammatory stage (not the septic) of diphtheria is so formidable that he was sure to have successors, if not successes. His doses of cubeb powder are for a child of from eight months to a year, 8.0 (3 ij.) daily ; of from two to three years, 10.0-15.0 ( 3 iiss.- 3 ss.) ; for an adult, 25.0-30.0 ( 3 vi.- 3 i.). Roger and Bastian opposed its administration because of its dangerousness, and mainly because of the difficulty of taking or giving it, and of the certainty of disordering digestion, which deserves of the greatest consideration wherever re- covery is, as frequently in diphtheria, depending on the power to resist the debilitating influence of the disease. Sanne opposes the use of balsamics, because of their being liable to produce nephritis, temporary though it may be. M. Larue (Gaz. Hop., 1877, No. 1 12) followed Tri- deau, however, adding quinia to obviate or relieve fever. Vedrini (Gaz. Med., 1878, July 27th, Aug. 3d) saw "great relief to children over ten years, in serious cases even," when he gave cubeb (12.0 [ 3 iij.] daily), and lost six out of ten. Others have given it, and what is worse still, recom- mended it. The objection to it, that it deranges digestion, is a very valid one, indeed, and Sanne is not correct when he believes the nephritis following the inordinate use of bal- samics to be but temporary. Smaller doses than those ordered above are well known to produce permanent nephritis ; unfortunately the opportunity to observe such cases is not so uncommon where diseases of the genito- urinary organs, in which the drugs of that class are so often used, are of frequent occurrence. Vaslin gave cubeb in 20.0 gramme ( 3 v.) doses daily in mild " anginas," and in thirty-four cases of croup. Of his eight cases of diph- theritic pharyngitis, one died of paralysis. Of the thirty- four cases of croup, three recovered without, ten with tracheotomy. This is high praise for tracheotomy, none for cubeb. T. M. Lownds (L. Lancet, 1879, March 22d) recommends TREATMENT. 211 tr. perchlor. ferr., 3 iij.-iv.; sol. ac. ammon., 3 iss.-ij.; pot. chlor., 3 i.-iss. ; aq., f, 3 viij., tablespoonful every hour. D. de Berdt Hovell (L. Lancet, Dec. 28th, 1878) com- mences his treatment with a dose of calomel. A. Erichsen (Petersb. Woch., 1877, No. 4), hydrargyr. cyan., 0.0006 (gr. y^-) to children under three years, 0.0012 (gr. -gL) over three years, every hour ; every two hours dur- ing the night. He did not succeed in losing more than 3 children out of 25. Collin (Rev. ther.. 1876), no cauterization, no depletion, but good nutriments. Aq. calc, 120.0-360.0 ( § iv.-xij.) ; liq. ferri chlor., 20.0-40.0 ( 3 v.-x.) ; ac. carbol., 0.06-0.12 (gr. i.-ij.). Anthony (Med. Surg. Rep., 1877, J an - ! 3 tn )' s °d. sulph. carbol., 3 ij. to a child of seven years. M. G. Sloan reported to the Iowa State Med. Soc, Jan. 27th, 1880 (Med. Rec, Feb. 21st, 1880), 34 cases of diph- theria treated successfully with quinine in large doses, alter- nated with sulpho-carbolate of sodium. He used locally tinct. ferri. chlor. and glycerine, applied gently to the affected parts, and in four cases of laryngeal complications he cured three by the use of inhalations of lime-water with the constitutional remedies named. D. McFalls (Med. Rec, Jan. 24th, 1880), Lugol's solu- tion thickened with tannic acid to the consistency of thin cream, as a local application. Peyrot (Gaz. hebdom., Oct. 17th, 1879), bromide pot., 15-20 (|ss.-3Y.); aq., 100 ( § iij.), as a local application, also brom. pot., undissolved for the same purpose. Hagenbach (Child's Hosp. at Bale, 16th ann. rep., 1878), ice internally, and externally inhalation of aq. calc, a solu- tion of sod. salicyl., lactic acid, or pot. chlor. A separate room filled with steam, zinc chlor. upon the tracheotomy wound. Emetics but rarely. T. Kaatzer (Berl. klin. Woch., 1877, No. 46) recommends still cauterization with the solid stick on three consecu- tive days, and pot. chlor. 10:300, a tablespoonful every 212 A TREATISE ON DIPHTHERIA. ■hour, gargling with the same solution, and ice exter- nally. Fehr (Deutsch. Z. f. prakt. Med., 1877, No. 25) gargles with sod. chlor. (on the meat-pickling principle) and carbon, sod. 1 : 150, a tablespoonful every hour, for the reason that, according to Tiegel, bacteria and micrococci are destroyed more easily by sod. carb. than other salts. H. Beyer (Brit. Med. Jour., 1878, May 4th), inhalation of a lactic acid solution. H. Roger and Peter (Un. Med., No. 100, 1877), in mild cases emetics ( ! ), ipec, 0.2-0.8 (gr. iii.-xii.) ; syr. ipec, 30.0 ( 1 i.), teaspoonful every 5 minutes, brushing of the mouth with lemon juice, twice daily irrigation with borax, alum, or aq. calcis. In serious cases repeated emetics ( ! ! ), syring- ing with aq. calc. 4-8 times daily, brushing with caustic soda 25 : glyc. 100, or arg. nitr. 10: 30 water. Bartels : ice, pot. chlorate, insufflation of alum or tannin, steam inhalations. Kidam : inhalations of whatsoever kind, if but warm and moist, warm poultices, pot. chlorate gargles. H. Zeroni (Memorab., No. 4, 1879), depletion and poul- tices. Kingford (L. Lane, No. 17, 1879), f° r more than twenty years, liq. ferr. mur., pot. chlorate, glyc. and water, every 2 or 3 hours, two daily applications of tr. ferri and glycerine. Food and stimulants. A. Schuster, no specific remedy, no antiphlog., but robor., stimul., and symptomatic treatment. Quinia, ether, brandy, camphor, pot. chlor., aq. calc, ice. John H. Gilman (Med. Rec, Sept. 20th, 1879), locally once or twice daily ac. carbol., gtt. xv. ; tr. ferri chlor., 3 iv.; aq., 3 iv. Internally, hourly through the day, pot. chlor., 3 iss.; aq., § iv.; ac. mur., gtt. x. A teaspoonful. In worse cases, pot. chlor., 3 iss.; aq., 1 iv.; tr. ferri chlor., 3 ss.~i.; quin., gr. ij.-v., teaspoonful every hour, spray or gargle of liq. sod. chlorin. v. Rokitansky (Allg. M. Cent. Z., Med. Rec, July 12th, TREATMENT. 213 1879), chloral and water, aa, brush every half-hour. Milder solution when the membr. has disappeared. F. L. Hartmann (Med. Rec., Jan. nth, 1879), chlorine in solution, sustaining diet, gargles of pot. chlorate, alum, salicylic acid, syr. ferri iod. F. A. Hubbard (Med. Rec, Nov. 15th, 1879), s °d. hypo- sulph. and pot. chlor., aa § ss.; may be dissolved in water as required for gargle, spray, internal use. Tully's powder, quinia, brandy, hot fomentations, or camphorated oil over swollen glands. In laryngeal diphth., vapor of lime in hot water from a coffee pot. M. J. Gahan (Med. Rec, Jan. 18th, 1879), tr. ferri mur., 1 i.; pot. chlor., 3 ij.; aq., 5 vij.; gargle 4 or 5 times a day ; tr. ferri mur., 10-20 drops every two hours. Thus in 200 cases, " it has yet to fail me — when " the disease was taken at its onset. E. Wiss (Deutsche Z. f. prakt. Med., No. 34, 1878), sulphate quin., 0.4-0.6 (gr. vi.-x.) ; aq. destill., 90.0 ( 3 iij.) ; ac muriat. dil., gtt. iij.; ammon. mur., 6.0 ( 3 iss.) ; syr. cort. aurant., 30.0 (f i.); |— 1 teaspoonful every two hours. No death (any patients ?). 3ouffe, no pot. chlor., no alkali, no emetics for exter- nal use. Every two hours ointment of axung, 75 ; camph., 25 ; tr. benz., 4-8. For internal use every hour a tea- spoonful or one-half tablespoonful of : lemon juice, 300 ; sod. chlorid., sod. sulphate, aa 10 ; honey, 15 ; with the addi- tion of some sod. carbonate. In the intervals, flax-seed tea, gargling, milk, touch the lips often with the mixture, keep the neck and chest warm, do not cauterize, ice, soups and bouillon. In albuminuria, milk with or without soda. Wm. A. Reiter (A Monograph on the Treatment of Diph- theria, Philadelphia, 1878), calomel and pot. Somebody is credited on page 29 with " Pittsburgh children are hard to kill." J. Dubrisay (Gaz. Hop., 1877) still writes against the extensive use of tart, emetic. H. Helmkampff (D. Z. f. pr. Med., No. 37, 1877), ice 214 A TREATISE ON DIPHTHERIA. internally and externally ; after three or four days, inhala- tion of steam, disinfection of oral cavity by mild solutions of carbolic acid; roborants. For swelling of submaxillary region a two-per-cent solution of carbolic acid hypodermic- ally. Taube (Jahrb. f. Kinderh., XIV., 1879, P- 20 9) : injection into the tonsils of a three-per-cent solution of carbolic acid, frequent injection into the nose, and sprays. Borax is preferred to turpentine, after this had been eulogized a year before. Local application in the night also. At 103 , quinia, a warm bath three times a day with cold shower. Frictions with alcohol. Cold applications around neck every half-hour. Cold pack every hour. No cauterizing. Milk and wine. Windows open. No draught. MECHANICAL REMOVAL OF THE MEMBRANES is not permissible unless they are almost entirely detached. As a rule, it is best to wait quietly till they are completely detached and cast off or swallowed, unless partly loosened membranes in the larynx or trachea afford an indication for an emetic. F. Barker alone has been fortunate enough to be able to claim that, with the assiduous and exclusive employment of turpeth mineral as an emetic, he has never had a death from croup of the larynx. Forceps requires very delicate manipulation, as any scratching or eroding of the neighboring mucous membrane increases at once the area of diphtheritic deposits ; sponges and brushes merely remove some superficial coating of the membrane without detaching the latter. Even where the membrane has been thrown off spontaneously, a new one often appears in a few hours. After a mould of the trachea and its bifurca- tion had been cast off, in a certain case — death occuring seven hours later — an autopsy revealed the presence of a thick membrane at the seat of bifurcation. Furthermore, the reports of good results from attempts at removal of local deposits are occasionally to be received with great care, particularly when they have reference to the larynx. TREATMENT. 21 5 Undoubtedly camel's-hair brushes and sponges may be thrust down, and in fact membranes removed by them, but in very small quantity compared with that which still remains. At all events, I should not expect good results from such practice in cases of membranous deposits in the larynx. Perhaps still less here than elsewhere. For after tracheotomy, the tube can never be removed before at least a week has elapsed after the performance of tracheotomy ; I have never succeeded in doing without it before the seventeenth day in my own cases. Besides, the examination of membranes in the cadaver demon- strates that they have nowhere a more tenacious hold than in the larynx. What success then can be hoped for from attempts at a mechanical removal from that locality? The difficulty I have sometimes met with in my attempts at partly clearing the nasal passages by mechanical efforts makes me hesitate to put much faith in a mechanical clear- ing out of the larynx. THE TONSILS. In mild cases of diphtheria of the tonsils I at times en- deavor to destroy the membrane, but only when it can be reached with ease. In my opinion, the indiscriminate use of mineral acids and lunar caustic have done more harm than good. Where I can easily reach the membranes, I usually apply concentrated carbolic acid ; where the mem- branes are not entirely within reach, I desist from this pro- cedure. A scratching of the mucous membrane and a wounding of the epithelium would assist in spreading the membranous process in a very short time to the surround- ing parts. I have already discussed the tendency of the disease to extend rapidly, and the danger of creating fresh wounds. In most cases of simple tonsillar diphtheria, I administer small doses of chlorate of potassium or sodium in water, or the tincture of the chloride of iron, so that from two to eight grammes ( 3 ss.— ij.) are taken in a day. I add a little glycerine, partly for the sake of keeping the 2l6 A TREATISE ON DIPHTHERIA. remedial agent longer in contact with the diseased sur- face, partly for its own antifermentative effects, and give it in short intervals. The accompanying fever is usually not high, and the neighboring glands are as a rule but little swollen or not at all. When there is a slight SWELLING OF THE LYMPHATIC GLANDS, cold water or ice applications are usually all that is needed. The latter should be made according to general indications. The glandular (and peri-glandular) swellings are less the result of an actual filling-up with foreign matter than of secondary irritation. Ice has a happy effect in such cases, both on internal administration, in the form of frequent small quantities of ice-water, ice-pills, ice-cream, and iced medicaments, as also externally by ice- cold cloths, or india-rubber bags filled with ice. In general, the treatment of the swelled glands must be both based on its causes, and adapted to the present con- dition. The adenitis and periadenitis is of secondary nature, the irritation being in the mouth, pharynx, and nares. In these localities it is where the main treatment is required. The sooner the primary affection is removed, or relieved, or rendered innocuous, the better it is for the secondary complaint. Frequent doses of chlorate of potassium, or sodium, or biborate of sodium (or benzoate ?) in mild doses frequently repeated, according to the prin- ciples laid down in another part of this book, mouth washes, gargles, nasal injections with water, salt water, or solutions of disinfecting substances are not only indicated, but highly successful. When the case is recent, cold ap- plications are required, but no washes. When it is of older date, stimulant embrocations are in order. Iodine ointments are absorbed but slowly ; mercurial plasters do good in some cases ; iodide of potassium dissolved in glycerine (i : 3-4), frequently applied, iodine in oleic acid (1 : 8-12), iodoform in collodion or flexible collodion (1 : 12-15) applied twice daily, the latter frequently with TREATMENT. 21? very good result, are beneficial. Copious suppuration is very rare. Cases in which a free incision meets with an abscess ready to heal are very uncommon. But local abscesses in large numbers, with gangrenous walls and pus mixed with a sero-sanguinolent or sero-purulent liquid are more frequently found. In such cases, a probe intro- duced into the lancet wound enters easily into the broken- down tissue in every direction, on slight pressure, to a distance of three to six centimetres (several inches), according to the size of the tumefaction. I have seen fatal hemorrhages from such gangrenous destructions ; therefore, the treatment must be both timely and en- ergetic. The incision must not be delayed too long. When the skin assumes a purplish hue, or is simply dis- colored, it is time to incise, and apply concentrated or nearly concentrated carbolic acid to the interior unless the neighborhood of very important blood-vessels or nerves yields a contra-indication to concentrated applica- tions. In that case, a milder preparation is advisable, but the application should be repeated often, until the suppu- ration becomes more normal. Then mild disinfectant in- jections into what has now become a cavity will be found satisfactory, particularly when meanwhile the general con- dition of the patient has been improved. DIPHTHERIA OF THE NOSE results either from an extension of the morbid process from the pharynx, or occurs primarily. It occasionally manifests itself by a peculiar, thin, flocculent discharge, not neces- sarily copious, and at times even trifling, and very often by a very early swelling of the glands of the neck, es- pecially those behind and beneath the angle of the jaw. Nasal diphtheria often occurs where the nasal mucous membrane has for a long time been the seat of catarrh. Especially during the prevalence of an epidemic of diph- theria must we be careful not to allow a nasal catarrh to have its own way ; we must likewise guard against con- 218 A TREATISE ON DIPHTHERIA. sidering the thin and flocculent discharge in infected cases as a mucous secretion. Whatever be the origin of nasal diphtheria, whether primary or the result of a simi- lar affection in the throat, local treament should at once be instituted, and if this be done, the great majority of cases will terminate favorably. The danger in this form of disease consists in an excessive absorption of putrid substances, and in the breathing of contaminated air. The indications for treatment are clear and decisive. The interior of the nasal cavities must be thoroughly cleaned and disinfected. If this be commenced early, the original seat of the affection may be reached, and the disinfectant process will, as a rule, have good results. It is not necessary to select very energetic disinfectants ; a solution of twelve to twenty-five centigrammes (two to four grains) of carbolic acid in thirty grammes (an ounce) of water is at once mild and effective, and hardly gives rise to more discomfort than luke-warm water. Nasal injections must be made very frequently, until each time the stream of fluid has a free exit through the other nostril or through the mouth. They must be made at least every hour, and even oftener if necessary ; at the same time it is advisable to be careful that the fluid does not enter the Eustachian tube. This can be prevented, to a certain extent, by compelling the patient to keep the mouth open during the procedure. I have seldom seen evil, or only disagreeable results from the administration of nasal injections in diphtheria. Still, a medical friend assures me that he has seen convulsions to follow an in- jection, an occurence I never met with. It is likely that the mucous membrane of the pharynx is swollen as far as the openings of the Eustachian tubes, to such a degree as to render the entrance of fluids into the latter improbable. The hardness of hearing, whichisof so frequent occurrence in the course of a severe catarrh or diphtheritic attack, seems to indicate that the mucous membrane of that part is in a state of swelling. An or- TREATMENT. 219 dinary syringe will suffice. However, when administered by parents or nurses, the blunt nozzle of an ear syringe or nasal douche is preferable , furthermore, by using the lat- ter, the distribution of fluid is more equal. Occasionally here, as in local applications to the mouth and pharynx, the atomizer may be used to advantage ; but the tube must be properly introduced into the nostrils. There are cases of nasal diphtheria, however, which are far more trouble- some to manage than the foregoing would seem to indicate. I have seen cases in which the nasal cavities, from the an- terior to the posterior nares, were filled and completely occluded by a dense solid membranous mass. I was then compelled to bore a passage with a silver probe, to gradu- ally introduce a larger-sized one, and then to apply the pure carbolic acid, in order to remove the densest and thickest masses, and finally was able to make injections ; even in such cases I have often had the gratification of being able to give a favorable prognosis. The dangerous secondary swellings of the glands will often subside after a steady employment of disinfectant injections for from twelve to twenty-four hours, but it must not be forgotten that these injections require to be made very frequently, either every hour or half-hour. We must not be drawn from our line of duty by the patient's desire for rest and sleep, but must continue the treatment uninterruptedly. It will be found that the children frequently do not object to this method of treatment ; I have even met with some who, after con- vincing themselves of the relief afforded thereby, asked for an injection. When we are about to bring each in- jection to a close, it is well to press together the nasal cavities for an instant with the fingers. By this proce- dure the fluid (unless doing so spontaneously) is forced backwards to the pharynx, and is swallowed or ejected through the mouth and thus washes the pharynx and mouth at the same time. Frequently, however, this latter object is obtained with every injection ; for, the palate being swelled, cedematous, and paretic, the fluid is not 220 A TREATISE ON DIPHTHERIA. prevented from reaching the pharynx, even in the average case. In regard to the choice of a disinfect- ing agent, I have but a few words to say. I believe that no one of them has important qualifications above the others. I avoid those which stain, and produce firm coagula. For the latter reason I do not use the sub- sulphate and perchloride of iron ; for the former, the per- manganate of potassium. I employ, as a rule, carbolic acid in solution, of the strength above mentioned. Where there is but a slightly foetid odor, I have frequently em- ployed lime-water, or water, with glycerine, or a solution (i : ioo, i : 50) of chloride of sodium, or sod. bicarb., also sod. biborate. Disinfecting agents and antiseptics, whether carbolic acid, salicylic acid, or iron, are of no service when administered internally only, unless the seat and cause of the septic infection be attended to previously. I refer to what I have said above in relation to iron and salicylic acid. Under the local employment of antiseptics, as de- scribed, or by simply washing out with water, or salt water, most cases recover; without them, death will result. This much my experience has assured me of, that there is a certain number of cases which terminate fatally ; but it is likewise true that the mortality need not. be ex- cessively great. It is a great satisfaction to me learn from a recent paper of R. J. Nunn (The Indep. Pract, Sept., 1880) that my method is appreciated and valued to its full extent. The author speaks very highly of the local treatment with iodine and boracic acid. I cannot grant that it is hard to carry out the exact and apparently bar- barous treatment necessary for a favorable result, for it is certainly more barbarous to sacrifice than to save life. It is a positive fact that when children suffering from nasal diphtheria, with its peculiarly septic character, are permitted to sleep much — and they are apt to be drowsy under the influence of the poison— they will certainly die. To allow them to sleep is to allow them to die. The first symptom of improvement is often a rapid TREATMENT. 221 diminution of the glandular swelling. But not in all cases of nasal diphtheria these glandular swellings will be so prominent ; in fact, it would be expecting too much to suppose that all at once there should be a rule allowing of no exception. The exceptions are of twofold nature : ist. There is very little absorption through the lymphatic ducts, and very little, if any, glandular swelling in such cases where the very beginning of the disease is marked by slight hemorrhages, or by a discharge of bloody serum from the nostrils. In these cases, the blood-vessels are so superficial that they rupture and aid in macerating and sweeping off the membrane before absorption into the lymph circulation can take place. These cases are not always, however, mild in character. Open blood-vessels do not only discharge, they are also apt to absorb ; and thus it is that many of these cases, be the glandular swelling ever so slight, prove very serious, and thus also, that they can be saved by very frequent disinfection only. The second exception is formed by those cases in which nasal diphtheria, or any other, attacks a mucous membrane which has been the seat of chronic catarrh and intestinal cellulitis, with consecutive thickening, induration, and shrinking. In color, thickness, and consistency, a normal tonsil, pharynx, or Schneiderian membrane differs greatly from those which have undergone a hyperplastic tissue- change. In the latter condition, blood-vessels and lymph ducts are compressed and atrophied, and no longer a high road into the system. It is, therefore, rather hazardous on the part of as careful a practitioner as Dr. Ripley (Med. Rec, July 24th, 1880, p. 90) to declare it a folly to expect to cure the disease by any local application ; or of trying to prevent auto-infection in a system already charged with the poison. For as there are cases in which its feverless character and the local changes clearly mark a case as probably of merely local origin, local treatment, if it could or can be applied, is indicated in just these cases ; and secondly, the " system being charged with the poison" 222 A TREATISE ON DIPHTHERIA. does not mean an unalterable condition ; for while elimin- ation is going on constantly, absorption of new poison is keeping pace with it more or less. Not even death is an unchangeable condition, much less a morbid process. Be- sides, Dr. Ripley says: " Even on the theory that these children die of septicaemia, and that the poison is absorbed from the nasal cavities, is syringing out these cavities several times an hour indicated ? Who thinks of washing out an infected uterus, or abscess of the pleural cavity, or other organ, with any such frequency ? " Certainly no- body, but nobody ever thinks of an equality of condition in nasal diphtheria on one hand, and a puerperal uterus or an abscess on the other. Even in the impossible case that all the membranes were washed away by a nasal injection, it is nothing new that the membranes will form again and again, and thus there is always, in addition to the former infection, a new one, and a necessity to meet it. If the doctor says: "If carried out as recommended, it must prove a most exhausting plan of treatment," I refer him to what he relies on, viz., clinical observation, and very much desire he should try and be satisfied. THE LARYNX. The severest form of diphtheria is that located in the larynx, "membranous croup." Its pathology has been discussed elsewhere. Its general treatment, whether the disease has originated primarily in the larynx or trachea, or been communicated from the pharynx, does not differ from that laid down for diphtheria in general. Naturally the larynx, with its principal symptom of stenosis (croup) of the organ, viz., the suffocatory phenomena, call for special treatment. This is represented by the administration of an emetic to fulfil the indication of removing mucus or partly detached membranes from the larynx. Such is their only indication in my experience. I never could satis- factorily explain the reason why Fordyce Barker's cases of membranous croup should all get well with no other TREATMENT. 223 treatment except repeated emetic doses of the yellow sul- phate of mercury (turpeth mineral). Somewhat like him, Lissdorf (Memor., 1876, p. 263) claims to have lost but five per cent of his two hundred croup cases treated with re- peated doses of sulphate of copper. Similar results are claimed by M. H. de Bey (Beitrag zur Casuistik, etc., 1879), but he adds: "It is true the diagnosis, in the majority of cases, was made from the well-known sounds of respiration and cough only ; in some, however, by the expectoration of membranes." Thus, evidently, the majority of cases were not those of membranous croup, but of " pseudo-croup," or laryngeal catarrh. The selection of the emetic, when indicated, is of great importance. Antimonials ought to be avoided because of their depressing and purgative effect. Ipecac is but rarely effective. The sulphates of zinc, and particularly of copper, deserve preference. Turpeth mineral acts promptly and satisfactorily. When no emesis can be ob- tained, the prognosis is decidedly bad. The mechanical treatment of membranous croup by the introduction of tubes (" tubage ") into the diseased larynx has first been recommended by Loiseau, and afterwards by Bouchut. The latter author's enthusiastic praises of that method have contributed more than its deficient suc- cess to its speedy downfall. For not only did he claim complete comfort and relief from dyspnoea for the pro- cedure, but instant restoration of the voice. Of late, Schroetter, Weinlechner, and Monti have employed catheters to provide an artificial aperture and dilatation. In regard to tracheotomy, that last resort in croup, 1 cannot refrain from stating that, in proportion to the increasing severity of the diphtheritic epidemics, the results of tracheotomy in my hands and in those of others have grown worse and worse. Of sixty-seven tracheotomies which I published twelve years ago, twenty per cent recovered ; about two hundred tracheo- tomies performed by me since that time, brought down 224 A TREATISE ON DIPHTHERIA. the percentage of recoveries to such a low figure that only the utter impossibility of witnessing a child's dying from asphyxia has goaded me on to the performance of trache- otomy. I here add that I do not wish it to be inferred that I have changed my views concerning the indications for the operation of tracheotomy, as Boehme (p. 10) seems to believe. On the contrary. In spite of numerous ill successes, I hold to the principle, that where there is danger from suffocation through stenosis of the larynx, there is the indication for tracheotomy. Where there is no stenosis, I am glad not to operate. The results are not so bad, after all, when we remember that only such cases are operated upon which would be sure to die, if the operation were not performed. Even the number of children under two years saved by tracheotomy is increas- ing yearly. Kronlein reports 567 cases of diphtheria ob- served in the clinic of Berlin. Tracheotomy was per- formed in 504, with an average mortality of 70.8 per cent ; the rate decreasing from 83.7 in 1870 to 61.81 in 1876. In the first year of life, the rate of deaths after tracheotomy was 93.3 ; in the second, 85.7 ; in the third, 80 ; and so on to 67.3; 66.6; 56; 76.4; 52.1; 53.5; 42.8; 66.6; 60 (in the twelfth year). The youngest child was 7 months old when it recovered. Of 85 under two years, 11 recovered. The 400 cases of tracheotomy, reported by O. Wanscher as having been performed in Copenhagen from 1863 to 1876, yield even more favorable results. The rate of re- coveries is as high as 42.1 per cent. He, too, finds the mortality increasing with the procrastination of the oper- ation. Even infants under two years of age recovered, provided the operation was performed at an early period. Of 50 cases of tracheotomy of Buchanan's (Brit. Med. Jour., April 10th, 1880), 17 were classed as croup, and 33 as diphtheria, the latter including all those forms in which there was a distinct deposit of false white membrane on the tonsils, palate, or fauces. Of those 17 patients, 10 died, 1 of whom immediately after the operation, the TREATMENT. 225 others in from 3 hours to 4 days. Of the 33 there was a mortality of 21, 1 of whom also died immediately after the operation, the others in from 6 hours to 13 days. The indications, after the performance of the operation, in regard to the general process remain the same. There- fore, the general medicinal and dietetic treatment must be continued. Disinfection of the wound by zinc chloride, before the stitches are applied, is advisable. When the wound shows a diphtheritic appearance after twenty-four hours, sooner or later, or when the neighboring tissues swell, or when erysipelas shows itself, the stitches ought to be removed, and the wound treated with acid, carbolic, pur. and glycerine aa. While the disinfecting local treat- ment of the nose and pharynx is continued, a similar treatment is resorted to in regard to the trachea. I have atomized through the tube, in many cases, a two-per-cent solution of carbolic acid, every hour, every half-hour; in most cases, however, used a solution of carbolic acid in water (}4~S P er cent), or in lime-water, or lime-water with glycerine. This procedure has been kept up every quarter of an hour, every half-hour, every hour, for days in succession. The children are not annoyed by the proceeding and rarely get awake except from a severe at- tack of coughing. The atomizing is repeated very fre- quently, but a single compression of the balloon suffices for the purpose. For more direct and thorough appli- cations — the tube either being removed for the purpose, or mostly through it — I use a long pigeon's or hen's feather, carefully examined before using, dipped in a so- lution of carbolic acid (1) to aq. calc. and glycerine (aa 5), or usually glycerine only (8-10). The amount of that liquid introduced into the trachea on that best of all in- struments for the purpose : flexible, uninjurious, and ef- fective, is sufficiently large, but not too large. A number of cases I have also exposed to a constant carbolic acid spray (2-3 per cent) ; a few I have treated with permanent turpentine inhalations as described above. All of them 15 226 A TREATISE ON DIPHTHERIA. were kept under the influence of steam. Thus surely Dr. Pauly is not correct when he attributes my acknowledged want of success with tracheotomy, during- the last ten years, to my neglect of inhalations after the operation, nor was his prophesy, that the results would be better in future. I must admit that they have continued to be but unfavorable, though, having tracheotomized these twenty years more frequently, perhaps, than any physician in the States, I have been as anxious as any one to use every means in my power to disinfect.* When, after the operation, the relief is next to none, particularly when the case takes a very rapid course, it is probably one of ascending croup which commenced in in the trachea. Mechanical relief by pushing down the hen's feather, or a bundle of them, and turning it about and twisting must be tried. It is a much better instru- ment than pincers of all sorts and shapes. But what relief will be accomplished is of but very short dur- ation. When fever will set in within a few hours, it means very much more frequently pneumonia than diph- theritic fever. It will soon be complicated by that dispro- portion between pulse and respiration so characteristic to inflammatory diseases. Then quinia in larger doses, 0.25, or 0.5 (grs. iv.-viij.) every two, four, eight hours, at the same time doses of sodium salicylate 0.25-0.40 (grs. iv. -vi.) every hour or two hours until the temperature goes down, small doses of digitalis, where the heart requires it, must be given at once. Procrastination is dangerous, the patients want careful watching, most of them die within two days after the operation. The results of any treatment in membranous croup are * Dr. Al. Hadden assures me that liq. subsulphat. ferri applied to the treachea, after the operation, has saved some of his cases. With boric acid, muriatic acid, bromid. ammon., aq. chlorin., pot. hypermangan., sod. salicyl., sod. sulpho-carbol., zinc, sulph.-carbol, I have not, like Kronlein, experi- mented. Like him, I have used alum, borax, pepsin, lime-water, but have in most cases proceeded as above described. TREATMENT. 227 01 so doubtful a character that any observation faithfully both made and reported may be of service. Bela Weiss relieved a boy of six years with undoubted croup by " massage," in the same manner in which he had previ- ously removed the urgent symptoms of pseudo-croup. The child sat on the lap of the mother, who held his head backwards, the doctor, sitting in front of the patient, placed a hand on either side of the neck, interlocking four fingers of either hand — well oiled — posteriorly, prayer fashion, and moved his thumbs slowly and gently in the be- ginning, more forcibly afterward, from the horizontal ramus of the lower jaw down to the clavicle, raised the thumbs, and repeated the same manoeuvre through five minutes and more. This operation was repeated a number of times in intervals of several hours, with favorable re- sults. Respiration became easier, cough looser, mem- branes were expectorated. The author adds that cold applications, warm inhalations, a short time also potassium chlorate were resorted to in the usual manner, and recom- mends his treatment, not as a panacea, but as successful in that case and worthy of further trials.* J. Szeparowicz (Centralb. f. Chir., No. 26, 1880) treated, in accordance with Schroetter's advice, a contraction of the larynx with bougies. A girl of four years had been tracheotomized for croup, eight months previously. The dilatation was persisted in for four weeks, with complete success. Whether the symptoms arise from a marked degree of cedematous infiltration of the tissues, or from fibrinous exudation or degeneration of epithelium, need not concern us as far as tracheotomy comes into question. In the first class of cases, the after-treatment is more successful, be- cause the trachea is more apt to be spared. Just as little need we consider whether, in individual cases, " the differ- * Casuistische Mittheilungen iiber die Anwendung der Massage bei Laryn- gitis catarrhalis und crouposa. Arch. f. Kinderheilkunde, 1880, p. 201. 228 A TREATISE ON DIPHTHERIA. ehtial histological diagnosis has been made between diph- theria and croup." DIPHTHERITIC PARALYSES. The treatment of diphtheritic paralysis is simple enough in many cases; for sometimes nothing but patience and waiting are necessary. The limbs are usually restored to their normal condition, if the circumstances be in any way favorable. Anasmia and debility are invariable concom- itants, and the diet and medical treatment must be regu- lated accordingly. We must not forget, however, that overfeeding and a sameness of diet are not permitted, for not rarely the muscular coat of the stomach suffers with the rest of the muscular tissue, and the secretion of gastric juice is very deficient in ansemic individuals. While therefore, from a therapeutic stand-point, iron is indicated, we must not neglect to pay particular attention to nutrition and digestion, and to aid the latter with pepsin and moderate amounts of muriatic acid, well di- luted. Quinine and stimulants are appropriate wherever there is no contra-indication to their employment. The treatment of the paralysis itself, where it is not deemed judicious to wait, will naturally depend on the diagnosis of the condition in question. This alone can explain why various modes of treatment, the electric current among others, after being recommended by some authors, are branded by others. Where we have to deal with those rare changes in the brain and spinal cord, with apoplexy, " the utmost care is necessary " in order "not to make the con- dition still worse," and in such cases there would be a contra-indication to the use of the faradic current, but this would not hold true with regard to the use of the galvanic current in short sittings. Besides, central paralyses are by no means so frequent as peripherous ones. In most cases, there is not the slightest elevation of temperature during the course of the paralytic phenomena. I lay great stress upon this point, for I am aware that many cases of central con- TREATMENT. 229 gestions and inflammatory processes at times exhibit but very insignificant elevations of temperature. But as the diagnosis will depend on a positive knowledge of whether there have been changes of temperature, I rely on the rectal temperature only, for many a myelitis runs its course with no greater elevation above the normal than one-half or one degree. In all cases in which the temper- ature is normal or subnormal, I do not hesitate for a moment to employ the faradic or the galvanic current, according to circumstances. In addition to the internal administration of iron, I advise by all means the employ- ment of nux vomica, in the form of strychnia. I cannot indorse Oertel's warning against the use of strychnia, on the ground that, as it acts centrally, it will positively give rise to an increased irritation of the morbid process in the spinal cord. The observations of a great many authori- ties, and my own which are rather extensive, cause me to look upon strychnia as the most reliable remedy in diph- theritic paralysis. Where there is no necessity for haste, we may give moderate doses, gradually increasing, in combination with iron ; where there is danger in delay, it is more judicious to have recourse to subcutaneous injec- tions, administered at regular intervals. Henoch has seen diphtheritic paralyses disappear in three weeks, under the use of hypodermic injections of strychnia. This, which has also been my experience on many occa- sions, corresponds with what Demme says (tenth report, 1873) in connection with the treatment of infantile paralysis. His statements I have seen verified in the latter disease, in cerebral paralyses and in diphtheritic paralysis. It also agrees with the favorable results from subcutaneous injections of strychnia in the temples in amaurosis, which Nagel was the first to witness, and which since have been observed by others, and by myself in several cases. I especially advocate the use of injec- tions where there are urgent and dangerous paralytic manifestatious, as in case of danger depending on the 230 A TREATISE ON DIPHTHERIA. paralysis of the muscles of deglutition and of respiration. Of course, where the former are affected, it is necessary to nourish the patient artificially, partly perhaps by nutrient enemata, but principally by means of the stomach-tube. In using the latter, it is unnecessary to introduce it into the stomach, as it only requires to be passed a few inches be- low the affected parts, when the oesophagus, far from manifesting the repugnance displayed by the pharynx, undertakes the further disposal of the food. In these cases, strychnia should be injected subcutaneously in the neck, once or twice daily. In a similar manner, it should be injected in the region of the chest, diaphragm, or neck, in paralysis of the respiratory muscles or of the glottis. In paralysis of the muscles of accommodation (in which Scheby-Buch claims to have seen the process cut short by the use of calabar bean, considered as insrt by Hassner) they may be given in the forehead or temples. Frictions dry and alcoholic, hot bathing, friction with hot water, kneading of the affected parts, will be found beneficial and pleasant. DIPHTHERITIC CONJUNCTIVITIS requires great attention and permits of no loss of time. Ice applications to the affected eye must be made con- stantly. Pieces of linen or lint kept on ice (better than in ice-water) of little more than the size of the eye, must be changed every minute or two, day and night. The dan- ger to the cornea is so imminent that constant watchful- ness is required. Boric acid in concentrated solution is, be- sides, dropped into the eye once every hour. The late Dr. H. Althof recommended and practised, where the rigidity of the eyelid was so great as to threaten rapid destruction of the cornea, a deep incision through the external angle to a distance of from one-half of an inch to an inch. Care must be taken that the well eye cannot get infected ; for that purpose it is best to cover it with lint and collodion, or lint, or cotton, and adhesive plaster. Local infections TREATMENT. 23 I of the kind are very frequent. But lately have I observed a local infection even of the tongue from a diphtheritic eye. CUTANEOUS DIPHTHERIA requires the destruction of the membrane or the infected surface by carbolic acid — either concentrated or somewhat diluted with glycerine — or the application of the actual cautery. After that, the use of ice, or iced cloths, or diluted carbolic acid are indicated. As soon as the sur- face is no longer diphtheritic, the local and general treat- ment is to be continued on general principles. SUMMARY. Every case should be treated on general principles, with symptomatics, roborants, stimulants, febrifuges, ex- ternally, internally, or hypodermically. The uncertainty of the termination, and the frequency of collapse or sepsis, prohibit procrastination. Waiting long means often waiting too long. Alcohol (p. 1 57) is a very important adjuvant and remedy. The dose must often be apparently large, from two to twelves ounces daily, according to circumstances. Deple- tion is absolutely contra-indicated. Debilitating compli- cations, such as diarrhea, must be stopped instantly. Mouth and neck must be kept in a healthy condition. Stomatitis, chronic pharyngitis, hypertrophy of the tonsils, glandular enlargements must be relieved or removed pre- ventively. Acute catarrh of mouth and pharynx requires the use of potassium or sodium chlorate (p. 159), in doses not exceeding a scruple daily for a child of a year, 1 J^-2 drachms for an adult. The single doses must be small and very frequent, every hour, half, or quarter hour. Large doses are dangerous, result often in nephritis, and have proved fatal. The main indication in local diphtheria is local disinfec- tion (p. 169). To disinfect the blood effectively we have no means. Salicylic acid changes into a salicylate which 232 A TREATISE ON DIPHTHERIA. is no longer a disinfectant. The amount of disinfectants required to destroy bacteria is so great that the living body could not endure them ; for instance, carbolic acid, quinine, and sulphur. But the discipline of the house, school, and social intercourse can be so modified as to pre- vent the spreading of an epidemic. The instructions for disinfectants published by the National Board of Health (p. 175) are as simple as they are effective. The inhalation of steam (p. 178) is very useful in catarrh of the respiratory organs, and also in inflammatory and diphtheritic affections. In fibrinous tracheo-bronchitis it has proved quite successful. But it may prove dangerous by excluding oxygen and overheating the room or tent. Drinking of large quantities of water (p. 181), with or without stimulants, also incites the action of the mucipar- ous glands and aids in macerating membranes. The in- ternal use of ice, and its local application to the affected parts, can be very useful. But the cases must be selected for each and any of the remedial agents and applications. The use of baths, and the cold or hot pack is controlled by general indications. The usefulness of lime-water (p. 183) and lactic acid has been greatly overestimated. Glycerine is a valuable adjuvant both externally and in- ternally, but not more. Turpentine inhalations (p. 185) are deserving of further trials, though naturally they are more effective in purely inflammatory than in diphtheritic pro- cesses. Inhalations of ammonium chloride (p. 187) act favorably in catarrhal and inflammatory conditions, and deserve a trial for the purpose of aiding maceration of membranes. Mercurials (p. 188) are contra-indicated in the septic and gangrenous forms of diphtheria, but in those which assume more the purely inflammatory charac- ter with less constitutional debility and collapse, as in " sporadic croup," or in fibrinous tracheo-bronchitis, some reliable clinicians claim good results. Astringents, such as tannin and alum, do not work favorably (p. 190). TREATMENT. 233 Chloride of iron (p. 191) is amongst the most reliable antiseptic and astringent agents. Small doses in long in- tervals are quite useless. Moderate doses frequently re- peated have a satisfactory general and local effect. A child of a year must take at least four grammes (a drachm) daily ; a child of three or four years, from eight to fifteen grammes. The same or a larger dose for an adult. The chloride is to be mixed with water and glycerine in various proportions, so that a dose is taken every hour, every half-hour, every ten minutes. Thus the local appli- cations to the throat become mostly superfluous. Potass- ium or sodium chlorate from two to four grammes ( 3 ss. -i.) daily may be added to advantage. Carbolic acid is useful both in local and internal ad- ministration. According to the end to be reached, it may be used either in concentrated form, or in a one-per-cent solution (p. 196). Internally, in doses of a few grains to half a drachm daily. Salicylic acid acts as a caustic when concentrated ; in moderate solutions it destroys fetor ; salicylates are anti- febriles only (p. 197). The antifebrile effects of quinine are not so favorable in infectious as in inflammatory fevers ; its antiseptic action is not satisfactory in practice ( P . 198). Deliquescent caustics are dangerous. Injury of the healthy mucous membrane must be avoided. Mineral acids, and particularly carbolic acid, when their applica- tion can be limited to the desired locality, are preferable (p. 200). Bromine both internally and externally is warmly re- commended by Wm. H. Thompson (p. 201). Boric acid, in concentrated and milder solutions, has been recommended as a local application to membranous deposits generally, and to the diphtheritic conjunctiva in particular (p. 206). Sodium benzoate does not deserve the eulogies bestowed on it from theoretical reasoning (p. 207). 234 A TREATISE ON DIPHTHERIA. Eucalyptus, sulphur, copaiba, and cubeb cannot be re- commended (p. 209). Membranes must not be torn off, and not removed un- less they are nearly detached. Caustics are contra-indi- cated except where their application can be limited to the diseased surface. No healthy part must be injured. Swelled lymph-glands require ice, iodine, iodoform, mer- cury, poultices, incision, carbolic acid, according to cir- cumstances (p. 216), and at all events frequent and careful disinfection of the mucous membrane from which their irritation originates. Diphtheria of the nose (p. 217) is apt to be fatal unless careful treatment is commenced at once. It consists of persistent disinfection of the nares and pharynx by means of injections. The tendency to sepsis forbids a long intermission of them. They must be continued day and night for one or several days, no mat- ter whether the glandular swelling is considerable or not. Laryngeal diphtheria (p. 222) proves fatal in almost every case, unless tracheotomy be performed. It is the less successful the more the epidemic or case bears a sep- tic character. Emetics, such as zinc, copper, or turpeth mineral, are useful for the removal of half detached mem- branes. Diphtheritic paralysis (p. 228) requires good and careful feeding, iron, strychnia, the faradic or galvanic currents, friction, hot bathing. Urgent cases indicate the hypoder- mic administration of strychnia. Diphtheritic conjunctivitis is benefited (p. 230) by ice and boric acid ; cutaneous diphtheria, by local cauterization and disinfection, besides general treatment. INDEX. Abscesses of lymphatic glands in diphtheria, 116. Absence of acinous glands to a certain extent prevents diphtheria of the vocal cords, 128. Adynamia in diphtheria, 51. Aetius, 1. Age when diphtheria occurs, 50. Air passages, anatomical appearances in the, table showing the, 126. Albuminous urine produced by chlorate of potassium, 166. Albuminuria in diphtheria, 51, 55, 90, 106, 136, 144. of scarlatina and diphtheria, diagnosis between, 90. Alum in the treatment of diphtheria, 190. America, first known case of diphtheria in, 3. Ammonium chloride in the treatment of diphtheria, 187. Anatomical appearances in diphtheria, 108 et seq. appearances of the epiglottis, 124. appearances of the mucous membrane of the mouth, 122. appearances of the mucous membrane of the nasal cavities, 123. appearances of the mucous membrane of the trachea and bronchi, 125. appearances, table showing the, in the air passages, 126. Anaemia from diphtheritic paralysis, 228. Angina ulcusculosa, 4. Animals causing diphtheria in human beings, 65. with diphtheritic affections, 65. Antimonials in diphtheritic laryngitis, 223. Antiseptic nature of chloride of iron, 194. Antiseptics in diphtheria, 220. Aphonia in laryngeal diphtheria, 137. Applications, local, beneficial in nasal diphtheria, 220, 221. Aqua calcis in diphtheria, 21 1. Aretseus, 1. Artificial diphtheritic membrane, ill. Arytenoid cartilages, cicatrization of, a sequel of diphtheria, 73. Asclepiades, 1, 2. Aspergillus nigrescens, 66. Asthenic and suffocative forms of diphtheria, 2. Astringents in the treatment of diphtheria, 190. 236 A TREATISE ON DIPHTHERIA. Ataxia, locomotor, in diphtheria, 101. Atomizer in treatment of diphtheria, 179. use of, in nasal diphtheria, 219. Autopsies in cases of diphtheritic paralyses, 103. Autopsy, first, in diphtheria, 3. Author's views as to origin of diphtheria, 54, 55. Bacteria, 170. destruction of, to prevent diphtheria, 174. experiments as to the methods of destroying, 174. in diphtheria, 49, 50, 111. not always found in diphtheria, 66. putrefaction without, 39. relation of, to diphtheria of the intestine, 117. Balano-posthitis, diphtheritic, 89. Ballonius, 2. Balsamica, the, in diphtheria, 209. Balsamics, the, nephritis following the use of, 210. Bard, 10, 165. Bastian, 23. Baths in diphtheria, 154. Benzoate of sodium in diphtheria, 170, 206. Bite causing diphtheria, 2. Bladder, diphtheria of the, 87. Bleeding in diphtheria, 157. Blood, the, in diphtheria, 92. Boric acid and iodine injections in nasal diphtheria, 220. acid in diphtheria, 206. acid in diphtheritic conjunctivitis, 230. Bougies used to remove contraction of larynx, 227. Brandy in diphtheria, 157. Bretonneau, 12, 13, 14, 16, 18, 165. Bromine in diphtheria, 200. Bronchi and trachea, mucous membrane of the, anatomical appearances of the, 125. Bronchitis in children, 27. Broncho-pneumonia in diphtheria, 80. Caelius Aurelianus, 1. Calomel in diphtheria, 157, 189, 211. Calves affected by diphtheritic poison, 65. Carbolated sulphate of sodium in diphtheria, 211. Carbolic acid, amount required to disinfect, 174. acid as a disinfectant, 175, 195. acid in the destruction of bacteria, 174. acid in diphtheria, 195, 214. acid spray after tracheotomy, 225. INDEX. 237 Catarrhal laryngitis, 138. Catarrh, chronic, after diphtheria, 104. chronic nasal, and so-called scrofula, 131. nasal, complicated with diphtheria, 72. nasal, followed by nasal diphtheria, 217. Catheterization in diphtheritic laryngitis, 223. Causes of diphtheria, 2, 25, 51, 52, 53, 61, 85. of frequency of diphtheria in children, 30. of pneumonia in diphtheria, 81. predisposing, of diphtheria, 32. Caustic action of salicylic acid, 197. Cauterization in diphtheria, 21 1. of diphtheritic membranes to be thoroughly done to be effective, 200. Central origin of paralysis, 97. Chemical nature of diphtheritic poison, 50. Childhood, diphtheria a disease of, 49. Children, bronchitis in, 27. causes of frequency of diphtheria in, 30. infectious diseases in, 29. Chloral in diphtheria, 213. Chlorate of potassium, action of, upon the heart, 162. of potassium causing cyanosis, 163, 165. of potassium causing death, 163 et seq. of potassium causing nephritis, 163, 165. of potassium, convulsions produced by, 163. of potassium, danger of administration in large doses, 162. of potassium in the treatment of diphtheria, 160. of potassium producing albuminous urine, 166. of potassium and of sodium, prophylactics in diphtheria, 159. Chloride of ammonium in the treatment of diphtheria, 187. of iron, experiments with, 193. of iron in the treatment of diphtheria, 191, 211. Chlorine in diphtheria, 213. Chromic acid in diphtheria, 199. Cicatrization of arytenoid cartilages a sequel of diphtheria, 73. Ciliated epithelium less liable to be affected in diphtheria, 127. Circumcision-wounds, diphtheritic infection of, 88. Clothing of diphtheritic patients should be disinfected, 177. Cocco-bacteria dissolved and eliminated, 41. in the living blood not proven, 41. . Colden, Cadwallader, 7. Collapse and death in mild cases of diphtheria, 132. Communicability of diphtheria, 52. Complications, danger of, in diphtheria, 152. Congestion of the pharynx may be either traumatic or diphtheritic, 134. 238 A TREATISE ON DIPHTHERIA. Conjunctivitis, diphtheritic, 17, 73, 143. diphtheritic, treatment of, 230. Constitutional nature of diphtheria, 52, 56. Contagiousness of diphtheria, 51, 57, 67. Contagium animatum, 36. Contraction of larynx relieved by bougies, 227. Convulsions a bad symptom in diphtheria, 70. produced by chlorate of potassium, 163. Copaiba in diphtheria, 209. Copperas solution to disinfect discharges from diphtheritic patients, 176. Corpses, manner of preparing, of diphtheritic patients after death, 177. Croup and diphtheria, symptoms compared, 139 et seq. and laryngeal diphtheria, identity or non-identity of, 112. ascending, 142. "massage " for relief of, 227. membranous, and diphtheritic laryngitis, 138. membranous, treatment of, 222. occurring when diphtheria is prevalent, 77, 78. prognosis in, 138. Croupous deposits in diphtheria, 70. diphtheria, 104. laryngitis and laryngeal diphtheria, 119. membrane formed by migration of white blood-corpuscles, no. Cubebs in diphtheria, 209. Curtis and Satterthwaite, 23, 43. Cutaneous diphtheria, treatment of, 231. Cyanosis an unfavorable sign in diphtheria, 153. resulting from an over-dose of chlorate of potassium, 163, 165. ushers in death in tracheal diphtheria, 143. Danforth, 3. Danger of allowing children affected with nasal diphtheria to sleep, 220. of complications in diphtheria, 152. of conveying diphtheritic poison during an epidemic, 158. of incisions for rigidity of the eyelid in diphtheritic conjunctivitis, 230. Dead bodies of diphtheritic patients to be kept moist, 173. Death caused by chlorate of potassium, 163 et seq. -rate in diphtheria, 157. sudden, in mild cases of diphtheria, 132. Debility from diphtheritic paralysis, 228. Deformity of penis caused by diphtheria, 90. Deglutition, difficulty of, caused by paralysis, 99. Deodorizers, definition of, 175. Deposits in diphtheria, 69. Destruction of the eye in diphtheria, 73, 105. Diagnosis between albuminuria of scarlatina and diphtheria, 90. INDEX. Diagnosis between enteritis and diphtheria, 84. between stomatitis and diphtheria, 134. of diphtheria, 134. of membranous laryngitis, 137. of myelitis in diphtheria, 229. Diagnostic feature in diphtheritic tracheo-bronchitis, 79. Diarrhoea, treatment of, in diphtheria, 158. Digestion interfered with by chlorate of potassium, 162. Digitalis after performance of tracheotomy, 226. Diphtheria a constitutional disease, 56. a disease of childhood, 49. after circumcision, 88. after urethrotomy and lithotomy, 88. age when it occurs, 50. albumen in urine in, 51, 55, 90, 136, 144. an adynamic disease, 51. anatomical appearances in, 108 et seq. and croup, symptoms compared, 139 et seq. and erysipelas, relations between, 86. and filth, 34. and milk, 63. and scarlatinal albuminuria, diagnosis between, 90. and stomatitis, diagnosis between, 134. antiseptics in, 220. apt to recur, 50. at different ages, 30. author's views as to origin of, 54, 55. bacteria in, 49, 50. broncho-pneumonia in, 80. causes of, 2, 25, 51, 52, 53, 61, 85. causes of frequency of, in children, 30. causes of pneumonia in, 81. causing deformity of penis, 90. changes of temperature in, 33. cicatrization of arytenoid cartilages a sequel of, 73. ciliated epithelium less liable to be affected in, 127. communicability of, 52. communicated by animals, 64, 65. communicated by kissing, 58. complicating various diseases, 72, 81, 82. considered by some a parasitic disease, 23- considered by some a self-limited disease, 156. constitutional symptoms in, 51. contagiousness of, 51, 67. convulsions and vomiting bad symptoms in, 70. croupous deposits in, 70. 239 240 A TREATISE ON DIPHTHERIA. Diphtheria, danger of complications in, 152. diagnosis between enteritis and, 84. diagnosis of, 134. diagnosis of myelitis in, 229. difference in invasion of, 54. disinfectants in, 220. division of remedies in, 178. duration of incubation of, 51, 59, 60. duration of prodromal stage of, 68. ecchymoses in, 91. emboli in, 115. endemic causes of, 62. epidemic nature of, 51, 61. epistaxis in, 145. etiology of, 27. excrements to be removed in, 173. fever not always a prominent symptom in, 135. fibrinous pneumonia in, 80. first autopsy in, 3. first known case in America, 3. first seen in respiratory passages, 53. forms of, 104. frequency of, 49. frequency of relapses in, 32. gangrene in, 71, 145. has a predilection for certain organs and localities, 120, 133. heart affections in, 91. histoiy of, I. identity of all forms of, 10. immunity from, 50. incubation of, in animals, 65. infectious nature of, 58. inflammatory affections of the lungs in, 80. influence of season on, 33. infrequent from third to seventh month, 31. in France, 10. in Holland, 10. in New England, 3, 4. in Sweden, 10. in Switzerland, 10. insidious nature of, 53. intestinal, 84. in the fowl, 66. isolation in, 158, 171. laryngeal, and croup, identity or non-identity of, 112. laryngeal, and croupous laryngitis, 119. INDEX. 241 Diphtheria, laryngeal and tracheal, local in character, 128. laryngeal, in the adult, 27. leucocytes in, 113, 114. locomotor ataxia in, 101. lung affections in, 115. manifestations of, 69, 70. manner of infection in, 51. mechanical removal of membranes in, 214. micrococci as carriers of, 24. mild cases of, sudden collapse and death in, 132. mitral valve affected in, 91. mortality in, 150. nasal, 72. nasal, sleep dangerous in, 226. nasal, very fatal, 129, 133. not necessarily caused by polluted water, 62. nourishment, 162. often accompanied by pharyngitis, 53. of the vocal cords, danger of suffocation in, 129. of the vocal cords, general infection uncommon in, 128, 129. or muguet, 134. paralysis in, 52, 73, 96, 97. parasitic nature of, not proven, 49. pavement epithelium liable to be affected in, 127. pharyngeal membrane often first affected in, 53. predisposing causes of, 32. primary, of the trachea, 142. prognosis in, 149 et seq. prone to affect mucous membranes, 121. prophylaxis and prophylactics in, 58, 158, 159, 172. pseudo-leukaemia in, 92. sequelae of, 73. severity of, dependent upon the vascular and lymphatic systems, 129. severity of paralysis in, 97. sewers and, 34. sex in, 29. skin eruption in, 144. sometimes limited to certain localities, 121. strabismus in, 10. suffocative and asthenic forms of, 2. swelling of the glands in, 131, 133. symptoms of, 68. synonyms of, 1. temperature in, 55, 68. the blood in, 92. the soft palate and pharynx in, 69. 16 242 A TREATISE ON DIPHTHERIA. Diphtheria, thrombi in, 91. tonsils in, 30. treatment of, 154 et seq. Diphtheritic affections in animals, 65. fever, 91. laryngitis and membranous croup, 138. membrane, 70. membrane, artificial, ill. membrane, character of, determined by amount of elastic tissue, number of muciparous glands, etc., 122. membrane does not originate in epithelium according to some, 112. membranes, cauterization of, to be thoroughly done to be effective, 200. membranes on the vocal cords not easily thrown off, 129. membranes to be rendered innocuous, 199. membranes, various methods of dissolving, 183, 184, 188, 189. patients, their corpses should be kept moist, 173. paralyses, 2, 96, 106, 145. paralyses, causes of, 98. paralyses do not run a certain course, 97. paralyses, electrical applications in, 103. paralyses, statistics of, 99. poison, chemical nature of, 50. poison, danger of conveyance of, during an epidemic, 158. poison impeded by the mucous glands, 127. poison, manner of entrance into system, 52. process affected by the character of the surface, 124. process, doctrines as to the, 109 et seq. process, statistics of the, 114. tracheo-bronchitis, 77. Discharges from diphtheritic patients to be received in vessels containing copperas solution, 176. Disinfectant properties of carbolic acid, 174, 195. properties of salicylic acid, 197. Disinfectants eighty years ago, 9. in diphtheria, 220. mode of using, 176. Disinfection of the clothing of diphtheritic patients, 177. of the wound caused by tracheotomy, 225. to be enforced by authorities in an epidemic of diphtheria, 172. to prevent diphtheria, 173. Douglass, 3. Duration of incubation of diphtheria, 59, 60. Drainage, bad, a cause of diphtheria, 61. Dyspnoea in laryngeal diphtheria without accompanying formation of membrane, 137. INDEX. 243 Ecchymoses in diphtheria, 91. Elastic tissue, amount of, determines the character of the diphtheritic membrane in some cases, 122. Electrical applications in diphtheritic paralysis, 103. Emetics in diphtheritic laryngitis, 223. Emboli in diphtheria, 115. Endemic causes of diphtheria, 62. Endocarditis, diphtheritic, 1 1 5. Endogenous formation of pus globules in epithelium doubted, no. Enteric fever complicated with diphtheria, 81, 82. Enteritis, diagnosis between diphtheria and, 84. Entrance of infectious material into the system, mode of, 130. Epidemic influences causing diphtheria, 53. nature of diphtheria, 51, 61. Epiglottis, anatomical appearances of the, 124. diphtheria of the, 76. Epistaxis in diphtheria, 145. Epithelial cells, changes in, considered by some characteristic of diphtheria, 109. changes in membrane in diphtheria, 108. Epithelium, ciliated, less liable to be affected in diphtheria, 127. endogenous formation of pus globules in, doubted, no. pavement, most liable to be affected in diphtheria, 127. the, according to some, is not the source of origin of diphtheritic membrane, 112. Eruptions of the scalp, treatment of, in diphtheria, 158. on the skin in diphtheria, 144. Erysipelas and diphtheria, relations between, 86. Etiology of diphtheria, 27. Eustachian tubes, diphtheria of, 74. Excrements to be removed in diphtheria, 173. Exhaustion in diphtheria, 155. Experiments with chloride of iron, 193. Exposure during tracheotomy causing diphtheria, 59. Extremities, upper and lower, paralysis of the, 100. Eye, destruction of the, in diphtheria, 105. diphtheria of the, 73. Eyelids, rigidity of, in diphtheritic conjunctivitis, 230. Fever, diphtheritic, 91. enteric, complicated with diphtheria, 81, 82. high, obscures diagnosis, 135. not always a prominent symptom in diphtheria, 135. relative absence of, pathognomonic of diphtheritic laryngitis, 138. Fibrinous pneumonia in diphtheria, 80. Filth and diphtheria, 34, 50. First known case of diphtheria in America, 3. 244 A TREATISE ON DIPHTHERIA. Fowl affected with diphtheria, 66. Frequency of diphtheria, 10, 49. of diphtheria and pharyngitis, 53. of diphtheria in children, causes of, 30. of diphtheritic conjunctivitis, 74. of relapses in diphtheria, 32. Frictions in diphtheritic paralyses, 230. Fumigation by means of roll sulphur, manner of, 176. Galen, 1. Gangrene in diphtheria, 71. 145. " Garget," differential diagnosis of, 64. Gargles in diphtheria, 212. of chloride of iron not useful in diphtheria, 192. Gas prevents diphtheria, 5S. Geddings, 16. Genito-urinary organs, diphtheria of the, 86. Glands, absence of acinous, prevents diphtheria of the vocal cords in many cases, 12S. lymphatic, appearances of, in diphtheria, 116. mucous, impede the action of diphtheritic poison, 127. swelling of the, in diphtheria, 131, 133. treatment of swelling of lymphatic, 216. Glandular swelling, diminution of, a good sign, 220. swellings, not always marked in diphtheria, 104. Glycerin as a solvent of diphtheritic membranes, 183. Graefe, 17. Granular infiltration characteristic of diphtheria, 10S. Granulation tissue, changes in, in diphtheria, 108. Hallier, 23, 47. Heart, action of chlorate of potassium upon, 162. affections in diphtheria, 91, 114. Henle, 36. History of diphtheria, 1. Hodgkin's disease occurring in diphtheria, 92. Holland, diphtheria in, 10. Home, 10. Hiiter, 109. Human beings inoculated with diphtheria by animals, 65. Hydrargyrum in the treatment of diphtheria, 183. Hypodermic injections of mercury in diphtheria, 190. Ice in diphtheria, 182, 230. Identity of all forms of diphtheria, 10. or non-identity of laryngeal diphtheria and croup, 112. INDEX. 245 Immunity from diphtheria, 50. Incisions, danger of, for relief of rigidity of eyelid in diphtheritic conjunctivitis, 230. Incubation of diphtheria, duration of, 51, 59, 60, 67. of diphtheria in animals, 65. Infection, general, a cause of diphtheria, 61. general, in diphtheria of the vocal cords uncommon, 129. of diphtheria, manner of, 51, 58. Infectious diseases in children, 29. material, mode of entrance of into the system, 130. nature of diphtheria, 58. Infiltration, granular, characteristic of diphtheria, 108. Inflammatory affections of the lungs in diphtheria, 80. Influenza complicated with diphtheria, 72. Inhalations in diphtheria, 212. of steam in diphtheria, 178, 181. of turpentine in the treatment of diphtheria, 185, 209. Injections in nasal diphtheria sometimes fatal, 218. of strychnia in diphtheritic paralysis, 229. Inoculability of diphtheria, 51. Insidious nature of diphtheria, 53. Insufflation of sulphur in diphtheria, 209. Intestinal canal, appearances of, in diphtheria, 116. Intestine, diphtheria of the, 84, 105. Invasion of diphtheria, difference in, 54. Iodine and boracic acid injections in nasal diphtheria, 220. ointments for swelling of the glands, 216. Ipecac in diphtheritic laryngitis, 223. Iron as a nervous stimulant, 195. increases the power of oxydation, 195. in the treatment of diphtheria, 176, 191, 193, 194, 211. Isambert, 18. Isolation in diphtheria, 158, 171. Josselyn, 3. J urine, 12. Kidneys, appearances of, in diphtheria, 116. diphtheria of the, 90. micrococci in the, 46. Kiss, a, communicating diphtheria, 58. Klebs, 23, 48. Lactic acid as a solvent of diphtheritic membranes, 183, 184. Laryngeal diphtheria, 136. diphtheria in the adult, 27. diphtheria, local in character, 128. 246 A TREATISE ON DIPHTHERIA. Laryngeal diphtheria more frequent in boys, 50. Laryngitis, catarrhal, 138. diphtheritic, and membranous croup, 138. diphtheritic, treatment of, 222. membranous, diagnosis of, 137. Laryngoscopic examination in diphtheria, 136. Larynx, contraction of, relieved by bougies, 227. membranous deposits in, 138. Le Cat, 9. Letzerich, 48, 82. Leukocytes in diphtheria, 113, 114. Leukocythsemia in diphtheria, 92. Lime-water in diphtheria, 183, 211. Lithotomy causing diphtheria, 88. Liver, appearances of, in diphtheria, 116. Local applications beneficial in nasal diphtheria, 220, 221. origin of diphtheria, 52, 53. Locomotor ataxia in diphtheria, 101. Lugol's solution in diphtheria, 211. Lung affections in diphtheria, 80, 115. Lungs and trachea, mycosis of the, 65. Lymphadenitis generally severe in nasal diphtheria, 136. gives rise to sudden elevation in temperature, 135. not necessary to diagnose a case of diphtheria, 136. Lymphatic and vascular systems, severity of diphtheria dependent upon the, 129. glands, appearances of, in diphtheria, 116. glands, treatment of swelling of, 216. Lymphatics, effect of chloride of iron on the, 193. Maingault, 17. Manifestations of diphtheria, 69, 70. " Massage " for relief of croup, 226. Membrane, artificial diphtheritic, in. diphtheritic, 70. diphtheritic, according to some authorities does not originate in epi- thelium, 112. formation of, in diphtheria sometimes prevented by chlorate of potassium and sodium, 160. the, a characteristic sign in diphtheria, 108, 134. Membranes in intestinal diphtheria, 85. mechanical removal of, in diphtheria, 214. mucous, prone to be affected by diphtheria, 121. Membranous croup or diphtheritic laryngitis, 138. croup, treatment of, 222. deposits in larynx, 138. laryngitis, diagnosis of, 137. INDEX. 247 Mercado, 2. Mercury given hypodermically in diphtheria, igo. given to liquefy diphtheritic membranes, 188, 189. in the treatment of diphtheria, 187. not a specific in diphtheria, 188. oleate of, in diphtheria, 190. sulphate of, in diphtheritic laryngitis, 223. to be given in small doses frequently to produce effect in diphtheria, 189. Micrococci, 194. as carriers of diphtheria, 24. disappear as erysipelatous process progresses, 40. excite no reaction, 25. in the kidneys, 46. Micro-organisms and septic poisons, no etiological connection between, 38. Middleton, 11. Milk a cause of diphtheria, 63. Mitral valve affected in diphtheria, 91. Mortality in diphtheria, 150. Mouth, diphtheria of the, 81, 105. mucous membrane of, anatomical appearances of, in diphtheria, 122. Muciparous glands, determining the character of diphtheritic membrane in cer- tain cases, 122. Muco-salivary diphtheritis caused by extirpation of the tongue, 85. Mucous glands impede the action of diphtheritic poison, 127. membrane of the mouth, anatomical appearances of, 122. membrane of the nasal passages, anatomical appearances of, 123. membrane of the trachea and bronchi, anatomical appearances of the, 125. membranes prone to be affected by diphtheria, 121. Muguet or diphtheria, 134. Mycosis of the trachea and lungs, 65. Myelitis, diagnosis of, in diphtheria, 229. Mykosis oesophagi, 82. Nasal catarrh complicated with diphtheria, 72. catarrh, treatment of, during epidemics of diphtheria, 158. cavities affected in diphtheria, 71. cavities, mucous membrane of, anatomical appearances of, 123. diphtheria, 72. diphtheria following nasal catarrh, 217. diphtheria, lymphadenitis generally severe in, 136. diphtheria, sleep dangerous in, 220. diphtheria, treatment of, 217. diphtheria, very fatal, 129, 133. Necrotic diphtheria, 104. Nephritis following the use of the balsamics, 210. 248 A TREATISE ON DIPHTHERIA. Nephritis resulting from an overdose of chlorate of potassium, 163, 165. Nervous system, affections of, in diphtheria, 93, 106. tissue, anomalies of nutrition of the, causing diphtheritic paralysis, 98 Neurin as a solvent of diphtheritic membranes, 184. New England, diphtheria in, 3, 4. Nitrate of silver in the treatment of diphtheria, 190, 199. Nostrils of attendants on diphtheritic patients to be filled with cotton, 173. Nourishment in diphtheria, 154. 162. Nurses of diphtheritic patients to wear cotton in their nostrils, 173. Nutrition, anomalies of, of nervous tissue causing diphtheritic paralysis, 98. CEdema glottidis detected by palpation, 137. glottidis, general, uncommon in diphtheria, 137. glottidis in diphtheria, 76, 105. Oertel, 37, 38, 78, 155, 190, 229. Oesophagus, diphtheria of the, 82. Ogden, Jacob, 9. Oleum eucalypti e foliis in diphtheria, 209. Origin, local, of diphtheria, 52, 53. of diphtheria, author's views of the, 54, 55. of diphtheritic paralysis, 96. Otitis in diphtheria, 74. Oxydation increased by iron, 195. Ozone in diphtheria, 205. Palate, soft, in diphtheria, 69. Panum, 38, 46. Parasitic nature of diphtheria not proven, 23, 49. Paralyses, diphtheritic, treatment of, 228. peripheral, more frequent than central, 228. Paralysis, diphtheritic, 2, 52, 96, 142. diphtheritic, statistics of, 99. of central origin, 97. of the lower and upper extremities, 100. of the pneumogastric nerve in diphtheria, 96. of the sense of taste in diphtheria, 97. of the vocal cords, 138. severity of, in diphtheria, 97. Paresis of the thyro-arytenoid muscles a sequel of diphtheria, 73. Pathological appearances caused by diphtheritic endocarditis, 115. Pavement epithelium altered in diphtheria, 108. epithelium most liable to be affected in diphtheria, 127. Penis, deformity of, caused by diphtheria, 90. Pepsin as a solvent of diphtheritic membranes, 184. Perforation and destruction of the eye in diphtheria, 74. Peripheral more frequent than central paralyses, 228. INDEX. 249 Pharyngeal congestion may be either traumatic or diphtheritic, 134. membrane often first affected in diphtheria, 53. Pharyngitis and diphtheria, 53. occurring during diphtheria epidemics, 159. Pharynx in diphtheria, 68. often not affected in diphtheritic tracheo-bronchitis, 79. Placental diphtheria, 88. Phlegmon, incision of, resulting in diphtheria, 52. Pneumogastric nerve, paralysis of the, in diphtheria, 96. Pneumonia, causes of, in diphtheria, 81. diphtheritic, 143. fibrinous, in diphtheria, 80. Polluted water not necessarily a cause of diphtheria, 62. Potassa in diphtheria, 199. Potassium chlorate a prophylactic in diphtheria, 159. chlorate, effects of, in diphtheria, 160 et seq. Powers' investigation as to communicability of diphtheria by means of milk, 64. Predisposing causes of diphtheria, 32, 50, 58. Premises, the, should be disinfected with copperas solution, 177. Prevention of diphtheria, 158, 173. Primary diphtheria of the trachea, 142. Prodromal stage, duration of, of diphtheria, 68. Prognosis in croup, 138. in diphtheria, 149. Prophylactic agents in diphtheria, 58, 159. Pseudo-croup, 138. Pus globules, endogenous formation of, in epithelium doubted, no. Putrefaction without bacteria, 39. Quinia after the performance of tracheotomy, 226. in diphtheria, 154, 171, 198, 213, 228. Recurrence of diphtheria, 50. Relapses frequent in diphtheria, 32. Relations between erysipelas and diphtheria, 86. Removal, mechanical, of membranes in diphtheria, 214. Remedies in diphtheria, division of, 178. Respiratory muscles, paralysis of the, most dangerous, 101. organs affected in diphtheria, 75. passages, diphtheria first seen in the, 53. Rhinoscopic examination in diphtheria, 136. Rigidity of the eyelid in diphtheritic conjunctivitis, 230. Rokitansky, 81. Salicylate of sodium in diphtheria, 197, 211. Salicylic acid as a caustic, 197. 250 A TREATISE ON DIPHTHERIA. Salicylic acid, disinfectant properties of, 197. acid in diphtheria, 170, 196. Satterthwaite and Curtis, 23, 43. Scarlatinal and diphtheritic albuminuria, diagnosis between, 90. Schools, necessity of closing them in diphtheria epidemics, 172. Sclerotic, destruction of, in diphtheria, 105. Scrofula, so-called and chronic nasal catarrh, 131. Season, influence of, on diphtheria, 33. Self-limitation of diphtheria, 156. Sensitive paralyses, 101 . Sequela? of diphtheria, 73. Severity of diphtheria dependent upon the vascular and lymphatic systems, 129. of paralysis in diphtheria, 97. Sewers and diphtheria, 34. Sex in diphtheria, 29. Silver nitrate in diphtheria, 199. Skin, diphtheria of the, 2, 86* diphtheritic poison introduced by the, 52. eruption in diphtheria, 144. Sleep dangerous in nasal diphtheria, 220. Sodii sulphatis carbolatoe in diphtheria, 211. Sodium benzoate in diphtheria, 170, 206. chlorate a prophylactic in diphtheria, 159, 160. salicylate of, in diphtheria, 154, 197, 211. Source of diphtheria, 50. Spleen, appearances of, in diphtheria, 116. Statistics of diphtheritic paralysis, 99. of the diphtheritic process, 114. of tracheotomy in diphtheritic laryngitis, 224. Steam, inhalations of, in diphtheria, 178, 181. Stimulants in diphtheria, 156. Stomach, diphtheria of the, 82. Stomatitis and diphtheria, diagnosis between, 134. follicularis not to be confounded with diphtheria, 134. occurring during diphtheria epidemics, 159. Strabismus in diphtheria, 10. Strychnia in diphtheritic paralyses, 229. Suffocation, danger of, in diphtheria of vocal cords, 129. Suffocative and asthenic forms of diphtheria, 2. Sulphurous acid in the destruction of bacteria, 174. Sulphur, roll, for fumigation, 176. insufflation of, in diphtheria, 209. Summary of anatomical appearances in diphtheria, 132. of diagnosis of diphtheria, 147. of etiology of diphtheria, 49. of history of diphtheria, 25. INDEX. 251 Summary of manner of infection in diphtheria, 56. of symptoms of diphtheria, 104. of treatment of diphtheria, 231. Suppuration rare when glands swell in diphtheria, 217. Sweden, diphtheria in, 10. Swelling of the glands in diphtheria, 131, 133. of the glands in diphtheria, treatment of, 216. Switzerland, diphtheria in, 10. Symptoms of croup and diphtheria compared, 139 et seq . of diphtheria, 51, 68. of laryngeal diphtheria, 77. Synonyms of diphtheria, 1. Table showing the anatomical appearances in the air passages in diphtheria, 126. Tannin in the treatment of diphtheria, 190, 211. Taste, sense of, paralysis of, in diphtheria, 97. Temperature in diphtheria, 33, 55, 68. Thompson, W. H., on the effects of bromine in diphtheria, 200 et seq. Throat distemper, 5,7. the, in diphtheria, 70. Thrombi in diphtheria, 91. Tissues acting differently after inoculation, 42. Tommasi, 109. Tongue, extirpation of the, a cause of muco-salivary diphtheritis, 85. Tonics in diphtheria, 155. Tonsils in diphtheria, 30, 215. Trachea and bronchi, mucous membrane of the, anatomical appearances of the, 125. and lungs, mycosis of the, 65. primary diphtheria of the, 142. Tracheal diphtheria, local in character, 128. Tracheotomy, 210. carbolic acid spray after, 225. causing diphtheria, 85. disinfection of wounds caused by, 225. exposure during, causing diphtheria, 59. in diphtheria, 150, 151, 215. in diphtheritic laryngitis, 223. in diphtheritic tracheo-bronchitis, 79. statistics of, in diphtheritic laryngitis, 224. treatment after its performance, 226. twice in the same subject, 27. Transmission of diphtheria by means of milk, 64. Treatment of diphtheria, 154 et seq. of diphtheritic laryngitis, 222. of diphtheritic paralyses, 228. 252 A TREATISE ON DIPHTHERIA. Treatment of membranous croup, 222. of swelling of lymphatic glands, 216. Trousseau, 15, 17. Turpentine in the treatment of diphtheria, 185, 209. Turpeth mineral in diphtheritic laryngitis, 223. Typhoid fever complicated with diphtheria, 81, 82. Urethrotomy causing diphtheria, 88. Urine, albumen in the, in diphtheria, 90, 144. albuminous, produced by chlorate of potassium, 166. Vaginal diphtheria, 87, 143. Varieties of diphtheritic paralysis, 146. Vascular and lymphatic systems, severity of diphtheria dependent upon, 129. Virchow, 17, 21, 117, 118. Vocal cords, diphtheria of the, danger of suffocation in, 129. cords, diphtheria of the, general infection uncommon in, 129. cords, diphtheritic membranes on the, not easily thrown off, 129. cords, paralysis of, 138. cords resting places for diphtheritic poison, 133. Vomiting a bad symptom in diphtheria, 70. Vulvitis diphtheritica, 87. Wade, 20. Water in the treatment of diphtheria, 181 et seq. polluted, not necessarily a cause of diphtheria, 62. Wounds, diphtheria, of, 2, 85, 143. disinfection of, after tracheotomy, 225. Zinc sulphate as a disinfectant, 176.