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Diphtheria, Croup,  Etc.

                  OR,

     THE  MEMBRANOUS  DISEASES:


THEIR NATURE, HISTORY, CAUSES AND TREATMENT;
    WITH A REVIEW OF THE PREVAILING
       THEORIES AND PRACTICE OF THE
           MEDICAL PROFESSION;

                  ALSO,

a  Delineation op  the New Choral Hydrate Method of
   Treating the Same ; Its Superior Success, and Its
       Title to be Considered a Specific.
        BY \S

C. B. GALENTIN, M.D.
        NEW YORK:
J. H. VAIL  &  COMPANY,
          1884. 
vice
Gr!53d
Entered according to Act of Congress, in the year 1884, by
              C. B. GALENTIN.
In the office of the Librarian of Congress, at Washington.
All rights reserved. 
PRE FA C E.
  Whoever adds a new book to the long catalogue of medical
works, should have something to say which has either not
been  well  said  before, or  that  is  new.  On  the  subjects
treated in this volume much  has been well said and written
by men in the profession, eminent as writers  and teachers.
In history, aetiology and pathology, it can be truthfully said,
they  have constructed an almost faultless edifice, wanting
only  a therapeutic finish to  complete the fabric.   On this
latter only has the writer anything very important or new to
contribute.  On the therapeutics of diphtheria so  indefinite
and diverse have  been the opinions of the architects,  that
the laborious  student is more dazed than  edified, by being
conducted into voluble labyrinths that end in the confusion
of uncertainty and  doubt.   " Systematic feeding," and direc-
tion to '• treat the symptoms as they arise," is nearly the sum
of what  has been  developed in  the medical  treatment of
diphtheria.
  The writer has been led, or  driven, into a new and hitherto
untried field of therapeutics in  this destructive disease, and
for several years, in the treatment of hundreds of cases, has
demonstrated  to his entire satisfaction the claims of Chloral
Hydrate  to specific  efficacy  in. the  membranous diseases,
diphtheria, croup,  &c.  It  is  expected that this  announce-
ment  will be received with reserve and a measure of incredul-
ity, even by men of fair  minds  and culture ; by others pos-
sibly  with positive  contradiction and  opposition,  and by
another too  numerous class  of pompous, opinionated  and
bigoted men, or doctors, if you please, with derision.   These
                            in 
IV
PREFACE.
latter are the obstructionists  of progress, ever ready to sneer
at, and strive to detract from the  influence of any discovery
in medicine so  unfortunate  as not to have  been developed
beneath their own hats.  However it may be  received b}r the
profession, it is  confidently believed that it will be sustained
by experience, and will stand, as have other  truths, upon its
own merits.
  Other  practitioners of ripe age  and large experience, both
in this city and elsewhere, at  the suggestion of  the writer,
have tested the efficacy of chloral  in a very large number of
cases of diphtheria, and unhesitatingly affirm its  efficacy, as
superior  to any other known  treatment.
  Among these I mention with pleasure  ury esteemed and
scholarly friend, Dr. A. Gr. Hart, and my  daughter and co-
laborer   in  this work, to whom its merits, if any be ac-
corded it,  are  largely due.  Finally, to  those whose  lives
and labors  are  honestly devoted  to the  true  interests of
the noble profession of medicine, and the welfare  of human-
ity, I wish to say,
  Gentlemen, the writer submits whatever  is new and use-
ful  in this little  volume to you, for your careful consideration
and use ;  in the pleasing hope of rendering both to you,
and through you, to the world, a tittle of the  good service
we  owe each other and humanity,  with  a  humilitating  sense
of its many defects,
                                                C. B. G. 
CONTENTS.
Introduction........".............................   vn
Diphtheria.
   Chapter   I.  Definition.........................    1
      "     II.  Nomenclature......................    2
           III.  History...........................    2
      "    IV.  Cause............................   14
      "      V.  Climatic and Atmospheric Influences ...   31
      "    VI.  Mode of Propagation................   33
      "   VII.  Predisposing Causes.................   39
      "  VIII.  Period  of Incubation................   42
           IX.  Prophylaxis  ........; :...,/. ..f?r..   44
      "      X.  Symptoms...........'.-.. ...TTTTr.. ,  ^45
      "    XL  Diagnosis .... r ................../ .  i 64
          XII.  Prognosis___■................ -<f. .yJ 66
      «  XIII.  Pathology.....\,._..t^rfv..^j.\..^  69
      *♦   XIV.  General Treatment. . . . vr. .  . . .".......   77
      "   XV.  Therapeutic Treatment...............   81
      '•   XVI.  Local Treatment....................   84
      '•  XVII.  Constitutional Treatment.............   92
                 Chloral Treatment..................  Ill
      " XVIII.  Nasal Diphtheria...................  121
      "  XIX.  Laryngeal Diphtheria...............  123
      "   XX.  Treatment of Diphtheritic Paralysis ....  126
      »  XXL  Medical Prophylaxis................  127
      "  XXII.  Croup............................  129
      " XXIII.  Tracheotomy......................  151
      " XX LV.  Plastic Bronchitis.................  156
FobmuljE........................................  163
                            v 
 
INTRODUCTION.
   The treatment of different diseases by similar remedies, as
advocated in the following pages,  to thoughtful practitioners
will appear neither strange  nor  unreasonable.    Diseases
differing  widely  in  their essential characters, are not  infre-
quently related by symptoms or phenomena that are common
to several.
   The entire system of the so-called " Rational  treatment of
disease,"  indeed, consists in the treatment of the  symptoms as
they arise, if we except only the few instances in which the
treatment is specific.  Pain in the chest for example, may be
occasioned  by a  variety of diseases, as  pneumonia, pleurisy,
and neuralgia,  but regardless of its cause, requires anodynes
for its cure.   Hemorrhage, whether  from  the  lungs,  the
stomach,  the uterus, or the bowels, depending on  different
organic or general  diseases, calls  alike  for gallic acid, ergot,
and the like.  An exhausting diarrhoea occurs in quite oppo-
site states and may be very properly controlled by opium, etc.,
regardless of the particular disease ; sleeplessness, occasioned
by very diverse causes, calls alike for chloral, morphia, etc.;
debility,  regardless of its cause,  is treated properly with
nutrients  and restoratives ; and an exalted temperature of
the body, whether inflammatory or tjTphoid, with antipyretics.
Symptoms, and not the names  of diseases, are treated by
intelligent practitioners, with the  exception of those treated
by specifics as before stated.
  In the diseases which we call Membranous, and which only
are the subjects of this  volume, we observe a common diag-
nostic symptom or manifestation.   It is not pain, nor diar-
                           VII 
VIII
INTRODUCTION.
rhoea, nor hemorrhage,  nor hyperpyrexia, nor debility, but a
peculiar  exudation from the blood, generally upon  mucous
surfaces, denominated false membranes.   These membranes
are so nearly identical in structure and materials as to render
a distinction nearly or quite impossible.
  As we shall have occasion hereafter to  note, their appear-
ance has been attributed  to both local  and general causes,
which are possibly so obscure, remote, or  ethereal, as forever
to elude discovery.   What we. wish here to observe is, simply
that these diseases, having a like prominent and diagnostic
symptom, may rationally be treated by the same or similar
remedies without the violation of any principle entitled to
professional respect.
  It is but  reasonable to infer, from  the identity  of these
plastic  exudates,  that  some similar S3'stemic  disturbance
exists  in  each of these diseases ;  and yet this is  only in-
ferential.    Many  regard  croup and plastic bronchitis  as
purely of local origin from the  lack of  early constitutional
symptoms;   while  others,  equally honest and  intelligent,
observe that common acute inflammation in the same local-
ities is not ordinarily attended b}' the membranous exudation,
and therefore conclude that in these, as  in diphtheria, there
probably exists primarily some peculiar toxaemia.
  Neither of these theories is thought to be entitled to, or
should be given, any particular influence by  the practitioner
in deciding upon  his therapeutical measures  at the  bedside,
and hence they are dismissed for the present without discus-
sion for matters of a more practical nature.
                                              AUTHOR. 
DIPHTHERIA.
                      CHAPTER I.

                      DEFINITION.

   Diphtheria  is an acute, specific, contagious, febrile disease,
 which occurs  epidemically, endemically and sporadically, in
 most countries of the world, and is characterized by general
 or constitutional symptoms like other pyrexia! diseases, with
 a greater or less degree of inflammation of the mucous mem-
 brane of the pharynx, larynx, air passages, or other mucous
 passages ;  and by  the formation on the surfaces of these
 parts, particularly upon the mucous membrane of the pharynx
 and  upper air passages, of a lympho-fibrinous membrane,
 generally in patches of a whitish, yellowish, or grayish color.
  It is further characterized by more  or less inflammatory
 swelling of the glands of the throat and neck  or adenitis.
   During the prevalence of diphtheria,  wounded,  abraded,
 or ulcerated surfaces, upon any part of the body, frequently
 become covered with a membranous deposit similar to that
 in the more ordinary situations.  The  constitutional symp-
 toms  usually  denote  a depressed state of the vital powers.
 Often the urine becomes  albuminous  from renal disturbance.
 The sequelae most common are lesions of the nervous system
causing a greater  or  less degree of paratysis, impairing  in
proportion, phonation, deglutition, respiration, sensation, etc.
Fatal cases usually terminate by gradual apnea ; less fre-
qently by asthenia and cardiac thrombosis.
                          d) 
2
DIPHTHERIA.
                     CHAPTER II.

                    NOMENCLATURE.

  The term diphtheria is of Greek origin, and may properly
be defined by the  English term membrane.  Diphtheria, diph-
therite, and diphtheritis  are all used as synonyms, and have
the same origin.
  Diphtherite, as applied to the disease under consideration,
was  originalby employed by 31.  Bretonnau, a  celebrated
Franch physician,  in his work entitled " Traite de la Diph-
therite," published in Paris in 1826. Trousseau, considering
the term objectionable because of the termination ite, used in
medical science to imply inflammation, changed the word to
diphtherie, in order to get rid of the aetiological doctrine of
inflammation expressed  by the suffix ; and, technically speak-
ing, diphtheria is the English synonym of the French diphtherie.
  Among ancient  writers the  disease received a varity of
apellations,  as; ulcus Egyptianum  vel Syriacum — the  Eg}p-
tian  or  Syriac  ulcer ;  angina gangrenosa — gangrenous  sore
throat ;  morbus suffocans vel  strangulatorius — suffocating or
strangulating  sickness ;  garotillo — throat  disease ;  angina
suffocativa — suffocating sore  throat ; malum canna — throat
sickness ;  and many  others.
                     CHAPTER  III.

                        HISTORY.
               (compiled from the best authors.)
  It is not the purpose of the writer, nor within the scope of
the present volume to enter exhaustively into the bibliography
of diphtheria.   This alone would fill a volume,  and could not
be made profitable to the laborious practitioner of medicine,
for whom  alone, in the interests of humanity, this treatise is 
HISTORY.                       3
 designed.  The  following epitome of what is known on the
 subject is derived from a careful study of the best authorities,
 and may be regarded as authentic.
   Diphtheria, or throat affections in some respects analagous
 to it, can be traced to a remote antiquity ; their identity with
 the modern  disease is,  however,  often  only  imaginary,  or
 inferred from the resemblance of a few symptoms.   There
 are no proofs of  any epidemic prevalence of the disease as it is
 seen at the present time, until about the middle of the eigh-
 teenth century.
   Among the more ancient  medical  records   quoted   by
 writers in proof that the ancients were acquainted with this
 affection are the following.  Nearly twenty-five hundred years
 ago, or about the time of Pythagoras, an East Indian physi-
 cian, named  D'hanvantare, gave a description of a disease,
 thought  by  some to have been diphtheria, in which "An
 increase of phlegm and blood causes a swelling in the throat,
 characterized  by panting  and pain,  destroying  the  vital
 organs, and  incurable : —■ a  large  swelling in  the  throat
 impeding food and  drink,  and marked  by violent feverish
 sj-mptoms, obstructing the passage of the breath, arising from
 phlegm combined with blood, is called closing of the throat."
   Galen of Pergamos, about the middle of the second cen-
 tury, speaks of a  membranous formation in the pharynx  being
 ejected by expectoration.  Aretaeus of Cappadocia, a physician
 of renown who practiced at Rome about the time of Augustus,
 has left a history of the Egyptian or Syriac ulcer, considered
 to have more points of resemblance to the  diphtheria  of
 to-day than any other disease of antiquity.  This was charac-
 terized  by ulcers on the tonsils,  some  mild and harmless,
 while others were pestilential and fatal.  " The  former, which
are common—are clean,  small, and  superficial, and are un-
accompanied  by  either pain  or inflammation.  The latter,
which  are rare — are extensive, deep, putrid, and  covered
with white,  livid, or blackish concretion.-----If  it extends 
4
DIPHTHERIA.
rapidly  to the chest  through the windpipe, the patient dies
on the same day by suffocation.
  Coelius  Aurelianus,  writing about the close of  the  third
century, " describes  the barking sound of the voice and its
occasional complete extinction, the stridulous breathing, and
lividity of the face.   His reference to the defective articula-
tion sometimes present, and to the passage of fluids into the
nose in swallowing, probably refer to the paralytic symptoms
of the disease.  It is supposed by some that the Askara
frequently mentioned in the Talmud  as a fatal epidemic, was,
in fact, diphtheria.  Rashi, the  learned  commentator of the
Talmud and Old  Testament,  remarks with reference to the
Askara, that sometimes it breaks out in the mouth  of a man
and he dies from it.   'Also that sudden death ensues from
suffocation.'"   (Mackenzie.)
  " Macrobius  speaks  of a  similar epidemic at Rome,  A. D.
380, during which,  sacrifices were  offered  up to  a certain
Goddess — ut populus Romaniis, morbo, qui angina dicitur
promisso  voto, sit liberatus."   (Slade.)   "Aetius, of Amida,
in the sixth century  delineated the disease as  presenting
white and ash-gray  spots in the pharynx,  slowly  ending in
ulceration."  (Mackenzie.)
  Brief and unsatisfactory as are the preceding quotations,
they  are  believed to  constitute the bulk and  basis of the
evidence extant that the  ancients were acquainted with this
malad}\   From the  sixth to the latter part of the sixteenth
century,  nothing  further  in medical  history  is  noted as
having  any very probable reference, or clear analogy to this
disease.   Hecker's accounts of the epidemics of the  four-
teeth, fifteenth, and  sixteenth centuries,  in Holland, France,
and England some of them  characterized by violent anginose
affections,  quoted by  Slade  to connect  the ancient and
modern records of the disease, must be considered irrelevant,
and wanting in any recorded appearance or  symptom charac-
teristic of genuine diphtheria. 
HISTORY.
5
   Of modern writers, Bailou, a distinguished French plrysi-
 cian, whose writings bear the date 157G, is believed to be the
 first who makes distinct mention of a false membrane.  In
 the early part of the 17th century an epidemic angina, denom-
 inated garrotillo prevailed in Spain.  Its  best description is
 by Villa Real,  who  states that he has  seen  "a  thousand
 times, in  patients at the first onset of the disease, a white
 matter in the  fauces, gullet, and throat.   He adds that the
 matter is  of such nature,  that if  you stretch  it with your
 hands it appears  elastic, and has properties  like those of wet
 leather — facts  which he noticed,  not only  by observing the
 matter coughed up by the living, but also by the examination
 of it in the dead."
   About the same period, accounts  of the disease, less satis-
 factory because of the omission of the post-mortem appearan-
 ces, were written by Herara and Fontecha.   They, however,
 confirm  the  prevalence  of  garrotilla  (diphtheria)  in Spain
 between the years 1581 and  1611.   The name "garrotillo"
 was  first  given the disease because those attacked by it
 perished as if strangled b}T a cord.   In 1617 diphtheria was
 prevalent in an epidemic and fatal form at Naples and in
 other parts of Italy.  (Sgambatus.)  It was sometimes called
 "3Iale-de-canna" — disease of the trachea.  It  continued its
 ravages for a period  of at  least twenty years, and has been
 described by several other writers of authority, as, Carnevale,
 Zacutus Lusitanius, and 3Iarcus Aurelius Severinus.  " Carne-
 vale in particular has given  us full data of this epidemic in
 his treatise entitled  'de Epidemico Strangulatione Affectu.'
 The children were first attacked, the disease afterward spread-
 ing among the  population generally, and  proving very fatal.
 The disease commenced  by mild inflammation of the throat;
 soon the affected parts  presented a whitish exudation ; the
 breath became fetid;  deglutition impossible ; the respiration
embarassed, and the patient died of  suffocation.  This writer
also  gives us the different appearances  which the pharynx 
6
DIPHTHERIA.
presented in this epidemic ;  he also speaks of the extension
of the disease to the trachea, aesophagus, and pituitary mem-
brane ;—of the diagnosis, prognosis, and the topical remedies,
all  of which are quite  in accordance  with modern views"
(Slade).  Carnevale also asserts  its identity with the disease
which had  been prevailing in Spain  under  the name of
garrotillo.
  In  1625 the writings of  Cortesius  show  that the  same
disease  extended, a little later, to  Sicily.  He speaks  of a
membrane in the throat, which could readily  be torn awa}7,
as being one of its characteristics.  In 1632 Alaymus pub-
lished a treatise upon  the  Syrian  ulcer.   He  prefers  this
term, he sa}s,  inasmuch  as  it applies to all  forms of the
disease, which he describes in a manner similar to Carnevale.
" In 1713 Dr. Patrick Blair, of London, in a letter to Dr. Mead,
described a  disease as  ' the croops' which, he says,  was epi-
demic and universal  at Coupar  Angus, and  which was no
doubt diphtheria."  (3Iackenzie).
  From  1743  until 1748 the disease prevailed in Paris, and
has been described  by  3Ialouin  and Chomel.   About the
same  date  Ghisi describes  an  epidemic  of the  disease in
Palermo, and noticed the paralytic sequelae.  Also about the
same time a similar epidemic appeared both in England and
at Cremona, accounts  of which were given  by Fothergill,
Starr, and Ghisi.  These epidemics were  very destructive,
especially in England, where it was regarded by Fothergill as
scarlatina.  He says, " If the mouth and throat be examined
soon after the  first  attack,  the uvula and tonsils arc found
swelled ; and these parts, together with the velum-palati and
pharynx, appear of a bright red color, which is most marked
on the posterior edge  of the palate, in the angles above the
tonsils, and upon the tonsils themselves.   Instead of redness,
a broad spot or patch of an irregular form, and of pale white,
is sometimes seen surrounded with florid red, which whiteness
appears like that of the gums immediately after being pressed 
HISTORY.
7
 with the fingers, or as if matter ready to be discharged was
 contained beneath.  Generally on  the second  day  of the
 disease, the  face, neck, hands, and breast, are of  a  deep
 erysipelatous color,  with a sensible tumefaction.  A great
 number of small pimples, of a color more intense than that
 which surrounds them, appear on the arms and other parts."
 (In a note he says, " The eruption  and redness have not so
 regularly  accompanied the disease  during the latter part  of
 this Winter, 1754, as they did last year.  In some cases they
 did not appear  at all,  in  others not till the third or fourth
 da}7.")   " The appearances in the fauces continue the same,
 except that the  white places become more ash-colored; and
 it  is now found that what  might  have been taken for the
 superficial covering of a suppurated tumor, is really a slough,
 concealing an ulcer.   Instead of the slough, in mild cases, a
 superficial ulcer, of an irregular form, appears in one or more
 parts, scarce to be distinguished from the sound, but bjr the
 irregularity of  surface  which it  occasions.   Towards night,
 heat and restlessness increase, and a peculiar kind of delirium
 comes  on, the pulse is generally very quick ; in some hard
 and small ; in some soft and full.   The tongue is generally
 moist,  and not  often  found coated.  In some it is covered
 with a  thick white  fur ; and  these generally complain  of
 soreness about the root of the tongue."   (Slade.)
   " In  1749 3Iarteau cle Grandvilliers described an outbreak
 of the  disease in  Paris, and the elder Cliomel, in detailing
 the symptoms,  accurately  described  diphtherial paralysis.
 In 1750 the formation of a membraniform concretion in the
 throat is distinctly described  by Dr.  Jno. Starr, as occurring
 as an epidemic in Cornwall, England."  (Mackenzie.)
   In 1757, Dr. Huxham in a treatise denominated "A Disser-
tation on the 3Ialignant Ulcerous Sore Throat," described  an
 epidemic which  had been prevalent  at Plymouth, in which
 some of the  cases were  undoubtedly of  the character  of
 secondary diphtheria.  " Not only,"  says he, "were the  nos- 
8
DIPHTERIA.
trils, fauces, &c, affected,  but the windpipe itself was much
corroded,  and pieces of its internal membrane were spit up."
  " Dr.  Starr, of Liskeard, published a paper in the Philo-
sophical  transactions, upon  the malignant ulcerous sore throat
epidemic which  appeared in that place in  1749.  In  this
paper,  besides other details of the epidemic, he  gives  the
full data of a case in which the false membrane commencing
in the fauces, extended to  the larynx.  He particularly dwells
upon the physical properties of the exudation, its  adherence
to the subjacent  surface, its frequent  detachment and repro-
duction.  In fact, he gives a complete picture of  Bretonnau's
diphtheria."
  In 1789,  Dr. Samuel Bard of  Philadelphia, in a work en-
titled, "Researches on the  Nature, Causes, and Treatment of
Suffocative Angina," gave a detailed account  of  " an uncom-
mon and highly dangerous distemper" which had recently
proved fatal to many children in  New York.  He recognized
the  analogy between this disease and croup, as well as  the
manner  in  which it spreads  from the throat to the larynx.
He  observed  it sometimes as simple angina; sometimes as
angina complicated  with laryngitis, and occasionally as lar-
yngitis alone.
  " In general the disease was limited to children under ten
years of age, though some few grown persons,  particularly
women,  had symptoms  very similar  to it.   Most of the per-
sons attacked were  observed  to droop before they were con-
fined.  Usually the first sj-mptoms were a slightly inflamed
eye, a livid countenance, and slight eruptions upon the face.
At the same time, or very  soon after,  those who  could speak
complained of an uneasy sensation in the throat,  but without
much soreness or  pain.   Upon  examination,  the tonsils
appeared swelled and  highly inflamed,  with a few white
specks upon them, which,  in some cases,  increased so as to
cover them all over with one general  slough ; this, however,
although a frequent symptom, did not invariably attend the 
HISTORY.
9
 disease.  The  breath  was not offensive, and deglutition but
 very little impeded.
   '• These symptoms continued in some cases for five or six
 days without  creating any alarm; in others, a difficulty of
 breathing came on within twenty-four  hours, especially dur-
 ing sleep,  and  was often suddenly increased  to such an
 extent as to threaten  immediate suffocation.  Generally  it
 came on later, increased more gradually, and was not constant.
   " This stage of the  disease was attended with a very great
 and sudden prostration of strength,  a  very peculiar, hollow,
 dry cough, and a remarkable change in  the tone of the voice.
 In some  the voice was almost entirely lost, and  would con-
 tinue  very weak and  low for several  weeks after recovery.
 These symptoms continued for one,  two, or  three days, and
 greatly increased  in those who  died; purging  in  several
 cases  came  on, the difficulty  of breathing became  more
 marked,  and  the  patient  died  apparently  of  suffocation.
 This commonly  happened before  the end  of the  fourth or
 fifth da}*.  One  child,  however,  lived under these circum-
 stances to  the  eighth day.   Shortly  before he  died, his
 breath and expectoration  were somewhat offensive ; but this
 was the only instance  in  which I could discover anything
 like a disagreeable smell, either from  the breath or expec-
 toration.
   " In  some cases instead of the difficulty  in respiration,
 verj- troublesome ulcers appeared behind the  ears.
   " ' These  began  with a few red pimples,  which soon ran
 together,  itched  violently, and  discharged a great deal of
 very sharp  ichor, so as to erode the  neighboring  parts, and
in a few days spread all over  the  back  part  of the ear, and
 down upon the neck.'
   " In a  few cases swelling  of the  parotid and  sublingual
glands was noticed.  Dr. Bard says :—
   "' I met  with but  two instances  of anything  like  this
complaint in adult persons.  Both of these were women, and 
10
DIPHTHERIA.
one of them had assisted  in laying out two  of the children
that had died  with  it.  At  first  her symptoms resembled
rather an inflammator}* angina ;  but, about the third day,
the tonsils appeared  covered  in  some places with sloughs:
her pulse was  low and feeble ;  she  had  a  moist  skin, a
dejection of  spirits, and  some  degree of anxiety, though
nothing like the difficult breathing of the children.
  "' The other was  a soldier's wife; who,  for some time,
before she perceived any complaint  in her  throat, labored
under a low  fever.   Her tonsils were swelled  and inflamed,
and covered  with sloughs resembling those of the children ;
but her breath was more offensive, and she had no suffocation.
  " ' I have had an opportunity of examining the nature and
seat of this disease from dissection  in  three instances.  One
was  a child  of three years old.   Her first complaint was an
uneasiness  in her throat.  Upon examining  it, the  tonsils
appeared swelled and inflamed,  with large  white  sloughs
upon them,  the edges of which were remarkably  more red
than the other parts  of the throat.  She  had no great sore-
ness in her throat, and could swallow  with little or no diffi-
cult}7.  She complained of pain under the left breast; her
pulse was quick, soft, and fluttering.  The heat of the body
was  not very great,  and her skin was moist; her  face was
swelled ;  she  had a considerable prostration of strength, with
a very  great difficulty of breathing; a  very remarkable
hollow cough, and a peculiar change in the tone of  her voice.
She was exceedingly restless  ; was  sensible, and when asked
a question, would give a pertinent answer ;  but otherways,
she appeared dull and comatose.  All these  symptoms con-
tinued or rather increased till the  third, night, on which  she
had five or six loose stools, and died early in the morning.
  "' Upon  examining  the body—which was  done on the
afternoon of  the  day she died—I  found the fauces, uvula,
and root of the tongue interspersed with sloughs, which still
retained their whitish color.  Upon removing  them, the parts 
HISTORY.
11
underneath appeared rather pale than inflamed.  I perceived
no putrid smell from them, nor was the corpse in the least
degree  offensive.  The  aesophagus appeared as in a  sound
state.   The epiglottis was  a  little  inflamed on its external
surface; and on  the inner  side, together with the inside of
the whole  larynx, was  covered with the same tough white
sloughs  as the  glands  of the fauces.   The whole  trachea,
from the larynx down  to its division in the lungs, was lined
with inspissated mucus, in form of a membrane, remarkably
tough and firm; which, when it came to the first subdivisions
of the trachea, seemed to grow thin and disappear.   It was
so tough as to require no  inconsiderable force to tear  it, and
came out  whole from the  trachea,  which it left with much
ease ; and resembled, more than anything, both in thickness
and  appearance, a  sheath of thin  chamois leather.  The
inner membrane  of  the trachea was slightly inflamed ;  the
lungs, too, appeared inflamed,  as  in peripneumonic cases,
particularly the right lobe, on  which there were many large
livid spots, though neither rotten nor offensive ; and  the  left
lobe had small black spots on it, resembling  those  marks  left
under the  skin b}~  gun-powder.  Upon  cutting into  any of
the larger spots  which appeared on  the right lobe, a bloody
sanies issued from them without frothing.' "
  " He  supposed the prevalence of the epidemic  to  depend
upon the state of the air or a peculiar  miasm " which more
or less,  according  to particular circumstances, generate an
acrimony in the humors and  dispose them to putrefaction ;
and which  have a singular tendency  to attack the throat and
trachea, affecting the mucous glands  of these parts in such a
way  as to occasion  them to secrete their natural mucus in
greater  quantities  than is sufficient  for the  purposes  of
nature,  and which in this particular species, when secreted,
is really either of a  tougher or more viscid consistence than
natural, or is  disposed to  become  so from rest  and stag-
nation." 
12                     DIPHTHERIA.

  Dr. Bard, says 31ackenzie, was a careful and painstaking
observer, and his  monograph contributed  very considerably
to the accuracy of contemporary knowledge  of diphtheria ;
to which we might truthfully add that it is the model after
which  have been constructed most of  the descriptions of
diphtheria  which have  since appeared, both in this country
and in Europe.
  In  1802  appeared the  "First  lines  in the practice of
Physic," Ivy Dr. Cullen, professor of the practice of physic
in the University of Edinburgh, in  which, under the title
uc>j;ianche trachealis," is to be found a description thought to
be characteristic of the  diphtheria of to-day.
  In  1826 appeared the works  of M.  Bretonneau.   These
owed  their origin  to the alarming outbreak of the  disease
among the soldiers in the barracks at Tours in the latter part
of 1818, spreading  from thence to the surrounding country.
In Tours most of the victims were children,  and the larynx
most frequently affected, while  among the soldiers the gums
were the favorite seat of the diphtheritic exudation.  Bre-
tonneau describes the disease in Tours  as mild at the com-
mencement, but becoming alarmingly severe  in a few da}*s,
and very fatal.  From thence it spread to two small villages
adjoining, and thence throughout France.  In  some towns,
remarkable for their salubrity and good  sanitary conditions,
it raged  violently,  while  others situated in  low  marshy
regions,  almost entirely escaped.  Elsewhere  it  seemed to
select  ill-drained localities,  and pass over  those in better
sanitaiy conditions.  As evidence of its virulence a case is
mentioned in which out of seventeen  persons in a single
farmhouse, thirteen died of the disease.
  In  Edinburgh, in 1826, the disease prevailed as  a fatal
epidemic, and was accurately described  as " diphtherite " by
Dr. Abererombie, in his work  on  "Practical Researches on
Diseases of the Stomach," published two years  later.
  After the  subsidence  of the notoriety Bretonneau gave 
HISTORY.                      13
 diphtheria, it attracted but little  attention for  several years,
 till in 1841  an epidemic in  the Children's Hospital in Paris
 brought it again before the profession.   This epidemic was
 described by 31. Becquerel.   The children of the institution
 were attacked with sore throat, often attended with mem-
 branous  exudation,  sloughing, and  gangrene.   The disease
 was not limited  to the faucial and  laryngeal  surfaces, but
 appeared also upon abraded and blistered cutaneous surfaces.
 He  noted also a remarkable  state of the blood in its want
 of coagulability.
   During the following fifteen years diphtheritic  epidemics
 prevailed from time  to time in  various  parts of Europe,
 especially in France, and were described by Empis,  Lemoine
 Jobert and  Lespiaen.  Dr.  Ernest Hart,  of  London, ably
 described the  great English  epidemic of  1858-1859.  The
 first case was supposed to have been imported from Bolougne
 (probably a relic  of  the fatal epidemic there in  1855) to
 Folkstone in 1856.   Assuming alarming malignancy in 1858,
 it spread widely; was very fatal during the following year,
 and  for three  years more continued prevalent.   The local
 name was " Throat fever."
  In 1856  an epidemic of this  disease prevailed in  San
 Francisco and other California towns, and was described by
 V. Fogeaud in an essay on diphtheria and by Dr. Jas.  Blake,
 of Sacramento.  The mortality was very great.
  About  the same date, Dr.  Beardsly  of 3Iilford,  Conn.,
 described a fatal epidemic of diphtheria in that and adjoin-
 ing towns, in which the first symptom almost uniformly  was
 pain in the ear a day  or two in advance of any other mani-
 festation of  the disease.
  In 1858 diptheria prevailed in Albany, N. Y.,  and in many
 other towns, and may be said to have been constantly prev-
alent from that period to the  present time, not only in this
countr}*, but also in England, France, Germany,  and most
other countries of the  globe ; and is amply discussed in the 
14
DIPHTHERIA.
books  on  general practice, and in monographs, of  recent
date, to be found in the library of every physician.
  A complete history of the medical treatment of diphtheria
would constitute one of the curiosities of medical literature
—more curious than instructive.  The terrible fatality which
has attended the disease, seemingly little abated by any treat-
ment hitherto practiced, has  led to the exhibition of almost
every known remedy;  but failure still  incites  to  laudable
research and trial of new remedies.
  Such conditions have caused discrepancy and distrust, and
have led many  practitioners  of eminence to ignore authori-
ties, to discard  precedents, to  repudiate so-called  specifics,
and to  treat the disease  on general principles, or  as  the
symptoms occurring in any  case might  seem  to demand.
Confusion and doubt here, as  generally, precede order and
confidence.
  The  therapeutical  history  of the  disease, although  not
intended to  constitute  an integral part of this treatise, will
of necessity, be somewhat developed when we come to speak
of treatment in  chapters 16 and 17.
                     CHAPTER IV.

                         CAUSE.

  It is found exceedingly difficult to define disease itself, and
is much more  difficult to discover or define its cause  or
causes.   The cause  of certain fevers is  said to be malaria,
but what is malaria ?  Malaria is a subtile miasm, or micros-
copic entity  or  vapor,  exhaled under  certain imperfectly
understood conditions.   Its properties, its  constituents, and
its sources, are not perfectly known.  If fevers prevail alike
on either side of  a river or morass, who can tell whether the
miasm is exhaled or attracted ?  Neither can we tell certainly, 
CAUSE.
15
 with any or all the chemical and  optical appliances  known,
 whether  it  is animal or  vegetable, solid, fluid or gaseous.
 Then, as we have learned but very  little of the laws that
 govern it, doubtless the part of wisdom is to call it a "subtile
 entity," beyond the borders of the visible, and  beyond the
 range of inductive philosophy.  We have defined diphtheria
 as a contagious disease,  and scientists have, for these many
 years, been searching for the entity which we denominate the
 contagium,  in hopes that its  discovery  might guide in the
 discovery of a logical specific remedy.  As Salisbury believed
 that he had discovered the  true cause of malarial disease to
 be  a  minute  vegetable  organism, so also Oertel,  Heuter,
 Nasseloff, Eberth, and other German investigators claim to
 have discovered and demonstrated the cause of diphtheria to
 be also minute  vegetable growths which are denominated
 Bacteria, and divided into several genera and species.
   Any overestimate of the importance of such a discovery,
 as tending to throw light upon the nature and treatment of
 the  malady is nearly impossible.  If,  on  the other hand, the
 supposed  discovery  is  not sustained by observation and
 scientific research,  it may equally tend to  obscurity and
 wrong theory, and  pernicious  treatment.  It seems, there-
 fore necessary in any treatise upon diphtheria, in  view of the
 powerful advocacy of the bacterian theory by eminent scient-
 ific writers as the above, and the great influence given to the
 theory by  the  recent publication of Prof. Ziemssen's Cyclo-
 pedia, to somewhat  carefully  examine   its  claims, that we
 may award it all, and only the merit and influence to which
 it is justly  entitled.  The following summary, it is believed,
 gives as correct and authentic a view  of  this German theory
 as can be presented in the space allotted.
   Two of the numerous species of bacteria, called  micrococci,
 or spherical bacteria, and micro-bacteria, or rod-like bacteria,
 are supposed either to constitute the disease germs of diph-
theria  or to be its carriers from  one person or  locality  to 
16                    DIPHTHERIA.
 others —to constitute the real contagium.   By means of the
 most powerful microscopes most skillfully manipulated, these
 minute bodies "just on  the borders of the visible" are seen
 only as minute specks, or as oscillating points.
   " In every tissue affected with diphtheritic inflammation, in
 every  diphtheritic  false  membrane, and, in severe cases, in
 the blood, the tissues, and excreta,  are  found large numbers
 of micrococci,  associated with  a smaller number of micro-
 bacteria, which  increase or  diminish  in  the  ratio  of the
 violence of the disease.   They  accumulate vastly just before
 the formation of the exudation upon any abraded or wounded
 surfaces of patients ;  especially on  the  edges of the wound
 produced by tracheotomy.
   If any mucous surface exposed to the air, or any abraded
 cutaneous surface, being the seat of inflammation and occu-
 pied by other forms of bacteria,  as the leptothrix buccalis, or
 oidium  albicans,  is  attacked by the  diphtheritic form of
 inflammation, these  bacteria at  once  disappear, and  are
 succeeded by the sphero and micro-bacteria.   Again, when
 the diphtheritic disease abates, these latter disappear  and are
 succeeded by the former.
   In the early stages of the disease the grayish spots upon
 the pharyngeal surfaces are found to consist entirely of these
bacteria, epithelial  cells,  and mucus, and in the later stages
only are  associated  with pus  and  fibrin,  as resultants of
inflammatory reaction.
   In order  more clearly  to  ascertain the  relations of these
bacteria to diphtheria, recourse was had  to various carefully
conducted   experiments.   Croupous  inflammation  of  the
mucous membrane of the  larynx was induced by the applica-
tion of a powerful irritant (ammonia) producing a croup-like
membrane.    Although the fibrous exudation  afforded a soil
which varied little, or  not at  all, in its histological composi-
tion from that induced by diphtheria, none of these organisms
were found upon  nor beneath the inflamed surfaces. 
CAUSE.
17
  In  further  experiments upon animals, inoculations  with
diphtheritic matter were practiced upon the mucous membrane
of the air passages, the cornea, and muscles, with the result
of inducing  a rapid increase  of  these  diphtheritic bacteria
(the micrococcus  and micro-bacterium)  which rapidly pene-
trated the tissues  and induced  systemic infection.
  Oertel says, ■■ I  have noticed in numerous inoculations, that
if various bacteria besides the micrococcus, as for instance,
bacillus, spirillum, and bacteria lineolum, were present in the
matter to be inoculated, only micrococci (sphero-bacteria)
and the bacterium termo (in its most minute forms  accom-
panying them) showed evidence of prolific growth, while all
the other forms  disappeared  altogether."
  Upon the cornea these  inoculations  produced a  vast multi-
plication  of  these bacteria, violent local disease,  systemic
infection, and death.
  Oertel  says,  "according  to  my  experiments, the bacteria
spread over the  mucous membrane of the trachea, beset the
cellular elements,  crowd  especially into the young exudation
cells,  or are taken up by them, and gradually cause  their dis-
solution ; they  fill the  blood  and  lymph-vessels, and bring
about in a mechanical way. a damming up of the  fluids, and,
as a  consequence, serous exudation.   As the}* close  up the
capillary vessels, the}* occasion stagnation in  the blood cir-
culation, which induces disturbance of nutrition  in  the walls
of the capillaries, and even  rupture of the same.    3Iuscular
fibres, also, which are  covered and  filled with   colonies of
micrococci, degenerate and slough ; in like manner,  in severe
cases, immense  numbers of bacteria appear heaped  up in the
uriniferous tubules and 3Ialpighian corpuscles of the kidneys,
and occasion  there parenchymatous  inflammation,  capillary
embolism of the glomeruli of the kidney, with ruptured ves-
sels and formation of epithelial casts of the tubes.   In the
lymph and blood streams  (compare also  Hueter), in  long con-
tinued sickness of the animal experimented on,.these bacteria' 
18
DIPHTHERIA.
also accumulate in masses.  They induce, as excitors of de-
composition  and  disorganization of  organic  nitrogenized
bodies, septicaemia, through the vegetative process they un-
dergo, and through their relation to oxygen."
  From  the foregoing  it would  be a  necessary induction
that these organisms,  wherever they exist in any consider-
able numbers in proximity to human beings or other animals,
must cause diphtheria, and that the disease could not prevail
without  their agency.   Indeed Eberth, one  of the leading
advocates of this  theory, declares  that " without micrococci
there can be  no diphtheria."
  Diphtheria, then, and  micrococci, according to this theory,
must, or should be, coexistent and coextensive.   A trial of
the theory by this rule certainly is not open to the charge of
unfairness.  Eberth's assertion, "without  micrococci  there
can be no diphtheria," is only the logical sequence of the
bacterian theory ; and, from the same stand-point it is equally
logical, and, indeed, fundamentally necessary to  the support
thereof,  to reason  that wherever and whenever this bacterian
cause exists, its effect, diphtheria, should  occur in the case
of nearly every exposed person, as cause and effect are  in-
separable ; and yet it is true that not even a* majority of those
most exposed contract the disease.
  During epidemics of  the  disease, according  to the  views
of those holding the theory of Eberth, the superabundance
of these entities, especially in the  presence of the  sick, where
they must be continually  inhaled by the  attendants, should
make infection the rule :  the actual general  exemption from
infection, shows, not only the general  innocuousness of bac-
teria, but may be regarded  as  an intimation of  their utter
harmlessness to  persons  in health, a  doctrine held by many
critical  observers.   Such comparative exemption, regardless
of exposure, is not true of the other contagious  diseases of
childhood, as scarlatina,  rubeola, pertussis, etc.;  and even if
it were, would avail nothing in support of the theory unless 
CAUSE.
19
it could be shown that they, too, were the  effect of bacterian
or similar infection.
  If upon a congenial  soil we sow seed in proper season, it
straightway germinates and grows through its several stages
to maturity ; and like results are almost certain to follow if
the seed be sown upon any number of fields.  Now suppose
the field to be the pharynx, and the seed,  living bacteria
germs ; can any reason be  given why the  crop should fail in
a majority of cases even during the  epidemic prevalence  of
diphtheria ?  This point may be still further exemplified by
reference  to the  habits of another of the  microscopic fungi,
the torulae  cerevisiae, or yeast  plant.  Its soil is chiefly the
mash or malt of the distiller and brewer, which, by  its in-
strumentality,  is converted largely into alcohol.   Wherever
this soil with the proper conditions of warmth and moisture
exist, thither almost invariably  the germinal  matter or seeds
of this fungus are attracted, and the whole mass speedily is
pervaded  by its  developing and developed progeny.  Here
failures rarely occur.  It  is, at least, presumable that the
pharyngeal mucous membrane,  in  a  condition of health is a
soil nearly always, if ever, in a condition to favor the develop-
ment of these microzymes,  or bacteria germs, and their rapid
multiplication ; therefore, as in the mash, the results  should
be very nearly  uniform, and infection be the rule  instead of
the exception.   It is certain  that no peculiar state  of  the
mucous membrane has been, or is likely to be discovered,
which insures exemption from, or specially predisposes to the
disease.   If the bacterian theory is at all tenable, all persons
of the same age, with like sanitary surroundings, by exposure
must be equally liable to  contract the disease, and  should
uniformly become infected, were the cause the lodgment of
these  germs  upon the  pharyngeal  mucous surfaces.  As
this is not the case, from reasons before indicated, we judge
that the theory lacks in essentials, and  is not worthy to in-
fluence our pathological views or therapeutical measures. 
20
DIPHTHERIA.
   That the  contagium or disease germs of the  contagious
diseases is living matter is neither contested nor conceded,
but  it  is not  probably a consequence  of the development
upon any part or within the system, of microscopic fungi, or
packs of micrococci.
   On this point Dr. Lionel Beale further remarks,  " We must
not,  however, conclude that if disease germs really do consist
of living bioplasm or germinal matter, they must necessarily be
of a vegetable nature, and have sprung from vegetable organ-
isms, or have originated  spontaneously, for  it is obviously
possible, that, though living,  their nature may be  very differ-
ent,  and they may have been derived from a different source.
While I freely admit that the facts of the case are conclusive
as regards the living state of the active matter of contagious
diseases, I am  quite  unable  to subscribe to the  arguments
advanced in favor of  the vegetable germ theory  cf  disease."
For a full discussion of these theories, the reader  is  referred
to Beale on Disease Germs.
  Bacteria, whose forms cannot be distinguished from  the
micrococci, are to be found in abundance wherever and when-
ever animal  decomposition is in progress, and yet often for
long periods  no cases of diphtheria are developed.  Bacteria
germs grow and multiply  whenever a change takes place in
the solids and  fluids of the organism, which  develops com-
pounds  suitable  for  the pabulum of these  living  bodies.
From the fact that bacteria grow and multiply, not only in a
few special fields, but in a great variety of  different morbid
conditions, it. is evident they have nothing at all  to  do with
any particular form of disease.
  " All  attempts  to demonstrate various constant species of
bacteria,  representing  different  contagious  diseases —  and
many attempts have been made — have completely failed.
There is greater difficulty than would appear at first in test-
ing the  matter experimentally,  for  it is  probably  impossible
to introduce  bacteria in quantity into the blood of a  healthy 
CAUSE.
21
animal  without  at  the same  time  introducing  putrescent
matters which by themselves would occasion the most serious
derangement.   Active  bacteria introduced into  a  healthy
wound or amongst the living matter of healthy tissues, will
die,  although the most minute germs present, which escape
death, may remain  embedded in the tissue  in a perfectly
quiescent state.  Before the bacteria can grow and multiply,
the death of the higher germinal matter  must occur; as long
as this lives, it, and the adjacent tissues,  are freely permeated
by healthy fluids, and will efficiently resist their assaults.
  " When pus bioplasts die, and  their death occurs when
they  are placed  in any fluid which is not adapted for their
nutrition, the  vital  movements  cease,  and  the  corpuscles
invariably assume the  spherical form.   Not  unfrequently a
change  occurs in the outer  part, and a sort of membrane,
like  a cell wall, is  produced;  the contents become more
granular,  and they assume the appearance usually given in
published drawings.   After  a short time the matter of which
they  are composed undergoes  change,  and  is invaded  by
bacteria  germs, which  grow and multiply.   These bacteria
are not formed directly from  the  matter of  the  pus  which
once lived, but it is quite possible that bacteria germs existed
in a living but perfectly quiescent state  amongst  the  oldest
particles of the living  matter on the surface  of the pus cor-
puscle when it was yet alive.
  "Bacteria  germs less than the  100,000th  of an inch in
diameter can readily gain access to all parts of the organism,
and  probably  remain  alive, though quiescent,  for a long
while."   (Bacteria germs  are not  bacteria,  but  only  the
elementary germs from which, as from seed, in favorable con-
ditions they are developed ;  denominated  also microzymes.)
"They may be destroyed  in vast numbers  in the healthy
state  of  the  body,  though,  under  certain local changes, the
conditions become favorable to their development and multi-
plication.  It has not been proved that these bacteria or their 
22
DIPHTHERIA.
germs,  ' microzymes' have  anything to do  either with the
condition  of health  or disease, and it has been  shown that
the}* do not necessarily  give  rise to suppuration, inflamma-
tion, or other morbid  change.   Nor has any form of fungus
germ whatever been  proved to produce any contagious fever.
The fungus  germ theory of disease,  as already shown, cannot
be  sustained  unless many important  facts  are  altogether
ignored.   Nor is it  more probable, that the  socalled micro-
zymes, which  ultimately become bacteria and vibriones, but
never, according to Dr. Sanderson, result in developing fungi,
have anything whatever  to  do with the production or propa-
gation of  contagion.   It must be clearly understood that the
minute particles of bioplasm, described and figured by me in
1863, and  in the second part of this work, are certainly not of
the nature of microzymes or fungi of any kind whatever ; they
cannot be  called microzymes unless  the meaning of the word
be  completely changed.   A microzym becomes a bacterium.
A disease  germ has no connection with bacteria, microzymes,
or fungi,  either  as regards its nature, properties, or origin."
Again,  the  same  author  says, " If contagious diseases are
due to the entrance into the organism of such minute vege-
table germs  as those described, is it not wonderful that any
one escapes  disease ? 3Iultitudes of germs of different species,
as numerous as are the contagious diseases  from which we
suffer, must, if  this theory be true,  surround us.   And yet
the fungus  germs, which are' to be detected easily enough,
and which indeed do exist in  great numbers, are not known
to cause any disease.  Still, upon  this view, these must be
the disease  producing  particles, for they are the only vege-
table germs that  have been discovered.  Passing into  our
lungs with every inspiration, entering our stomachs with our
food and  drink, everywhere in contact  with our cuticle, in
the chinks of which they might grow  and multiply, these
fungus germs  must,  one would think, pass, in vast numbers
into our blood,  and be carried to every part of our bodies. 
CAUSE.                       23
Contagious diseases ought, therefore, to be more common
than they  are, and escape from attack should  be  almost
impossible."  (Beale, Disease Germs.)
   Again, according to these authors, i.  e. those holding to
the bacterian theory, diphtheria is at first a local  disease of
the  pharynx,  air  passages, or some  denuded  surface,  and
thence is developed into a constitutional one by absorption
of the specific principle into the blood, whereas most prac-
titioners  and  authors  reverse the  order.   Constitutional
symptoms are  generally first to appear,  and the local follow
just as  is  the case in variola, scarlatina, measles, etc.  It
seems quite irrational to ascribe the pyrexial  symptoms to
a local disease that cannot be said as yet to exist.  We might
with equal propriety ascribe the rigors,  the cephalalgia, the
rachialgia, and the fever of the  early stages of small pox to
a  cutaneous eruption which we only  expect, and which  may
never appear.
   J. Lewis Smith,  31.  D., of  Bellevue Hospital 3Iedical
College,  New York, in his work entitled " Diseases of Infancy
and Childhood,"  in reference  to the  Bacterian  theory of
diphtheria,  writes  as follows.  " With an experienced micro-
scopist  of New York, I have examined the secretions  and
exudations  upon the fauces in various cases  of pharyngitis,
both diphtheritic  and non-diphtheritic,  and  we  ordinarily
found the micrococcus  in  abundance in the inflammatory
product, whether diphtheritic or non-diphtheritic, a secretion
or exudation, if it  had remained some time upon the surface
of the fauces.   In one case  of simple pharyngitis, no bacteria
could be discovered on the first day  in  the secretion which
lay in the depressions over the tonsils, while,  on the  second
day, numerous  micrococci  had appeared.  3Iicrococci, then,
which  are not distinguishable  with our present  means of
observation from  those  in  a  diphtheritic exudation,  may
occur in great numbers in the secretion of non-specific imflam-
mations, so that their presence does not afford certain  indica- 
24                     1)1 PHTHERIA.
tion of the diphtheritic disease.  It is also well known that
bacteria, which seem to be identical with those in diphtheria,
are frequently found upon the gums, and  between the teeth
in  health.  3Ioreover, in  the  intervals of epidemics  and in
localities where diphtheria has not occurred,  or has occcurred
rarely, the microscope  discloses the  existence  of bacteria}
which resemble in form and activity  those found in diph-
theritic  products, and  in  sufficient numbers to  justify the
belief that they  frequently  pass  over the fauces with  the
inspired air.  How  remarkable, if the bacterian theory is
true,  that fungi,  which,  under ordinary  circumstances are
innocuous should exhibit  the  fearful  energy and destructive
power which we observe in diphtheria !  It has however been
suggested to me, that the  diphtheritic  bacteria may possess
peculiar functions and properties,  since it  is  very difficult to
observe  differences,  which may exist, and classify organisms
which are just on the borders of the visible.  A fact which,
till it is satisfactorily explained,  must, I think, throw doubt
on  the bacterian theory, is  that  the  bacteria do not irritate
the lungs.  If, during inspiration they are carried along the
current of air, and  certain of them lodge upon  the  fauces,
where they produce the specific inflammation, a larger num-
ber must enter the lungs,  where we would suppose, from the
delicate  structure of these organs, and their proneness to
inflammation, they would produce severe results ;  so far from
this occurring, bronchial and pulmonary catarrhs  are  rare at
the commencement  of diphtheria,  and not common at any
stage of the malady."
  The foregoing and other  considerations,  it seems  to me,
justify, nay,  demand, dissent to a theory at once  so novel
and unsatisfactory.
  Facts  compel the belief in primary constitutional infection,
whereas  this  theory makes  diphtheria only a local disease
with constitutional expressions or symptoms.
  That blood-poisoning, toxaeemia, is alone capable of indue- 
CAUSE.
25
ing the phenomena of the discease, we  may  now attempt  to
elucidate.
  The local  disease,  if it  exists at all in the beginning,  is
quite too  trivial  to  induce  the systemic derangements  so
generally manifested  in the early stages of the disease : as
  a) The  chilliness  and  pyrexia,  with  the appearance  of
general indisposition.
  b) The increase of  temperature, which is often from two to
six degrees, and sometimes even more.
  c) The accelerated  pulse, often reaching 120 to 140.
  d) The prostration, which  is  often so  great in the very
beginning as to cause the patient to keep his bed.
  e) In  malignant cases  the  great prostration and general
lividity  of the surface,  and  occasional  sudden death with
almost no throat affection.
  /) The  troublesome vomiting and  occasional  diarrhoea,
which occur sometimes as the initial symptoms.
  These are indications pointing only to systemic  disease,
and as certainly as  the magnetic  needle  points to the pole.
They are not all to  be expected in any one case, but upon
what other theory can we account for  any  one  of them ?
They,  as before  remarked, constitute the initial  symptoms,
and often precede any considerable local disease, as in the
following case.
  Oliver  Fletcher,  of 22  Barber  ave.,  Cleveland. 0.,   a
laborer about thirty  years of  age,  suffered severely while
at work during  the  day of  Oct.  16th,  1883, with violent
headache,  frequent paroxysms of chills and fever, together
with a  feeling of intense fatigue and general indisposition,
accompanied by anorexia.  Patient was visited by the writer
at 7 P.  31.,  after  his return from work.   He was in bed
groaning and exhibiting  signs  of greac distress and alarm.
Said he had felt indisposed for several days, in consequence,
as he thought, of working with  wet feet.   He had  vomited
twice ; his countenance was suffused and dark, and the nausea 
26                     DIPHTHERIA.
continued.   Pulse 110; temp.  104£.  He exhibited signs of
mild  delirium, and  had  violent  pains  in  region of  the
kidneys, and occasional rigors occasioned by contact  of air
in turning over or rising.  Tongue lightly coated, fauces
moderately injected, not  in the least  painful;  no signs of
any  exudation,  nor complaint  of tenderness.  Respiration
hurried and nervous.  Urine scanty, and loaded  with urates.
(Not tested for albumen.)  Diagnosis  reserved.  Prescribed
an alterative cathartic,  and three  drop doses of tr. veratrum
viride.  17th, 11 A. 31.  Less  feverish excitement.  Pulse
100; temp. 101°.  A little less nervous, but complained of
severe pain  in the throat.  Examination revealed a mem-
branous patch ^ by f in., on posterior  faucial surface, tonsils
swollen and  studded with numerous  specks of false mem-
brane,  which  rapidly increased in size ;  twelve hours later
they had coalesced into large patches.  The patient had been
delirious during the night, but at  time of morning visit was
entirely rational.  He was put  at  once  upon the chloral
treatment, and on the 20th was discharged convalescent.
  To the foregoing evidences of primary systemic contamina-
tion  may  be  added, others derived from the  secretions, as
ichorous discharges from the nares, excessive secretion in the
mouth and  fauces  of  offensive sticky mucus,  suffusion of
the eyes, &c.   These are so often observed among the earliest
symptoms that I will pass by them as too common to require
further notice.
   The  Kidneys.  Albuminuria is frequently  observed  before
the blood has had opportunity to become  contaminated by
absorption of decomposed pharyngeal  exudation, and there-
fore  can only be regarded as  evidence of the priority of the
general disease to the local manifestations.  Its  occurrence
is not  to be regarded as evidence of unusual severity  of the
attack, or of  great  danger,  nor even  of  disease of  the
kidneys  themselves,  but is  evidently  due to the altered
State of the blood and the rapid  waste of tissue, which are 
CAUSE.
27
 very early effects of the poison of diphtheria.   Urea,  nor-
 mally a principal constituent of the urine, and a product of
 the decomposition of the tissues  of the body, is also found
 in excess in the very beginning of diphtheria.  This  is only
 to be accounted for in the same way as the  early  occurrence
 of albuminuria, and affords another incontrovertible evidence
 that the  disease  is  primarily  general,  and  not local, as
 claimed by those  who uphold the bacterian theory.
   The  hyaline and granular casts, which  subsequently or
 simultaneously appear in the urine, are to be regarded as the
 consequence of nephritis occasioned by the overwork of the
 kidneys in the excretion of the enormous tissue waste, together
 with the impairment of  these organs by the general disease.
   In a paper published  in  the British and Foreign Medico-
 Chirurgical Review (Jan.,  1860), it is affirmed by 3Ir. San-
 derson,  "that diphtheria  agrees  with the other pyrexiae in
 being  attended with  a  marked increase in the excretion of
 urea, and  that  the existence in the kidney of the condition
 which is implied by albumen and fibrinous casts in the urine,
 does not necessarily interfere with  that increase in the elimi-
 nation  of nitrogenous  material.    There is,  therefore,   no
 reason  to  apprehend the occurrence of uraemia as a conse-
 quence of  the renal complication in diphtheria; this compli-
 cation not being the cause of the dyscrasia, but  merely  the
 index of its existence."
   31. 31. Bouchut  and  Empis, as  early as  1858 attached
 great  importance  and  significance to the  occurrence  of
 albuminuria as especially indicating primary blood-poisoning,
 in  which  its resemblance  to purulent  infection,  which is
 accompanied by a similar alteration of  the urine, is observed.
 On this point 31.  Bouchut concludes that "albuminuria, in
 the  absence   of  scarlatina  or  asphyxia  (dependent  upon
 laryngeal obstruction), is  a sign in  diphtheritic disease of a
 commencement  of purulent infection,  and coincides  with a
very great  gravity of the disease." 
28
DIPHTHERIA.
   Sir Jno. R. Cormack, of Paris,  1876, asserts that  albumi-
 nuria sometimes occurs on the first day of the disease, and,
 necessarily, the nephritis upon which it depends.
   Smith says  (Diseases of Children, page 230), " Important
 evidence of the constitutional nature of diphtheria is afforded
 also by the state of the kidneys.   No internal  organs are  so
 often affected in  diphtheria as the  kidneys, and on  account
 of their location and  anatomical  relation, it is  evident, the
 poison first passes through the system before reaching them.
 Any  clinical  or  anatomical fact,  therefore, which indicates
 that  the  diphtheritic  virus  has  reached and  affected the
 kidneys, affords proof  that it has penetrated the  system and
 poisoned the blood.   Now the occurrence of albumen, with
 granular or hyaline casts, in the urine, in cases unattended
 by dyspnoea, affords proof of nephritis,  caused  by the action
 of the poison on  the kidneys."  He  also quotes Sir John R.
 Cormack of Paris, and gives the two following  cases  to  con-
 firm the statement quoted,  that  albuminuria and, of course,
 the nephritis on which it depends, sometimes begins as early
 as the first day of the  disease.
   "Case I.  L. 31cD., aged three years,  was first visited by
 me on February 29th, 1876.  I learned from the parents that
 she had been feverish during the previous forty eight hours,
 and  her urine very scanty.  A  moment's examination  was
 sufficient to show that the  case was one of malignant diph-
 theria, for the fauces  were already  nearly covered  by the
 diphtheritic pellicle, the  temperature war, 103^°, and the
 pulse 140.   The  skin was hot and dry, and there was moder-
 ate swelling under the ears, and  a  muco-purulent discharge
 from  the nostrils.   On  account  of the scantiness  of the
 urine, the amount not  exceeding four to five ounces daily,  it
 was  impossible to obtain sufficient  for examination  till the
 next  day.   It was then found to  have a specific  gravity
 of 1032,  to contain  a  deposit of  urates  and hyaline and
granular casts, a diminished  amount of urea ; and  a large 
CAUSE.                       29
 quantity  of albumen.    It can hardly be  doubted from the
 scantines of the urine,  and  the  large  amount of albumen
 found when  the urine  was first examined, that albuminuria
 had been present on the first day.
   " Case  II.   The following  was a similar  case;  K., aged
 four years, living in AVest thirty-sixth street, was  visited by
 me in consultation on Jan. 29, 1875.  Her sickness had also
 continued forty-eight hours ;  her  fauces  were  swollen, and
 covered with  the diphtheritic pellicle,  which  was dark and
 offensive; respiration guttural;  pulse 120 ;  temp. 101°; she
 had a free  discharge  from  each  nostril; urine scanty, its
 specific  gravity  1030; it  contained  a  small amount of
 albumen,  with casts, and a large amount of  urates, with no
 apparent  diminution of the urea.   Death occurred  on the
 fourth day."
   The false membrane presents still further  evidence of the
 constitutional  cachexia or  contamination  of the  blood.
 There are but two classes of cases in which it is not present,
 viz, those in  which death from  blood  poison  takes  place
 before the exudation has  time  to form, and those in which
 the local  disease  is not severe  enough to  cause sufficient
 exudation to form one.
   As before  stated, these membranous deposits  are  often
 formed upon the surfaces of wounds and  sores.  In nursing
 women they sometimes  form upon  the nipples.  They some-
 times appear at the orifices of the nares, and mry* form also
 in the lachrymal duct  and thence  extend themselves to the
 conjunctiva.   In a few  instances  they  have  been known to
 invade  the  oesophagus.   The  surface of the tongue, the
 buccal and gingival mucous  surfaces,  and,  in short,   any
 surface  of the body open to the air and not covered by a
thick epidermis, is liable to be invaded.
   It  would seem as though in bad cases  the virus  is so
abundant  that every available  point is sought  for  its expul-
sion.  It  is affirmed that  the disease only localizes itself at 
30
DIPHTHERIA.
these several points, and  that each is separate from the rest
and is only a local malady. What, then, becomes of the other
symptoms already alluded to ?  How are they,  or those still
more grave that are now so emphatically announced  by the
rapidly failing powers, to be accounted for ?  These mem-
branous  patches  are  evidently  exudations  mainly  from
beneath, and not merely deposists from above. This is shown
by  their similarity to the contents of the  inflamed structures
beneath them.  The glands of the throat and neck are stuffed
with  coagulating  fibrin   abstracted from the blood; from
which, in health, it obstinately refuses separation, save for the
legitimate purposes  of nutrition.   A little of this fibrinous
material  exudes  and  immediately  coagulates  to  form the
basis of the membrane, in the meshes of which, are found
entangled  lymph and blood  corpuscles, epithelial  cells,
granular matter, micrococci, pus corpuscles," etc.  Nearly all
•of these morbid products  are of, or from, the  blood and are
therefore demonstrative proof of the primary toxaemia.
  Glandular swellings in a large majority of cases are observed
in the beginning of the attack, before any inflammation of the
faucial surfaces or any exudation has occurred, and is another
evidence of the  primary  blood poisoning.   " It is  not  a
secondary result of the throat manifestations,  but belongs  to
the general disease itself."  (Sir Jno. R. Cormack.)
  In those cases which are fatal within the first two or three
days, very often no  false membrane  has formed, and the
autopsy reveals only sanguineous  congestions of the lymph-
atics,  mucous  membranes, and internal  organs.   In  these
cases the violence of the toxamia kills, without producing the
characteristic pellicle.
  Finally, on this point, it may be remarked,  that in at least
two  epidemics  reported  by  competent  writers, the  initial
symptoms did not relate to the throat.   In that of 1789  in
New York, reported by Dr. Samuel Bard, a slight inflamma-
tion  of the eyes  and a livid countenance were  generally the 
          CLIMATIC AND ATMOSPHERIC INFLUENCES.        31

first symptoms.   In the  epidemic in New England in 1856,
reported by Dr. Beardsley of Milford, Conn., pain in the ears
preceded by a day or two the other manifestations.   In these
cases to  assign  as  the cause of the pains the lodgment of
bacteria in the eyes,  the  ears, or upon the fauces, seems
puerile.
  Having shown, though not exhaustively, that the so-called
" bacterian theory" of diphtheria merits little confidence, and
that the malady is of a general or constitutional character,
which I designate diphtheritic toxaemia, I am ready to confess
ignorance of the real nature of the virus.  That it originates
in the  living  organism  is  most satisfactorily shown in the
elaborate treatise of Dr. Beale, already quoted, and to which
the inquirer is confidently  referred  as the most able, satis-
factory, and elaborate  work  on  the mooted subject   of
" Disease Germs."



                      CHAPTER V.

      CLIMATIC  AND ATMOSPHERIC INFLUENCES.

  Climate  exercises no  inconsiderable  influence  upon  the
prevalence of diphtheria, although it prevails to some extent
in nearly every country.
  It  has  been observed within the tropics,  but  never,  I
believe, in  the  Arctic regions.   It  is most prevalent  in
temperate  climates,  neither extreme favoring its prevalence.
It  does exceptionally,  however, prevail  in all seasons of the
year.   Autumn and Spring seem, in this country,  most to
favor its prevalence.
  I have  known  the occurrence of extreme  heat  or cold to
greatly  mitigate the prevalence of an epidemic.
  The germs of  diphtheria may remain dormant for a con-
siderable  time  external  to  the  body,  and then be rendered 
32
DIPHTHERIA.
active by favorable climatic or atmospheric states, or  when
other conditions, favoring such change,  occur.  Dr. Thursfleld
found in certain  isolated houses  and  hamlets in England,
where, in recent  years,  he had been  called to investigate
cases of diphtheria, that,  at  intervals  of five,  ten, fifteen,
twenty,  twenty-five,  thirty, and even more years,  there had
been previous outbreaks of fatal sore throat.   In Reynold's
System of 31edicine is recorded an instance in which the virus
remained latent eleven months,  and then led to the develop-
ment of the disease when a  person occupied the room, in
which a case of diphtheria had previously occurred.
  Dr. 3Iackenzie  says, " I have known the poison to remain
dormant for four, seven,  and eleven  months, and  in one
instance  for three years,  and then again to become active."
Like observations have been made by  others, leaving little
room to  doubt the long  continuance of  the  vitality of the
disease germs.
  In  this country the disease  in  its prevalence  pays little
regard to locality, being as frequently met with in high and
dry localities as in the valleys or in the vicinity of morasses.
It is more prevalent in cities and towns than in the country,
although, according  to reliable  authority,  the reverse is true
in England, as shown by  Dr.  Thursfield's  observations  as
sanitary  inspector of  a  district extending  over 1200 square
miles,  -with a population of a little over 200,000, of  which
rather more than  100,000 are rural; the number of fatal cases
of diphtheria i-n the rural portion is nearly three times that in
the urban."
  In (iermany,  and  some other  European  countries,  the
disease  is said to prevail more extensively in winter than at
other periods of the year.
  Severe epidemics, however,  have been known to  prevail at
all  seasons, regardless of weather  and temperature.   Diph-
theria, then, is practically unlimited by latitude or season or
altitude. 
MODE OF PROPAGATION.
33
                       CHAPTER  VI.

                 MODE OF PROPAGATION.

   I have already in chapter I.  designated diphtheria as a
 " contagious disease," hence, in brief, its mode of propagation
 must be by contact with the " disease germs," be their nature
 never so obscure or intangible.
   Something is generated within the organism of the infected,
 and disseminated in the air, the water, or the food, which is
 capable within  certain limits  of conveying the disease  to
 others who may be  susceptible of a like infection.   This is
 what is implied in the phrase " contagious disease."
   That this  is  the  mode  of propagation observed  in this
 disease, although formerly  controverted,  is  so  generally
 admitted at  the present time, that little need be said in its
 vindication.
   Bretonneau maintained that the  exudation in  diphtheria
 possessed a  special virulence, and constituted the real virus
 of the disease.   He  says, " Innumerable facts have proved
 that those  who  attend patients  cannot contract the disease
 unless the diphtheritic secretion in the  liquid or pulverulent
 form is placed in contact with  the mucous membrane,  or
 with the skin on  a point denuded  of epidermis, and this
 application must be immediate.   The Egyptian disease is not
 communicable by volatile,  invisible emanations,  susceptible
 of being dissolved in the air, and of acting at a great distance
 from their point of origin.   It no more possesses this quality
 than the syphilitic disease.  If the liquid which issues from
 an Egyptian chancre, as visibly as that which proceeds from
 a venereal chancre,  has seemed under certain circumstances
to act like  some volatile forms  of virus, the mistake has
arisen from its not having been studied  with sufficient atten-
tion.   The appearance has been taken for the reality."
  He supports this view by citing the following cases.
          3. 
34
DIPHTHERIA.
  31. Herpin was surgeon to the hospital at Tours.  One day
while visiting a child suffering from diphtheria, during the
process of sponging the pharynx, in a paroxysm of coughing
a portion of the diphtheritic  matter  was ejected from  its
mouth,  and lodged in the mostril of 31. Herpin.  Neglecting
the removal of this particle,  the  consequence was a severe
diphtheritic  inflammation which spread over the nares and
pharynx.   The constitutional  symptoms were  extremely
severe,  the  prostration  great, and  convalescence  occupied
more than six months.
  Dr. Genclron  received a portion of the diphtheritic  exuda-
tion expelled by a patient during a fit of coughing, upon his
lips, in  consequence  of which he suffered severe  laryngeal
inflammation, and his life was only saved by  prompt and
decided  measures.
  A boy affected with  frost bite of his foot used a  bath that
had been employed for a diphtheritic patient, and became the
subject of painful, diphtheritic exudation on the great toe.
  Trousseau failed in his attempts  to inoculate  himself and
two of  his pupils with diphtheritic matter, as did also Dr.
Harley  of London  in his experiments on animals.   Still 31.
Bretonneau maintained that the virus of diphtheria was only
transmissible by  inoculation.  Isambert controverts  the
opinions of Bretonneau, and says, " We cannot reject infection
at a distance as one of the means  of propagation possessed
by  diphtheria."  Carnevall and 31.  Aurelius  Severinus,  as
well as  Franciscus  Nola and most other writers of the 17th
century, admit the contagious  nature of diphtheria.
  Dr. Samuel  Bard, speaking of  suffocative  angina,  says,
"The disease I have described appeared to me to  be  of an
infectious nature, and  as  all infection must  be  owing to
something received into the body, this, therefore, whatever it
is, being drawn in by the breath of a healthy child, irritates
the glands of  the fauces and trachea as it passes by them,
and brings about a change in their secretions.  The infection, 
MODE OF PROPAGATION.
35
however,  did  not seem, in  the  present case, to depend so
much on any generally prevailing disposition  of  the  air, as
upon effluvia  received  from the  breath of infected persons.
This  will  account why the disorder  should  go through a
whole family and not affect the next door neighbor."
   The views of more recent writers on this question may be
gleaned from the following extracts from their writings.
   Dr. Rankin  says,  " My own conviction  is that it is infec-
tious to a limited degree, by which I mean that when patients
are accumulated in small, ill-ventilated rooms, the disease is
likely to be communicated, but I  do not fear that, like scar-
latina or erysipelas, it may be propagated in spite of sanitary
precautions still less that the infection may be conveyed by
the clothes of those who visit or superintend the patients."
   " Out  of forty-seven families  infected," says Dr. Ballard,
"there were only fifteen in  which the other members all
remained healthy.--------As a rule, it spread in the houses
it invaded  chiefly among those  members who  were  most
closely in communication.   In no case where separation from
the sick person has been effected early in the  disease, have I
noticed that it has  spread to the separated individual.-----
Jane J., aged ten years,  resided at  Islington,  with her
mother,  an aunt,  and three  sisters.  On May 1st and 2d
she was on a visit at the house of an uncle, whose daughter,
Jane's cousin, was kept at home,  because she was believed to
have  a  cold.   On  the  2d, this child exhibited decided
symptoms of  diphtheria;  the attack  was slight, and she
recovered.   On 3Iay 6th, a  servant in this house was taken
ill with a severe attack of diphtheria and was  removed to St.
Bartholomew's Hospital, where she died.  On the 2d Jane
returned  home, was taken ill on the 3d with  diphtheria in a
severe form, and  died  an  31ay  9th.    Her  mother   and a
sister, aged fourteen years,  were  both taken ill on May 11th.
She  had  not  been  so  much with  her daughter  as other
members of the family  up to the 8th, when she sat up with 
36
DIPHTHERIA.
her all night.   The tonsil sloughed, and there was a complete
cast of the trachea expectorated.  She died on the 18th.  The
sister, who was also attacked  on the  11th, slept with her
mother,  and when not  at school, was continually in and out
of Jane's room, sitting there sometimes for hours together.
She died on   May  14th, asphyxiated.  Another sister who
slept with Jane and the aunt,  suffered from nothing  but a
slight sore throat."
  M. Daviotand Dr. Moncton, (London, 1857), regard diphthe-
ria as purely and simply an epidemic disease, and not contagious.
  Dr. Jenner  comes to the following conclusions:—"First,
that the disease is infectious; second, that the infecting ele-
ment does not require for its development any of the ordina-
rily considered antihygienic conditions ; third, that the family
constitution is one of the most important elements favoring
the development of  the disease  and determining its progress;
fourth, that it is very doubtful  even if any of these hygienic
conditions favor its development, or give it a more untoward-
course when it occurs."
  Dr. 3Iackenzie (1879) gives it as his opinion that "The dis-
ease may be imparted to others  by a person actually or lately
suffering from it, but the extreme difficulty of effecting arti-
ficial implantation would tend to show that  direct contagion
is rare.   From this fact it would seem probable that the con-
tagium,  when  set free from the  affected individual, undergoes
further  development,  which increases its disease-producing
properties."
  In  proof that the contagion  may be conveyed by a person
not actually affected by the disease, Dr.  3Iackenzie quotes the
following very remarkable case  reported by Dr. Thursfield :
  " A woman living in an infected house,  but  not  at any
time suffering herself, walked  a  mile or two and crossed  a
ferry to  visit a friend.   She only remained a short time in the
house, but  sufficiently long to leave the germs of diphtheria,
which broke out a day or two afterwards." 
MODE OF PROPAGATION.
37
   Again he says, " I have known the disease caught from a
 patient, who had entirely recovered from  it four months pre-
 viously ;  but whether  it was conveyed by  the  person or
 clothes of the individual, it was impossible to determine."
   The distance at which the  contagion can act through the
 medium of the atmosphere appears more limited than is the
 case in typhus or small  pox.  Thus in my own practice, two
 families  resided  in the  same house, in  one of which were
 three, and in the other four children.  In the  former all the
 children were affected with the disease, and one died ; in the
 latter, although the children were continually about the yard
 and house,  though not admitted to the apartments of the
 sick, all escaped infection.
   3Iackenzie  says, " I  have  known an instance  in which
 seven children were affected in a house, which had a residence
 on each  side of it, and a third  opposite, at a distance only
 twenty-five feet.   Although in  all of these buildings were
 young children, no other case of diphtheria occurred."  31any
 similar  illustrations might be given.  It would  seem, how-
 ever, that in certain conditions  the  diffusive powers are in-
 creased, and the poison wafted over extensive tracts of coun-
 try.
   It is seen by the foregoing  that the poison may enter the
 system, a. Possibly by direct contact.
   b. Through the circumambient air ; (see remark 2.)
   c. With the water that is drunk, or the food that is eaten.
   This  last  proposition, though apparently  self-evident,  I
 regard as most  difficult of satisfactory proof.  During the
 prevalence of epidemic disease people are more  guarded in
 this than most  other  respects.  The following cases, some-
 what to the  point, are  taken from Prof.  31. 31ackenzie's late
work.  A greyhound was seized with symptoms akin to diph-
 theria four days after  swallowing  the excrements of a child,
who died of that disease ; after death, a membraneous exuda-
tion was found upon the animal's fauces. 
38
DIPHTHERIA.
  Three sows which had access to a piece of waste ground,
on which the discharges or excretions of some  patients suf-
fering with diphtheria, were thrown, quickly died with  symp-
toms of  suffocation, enlarged sub-maxillary glands, and,  in
one case, with diphtheritic membrane in the fauces.
  These  instances go to prove  the possibility  of systemic
infection by means of the ingestion of morbific matter.
                       REMARKS.

  1. The infectious matter contained in the secretions may
not only be exhaled into the air, and thus by inhalation, or
absorption  through the cutaneous surfaces, be the means of
infection ; it may likewise find its way into privy vaults and
thence to neighboring wells, contaminating the water, making
it infectious ; or into  sewers  from which through defective
traps it may be exhaled  into dwellings at even remote dis-
tances : or  through catch-basins it may infect children pkvy-
ing in the immediate vicinity.
  2. Inoculation with diphtheritic false membrane,by Trous-
seau, Peter, and Duchamp, upon themselves, and by Harley
upon animals  produced  either  no effects or only such  as
relate  to  common  purulent  infection.   As  practiced upon
rabbits by Trendelenburg and Oertel, it produced diphtheritic
membrane  in  the  trachea, general infection, and death  the
third day.
  Nassiloff and Eberth, Heuter and Oertel, succeeded  in
inducing  membranous exudations upon the cornea, upon the
edges of wounds, and death  of the  animals on the  second
day from  septicaemia, which  may have resulted  from  the
inoculation  with decomposing  animal  matter.  It  is not,
therefore, rendered certain by  these or any other experiments 
PREDISPOSING CAUSES.
39
with which the author is acquainted, that true diphtheria has
yet been induced by the process of inoculation.
  Further critical observations seem necessary to settle this
point.
                     CHAPTER VII.

                 PREDISPOSING CAUSES.

   Age.   In Great  Britain  the  Registrar General's  returns
give an analysis of about 70,000 fatal cases.  In each  thou-
sand the age at death is shown in the table below:
         Age.                                     No.
     Under 1 year............................    90
     From 1 to 5 years........................   450
       '•   5  : 10'  "   .......................   260
       "  10 " 15   "   ........................    90
       <;  15 '■ 25   "   ........................    50
       <•  25 '•' 45   "   ..................,......    35
     45 and upwards..........................    25

                                                1,000
   In the epidemic of Florence, in the  years 1871 and  1872,
out of a total number of cases of 1546,  only fifteen were over
thirty years of age.
   It will thus be. seen that  diphtheria is peculiarly a disease
of childhood, the vast  majority  of cases  occurring between
the ages of one and ten years.  Infants at the breast gener-
ally  escape, and the younger the child  the less liable it is to
contract the disease.
   In the table above given, we notice that the liability during
the first year is (judging from the fatality) just equal to that
of the aggregate of the five years between  ten and fifteen.
If then it be proper to  say, as above, that  " infants at the
breast generally escape," so it may be said that those above 
40
DIPHTHERIA.
ten }*ears of age generally escape, and the greater the age
past fifteen the greater the exemption.
   Sex seems to exercise  no appreciable  influence upon the
susceptibility to diphtheria.
   Constitutional predisposition varies greatly in different  fam-
ilies, and  is no  doubt greatly influenced  by modes of living
and  sanitary surroundings.   The  author  is able  to recall  a
number of instances illustrating this statement.  The  family
of H., residing at No. — Columbus St., Cleveland, Ohio, with
no particular constitutional taint except that  induced  by the
intemperance  of the  father, gross and  unhealthy food, and
filthy habits, were attacked in  the Summer of IS74, and two
of three cases were quickly fatal, while all the other families
in the same neighborhood, of better habits  and consequently
better constitutional  health, and  with  an equal  or grearter
number of cases, at first, at least, of apparently equal  malig-
nity, and  having the same medical care, recovered without
loss, except in a single  instance with similar surroundings to
the first.
   Sir Wm. Jenner  lays great stress  upon " family  constitu-
tion " as being " one of the most  important elements favor-
ing the development  of the disease  and determining its pro-
gress."
   In one  of his families  five  members took the disease, in
two others,  four each, and in eight, two each.   In the Lancet,
vol.  I., p. 919, are  reported two  examples;  in  one  family
eight,  and in the  other six cases were  fatal within a few
days.  Few active practitioners of the present day  in our
cities but have noticed similar cases.  I have  known  several
such in our  own city,— cases in which every child in families
numbering from one to five, have been suddenly removed.
   I have  been  wont to attribute  these  results to constitu-
tional  predisposition ; meaning dyscrasia and the result  of
evil habits,  which I think more expressive of the facts than
"family susceptibility" employed  by  Jenner  and  others. 
PREDISPOSING CAUSES.
41
 3lackenzie  gives  the  following.  A  poor woman had three
 children of her own, and took care of two others in no way
 related to herself; her own children were attacked by the dis-
 ease and one of them died.   The two other children not her
 own, who  were constantly  in the  same rooms with  the pa-
 tients, never suffered from the disease.
   Four  families occupied the same house, and each had sev-
 eral children.  In two the  mothers were sisters, but not re-
 lated to the others.   All the children related to each other
 had diphtheria severely whilst the children of the other two
 families escaped entirely, although no  attempts  at  isolation
 were made, the healthy children often entering the rooms of
 the patients.
   Neither  rank,  station nor occupation seem materially to
 influence the liability to the disease.  Its visitations are regard-
 less of modern improvements in  human habitations, of the
 ease and luxury of the rich, the exaltation of rank, as in the
 family of the first Napoleon, the present royal house of Eng-
 land, and as some claim, the revered Washington. Dr. Green-
 how remarks, " Station of life and the enjoyment of affluence,
 or exposure to the  privations of poverty, seem to have but
 small influence either in predisposing persons to take or to
 suffer severely  from  the disease."
   Prof. 31. 3Iackenzie  says,  " It must not be forgotten, more-
 over, that when diphtheria  becomes epidemic in a town, an
 elaborate system  of drainage is  calculated  to  convey the
 poison by means of  the sewers, and that water closets afford
 a  ready means of contaminating  cisterns and  introducing
 sewer  gas  into residences.  Hence  the wealthy are some-
 times subjected to the causes of infection, which the  poorest
 may escape."
   Although the prevalence of diphtheria may not be material-
 ly affected  by sanitary conditions, no medical man will doubt
 that its fatality is.   Every one knows that good medical care,
good  nursing,  and  good sanitary surroundings, are prime 
42
DIPHTHERIA.
factors each in the restoration of the sick, and not less so in
diphtheria than in typhoid or scarlatina.
  Among the affections predisposing to the disease we must
not omit catarrh of the air passages.   We have before shown
the increased liability to diphtheria  in inflamed and irritated
states  of the mucous and cutaneous  surfaces ;  hence also
scrofulous inflammation  and  other  glandular enlargements
and diseases of the skin may properly be ranked with  the
predisponents.
  Measles and scarlatina  stand prominent among the predis-
posing causes, and when they  are succeeded by the disease it
is commonly denominated " Secondary Diphtheria."
  It is the opinion of. writers that the predisposition to diph-
theria  is  lessened  by previous  attacks of the disease.  The
immunity thus conferred must be very trifling, as it is no un-
common  occurrence for persons to have the disease a second
and a  third time.  I have seen in  my own practice several
such cases, well characterized, and one  in my own  family of
great severity and danger with large membranous patches  in
the fourth attack.   Dr.  3Iackenzie  says,  " I have  myself
known three  instances in which  children have died from the
second attack."  In another case a patient had diphtheria in
31ay, and again in a fatal form  in the July following.  Still,
it is not  necessary to dissent entirely from the idea of partial
immunity resulting from antecedent  attacks.
                    CHAPTER VIII.

                PERIOD OF  INCUBATION.

  This  may  and probably does vary according to different
degrees of susceptibility, and  the greater or less dilution of
the contagium.   According to  my observation of cases, I 
                  PERIOD OF INCUBATION.                43

should  say it  ranged from a single  day or  less (rarely), to
fourteen or fifteen days.
   Prof. J. Lewis Smith, of New York, reports the following
on this point:   'A boy of nine years was  in the same room
about one hour on Saturday with a child who had fatal diph-
theria.  On the  following Tuesday,  without  any other ex-
posure, he sickened with a malignant form of the same dis-
ease.  3Irs. E.  assisted in nursing a  fatal case of diphtheria
from Nov. 11th to 13th, 1874, after which she returned home,
several blocks away.  On the evening of the 15th she complain-
ed of sore throat, and on the  following day the diphtheritic
pseudo-membrane was observed over her tonsils.  On  the
19th the exudation had disappeared, and she was convalescent.
On the 20th her sister residing with her, and who had not
been elsewhere  exposed, was  similarly affected, and after
three or four days also convalesced.   The only other case in
the family, a boy, sickened with  diphtheria on Dec. 2nd."  He
pronounces the period of incubation to be from two to eight
days, with perhaps an occasional case  outside of these limits.
   Prof. 3Iackenzie writes, "A  girl, aged six, who had been
absent from home five weeks, returned one afternoon at four
o'clock.  Her young brother, aged four, had shown symptoms
of sore-throat the same morning, but no suspicion was enter-
tained that the  disease was diphtheritic.  These two children
remained together till bedtime, but did not  sleep in the same
room.   The next morning both of them had marked diph-
theria,  with an abundance of false membrane.  The little
girl had not been subjected to any infection before reaching
her home."  The extremes seem to be  a few hours and fifteen
days.  These  deductions  are  in accord with  most  other
authorities, and are entitled to great confidence. 
44
DIPHTHERIA.
                      CHAPTER IX.

                      PROPHYLAXIS.

   " Patients affected with the disease  should be isolated as
 far as practicable.   Vessels  receiving the excretions should
 be disinfected.   Everything  coming  in  contact with  the
 patients should  be disinfected or destroyed, and disinfection
 should  be  added to thorough  cleaning  of  the rooms and
 furniture after cases have terminated."  (Flint.)
   The foregoing is an epitome of the teachings of the best
 authorities  both in  America and Europe.   Isolation may
 be effected by the removal of the patient or the other  mem-
 bers of the  household to separate apartments as far apart  as
 practicable,  and prohibiting all intercourse.   Disinfection of
 the vessels  receiving the excrements may  be  effected by
 keeping in them a small  quantity of dry calc.  chlor.,  a ten
 percent solution of acid, carbol., or an eight percent solution
 of choral, hyd.,  &c,  with frequent scalding  with hot water
 after use. These measures are also useful for disinfecting the
 atmosphere  of the  apartments, which may also be promoted
 by hanging  sheets or blankets, wet with similar solutions  in
 the windows or doorways  of the sick room.  The clothing of
 patients and cloths used around  them are' disinfected by im-
 mersing them in hot solutions  of calc. chlor., of  about the
 strength of 3 i to cong. i.
   All carpets and unnecessary  furniture  and  hangings  as
 well as needless clothing should at once be  removed  from
the apartments  of  the sick.   After recovery  the  room,
 tightly closed and containing all its furniture  of every kind
 not otherwise purified, should be  disinfected by the fumes of
 burning sulphur, in  the  following manner:  Dip  cotton  or
 linen cloths  of considerable size  in melted sulphur, and put
 one or more of these in an open iron vessel so placed in the
apaitment,  as not to endanger  it by too  great heat, and 
SYMPTOMS.                     45
ignite.  Having thus filled the room with a dense volume of
the smoke,  leave  it closed two  or three hours,  when,  after
thorough  ventilation, disinfection may  be considered per-
fected, and the apartment fit for occupation.
  The author's views on medical  prophylaxis are given inci-
dentally in the subsequent parts of this work, and  at the close
of chapter XXI, and they are regarded as of  prime impor-
tance on account  of the  efficiency of the  measures recom-
mended.
                      CHAPTER  X.

                       SYMPTOMS.

  We will next describe a  typical case of diphtheria as it is
generally seen in this country, with the most  common com-
plications, in the  order of their  occurrence.   In order  to
facilitate the description and aid in the investigation, I have
divided the disease into three periods  or  stages, all neces-
sarily varying in  degree and duration.   The first or initial
stage extends  only to the formation  of  a  distinct false
membrane, the only real diagnostic of true  diphtheria.   The
second period or stage begins with the  close  of  the first, and
extends  to  the  disappearance of the false  membrane.   The
third period embraces the entire period from the close of  the
second to complete recovery.
  First stage.   This  stage is characterized by languor,  the
patient evincing little relish for amusements ; the appetite is
impaired, there  being sometimes  complete  anorexia with
vomiting, which in this early stage is indicative of consider-
able severity as the disease shall  develop.  Diarrhoea at this
period is occasional but not common,  and if slight, may be
regarded as  salutary ; but if severe  and accompanied by other
violent svmptoms, indicates a grave form of the disease. 
46
DIPHTHERIA.
   " The symptoms of invasion have less prognostic value in
diphtheria than in most other infectious maladies.   We meet
cases with a severe  beginning, attended by delirium,  which
terminate in apparently complete restoration to health in less
than  a  week, the presence of the characteristic pellicle on
the fauces, and the  occurrence of diphtheria in other mem-
bers  of the  family rendering diagnosis  certain.   On  the
other hand,  a mild commencement  sometimes  ushers in  a
fatal  form of  the disease.  This  is notably true  of these
cases in which laryngitis  supervenes, as it not infrequently
does in cases which begin very mildly."  (Smith.)
   If inquired of,  the patient will probably  complain of head-
ache, and a sense of  fullness or slight soreness of the throat.
The neck feels stiff,  swollen, and  tender, and  deglutition is
slightly painful.  Examination will be likely to reveal redness
and congestion of  the  faucial surfaces.   The  tonsils will
appear somewhat swollen, and coated with tenacious mucus.
Occasionally  specks  of  }*ellowish  or  whitish exudation
scarcely distinguishable from thickened mucus,  translucent,
and appearing slightly elevated, will be observed  upon the
tonsils, uvula, or other parts of the faucial surfaces.   These
are  to be regarded as the elementary exudation, or false
membrane, characteristic of diphtheria.
   Severe chills are  rare; the patients,  however,  generally
complain  of  chilly  sensations,  and instinctively  avoid
exposure to cold.  This state is quickly followed, or  it may
even be accompanied by increase of temperature, proximately
100° to 105°.   If the patient  is an adult,  he often complains
of giddiness, and pain in the  loins.
   The tongue is moist and clean, or  slightly coated. The
pulse will generally  be found  soft,  and  only slightly if at all
accelerated.   The patient may still continue  to walk about
and regard his  ailment  very trifling,  notwithstanding the
physician may regard  it with  considerable anxiety.
   In malignant cases the attack  often begins  with  severe 
SYMPTOMS.
47
 rigors, and in addition to headache and vomiting there may
 be haemorrhage  from the nose, and  the patient is greatly
 prostrated by  the virulence  of  the attack.   The  throat
 symptoms  may not  be more severe,  but  the secretions
 undergo rapid decomposition  and  impart to the breath an
 intolerable fetor.   The pulse is small, rapid, and irregular;
 the  temperature is not high and may  even be less than
 normal.  The patient, restless at first, soon becomes apathetic
 and drowsy; face  pale;  skin cold  and clammy, and  of  an
 ashy color; the  tongue  dry, tremulous,  and of a brown or
 blackish color, and sordes already begin  to accumulate  on
 the  teeth.   Haemorrhages sometimes occur from the  throat
 or nasal passages  or  other  mucus surfaces, and  petechias
 often appear beneath  the skin.  In such cases the patient
 loses consciousness or becomes delirious, and may die even
 in this early stage in a state  of coma,  or  from an attack  of
 syncope.
   This  period, sometimes inappreciably brief, may continue
 one or two days, and is terminated  by the appearance  of the
 distinct  false membrane which characterizes the beginning
 of the second stage.
   It must not,  however, be inferred  that cases, stages, Or
 symptoms, are so uniform that all  the conditions of  any two
 cases will  be found identical.  They vary widely,  but are
 recognizable  by the experienced physician by  common char-
 acteristics which cannot be fully defined.
   Second stage.   The patient has generally by the beginning
 of this  period taken to  bed, and appears really sick.  The
 eyes seem  a little  suffused,  the cheeks red or dusky.  The
 voice  sounds  thick  although respiration  is   unimpeded.
 Pyrexial indications are more pronounced.   Complaint is
 made of painful deglutition; the parotid  and submaxillary
 glands  and  the  lymphatics  of the front and  sides of the
 neck are some  or  all  of them swollen and tender.   When
this swelling is limited to the parotids, the appearances are 
48
DIPHTHERIA.
often suggestive of mumps, for which the disease has been
mistaken.  The  neck often appears large and brawny, ther*;
being superadded to the glandular  infiltration no inconsider-
able degree of cellulitis.   The cells are filled to a greater or
less degree with solid material,  in its composition doubtless
analagous to the exudation that occurs  where  the  epidermis
is removed.
  This state of  the structures of the neck may continue or
even increase  during this entire period.  Occasionally sup-
puration occurs, especially in cases following scarlatina.   In
cases of  unusual debility, this condition must be considered
critical.  Preventive means should be employed.
  The  skin in  most cases feels hot and dry,  in others it is
moist.   The pulse is generally accelerated and may number
90,  100, or even 120  or  more,  and is  soft.   In those cases
tending  to malignity, as before stated, it is greatly acceler-
ated, small,  and  irregular.    Exceptionally,  too, at  this
period, the pulse rate is found extremely low, counting only
from 30 to 60.   This is to be accounted for by  the  effects  of
excessive toxaemia upon  the brain and nervous system.
During the early part of this stage the  temperature in most
cases is high,  often reaching from 104° to  105° or even
higher,  but during the  first  few  days,  in  most  instances,
gradually  subsides  as  the exudation  extends.   In  a  few
cases it remains  high, and  may even  increase during  the
period of  exudation.  31. Farralli, of Florence, states that
it  usually falls to the  normal by the fourth or fifth day,
though in moderately  severe  cases it shows a tendency to
rise after that date.
  " The  fever which ushers  in diphtheria,  abates after the
second or  third day, and subsequently,  in  grave as well as
in benign cases, there may be little or even no elevation of
temperature.   The diphtheritic poison does  not,  therefore,
like that of scarlet fever, exhibit any marked tendency to
increase  the animal heat.   Even in profound and fatal blood 
SYMPTOMS.
49
poisoning in this disease, the thermometer shows the normal,
or scarcely more than normal, temperature, so that the inex-
perienced practitioner is apt to be deceived in his prognosis.
On the other hand,  a continued elevation  of  temperature
with only moderate angina  should lead  the physician to
examine for some complication, perhaps a nephritis." (Smith.)
   The asthenic character of the disease as well  as the prim-
ary blood poisoning is not only exhibited by the temperature
and character of the pulse, but by the appearances of debility,
which  the patient exhibits, and by the albuminuria, which  is
at this stage a common symptom.   The urine is high colored
and scanty, and, as in other febrile diseases,  is found to con-
tain an excess of  urea as well  as albumen,  with hyaline,
granular, and epithelial casts.  As might be expected, the
patient is thirsty, though often refraining from drinking on
account of pain in swallowing.  The appetite is variable, gen-
erally  poor, and vomiting not rare, which, with the painful
deglutition, often renders nutrition difficult.   Vomiting is,  in
my opinion, generally to be attributed to the influence  of the
primary morbid poison on the nervous system, being in some
sense  a measure of the toxaemia.   Smith  regards  it as fre-
quently the result  of uraemia.  The strong  analogy of this
effect  of  diphtheritic  poison  to other well known  systemic
poisons,  for which  antidotes have been discovered, is  a sug-
gestion of some weight  in  favor  of the antidotal treatment
of this malady, which will  be brought  forward in  a  subse-
quent  part of this treatise.
   The bowels may  be constipated, relaxed, or normal.
   The mind, except in malignant  cases, generally remains
clear  throughout the  disease.  31ore  or less delirium, how-
ever, is often met with, and is to be interpreted  in connection
with the other symptoms.
   The tongue  in the early  part  of this stage is generally
moist  and slightly coated.   The coating is generally yellowish
or grayish;  if  dark colored and dry generally indicates a
       4 
50
DIPHTHERIA.
typhoid  state, and is one of the indications for stimulating
treatment.
   The tonsils are more swollen than in the first stage, and
the secretion covering them more  dense, yellow, and viscid.
This  condition occasions  often  repeated efforts by hawking
and spitting to clear away the annoying secretion.   Even the
hawking may indicate varied degrees of  violence.   Upon the
surface of the tonsil or in  other parts of the pharynx will now
be observed the characteristic patches of exudation, of a yel-
lowish or whitish color, elevated  above  the surrounding
mucous  surface,  and, in  proportion to their  development,
presenting a more dense  and leathery or felted appearance.
These render the diagnosis  positive.   If they be forcibly
detached, their intimate connection with the submucous tissue
will be rendered apparent.  3Iore or less  haemorrhage follows
their  separation, which with the fibrils projecting  from their
under surface shows their  connection  with the  capillaries
beneath,  and evinces the  derivation of the  membrane  from
the blood by  exudation.  If abundant,  therefore, it  shows
violent toxaemia,  and the  future developments  will probably
be proportionate  in severity.   They further  indicate by their
fibrinous  structure such  a  condition of blood as  leads to
coagulation of  its fibrin.  This  state is further evinced by
the frequent occurrence of fibrinous clots in the heart, and in
the course of  the circulation.   As  the  disease  progresses,
these  patches tend to extend their area  and coalesce, some-
times forming a continuous coating over  most of the pharyn-
geal surfaces.   Their thickness is at first  constantly increased
by continued exudation upon their lower surfaces,  and hence
their  elevated  appearance.   If, however,  the  contiguous
mucous surfaces be so swollen as to be even with or elevated
above the edges of the membrane, it appears depressed.
  By extension and coalescence  these membranes  sometimes
reach the epiglottis and ary-epiglottic folds, or the larynx,
and even the lower air-passages,  constituting diphtheritic 
SYMPTOMS.
51
 croup.  This form of disease is characterized by most of the
 symptoms of pseudo-membraneous laryngitis, or true croup,
 with which it was considered identical  by Brettonneau, and
 since his time  by many French and English authors.  The
 most  recent and able  advocate of their identity is Prof.
 Morell 3Iackenzie, 31. D., of  London.  We are obliged, how-
 ever, after a careful consideration of facts,  to  dissent from
 this view, which will receive further consideration hereafter.
   The voice in this  condition at  first becomes  husky, high-
 pitched, and is at length extinguished.   The cough becomes
 hoarse, shrill, barking, stridulous, and finally entirely aspirate
 or voiceless.   This is often called  the  croupy cough, and
 never fails of  recognition  after  being  once  heard.   The
 breathing becomes labored, stridulous, and insufficient  for the
 regeneration of the blood,  hence the  countenance becomes
 suffused,  swollen, purple,  and  the eyes  seem  to  protrude
 from their sockets.
   If the  chest  be examined, both the inspiratory and expi-
 ratory sounds  will  be found prolonged,  and  the bronchial
 and vesicular murmurs  obscured or rendered  inaudible by
 the  laryngeal  stridor.   The intercostal and supraclavicular
 spaces are  more  depressed  during inspiration  than  during
 healthy breathing,  and  more prominent during expiration.
 The dyspnoea continues to increase and  the patient  suffers
 from repeated  attacks of  suffocation.  When these attacks
 occur, the little sufferer springs up in bed, the face is gorged,
 and livid, the expression terrified and indescribably  anxious.
 The nostrils are  rapidly expanded and  contracted, breathing
 is nearly impossible by even  the greatest effort, and  the
 hand is often thrust into the mouth or  clutches  the throat in
 a vain effort to remove  the  obstruction.   After a few min-
 utes the paroxysm  subsides, and a period of comparative
 repose, sometimes of several hours' duration, ensues.  The
continuous cough and sense of  a foreign body in the throat
leads to paroxysms of vomiting,  during which patches of false 
52
DIPHTHERIA.
membrane, varying in  size, are often ejected with consider-
able relief to the sufferer.  Death, however, from closure of
the glottis by the exudation or by oedema has been the usual
result, which is only occasionally prevented by energetic timely
treatment.  Such is laryngeal diphtheria or diphtheritic croup.
  If, on the other  hand, the membranous extension be to the
nares. or if they constituted its original seat, the case is de-
nominated nasal diphtheria.
  " In some epidemics of diphtheria the disease commences
with nasal catarrh, and this phenomenon was  so common in
the epidemics witnessed by Bretonneau that he regarded it as
the ordinary course of the disease.   Further experience, how-
ever, has demonstrated that catarrh of the  nose is far less
usual than was  at one time  supposed, and that true nasal
diphtheria  is generally due to  the  extension  of the  plastic
inflammation from the pharynx.  The disease commonly first
shows its appearance by an unhealthy  brown ichorous dis-
charge,  which causes  abrasion,  and even ulceration  of the
skin in the neighborhood of the nostrils.  Soon afterward the
parts  are covered  with false  membrane, which can be  seen
extending through the  nose.  At other times the false mem-
branes do not reach the external orifice, but, on using the
speculum, a few scattered deposits of lymph can be discover-
ed on the mucous membrane  of the septum  or  turbinated
bones.  The  false membrane,  however, is  generally most
abundant at the posterior nasal orifices " (3Iackenzie.)   Dur-
ing the progress of nasal diphtheria epistaxis often occurs.
  The lachrymal duct is occasionally the seat of diphtheritic
inflammation and exudation, causing by closure of the puncta
an overflow of tears.   Following this route it occasionally ex-
tends to the conjunctiva.
  If it follow  the tract of  the  eustachian tube it occasions
complaint of noises and darting pains in the ears, and deaf-
ness,  followed, perhaps, by  perforation of  the  membrana
tympani and purulent discharge from the ears. 
SYMPTOMS.
53
   When the false membranes begin to decay or separate, the
 breath  sometimes becomes fetid  and very  offensive.  The
 fetor is often erroneously regarded  as that of gangrene.  The
 products of  the decay of these membranes, if neglected, may
 lead  to  true local gangrene of the diseased  and debilitated
 structures of the throat.   They may  also by  absorption into
 the circulation produce  pyaemia with its troublesome or fatal
 consequences.   These may all  be  prevented by  the  timely
 use of appropriate antiseptic medication.
   If a patient suffering from diphtheria in this stage has any
 portion  of the body denuded of  its covering  of cuticle, as
 from blisters,  open  sores, or surgical injuries, these parts
 often become coated with the  exudation, sometimes forming
 troublesome ulcers, occasionally, perhaps,  fatal.   Two chil-
 dren in  the same  family living in L. st., Cleveland, were at-
 tacked upon the same day with diphtheria.   When first seen
 the boy  had large patches in the throat, much glandular en-
 largement, and upon a sore on his left ankle, a diphtheritic
 membrane well formed.   The foot  was hot, swollen, and ex-
 quisitely tender.   The girl, beside severe  diphtheria  in its
 usual locality,  had marked manifestation of the disease upon
 two  sores  upon the  dorsum of the left  foot.   The limb, as
 far as the knee, was greatly swollen and  of an  erysipelatous
 color. The sores were foul at the edges, with a distinct mem-
 brane covering the centre, and depressed below the level of the
 surrounding swollen integument.  The  constitutional dis.
 turbance was very great.   Under appropriate treatment both
 cases terminated favorably in about ten days.
   The other mucous  openings,  as the rectum, vagina, and
 urethra,  are  likewise the occasional  seats  of violent diph-
 theritic disease.  I  have known a female  patient, otherwise
apparently  likely  to  recover, destroyed  by vaginal  diph-
 theria.
   Occasionally  also quite  severe  diphtheritic  inflammation
 with  patches of exudation may be observed  on  the  buccal 
54
DIPHTHERIA.
and  gingival mucous surfaces :  upon  the  lips, and upon or
beneath the tongue.
  So great, indeed, is the dyscrasia that wherever in the nat-
ure of the case it is  possible, there occurs  this exudation of
the fibrinous elements of the blood, depriving the circulating
fluid, in a measure, of its nutritive properties.  It  is during
this  second stage  of diphtheria that gangrenous  symptoms
occur, constituting gangrenous diphtheria.  As before remark-
ed, this state  may  result from  the  irritating and poisonous
effects of the matter of decomposition of the false membrane,
upon the inflamed  and weakened  contiguous structures.   It
may likewise result from constitutional peculiarity or debility,
but most frequently occurs in cases supervening upon scarla-
tina.  '; The gangrene frequently supervenes with great rapid-
ity after the formation of the false membrane, so that in two
or three days a large portion of the pharyngeal mucous mem-
brane may be  sphacelated.   In some cases there  is consider-
able swelling of the cervical glands, but this lesion is  not
invariably present.   As  the morbid process becomes  fully
developed, it is. in all instances, accompanied by a remarkable
prostration  of the vital powers.   A state  of collapse  com-
parable to that which occurs in cholera, indicates the inten-
sity of the blood-poisoning  : there  is great  loss of body-heat,
and the pulse soon becomes slow and infrequent.  The  ex-
tremely feeble  condition of the  circulation  is shown by  the
pallor, coldness, and bluish discoloration of the skin, especially
of the extremities and prolabia.   The expression  of the face
is strikingly altered and pinched.  The patient generally dies
from syncope, the intelligence often remaining intact to  the
last.  In some cases, however,  he  becomes comotose. and
occasionally symptoms indicative of profound lesions of  the
thoracic or  abdominal viscera are manifested.  These  cases
always terminate fatally."   (3Iackenzie.)  It is by no means
rare  during the second stage for hemorrhages from the pha-
ryngeal or  nasal surfaces to occur, either  as a consequence 
SYMPTOMS.                     55
simply of the intense local congestion or the detachment of
the false membranes.
   This ought,  perhaps,  to be  attributed as much  to the
disorganized state of the blood  as to vascular engorgement,
which is not sensibly lessened by the loss.  The  effects  of
haemorrhage, be it never  so slight, in a disease so generally
characterized by debility, is to be deprecated, as by increasing
the debility it decreases the chances of recovery.  It should
be prevented or arrested when possible.
   Skin eruptions occasionally occur during this stage, and in
some  epidemics  are  common among children, and generally
consist of a rash upon the neck and chest? resembling that of
scarlatina.  It sometimes appears upon the  face, abdomen,
and thighs.  Neither  the  date  of  its appearance  nor  its
duration are at  all uniform.  In a few cases it persists for
several days ; in others but a few hours ; and it is seldom or
never  followed by desquamation, like that of scarlatina.  It
usually disappears before the close of this period.
   The catarrhal  state, mentioned among  the  predisposing
causes, may, during this stage, occasion  cough from bron-
chial or pulmonary  irritation.   Any catarrh,  whether recent
or otherwise, is  mainly pernicious  as tending to change the
more  common forms of the disease to nasal  or laryngeal
diphtheria,  therefore  any exposure to its  causes  should be
studiously avoided.
   The duration of this stage is  exceedingly various.  In the •
mildest forms of the disease it  can hardly be  said to exist,
there  being very little exudation,  or none  at  all, and but
trifling indisposition.   In more  violent typical  cases it may
extend through a period of five to fourteen days.
   The fever of diphtheria has certain peculiarities entitling
it to still further consideration.   Like the fever of small pox
it is, in tj-pical cases, divided into  two periods, which may
be  denominated  primary and  secondary,  and  it follows a
tolerably  regular course.   The primary  fever,  as  before 
56
DIPHTHERIA.
mentioned,  comes  on  rapidly, and  even in cases of only
moderate severity the temperature frequently rises as high
as  103°  to 105° F.  Within twenty-four  hours it begins to
decline, and by the  end of the third or fourth day the tem-
perature becomes  nearly  normal.   This fever is the  result
of the diphtheritic blood poisoning.
   In cases of only moderate violence  the temperature begins
again to rise on the fourth or fifth day,  and is found to be in
proportion to the other symptoms of septicaemia, notably the
glandular swelling,  which  is often attended  by renewed
exudation.  As in small pox, so in all probability this  secon-
dary fever results from the absorption of septic matter  at the
points of local disease. The effects of this secondary infection
are more manifest in  severe cases which  exhibit a typhoid
type.  In these it rises less regularly, and in degree it is in
proportion to  the  amount of local disease and putrefactive
changes. In the more favorable cases the normal temperature
is again reached in a few  days, whilst in very severe cases it
may continue to rise until a  fatal termination ensues.   Com*
plications may  interrupt the natural course of this secondary
fever ; if of an inflammatory  nature  they may increase the
temperature : if malignant or tending to obstruct respiration,
the temperature will be reduced.  The course ©f the fever has
been the same where the local manifestation of the disease
was limited to a  wound, as  when  upon  the  pharynx  or
larynx.
  31. Labadie  Lagrave gives the  following as the results of
carefully conducted  thermometric  observations in fifty-five
cases :
  '•1st. The temperature  generally rises to 104° on the first
day, and remains at about that point for two or three days,
without an}* marked  morning or evening  remissions.   2nd.
It begins to fall on the  third or fourth day of the disease,
and then invariably continues  to fluctuate between 99.5° and
101.5° unless some complication develops.  3d. Tracheotomy 
SYMPTOMS.                      57
exerts no  marked influence on  the temperature.   4th.  In
favorable cases after the initial pyrexia has  subsided, the
temperature never rises above 102°.   A sudden ascent to
103° or 104° on the fifth or sixth day of the disease points to
the development of some complication;  either acute neph-
ritis, lobular pneumonia, or acute eudocarditis."
   Either continued  high temperature or a sudden rise after
the fourth day should, therefore, lead to careful search for
these complications, but may be occasioned by the absorption
of morbific matter as before stated.
   A few remarks on the manner of the separation of the false
membrane will conclude the  consideration of  the  second
period.   Some forms of  treatment  cause its  apparent  dis-
integration  by either local  or  constitutional effects, or both
combined, but reference here is only had to the pathological
processes by which separation is effected, independent of the
effects of medicinal agents.   Prof. Rindfleisch  of Bonn says
of the false membrane, " It  is a whitishgray, compact, felted
membrane,  which is elevated,  perhaps to the height of one-
half line above  the level  of  the mucous membrane,  and
penetrates just as deep into the substance of the mucous
membrane, and is most intimately connected with the latter."
A sharply defined boundary  line separates  the living tissue
from the dead, as we can convince ourselves with the  naked
eye, but numerous  connective tissue  fibres,  blood-vessels,
nerves, and elastic fibres, pass over from the dead ; they must;
all have  separated ere the loosening can proceed.  The means
which are placed  at the command of the organism are inflam-
mation and suppuration.  We call this inflammation reactive,
and unite with it the idea as though this were an answer to the
irritation which  the diphtheritic  scab exerts  upon the  sur-
rounding mucous membrane ; yet a portion of the hyperaemia
also may be explained  according  to static principles, as col-
lateral fluxion.  The pus collects between  the scab and the
healthy parts, and always, accordingly as the fibrous bridges 
5S                     DIPHTHERIA.
mentioned melt down and tear, the separation begins now at
the edges, then at the centre.  After it is completed an ulcer
remains behind which is disposed to rapid  cicatrization; not
nnfrequently, however, the process repeats itself again at the
same place;  we have  a new scab,  and  with  it  anew the
necessity of a purulent separation, after whose termination a
very considerable loss of substance remains.  The cicatrices
finally resulting distinguish themselves by  their capacity of
vigorous retraction, so that  the  danger of subsequent con-
traction of mucous  membrane canals, especially of the large
intestine after dysentery, threatens  so  much the more, the
more diffused the ulceration was."'
  During this process,  there is  no doubt, cases  are  often
complicated by blood poisoning  from the  absorption of the
septic matter formed on the under surface of the decomposing
membrane, in a manner analagous to that which occurs in
surgical cases.  Liability to this complication therefore must
be somewhat in proportion  to the  size and thickness of the
exudation.  It is no doubt difficult to distinguish the effects
of this septic  material in the blood  from the constitutional
poisoning by the diphtheritic virus.
  Secondary blood  poisoning might be  suspected from the
following symptoms arising during this process.   1.  High
temperature,  preceded or  not by  chills, followed in a few
hours by perspiration and  a decline of  temperature,  suc-
ceeded,  it may  be, by a repetition at irregular intervals of
chills, fever, and sweating; feeble frequent pulse, sallowness
of the skin, and great prostration.   2.  Increased adenitis
and cellulitis.   3.  Formation of abscesses in the affected
glands or in the joints.   4.  Evidences of embolism.
  Third  Period.  The  pharyngeal, faucial. and nasal or
other surfaces are now supposed to be freed from the exudate
or false membrane which during the second period demanded
such particular attention, and  generally the period of con-
valescence has  fairly  commenced.   There  remains  little 
SYMPTOMS.
59
danger of the  reformation  of the membrane, and should it
occur, the patient would still be regarded as in the second
stage.
   Usually during the  process  of separation of these mem-
branous patches, in the manner described, the  more violent
symptoms abate, and in a majority of cases the patients need
little  subsequent professional  care.   Convalescence  will
probably be uninterrupted  if the patient have suitable nurs-
ing, but  all ^danger  is not yet  past.   On examining  the
condition of the  fauces or other surfaces from which false
membranes  have  been  removed, in the  lighter cases, and,
indeed, most others, no abrasion remains, and little or no loss
of substance having occurred, no cicatrix even marks their
former location.   The swelling  and injection of the mucous
membrane steadily subside.  All local  discomfort  is gone or
rapidly disappears as the general symptoms improve.
   The  temperature and pulse rate are nearly  normal,  and
remain so.
   The  appetite is becoming good, and the urine of natural
color and quality.  The skin has resumed its functions, and
the  patient is  beginning  to move about.   The muscular
weakness is  still  considerable, and  often  apparently out of
proporation to  the preceding illness.
   Occasionally, even in cases like the above, the heart's  ac-
tion, still weak, may show signs of failure upon any exertion,
and the patient may die suddenly from syncope.  Ordinary
cases, as well as grave  ones, not infrequently are still liable
to be affected with diphtheritic paralysis, which will presently
be discussed.
   A few cases enter this third period  with troublesome ulcers
of the tonsils or fauces which may be slow of healing, as well
as  occasions of increasing the  debility,  and  consequently
augmenting all the dangers  incident to this state.
   In  cases supervening upon scarlet fever, and  a few other,
large  abscesses of the glands of  the  neck  are sometimes con- 
60
DIPHTHERIA.
tinued into or are formed during this period, and with every
care, occasionally have led to fatal results.
  Cases of secondary blood-poisoning extend into this period,
the patient suffering from grave typhoid  symptoms.   These
may gradually sink into a profound coma, or suddenly die of
cardiac embolism.  Convalescence, if it occur, will probably
be slow, tedious, and irregular.
   Faralysis is the only common, if not the only,  sequel of
diphtheria.  The extreme debility which is observed in  con-
nection with and following severe forms of diphtheria, some-
times resulting in fatal cardiac syncope, has sometimes been
regarded also as a sequel, but should  rather be  regarded as
characteristic of the disease itself.
  Paralysis never occurs during the first stage of the disease,
and but very rarely during the second.  A few cases have,
however, been observed  during  this second or  membranous
period, of which the following is an example :
   E. W.. aged thirteen years,  attacked with  diphtheria  Oct.
6th, 1S7?. was first seen on the 7th.  Pulse 10S.  temperature
102°, respiration accelerated, anorexia, and constipation.  The
countenance was dull, and deglutition extremely  painful.  The
cervical and submaxillary glands were swollen  and  tender ;
the faucial surfaces and tonsils were  violently  inflamed and
were characteristically coated with tenacious  mucus.  L'pon
the velum and tonsils in several places were points of exuda-
tion, and hoarseness indicated  a like condition  within the
larynx.  Within a few hours  these points extended rapidly
and coalesced, presenting on  the Sth  an almost  continuous
surface of dense, yellowish-white,  felted,  tough,  membrane.
On the 9th the nostrils were stuffed and patchy, and the voice
hoarse.  By the evening of the  10th  the laryngeal affection
became so great that phonation was impossible and the breath-
ing difficult and  stridulous.  On the 11th the visible mucous
surfaces were nearly covered with a continuous dense mem-
brane, and suffocation seemed imminent, and but for the fre- 
SYMPTOMS.
61
quent inhalations of a five per cent, solution of chloral hydrate,
must,  in  all probability, have terminated the case fatally.
From this time to the 14th the struggle was continuous, and
the result doubtful.
  Wherever the membrane  became  detached from the soft
palate it seemed relaxed and utterly incapable of retraction.
As the surfaces continued to clear up, the voice was nasal, and
deglutition  and articulation nearly impossible from the mus-
cular paralysis.   This palsied state was carried over into and
through the third period, and was hardly cured at the end of
three months.   Restoration  was, however, finally complete.
Trousseau mentions a case in which paralysis was  manifest
three days before the disappearance of the false  membrane.
The occurrence of paralysis is usually, however, during the
early part of the third period,  and after convalescence has
progressed from two or three days to as many weeks, or even
after thirty  or forty days.  The accession is  always gradual.
It is observed by the attendants at first in defective articula-
tion, nasal voice, or incapacity for suction.
  Deglutition is equally  difficult.  The paralyzed epiglottis
allows portions of food to enter the larynx, occasioning  spas-
modic closure of the glottis and  threatened suffocation.  An
attempt to swallow liquids results in  their  discharge in part
from the nostrils, from paralysis of the  muscles of the soft
palate ; a small portion enters the air passages causing stran-
gulation,  cough, and spasm.  In occasional  cases the paralysis
affects the senses, as the vision, the smell, the taste, the touch,
and also different sets of muscles, as those of the eye, the
oesophagus, the arms, legs,  &c.  It very  rarely affects the
muscles of the bladder and rectum, and still more rarely those
of the face.   When single muscles only are affected,  the ab-
ductors usually suffer.  McKenzie has seen two cases of per-
manent paralysis of the  recurrent laryngeal nerve following
diphtheria.
  Diphtheritic  paralysis affecting  the vision is  manifested 
62                     DIPHTHERIA.
 variously.  Some have amaurosis in various degrees, others
 have myopia, or presbyopia, or double vision, or unequal con-
 traction of the pupils, as a result of feeble and unequal sen-
 sibility to light.   Strabismus has but rarely been  observed.
 Dr. Reynolds has. however, reported a case in the >"ew York
 Journal of 3Iedicine, 3Iay, 1S60. in which  strabismus  coex-
 isted with partial  paralysis of the limbs, and the  pharyngeal
 and cervical muscles.
   Of the extremities, the lower are generally first affected, the
 patient experiencing more or less tingling and numbness, fol-
 lowed or attended by trembling,  and  an uncertain wavering
 gait, which in severe cases increases to great awkwardness or
 complete paraplegia.  The power of muscular coordination  is
 sometimes so deranged as to resemble chorea.  The muscles
 of the affected part feel soft and flaccid  and are in a  great
 measure insensible to electric currents.  There  is  also  more
 or less impairment of cutaneous sensibility.   One or both
 arms may be similarly affected.
   Inability to hold the head erect shows the muscles of the
 neck to be implicated, as in the case of Dr.  Reynolds'  before
 alluded to, in which the head fell forward upon the chest.
   Paralysis  of the  trunk muscles has also been  observed,
 deranging and impairing their action and likewise embarass-
 ing respiration by the  implication of  the intercostals and
 other muscles of respiration.  Paralysis of the diaphragm in
 proportion to its severity occasions dyspnoea, and if complete,
 which is rare in all diphtheritic paralyses, must lead to fatal
 asphyxia.                                    •
   The sphincters are also in rare cases  involved and  occa-
 sion incontinence of urine or feces.   Should the bladder be-
 come affected we might expect retention.
   An unlooked for fatal result, occurring suddenly, has some-
 times been attributed, with reasonable probability, to paraly-
sis of the heart.
   No other contagious disease is so often followed by paralysis 
SYMPTOMS.
63
 as is diphtheria.  Its cause has not been revealed by the vast
 labors bestowed in its investigation, and we are only able  to
 say that it is one of the effects  of the diphtheritic toxaemia.
 Brown Sequard attributed it to reflex irritation.   Others at-
 tribute it to anaemia, to degenerative  changes in  the periph-
 eral nerves of the paralyzed parts, evinced by the disorganized
 state of the nerves seen in post mortem examinations, &c.
   The pathological changes observed  in the nerves are not
 probably limited,  however, to the affected parts ; but  being
 occasioned by the general toxaemia, rather than by any special
 local cause, are general.  What relation these changes bear to
 local paralysis, often remote from the seat of membranous
 exudations, is altogether conjectural.  Sanne reports  a case of
 paralysis in a child having no false membrane except  upon
 the skin about the navel, and another, in  which it  was  only
 observed upon one ear.
   The proportion of cases of diphtheria followed by paralysis
 has been estimated by 3Iansord at about ten per cent.   Of
 the 1117 cases collected, it occurred in 111.
   The ratio of cases is probably not uniform  and has  been
 rated as high as 15 per-cent.
   According  to Trousseau the operation of tracheotomy in-
 creases  the proportion, or predisposes to the affection.
   Finally, all that is really known of  this remarkable sequel
 of diphtheria  may be condensed into a single sentence, thus :
 Its accession is  insidious, generally beginning in the pharynx,
 is slowly progressive, continues  for a  variable period,  and
 then still more  gradually  declines, and is rarely permanent
or fatal. 
64
DIPHTHERIA.
                     CHAPTER XL

                      DIAGNOSIS.

  The diagnosis of diphtheria during the first  stage is dif-
ficult or impossible.   There is hardly one of its  symptoms or
appearances but is common to one or more diverse diseases.
We  have  stated before that the appearance of false mem-
brane alone is  diagnostic  of diphtheria, hence a diagnosis
based upon any other evidence,  or all others  combined, par-
takes to some extent of the nature of guess work.
  Generally the physician is able at his first visit to recog-
nize the disease by the presence of the pseudo-membrane, as
he  is not commonly called till patches in the throat have
been  discovered.  When any difficulty arises,  therefore, it
will probably depend upon some deviation from its ordinary
manifestations.
  The case may be diphtheria, and yet so mild in its type as
not  to occasion any membranous  exudation, and  therefore
cannot be positively diagnosed.  Again, the patient may be
stricken down  by such violent  diphtheritic toxaemia  as to
die before a membrane forms ; diagnosis is here also impos-
sible.
  In the first stage the question may arise as to whether the
case is  ordinary catarrhal sore throat or diphtheria.  The
known differences are  so  slight that only a history of epi-
demic prevalence or  individual  exposure can throw any light
upon the question,  and  the diagnosis should  be  simply
"doubtful." 
DIAGNOSIS.
65
   In common sore  throat  in which the tonsils are covered
 here and there with patches of a grayish  pultaceous deposit,
 easily removed, the deposit may safely be pronounced non-
 membranous, but yet leaves the case in doubt.
   Is the case to be differentiated from thrush with patches of
 muguet on  the   tonsils?  The spots of  elementary diph-
 theritic  membrane may  sometimes be  distinguished by the
 greater  difficulty of detaching the exudation, and the slight
 haemorrhage  which  follows  its removal;  the product  of
 thrush  bring more easily detached  and  usually  without
 bleeding.
   Diphtheria has very  often been mistaken for scarlet fever,
 and vice versa.   Although there are here points of resem-
 blance, there  are  also differences sufficient for a pretty safe
 diagnosis.  There may be fever,  sore  throat, and  possibly
 a papillary eruption, yet neither, separately, nor all combined,
 are diagnostic.  We perhaps find  the  papillae of the tongue
 elevated and red, and  place this appearance on the side  of
 scarlatina.
   Fever characterizes both ; if  the skin have a pungent feel,
 this too is indicative of scarlatina.  In scarlatina the capil-
 laries  are  generally congested,  and the face and skin red; in
 diphtheria more   frequently of  natural color or rather pale.
 The constitutional disturbances are usually greater in scarla-
 tina than in diphtheria.  The throat  in the former  is more
 uniformly reddened, often presenting  the  appearance of a
 papillary eruption, which is not seen  in diphtheria.   Albu-
 minuria may exist in either disease, and cannot be regarded
 as very significant.  The rashes cannot be  differentiated.
  In diagnosing diphtheria  from scarlet fever, the history of
 epidemic prevalence of either or both  diseases,  and of in-
 dividual exposure, must be  considered.
  The diagnosis  of diphtheria  from membranous laryngitis
or croup is often difficult.  Usually the diphtheritic laryngitis
is  accompanied by swelling of the lymphatic glands of the
       5 
66
DIPHTHERIA.
neck, and is. moreover, often secondary in point of time to
pharyngeal diphtheria.  In  croup the laryngeal  affection is
primary, and is not attended with glandular swelling.  Some-
times, as in  a case quoted b}* Smith, subsequent events  may
reverse  the  diagnosis.  :A boy,  aged two  years and ten
months, died of acute laryngo-tracheitis. lasting about four
days.   He lived in the suburbs of the city, where the  houses
were scattered, and  where there had  been  no recent diph-
theria.   The case  commenced with hoarseness,  which grad-
ually increased  to a fatal  obstruction in  the  air-passages.
without any pseudo-membrane upon the  fauces or upon  any
other visible part.   The case seemed to be identical with the
true croup with which we were familiar before the occurrence
of diphtheria in Xew York ; and yet it was diphtheritic, for
two or three days after the death of the child, the two young
women who  nursed him. were affected with severe diphtheritic
pharyngitis, with the characteristic- pseudo-membrane."
  Acute tonsillitis in its  onset  has many points of resem-
blance  to the  inflammatory type of diphtheria, as  in  both
there is violent constitutional  disturbance and acute  inflam-
mation  of the  tonsils.  If the  patient has  been subject to
quinsy, this fact will have weight in the decision of doubtful
cases, as will also the prevalence of diphtheria  in  the  com-
munity.  The practitioner may be compelled, at  best, to oc-
casionally endure  a  few  hours  of doubt while  waiting for
diagnostic developments.
                     CHAPTER XII.

                      PROGNOSIS.

  The mortality of diphtheria is without doubt exceedingly
various in different epidemics, and is usually especially great
in the earlier stages of its prevalence.  In an epidemic which 
PROGNOSIS.
67
prevailed in France in 1S47, the  mortality is stated by Sir J.
R. Cormack as 91  per cent.; in the first quarter of 1S76, in
the hospitals of Paris, as 79.75 per cent., and in the preceding
six years as 76.54 per cent.  According to authentic statistics
of the  Florentine  epidemic in 1872 and 1873,  881 persons
died  out of a  total of  1546 attacked, a mortality of over
fifty-six per cent., which,  Dr. Bergiotti  remarks,  should  be
regarded as rather the relation of the  gravely affected to the
dead, owing to incompleteness of the health returns and the
probable omission of slight cases.
   I know of no means of arriving with certainty at the aver-
age  mortality of diphtheria.   As already stated, it probably
varies within wide limits.   In Prof. Smith's  report  of cases
in  New  York,  the  mortality was forty-seven per cent.,  of
which he remarks, " The mortality of the cases  embraced in
the above table was probably larger than the average in New
 York practice, for several of them were seen in consultation,
and their type was severe."
   Dr. Ringer  (Boston Medical and  Surgical Journal, Oct. 6th,
1881), says, "According to the  best statistics at hand, namely,
those of our own city of Boston,  two  thirds of all reported
cases recover, and the remaining one third die."  With this
Mackenzie  agrees, saying, "It may, perhaps,  be  laid down as
a rule  that of the cases in which a  definite membrane is
present, one third, at least, will probably prove fatal."  About
the same rate of mortality was exhibited in  the recent epi-
demic in the city of Brooklyn,  N. Y.  These rates accord with
other American and  European statistics, but are believed by
the writer to be too high  for a general average, which would
probably range between twenty-five and thirty-three per cent.
  Few epidemic diseases can be  shown to be nearly so fatal,
even  after  making the  most  liberal  deductions from these
ascertained  rates of mortality.
  Since  fully adopting the chloral  treatment in 1875,  the
author has  treated upward of 400 cases of diphtheria, well 
68
DIPHTHERIA.
characterized by false membrane,  the  only real  diagnostic
feature of the disease, with a loss of less than two per cent.
  In the first stage of the  disease the dangers are almost
entirely from severe blood-poisoning, in which the  patient is
in danger of sudden death from the toxaemia.  In the second
stage we have in addition to the dangers  of the first, those
arising from  extension of the  membrane to the  larynx, or
diphtheritic croup,  and also in its later  stages from septi-
caemia from the absorption into the blood of the products of
the decomposing exudation.  In the former case the patient
is in  danger of death from asphyxia : in the latter from
asthenia.
  Infants at the breast are sometimes rendered wholly unable
to nurse because of obstructed  respiration.  Such cases have
been known to be fatal.
  T.here is  little doubt that in consequence of  the diseased
state of the  kidneys, patients  are sometimes destroyed by
uraemia ; the prudent practitioner should, therefore, carefully
regard the  character of  the renal  secretion in forming his
prognosis.  Again,  in  cases of marked debility, either from
anaemia or  an)* other cause, the heart's action is liable to fail.
Debility, therefore, is an important  element in prognosis.  It
is impossible to estimate the danger to be apprehended from
thrombosis and  embolism, which in severe cases may ensue
at any period of the disease.   Passive  congestions and  pul-
monary oedema, also mainly due to debility or paralysis of the
respiratory muscles, are not infrequently  sources of great
danger.   I  have several times known  patients in these states
to die as the immediate result of  some exertion or excite-.
ment, as  in opposing the administration of  medicine, or in
fits of anger.
  Among the symptoms to be regarded as indicative of ex-
treme blood-poisoning, and hence as unfavorable to recovery,
are blueness  of the skin, with coolness, if even only of the
lips and extremities ; extreme debility with pallor ; anorexia 
PATHOLOGY.
69
and persistent vomiting ;  albuminuria, especially if accom-
panied by  vomiting;  implication of  the  nasal passages,
denoted by stuffing or occlusion, with ichorous or fetid dis-
charges, haemorrhages, and feeble or obstructed breathing.  If
the cause of obstructed  breathing be  the  invasion of the
larynx by the specific diphtheritic processes, the prognosis is
most unfavorable.
   We  should  also regard a  very rapid, a very  slow,  an
intermitting,  or an  unsteady pulse  as indicative of great
danger; as also a very high or very low temperature of the
body.  In patients affected with scrofula or having a syph-
ilitic taint the disease tends to become malignant, and there-
fore the danger of a fatal termination is extreme.
   In any case having passed  into  the  second stage,  the
danger is very generally  in  proportion to  the extent and
thickness of the false  membrane.   With  adults,  other con-
ditions being  similar,  the prognosis  is more favorable than
with children, and for very obvious reasons.
   During the period of convalescence, paralysis  constitutes
the chief danger, which cannot be  said  to be great, unless it
extend to the muscles of respiration or to the heart, in which
cases there is imminent peril.
   In all  cases  of diphtheria the prognosis should be  so
guarded that the occurrence of dangerous conditions, which
cannot be predicted by  the most practiced physician, may not
reflect distrust or discredit upon the profession.
                     CHAPTER  XIII.

                       PATHOLOGY.
  In general, during the first stage of diphtheria the fauces
present the following appearances.   The general mucous sur-
face appears  reddened, injected, and perceptibly inflamed.  In
malignant  and  secondary  cases  the  color is  more or less 
70
DIPHTHERIA.
dusky.  The tonsils are swollen, and  often  upon ;helr sur-
faces are  seen  one or several elevated yellowish or grayish
mucoid spots, about  a line in diameter.   The parotid, sub-
maxillary,  and often  the cervical lymphatic glands are <"-b-
served to be swollen.  The uvula, too, in cases of considerable
severity, is elongated  and enlarged,  and the  submucous
tissues are similarly injected.  Within a brief period,  a few
hours to a day, from the beginning of the inflammation, the
spots up n the tonsils or uvula lose their equivocal character,
and become specific and significant, as  well as diagnostic.
  These patches gradually  ncrease in  size,  become  firmer
and  thicker from  the  exudation  taking  place beneath them,
appear more dense and leathery, and constitute the pseudo
membrane,  the characteristic product  of diphtheritic inflam-
mation.
  When well  formed  and removed, this  membrane  has a
somewhat  felted appearance,  or  like  the buffy coat of the
bLod.  When handled it feels firm,  is  slightly elastic, and
easily toro. If acetic acid  be poured upon it, it swells and
is rendered transparent.  The caustic alkalies  dissolve it.
Chloral solutions partially dissolve it. and cause its speedy
disintegrate 11.   It is insoluble in water and in alcohol, and
to the former yields neither gelatin nor albumen, an indica-
tion  of its fibrinous character.  Its thickness  varies from a
mere pellicle to one-eighth or even  one-fourth of an inch.
Under the microscope  it exhibits  a  fibrous structure  with
numerous bacteria and cellular bodies entangled or inclosed
in its meshes.
  These membranes are found intimately connected with the
mucous and submucous structures upon which they are pro-
duced, and as shown before, can only be detached by consider-
able  force or by the means of inflammation and ulceration.
Occasionally the ulcerative process does not stop  with the
separation  of the false membrane, but gangrene results, and
contrary to the more ordinary rule observed in  the process. 
PATHOLOGY.
71
there is considerable loss of tissue.  In many fatal cases the
gangrenous process is exceptionally active, and its offensive
odor and its destructive energy are rendered painfully manifest
during life, as well as upon the post mortem table.  The  idea
of the ancient physicians, that diphtheria was gangrenous per
se,  was  however  derived  solely  from resemblance  of the
membranous exudation to a slough.  The gangrenous process
may be,  and doubtless is, generally aided or caused by the
injection of the submucous tissues  with fibrinous elements,
resembling that which  has  exuded  to  form  the  pseudo-
membrane, together with the use  of violent  local treatment.
   "The  exudation and  infiltration sometimes  compress the
nutrient vessels of the part, and thus arrest the blood supply.
Necrosis of the involved  tissues results  and leads  to the
formation of a slough, which is, in course of time, separated
from the  healthy parts.  On the  slough becoming  partly
detached there  is left an open ulcer of various  depth  and
extent."  (Mackenzie.)
   Smith attributes the result  ■■' to the presence and contrac-
tion of the fibrin with  which the mucous membrane is in-
filtrated."   In this manner are sometimes destroyed portions
of one or both tonsils or  the uvula.
   The mode in  which these membranes  are  produced  will
be readily understood by the following from Beale on Disease
Germs :   " The  transparent  colorless fluid which moistens
the  surface of a  superficial wound after it  has ceased to
bleed,  is poured out from the capillaries, or from the lymph-
atic vessels, or from both sets of vessels.   This fluid, besides
containing albumen in solution, contains multitudes of minute
particles of bioplasm, which  grow  and multiply upon the
surface.  These  form fibrin and matters more.or less allied to
it, and perform an essential part in the healing process, or in
the  formation of  pus, as  the  case  may be.  These  minute
particles of living  matter are present in the blood and lymph
in countless numbers.  They are concerned in the production 
72
DIPHTHERIA.
of fibrous tissue outside the capillaries, which takes place in
many pathological processes, and also  in the production of
pus-corpuscles, and other  -corpuscles' in the same situation,
in disease.   All exudations contain these particles of living
matter.-----When the capillary vessels are distended, as in
that extreme congestion which soon passes into inflammation,
a  fluid  which  possesses coagulable  properties  transudes
through the stretched capillary walls.  It is probable that in
such cases minute and narrow fissures result, which, however,
are too narrow to  allow an ordinary white or red blood corpus-
cle to escape, but, nevertheless, wide enough to permit many
of the minute particles of the living or germinal matter, the
existence of which in the blood has been already  referred to,
to pass through.   The small protrusions upon the surface of
the white blood corpuscle might grow through the capillary
walls, become  detached, and pass into the tissue external to
the vessels.  Such minute particles of living matter external
to the vessels,  being surrounded with nutrient pabulum, and
stationary, would grow and multiply rapidly, while a similar
change would  of  course go on in the now stagnant fluid in
the interior of the  capillary.------—Some  of these active
living particles may be so small as to be invisible by a power
magnifying  5000  diameters.   I have seen such particles less
than the 50,000th of an inch in diameter, and have no reason
whatever for assuming that these are really the smallest that
exist."
  The bacterian  bodies found in these membranes  may be in
great  part derived from the blood,  the  tissues, or the air, in
all of which under favorable conditions  they  are shown by
this distinguished author to abound ; and of the same varie-
ties as that of which Eberth  declared, '• Without micrococci
there can be no diphtheria."  Beale further states that he finds
vegetable germs  in  every part of the  body, and  that  they
probably exist there from the earliest age and in all states of
health; that millions are always present on the dorsum of 
PATHOLOGY.
73
the tongue and in the alimentary canal ; that if in their active
and not in a germinal state they be  introduced among the
living matter of  healthy  tissues they will die, although their
minute germs which escape death may remain embedded in
the tissues in a perfectly quiescent state.
   Senator considers the minute round bodies described  by
Oertel  as  Spherical bacteria,  to be the spores of the Lepto-
thrix  buccalis. and says the same  fungi are found in diph-
theria as in stomatitis.  By other competent observers the
bacteria of diphtheria  are  found  in no way different  from
those  observed  in small pox,  typhoid fever  and  vaccina.
Although  these bodies abound in the membranous exudate
of diphtheria, their origin is not obscure, nor do they stand
in a causative or  other necessary relation to the disease.
   These membranes, excreted from the blood, are shown under
the  microscope  to be composed of  fibrinous bands, in the
spaces or interstices of which are found  abundance of bac-
teria and numerous cells and granular matter as before stated.
*" No certain  and  invariable  chemical or microscopical  differ-
ence has yet been established  between the  pseudo-membrane
of croup and that of diphtheria.   The difference universally
recognized is this : that while the croupous  membrane lies
upon the mucous membrane, and does not  penetrate it, that
of diphtheria, in the localities  where  it most commonly forms,
namely, upon the buccal,  faucial,  and laryngeal surfaces,
penetrates and becomes blended with the mucous membrane,
so that it cannot  be detached by force without the risk of in-
juring this membrane, and  lacerating its vessels; moreover,
by its  presence in the mucous layer, it is apt  to obstruct cir-
culation in it and cause  ulceration, even in the submucous
tissue."  (J. Lewis Smith.)
   The septicaemia previously alluded to, most frequently occurs
in cases in which, from decomposition of the membrane and
the blood exuded beneath it, the exudate has assumed a dark
color and become friable, causing ichorous discharge and fetor 
74                    DIPHTHERIA.
of the breath.  Absorption of this diseased material causes in-
flammation of the lymphatic vessels and glands, or iLcreased
adenitis, which also occasions inflammation of the perigland-
ular structures.  On  sectiou the glands appear redder than
natural with evident increase in their cell elements.   The sur-
rounding tissues are found  infiltrated with serum  and r.us
cells.  The parotids  and submaxillary glands  are  similary
affected  and frequently  contain  small collections  of pus.
The bronchial tubes are almost always more or less infamed,
and in some cases are the seat of membranous  exudation
which often extends to those of smallest calibre, and in these
cases  fibrinous  bands  extend  into  the alveoli,  forming a
network containing pus and at times blood corpuscles and
bacteria.
  The lungs are generally somewhat engorged and cedematcr.s,
especially at  their  bases.  Pneumonia of a low type  is also
quite common,  and may be either lobar or  lobular, catarrhal
or diphtheritic.
  The heart may appear healthy, but in death from toxaemia
its tissues  are  found  soft and friable from  fatty or  granular
degeneration, and of a color  that has been  compared to new
leather, or coffee and  milk.   In some cases its chambers con-
tain fibrinous  coagula of antemortem  formation, and a not
infrequent cause of death.  Similar coagula are found in the
larger blood-vessels, blocking up  the channels of the circula-
tion.   We cannot  avoid again  calling attention to  the  con-
stant tendency manifested in diphtheria in almost even* local-
ity, to the  coagulation of the fibrinous elements of the bleed.
The loss from the  circulating blood of the fibrin  abstracted
by  this coagulation within  the glands and blood-ves*els. as
well as upon the surfaces of the body, greatly impoverishes
it,  and,  with its  impairment or decomposition  within the
bloodvessels, is chiefly the cause of its  comparative incoag-
ulability when abstracted by phlebotomy.  Back of  this lies
of course,  in a causative relation, the original septicaemia 
PATHOLOGY.
75
induced by the subtle  contagium generated in the body of
some other person previously affected with the disease.
   This great  loss or destruction of fibrin robs the blood of
its vital  and nutritious properties, and in connection with
other effects  of the  blood poison  is doubtless the cause of
the ever noted asthenic phenomena of the disease.
   In 1S72 Dr. Johnson, as quoted by Mackenzie, put forward,.
as the result of a careful comparison of many accurately re-
corded cases,  the view that cardiac thrombosis is of very fre-
quent occurrence in  cases of diphtheria, and is a very fertile
cause cf their fatal  termination.   He also described in detail
the  physical  signs by which its  occurrence might be  diag-
nosed during life.   These views  have been controverted' by
M. Collandreau Dcfreese, and the  phenomenon attributed to
antecedent cardiac disease, rather than to the  diseased state
of the blood ; but be it observed that it is not  in the heart
alone the tendency to coagulation exists, but it is manifested
also in the lungs, the  glandular structures, upon the mucous sur-
faces, and upon wounds, and very probably throughout the vas-
cular system ; showing, in the author's judgment, the  antece-
dence  to belong to the blood and  not to the heart. Again, this
condition cf the blood is shown  in the earliest stages of the
disease, before the period of cardiac complications or thrombosis
is manifested, and is one cf the evidences before noted of pri-
mary blood-poisoning in diphtheria, and points significantly to
such haematics as remedies as are known to possess the power
of preventing such, coagulation and of thus limiting the forma-
tion of an exudation.
   The brain manifestations depend largely upon the mode of
dying.  If death be from asphyxia, there are  found  venous
congestion with minute extravasations of  blood.  Pus and
lymph may be found upon  its  membranes in cases of severe
toxaemia,  and certain degenerative  changes have  been ob-
served in  the peripheral nerves and muscles affected by  diph-
theritic paralysis.  31. Charcot found certain nerve  cylinders> 
76                     DIPHTHERIA.
 from a paralyzed palate, nearly or quite destitute of medullary
 matter, and to contain fatty granules of elliptic form, some of
 which were nucleated.
   Neither the liver nor spleen have been  shown to present
 any uniform lesions characterizing the disease.
   The kidneys are more frequently found  affected than any
 other internal organs, as from their  anatomical situation and
 physiological function, as well as from the toxaemic character
 of the disease, they seem more exposed and overtaxed than
 any other viscera.
   The blood in diphtheria, as  before remarked, exhibits  de-
 rangements,  such  as.  from  the  disease phenomena noted,
 might reasonably be  expected.  From its necessary  poverty
 of fibrinous  elements it forms but  an imperfect, soft, ill-de-
 fined coagulum.   In cases of death by  asphyxia from  the
 laryngeal form of the  disease, as  might be inferred, it  is
 blackisli from excess of carbonic acid.  Some observers have
 noted an undue proportion of white blood corpuscles  in diph-
 theritic  blood, as  in other forms of asthenia, as anaemia and
 chlorosis.  It has  also been observed to show evidences of
 decomposition from the effects of the diphtheritic poison, by
 the  abnormal accumulation  of dark-colored debris.    In
 many of the organs are found small exudations of blood, as
 already observed.   These are most  constant within  the cra-
 nium, and are common in the lungs, the  kidneys, and  the
 spleen, and have  been observed in the coats of the stomach.
   " The most cursory study of the general pathology-  of diph-
 theria suffices to assure us that it is an acute general disease
 -with  certain local manifestations.   The  primary  septicemia
 is due to  the specific poison, but  absorption from the decom-
 posing lymph is. no doubt, a cause of secondary infection.  Da
 all cases,  the attack is associated with some decree of consti-
 tutional disturbance, while in the severest forms there is  ex-
 treme disorganization of the blood,  and  consequent implica-
tion of nearly every tissue of the body.   The general infec- 
GENERA^ TREATMENT.
77
tion is  shown  at a  very early stage, as well as at a period
when the local manifestations have disappeared.  Besides the
constitutional disturbance, by which the attack is ushered.inr
there is the frequent derangement of the  renal function, the
marked prostration of strength, the functional disturbance of
the heart, and, at a later period, the extensive implication of
the nervo-muscular system.  The local symptoms — the false
membrane, with its parasitic growths — must be looked upon
as the first (?) evidence of  constitutional poisoning; in fact,
as the first of the secondary phenomena."  (3Iackenzie.)
                     CHAPTER XIV.

                 GENERAL TREATMENT.

  Having shown diphtheria to be, as defined in chapter I., an
acute, infectious, specific, febrile, disease, depending primarily
upon infection of the blood, manifested not only by general
symptoms, but also by a peculiar and often dangerous specific
inflammation ; and havfng described the type and course of
both, and the pathological phenomena they severally exhibit;
and  also the  complications incident to the several types  and
stages  of the disease, with their significations and tendencies ;
there yet remains for us to consider its treatment.  This  will
be done under the heads of General, therapeutic, and Pro-
phylactic treatment.
  The  remarkable mortality hitherto exhibited by diphtheria
under all the various modes of treatment hitherto practiced,
amounting to from twenty-five to ninety-one per cent of the
persons attacked, as estimated by several of the most trust-
worthy modern  observers and authors (See Chapter  XII),
gives to this portion of our work  peculiar  interest and  im-
portance, and is a sufficient warrant and excuse for putting 
78                     DIPHTHERIA.
forward and defending the peculiar and novel mode of thera-
peutic treatment introduced by the author, and herein first
given to the profession.
  Without disavowing  the ordinary motives prompting  to
research and  labor, the writer distinctly claims  the  chief
motive  in -view in giving these pages to the medical profes-
sion is ailesire to diminish the sum of human suffering and
the ravages of death from this fearful malady.
  As diphtheria is a disease manifested  by great  depression
of the bodily powers, the general  treatment should be sup-
porting.   The patient should be placed in the best available
apartment, which should be large, cheerful, well-lighted, well-
ventilated, and well-warmed.  As a general rule the tempera-
ture should be such as is most comfortable to the patient, and
hence should be varied in different stages and cases to gratify
his demands.   The limits of variation  may properly be be-
tween G0° and 75° F.  When the larynx is invaded, moisture
diffused in  the atmosphere of the sick  room  is of  signal
benefit.
  Whatever be the means  of ventilation, keep the air pure
and sweet, and its odor may be  rendered agreeable by the
use  of  pleasant perfumes.  Keep the  patient  out of cold
draughts.
  The food must be not merely  nutritious, but  nicely pre-
pare!, fresh, and agreeably flavored.   It may  consist  of
sweet  or buttermilk,  eggs, tender  beefsteak  well  hashed
while raw,  and  lightly cooked,  scraped beef,  beef-tea  or
essence, egg-nog, milk-punch, soft cream-toast, rice thoroughly
cooked, rice water, toast water, &c, and given regularly and
frequently, day and  night, in such quantities as are well
borne. A little lime water ( 3 i ad 3  ii to 3 i) renders sweet milk,
it is thought, more  digestible.  Food may be disrelished or
swallowing  very painful, still it  should be  given in  some
eligible form, or by  enemata if that be the only available
way.   Most children  will drink freely  of cold  fresh milk or 
                   GENERAL  TREATMENT.                79

buttermilk ;  if, however, it agree better, let it bo warmed.  If
milk be taken freely, especially if a little raw egg with sugar
be added, no fear need be entertained of want of nutrition.
A  high authority has recently stated, " There arc few cases
of diphtheria in which systematic feeding does not constitute
the most important part of the medical treatment."
   In cases  of marked anorexia, or of continued nausea and
vomiting, to  force into the  stomach  large quantities of food
only to be ejected,  cr that can  at  best  be  but sparingly
•assimilated,  is  dangerous  and  reprehensible,   and   hastens
rather  than  retards  the  rapid  emaciation,  and  lessens  the
patient's  chances of recovery.  This  is true  equally  with
adults and children.  Among the latter arc found many who,
born to rule, have never been taught proper  subjection to
-authority,  and hence are, by most emphatic exhibitions of
will, in the habit of controlling all about them by the force
of unreasoning  passion and resistance ;  and, also, the timid
and over-sensitive class, who, from their loathing of food and
medicine, painful deglutition, enfeebled powers,  and unwonted
surroundings, are bereft  of their accustomed docility.  Both
these classes of children, when crowded by force, often resist
-absolutely necessary  treatment with so great excitement and
physical exertion as greatly and dangerously to exhaust their
prostrate powers,  thus increasing the imminent perils  of
disease.
   Here arises a necessity for discrimination and the  exercise
of tact, often more potent for good than drugs, or even food
administered unwisely  or forcibly.  Yield  what is necessary
in order to conquer peacefully.  A little gratification of some
longing desire, a little praise or sympathy well expressed, a
little quiet repose, a firm look or word, or expressive gesture,
or the exercise of any of the nice arts tbat spring spontane-
ously  from the breast of sympathy or  affection, will some-
times  remove mountains of opposition, and are not to be
neglected. 
so
DIPHTHERIA.
  Make the necessary food and  medicines as agreeable as
possible ; manage the patients well,  and they will submit to
necessary general or therapeutic treatment.
  Sinapisms to the epigastrium or spine for older patients, or
bits of lint  or brown paper wet with chloroform or chloroform
liniment and held in place with  the hand a few moments,
and, for children, spice poultices containing half a drachm of
chloroform, are well borne and beneficial.  A small glass of
lemonade,  iced or hot, as is thought  best, or a litte freshly
prepared tea or coffee are to be commended, as also are any
aromatic mint or ginger teas.  Recourse  may  also be had to
the remedies advised in chap. XVI, or the formulae appended
to this volume.
  In every case of marked debility, and  such  constitute a
large proportion, the use of alcohol is indicated, in  quantity
proportioned to the condition and age of the patient.  Three
or four drachms  of brandy or pure whiskey in twenty-four
hours  for  a child  of  three  or  four  years, given in punch or
milk and egg mixture, may  suffice in cases of only  ordinary
depression.   In similar conditions  an adult may  take an
equal number of ounces.   Attacks of fainting, irregular, very
slow,  or very  rapid pulse, sighing, great pallor or duskiness
of countenance, or stupor or  delirium, are each among the
symptoms  calling  for a  more liberal administration of this
class of stimulants, regardless  of body heat.   If. however, in
cases of high temperature with rapid pulse, these be increased.
the stimulant is of doubtful  propriety, and  had better be
diminished or  suspended.
  The character of the pulse should  be carefully noted as
one of the chief criteria in the use  of any form of  alcoholic
stimulus.   From  the overwhelming effects  of the  severe
toxaemia of diphtheria, manifested  by feeble  action  of the
heart, or the occurrence at any period of the disease  of great
exhaustion, it should be given liberally ; in  great emergencies,
unsparingly. 
THERAPEUTIC  TREATMENT.
81
  The patient's clothing and  that  of the  bed should  be
changed  daily, and oftener  if they  become  soiled,  and ex-
crementitious  matter immediately removed.   Time  must be
given the patient  for sufficient  sleep, especially during the
night.
  No persons except necessary attendants and unexcludable
relatives should be allowed to visit the sick room.  All un-
pleasant odors, especially from the kitchen, must be excluded,
and the most rigid order and quiet enforced.
  The patient should have a general tepid sponge bath ouce
or twice a  day, following which the skin, if hot and dry, may
be  rubbed with a little olive oil, to which may be added a
few drops of carbolic acid or agreeable perfume.  If the skin
be  too much relaxed, the bathing should be with alum-water
and alcohol.
   Other details of  the  hygienic treatment  are omitted as
needless for intelligent  doctors  into whose  hands  only, or
chiefly, is this volume expected to find its way.
                     CHAPTER XV.

              THERAPEUTIC  TREATMENT.

  An eminent writer says, " Few  diseases more  severely tax
the therapeutic resources of the  physician than diphtheria."
Why ? It is, as stated, because " he has to devise and carry
out innumerable little details — hygienic, dietetic, and medi-
cinal __which do not admit of description,  and yet, upon the
minutiae of which, success or failure depend ;  because, too, of
its  various types and degrees of violence ;  and mainly, I
apprehend, because the records  of diphtheria  disclose  no
authoritative,  established,  generally acknowledged, or even
reasonably successful mode of treating the  disease.
       6 
82
DIPHTHERIA.
   The  diversity  of  the  therapeutic  measures  advocated
amounts to little less than confusion, and tends to beget the
prevailing distrust of all authorities and all remedies, and to
drive each individual member of the  profession to trust him-
self to "devise," from his own resources, measures of  treating
the symptoms of each individual case as they may  occur.   It
may appear to  some to be a reflection upon medical science,
to be so barren of acknowledged facts, as to be forced to such
an acknowledgment in so vital a matter.   Such, however, is
not  the fact.   3Iedical  science  is  not  a  revelation, like
theology ; nor demonstratively exact, like  mathematics ;  nor
so palpable as  physics; but. like chemistry  and electricity,
has grown from the minutest germ, into a structure so stately
as to rival  all its contemporaries.   In  this  stately edifice
each  stone  is a golden fact, worked out from the quarries of
eternal  truth by patient research and careful observation.
   From its very  nature medical  science can  never  be com-
plete, but must be ever progressive,  and this state of inhar-
mony and  unrest is only  the  earnest  of progress.   It is
unreasonable to expect the  votaries of this science to rest
quietly  in the  presence of  a mortality  so appalling as is
disclosed  in the records  of  diphtheria.   Inaction  would be
disreputable, non-professional, criminal.   The search for  a
better,  for  a specific therapy  in  diphtheria  will  continue
despite  the  taunt of "a hobby," ignoring a blind deference to
the dead past, refusing servile submission  to  the dogmas of
the present, until the goal is reached, and  the prize shines in
the diadem of the victor, embellishes the great temple of
medical science, and becomes a blessing to the human race.
   All honor, we  say,  to Bretonneau and his compeers,  the
heroes of general and local blood-letting, of blisters, of caustics
to the pharynx, and of  mercury.   Dr. Bard wrote. - But al-
though  I consider mercury the basis of cure, I do not by any
means intend to condemn or omit the  use of proper alex-
ipharmics and antiseptics." 
THERAPEUTIC TREATMENT.
83
   These authors of the past belonged, as leaders of medical
thought, to their  own day and generation, and not to ours,
and if we judge them by our own standards we judge them
unjustly, because  the march of  progress has been forward.
Occasionally only, in this age, can  be  found an  irrational
advocate of mercurial treatment, whilst,  with our  better
knowledge of the asthenic nature of diphtheria, the  blood-
letting and blisters, with all other depleting  measures,  we of
the present day treat as  madness.  A few high names may
still be quoted in advocacy of strong caustic  applications to
the  throat, among whom we may mention West, Bouchut,
Trousseau, Slade,  Oertel,   and  Aitkin.  Fortunately for the
interests  of humanity,  as well as in honor of the medical
profession, in obedience to the advancing sentiments  of the
age, these and all other  violent measures  of treatment are
being abandoned.
   With  regard  to the want of harmony in modes of treat-
ment by different  practitioners,  J. L. Smith  writes:   "The
wide discrepancy which  exists  in reference  to the  proper
therapeutic measures, receives partial explanation from the
fact of a wide difference of opinion as to the nature of diph-
theria and its mode of commencement, but is more  often due
to the fact that statistics of its treatment afford very unrelia-
ble  and often  conflicting  data,  by  which  to determine the
proper medicinal agents.
   " For scarcely any other disease presents such a diversity in
type as diphtheria, from cases so  mild that nearly all recover,
whatever the measures employed, to those so severe  that a
large proportion die  under the best  possible  treatment, and
this difference in type may be observed in cases occurring at
the same time  in a great  city like New York, or even in the
cases, which two physicians, practicing near each other, may
be called upon to  treat.   Hence,  one  physician  recommends
with confidence a medicine or mode of treatment, as eminent-
ly successful in his hands, of which another physician of equal 
84
DIPHTHERIA.
experience  speaks  disparagingly.   The theory  relating to
diphtheria, which, in my opinion, has of late years done most
harm, is that which attributes it to low vegetable organisms,
visible under the microscope, which alight upon  one of the
exposed  surfaces,  usually  the fauces,  where they  excite a
local inflammatory action, and if not promptly destroyed, are
apt to penetrate the tissues, enter the blood, and  establish a
constitutional disease.  Acceptance of this  theory evidently
leads  to  the employment of parasiticide medicines, the  so-
called antiseptics, or  antiferments. externally and internally,
to arrest and destroy the vegetable growth, their local use
sufficing, according to the theory, in the early stage,  when
these organisms have passed no further  than the surface : but
their internal use being required in addition, if the malady
have continued longer, and  the disease have become general."
   Therapeutic treatment is divided  into local and general or
constitutional.


                     CHAPTER XVI.

                  LOCAL TREATMENT.
KUMBER3 OCCDEEIXG KJ THE TEXT REFER TO THE FOEMCX^ AT THE EST) OF
                        THE VOLUME.

   We have already incidentally alluded to the  <: savage ener-
gy" of the local measures advised by Bretonneau and others.
The propriety of local treatment of its local manifestations
is not to be questioned  in diphtheria, any more than in other
constitutional  diseases  with  local  manifestations,   as  in
syphilis, scrofula, rheumatism, mumps.   We must be careful,
however, to put only  a cautious  and limited trust in our local
measures, as some  in use only increase the local irritation,
and none are curative  of  the constitutional  affection.  Dr.
Bristowe. in the Medical  Times and Gazette.  1S50. maybe
regarded  as leading  the  modern sentiment on this subject. 
LOCAL  TREATMENT.
85
He says, " 1. That the throat  affection is  merely a  local evi-
dence of a constitutional  disease,  which is unlikely  to be
arrested in  its progress by  any treatment directed to  the
secondary manifestations only.   2.  That  the throat affection
rarely kills, except by involving organs, such as the trachea
and deeper  tissues of the neck, which are beyond the region
of  the possible influence of  such agents.   3. That if  the
theoretical  correctness  even of such treatment  be  admitted,
the  application of remedies to  the  surface of a thick  false
membrane,  with the hope that  they may affect the adjacent
mucous tissue, is not only clumsy, but, as regards  the object
intended, practically  useless;  and that the prior  forcible
removal of  the membrane from the entire surface, in order to
their efficient employment, is  unjustifiable in the early stage,
even if  possible, and  is likely only to  be followed by in-
creased inflammation,  and reproduction of false membrane.
Of course, if a gangrenous  state of the tonsils, or  any other
local complication, supervenes, such topical  applications as
are commonly had recourse to in like conditions of  the threat
should be employed."
   Mr. Wade, in 1SG2,  expressed the conviction that interfer-
ence would neither  prevent the reproduction of the false
membrane,  nor prevent its  extension to the larynx.  Green-
how's maturer views  may be inferred  from  the  following
language :   " I  very  soon  discontinued this  rough  local
medication  to the tender and enfeebled  mucous membrane.
The propriety of this course became evident at the very first
post-mortem examination I had the opportunity of witness-
ing, and has been confirmed by my subsequent experience."
  Dr. Hartshorne recommends the use of hydrochloric acid
and honey,  equal parts, painted over the surfaces,  or diluted
and used as a gargle, also creosote in glycerine ; lime-water;
ice ; and the inhalation of lime-water steam.
  Aitkin advises warm fomentations externally, and' the in-
iialation of water vapo^  .vith acetic acid :  he also thinks  a 
86
DIPHTHERIA.
o-arde. composed of a fluid drachm of diacetate of lead in
eight ounces of rosewater, may be of service, but says gargles
must not be  persisted in if pain be caused by their use.
" The tincture of the perchloride of iron  is now fully recog-
nized as having  a  beneficial local as well as general effect,
and  may be advantageously  combined with  quinine.*'   He
advises that the throat be syringed with a solution of per-
chloride of iron, and that the exudation be painted with  a
strono- solution  of  the same, and  also recommends a single
efficient application of nitrate of silver, or equal parts hydro-
chloric acid  and water, and  considers useful  a gargle of
medicinal carbolic acid, one part in a hundred.
  Cohen  does not  think highly of  local  applications  or
gargles.
  Fothergill recommends  the free use of nitrate  of silver,
as also do West and others.
  Oertel, in  Ziemssen's Cyclopaedia,  says.  •• In  diphtheria
we have to deal at first with an infection which is localized,
and  afterward with a  general  disease resulting from  this,
out  of which  may  ultimately be developed still a later infec-
tion of various organs."   As  disinfectants,  to be used  with
the  atomizer,  he advises  chlorate of potash, salicilic  acid,
and. in  the more  advanced septic  states, permanganate  of
potash.   (See formulae at end of volume.)
   Prof. Smith  savs the  object  of local treatment  is --to
reduce the inflammation of the mucous surfaces, and destroy
the  diphtheritic poison,  and contagious properties in the
pseudo-membrane,  and to destroy the  septic  poison,  and
prevent its absorption, if any forms.-----Irrigating applica-
tions,  the use of the sponge or  other rough instrument for
making the application,  should be avoided as likely  to do
harm."  He  advises the  application to be made with a large
camel's  hair  brush, or better,  for  most mixtures,  with an
atomizer.
   In laryngeal  cases he considers lime-water spray the most 
L00AL TREATMENT.
87
efficient, and reports  seven recoveries in twenty-five  cases
thus treated.  He advises the inhalations to be nearly con-
tinuous.  For cleansing and disinfecting the nasal passages
he advises Form. No. 8.   A very excellent spray solution may
be made  by the mixture of lime-water  and carbolic acid.
Favorable effects are reported from dusting the affected parts
freely with washed or sublimed sulphur.
  Prof. M.  Mackenzie  writes,  "In  fact,  the profession has
given up the use of caustics  altogether," and in regard to
various astringent  applications, as  tannic  acid, powdered
alum, and tincture of  the  chloride of iron,  " The disease is
sometimes checked by this class of remedies, but on the other
hand they sometimes irritate the throat—especially if there
is much hyperaemia — and frequently increase the nausea and
dislike  for food which are  so common.  I  now seldom use
these drugs with the exception of iron, which when employed
as a constitutional remedy also acts topically."
  The objects  had in  view in the  local treatment of diph-
theria may be thus  briefly summarized :  1st. Cleansing  the
mouth, throat, and air-passages ;  2d.  Disinfecting their secre-
tions ;  3d. Allaying inflammation by promoting  secretion ;
4th.  The solution of the membrane or its  detachment.
  Two, three, or even  all of these  indications may be more
or less perfectly fulfilled by a single remedy.  Thus washing
the mouth and throat thoroughly with warm water or weak
solutions  of chloral hydrate, borax, or  chlorate  of  potash,
purifies the surfaces,   measurably  disinfects the  secretion,
and  promotes secretion and  the  detatchment of the false
membrane.
  But it is well known that sick children are very generally
refractory, and by  reason of perverseness, fear,  or nervous
irritability,  or all  combined,  refuse to  gargle,  and  resist
any  efforts  to wash thoroughly  the  mouth,  throat, or nasal
passages.  To force them into submission is to exhaust the
strength  and vitality,  already, it  may  be,   alarmingly  de- 
88
DIPHTHERIA.
pressed,  and which are  so necessary to  any  satisfactory
treatment,  and  to recovery.  Let there be no occasion given
the little sufferers to either fear or fight their medical atten-
dants or nurses—rather  let  them be  coaxed, cajoled,  or
hoaxed into the use of the best available measures.
  Some quietly submit to topical applications with  a large
soft camel's hair brush, which should be rinsed  in  hot water
as  often as it  becomes loaded  with  the viscid secretions.
For use in  this  manner or for gargling, formulae  Nos. 2 and 3
are specially recommended.
   For cleansing and  disinfecting the nasal passages when
involved in the diseased action, inject three or four times a
day the weaker  solutions  Nos.  G and  7.  or Prof. Smith's
solution No. 8.
  Avoid caustic and irritating applications, as they  greatly
aggravate the local mischief by coming unavoidably  in con-
tact with and destroying parts  of the pharyngeal and laryn-
geal surfaces not yet invaded by the exudation,  thus making
new foci for the  appearance and diffusion of the membrane ;
by  impairing the ability to  take nourishment, and, from the
pain they  occasion,  engender opposition and  strife  on the
part of the patient;  and  increase the absorption of septic
matter.
  No other local application has proven of equal value in my
practice with chloral hydrate.  I have  used  it constantly and
exclusively for the last six years in every form of the disease,
and in not less than four hundred cases, and can confidently
affirm its  great  superiority, if  not  its specific control over
membranous exudations, especially when used  constitution-
ally at the same time.
   In cases of but ordinary violence in which the air-passages
are not invaded, the contact by gargling and swallowing*, or
simply  swallowing the solution  prepared  for  internal use
hourly, prohibiting drink or  gargling: for  five minutes after
the administration, proves  quite  sufficient • both the  local 
LOCAL TREATMENT.
89
and constitutional symptoms beginning  in a few  hours to
abate.   The average  duration of such cases has been about
four clays, exceptionally longer or less, with no other medical
treatment.   The ordinary sequelae rarely occur to retard the
convalescence in these cases, the proportion thus affected not
being above, two or three percent.
   When the nasal passages are involved  in the diphtheritic
process,  as evinced by the symptoms detailed, they should
be carefully cleansed  and disinfected by syringing with weak
solutions of  chloral  every  four  hours.   (Formulae  Nos. 6
and 7).
   Regarding the topical use of chloral, Prof. Mackenzie says,
" It was  first recommended by Dr. Accetella, and subsequently
by Dr. Ferrini, of  Tunis,  and  has  since been highly extolled
by Dr. Caesare Ciattagli, of Rome, and Dr. Massei, of  Naples.
In this country (England) it has been employed with great
success by Mr. Hughes Hemming, of Kimbolton, to whom I
am  indebted  for  its  recommendation.  Mr.  Hemming uses
the  syrup of chloral (grs. xxv in  3 i)  and directs  that it
should be employed  every hour or  two.   It  does  not, as
a rule, cause any pain, and the nurse can  easily  be  taught to
apply it.  Mr. Hemming  observes that 'whilst it rapidly  gets
rid of the fetor,  it is beautiful to see the membrane loosen
and come away,   leaving  a  healthy surface  underneath.'
This remedy  has  also been very successfully  used by  Dr.
Charles Hemming, of Bishop's Waltham."
   The following   testimony of the  remarkable efficacy of
chloral,  topically  applied, is  borne by Dr. Rokitansky in the
Medicinisch-Chirurgische Rundschau, Nov. 1878, as  quoted
by the American Journal of Medical Sciences, April,  1879.
   "Dr.  Rokitansky  has used  a 50  percent solution of
chloral in  three cases of diphtheria which had resisted the
usual remedies, such  as salicilic acid, carbolic  acid, &c, and
every time with the same results.  The solution was applied
every  half hour with a  camel's hair brush, and caused  very 
90
DIPHTHERIA.
little pain, except in one case where the tongue was thickly
covered with a layer of diphtheritic matter -  here a very con-
siderable secretion of saliva was always observed immediately
after the application, and the pain ceased entirely after a few
moments.  In the other two patients, in whom both tonsils
were partly covered with the diphtheritic membrane, the pain
was  insignificant.
  '■After the solution had been applied three times, i. e.,  one
hour and a half after the first application, large pieces of the
membrane  could be  easily removed with  the  brush.   The
underlying portion of the mucous membrane was  red  and
covered with fine granulations.  As soon as the normal tis-
sue could be seen, weaker solutions of chloral  were gradually
used during a week, at the end of which the patients  had
entirely recovered."
  I have rarely used for the last five or six years any other
topical treatment within the throat, and therefore feel qual-
ified to  indorse the preceding testimonials of its remarkable
efficacy, and to recommend chloral for this purpose  as more
effective than any other remedy.   According to my observa-
tions it  will not only cause a  rapid  separation of the  false
membrane  in mass,  but so act  upon  it also  as  to cause
its disintegration,  thus depriving it of its structural charac-
ter and much of its power for mischief.  In this manner the
exudate can often be defibrinated as fast as  transuded, and
its membranous or structural character  be  prevented.
  Its local  application  should  be by means of  a soft pencil
of camel's  hair or a  feather,  and when the constitutional
treatment  is also by chloral,  and timely,  will seldom  be
required and need never  to be repeated more  than two or
three times a day, and in strength of from twenty to fifty per
cent.
  The patient, if it be agreeable to him  (but  not otherwise),
may be  allowed to take small  pieces of ice frequently into
the mouth  as a means of allaying thirst and  morbid heat and 
LOCAL TREATMENT.
91
dryness.   It is thought by some also to have the effect some-
times of reducing the local  inflammation and  swelling about
the fauces.   This, however, there  is  ample ground to doubt,
and  when we  consider  the nature of the disease, and the
peculiar low grade of the inflammation, there is good reason
to fear harm from its effects upon the obstructed capillaries
of the parts, by causing in them  a decrease of the  already
low vitality ; and also by favoring further fibrinous coagula-
tion within  the capillary walls, and in the contiguous cellular
and  glandular structures.
   The external use  of ice by  means of ice-bags applied  to
the  neck, although  reputably indorsed, for  the  preceding
and  other self-evident reasons, can only be potent for evil,
and  is unwarrantable.
   Poultices and fomentations are also  advocated by many
physicians,  but  in my  observation  have not proved highly
beneficial except  in laryngeal cases, in which  they are  of
great value  when carefully applied.  The use  upon the neck
of large slices of fat pork  is  also recommended,  but is re-
garded by the author as not only  useless and  filthy, but mis-
chievous.   The neck should in all cases  be enveloped in sev-
eral  thicknesses of soft, dry  flannel.  If there be much adenitis
and  cellulitis, the most efficient application is, in the author's
estimation,  a combination of equal parts of tincture of iodine,
glycerine, and  a fifty per cent, chloral  solution, with which
the  swollen and  inflamed  structures are  frequently to  be
thoroughly  painted  ; and always  to be kept well protected
from the air by means of  several thicknesses of soft, dry
flannel, as before mentioned. 
92
DIPHTHERIA.
                    CHAPTER XVLL

             CONSTITUTIONAL TREATMENT.

  The experience of the medical profession in the treatment
of all general or constitutional diseases warrants the assump-
tion that it must be  largely addressed to the general  system
through the medium of the blood.   If the blood be not itself
the sole seat of disease, it must at least be the bearer of the
disease germs,  and  must be made to carry most remedial
agents, whether antidotal or recuperative, to  the invaded
structures.    Diphtheria  has been  shown  to be  a  general
disease of the  blood,  exhibited only incidentally, although
with surprising uniformity,  by  local manifestations.  Prima-
ily  it  is to  be regarded as a  blood disease  only, manifested
first, or during the  stage of incubation, by very slight de-
rangements,  or none at all.  The system is poisoned by the
infection derived from some person previously diseased,  and
the poison is '-working.'' but is endured without  manifesta-
tions or complaint up to a certain degree, when it is distinctly
declared by  symptoms,  systemic and local.  This period is
rather illogically called '• the attack."
  The treatment of diphtheria has been and still is. to most
practitioners, exceedingly  miscellaneous  and  unsettled, as
well as unsatisfactory.   The following  quotation  expresses
truthfully  the  general sentiment of the profession  on  this
subject.  Prof.  Lennox Brown,  F. R. C. S.. writes as follows:
-• Many general remedies have been suggested, and some have
been vaunted as specifics, but the most rational and satisfac-
tory method  seems to be that  of treating symptoms  as they
arise.....Those who look on the disease as occurring under
circumstances similar to those producing erysipelas or phleg-
monous sore  throat:  and especially having  regard to its re-
markable tendency to produce anaemia, as well as its extremely
asthenic character,  will be disposed to give perchloride  or 
CONSTITUTIONAL  TREATMENT.
93
other forms of iron;  others who may consider  the  poison of
diphtheria allied  to  that of scarlatina, will prefer to rely
upon cinchona with acid or ammonia ; other  practitioners,
again, may be  more  willing to  depend  upon the sustaining
properties of strong  and  easily  digested nutriment, with the
moderate use of diffusible  stimulants.  Seeing how unsatis-
factory the results of drugs  are  in this disease, it  certainly
does  not appear  desirable to push nauseous, and often not
easily assimilated medicines, in a disease so prevalent among
young children, who in addition to having a natural dislike
for medicines,  experience great pain in attempts at deglu-.
tition."
   Mackenzie says, "There  are  few  cases  of diphtheria in
which systematic  feeding does not constitute  the most im-
portant  part of the  medical treatment."  Prof.  J. Lewis
Smith says, -'It is remarkable that there is so little agreement
in the profession  in  regard to  the medicinal  treatment of
diphtheria,  since  this disease  has now been under  almost
constant observation  during the last twenty years in the prin-
cipal  cities of this country,  and many  epidemics have  been
closely observed and  reported by intelligent physicians in the
rural  districts."
   In  the presence of the prevailing  professional  sentiment
regarding  the  therapeutic   treatment  of  this  disease,  so
elegantly and   truthfully expressed  in  the  above  quota-
tions, which fairly represent the  diversity of opinions, or
positive  antagonisms existing   among  medical practitoners
and writers on this subject; to dissent  to the views or  prac-
tice of eminent medical  authors is neither discourtesy nor
professional  heterodoxy.   On  the  contrary, this condition
invites research, observation, experiment; a struggle for new
light  to supplant  the confusing darkness;  and imposes  on
physicians an imperative  duty to report to  their brethren the
discovery  of any  new plan of treatment or  new  remedy,
which, supported by  sufficient  experience,  and success  on 
94
DIPHTHERIA.
trial, furnishes  a basis  for a true faith,  and a consistent
uniformity, or at least similarity, in the means employed.
   The writer comes before the medical world with a new book
not  merely containing a  rehash  of what has  been said  or
written before  on this  subject, (alchough the  writings  of
others  have been searched, freely quoted, contrasted,  and
weighed;  and in the department of therapeutics mainly re.
jected on account of their want  of specific practical value) -
but he appears in these pages as the herald of  a new depart-
ure,  which is not new in the sense of being  untried  or un-
proven; and as  the advocate  of a specific treatment  of the
membranous diseases by a remedy which has championed its
way to his- full confidence by the  exhibition of such remark-
able power in diphtheria as to have reduced its mortality to
a percent not greater than that of malarial fever when treated
with its specific, quinia.   It is hardly necessary to say, after
"what has been already written, that this remedy i s chloral hydrate.
   It is not used to  the exclusion of such  other rational
remedial  measures as are indicated  by the symptoms, nor
such  as  are  believed  to  aid its  specific action.   Before
detailing  the  mode  of   administration  and   its  supposed
modus operandi, it seems best,  in order to a full view of
the subject  in hand, that we  should cursorily  pass  in  review
the remedies in most general use ; that each may be, as near-
ly as possible, assigned its  appropriate  sphere by  the prac-
titioner ; and  also to give to the  student a correct but  con-
densed view of the entire literature of the disease.
   Cathartics.  The operation of an efficient laxative  in diph-
theria is not open to the  objection of  Dr. Slade, based upon
the idea that it increases the asthenia.  Quite  the reverse is
the fact if the remedy be  properly selected and its effects lim-
ited within  reason. By its operation we not only relieve the
plethora and the fever, but by promoting the  secretion  may
reasonably hope to eliminate from the system some portion of
the specific virus of the disease. 
CONSTITUTIONAL TREATMENT.
95
   The weight of authority in this matter is on the  side  of
 reason, in favor of the administration of a prompt efficient lax-
 ative as early as possible in the disease, unless contraindicated
 by some such conditions as diarrhoea, unusual debility, or ex-
 treme malignancy, all of which must enter  into  the  account
 •of the attending physician in adjusting his treatment.  Sir
 Wm. Jenner and Dr. Aitkin advise calomel and jalap for this
 purpose, or a calomel and colocynth pill, followed in  the in-
 flammatory forms of the disease by a saline aperient.  My
 practice is to give from  five to fifteen grains of calomel, ac-
 cording to age and  conditions, combined with  an equal  or
 greater weight of bicarbonate of soda, and followed in three
 or four hours, if by that time it have not moved the  bowels
 sufficiently, by a draught of Rochelle salt, a portion of castor
 oil, or an enema of tepid salt water, or soap suds.
   Emetics, although of doubtful  utility, are often employed in
 diphtheria for the purpose of effecting the detachment and
 expulsion of the false membrane, and are thought by  some to
 be of especial value  when  the  larynx is  involved  in  the
 diseased process.   If in  such cases  they prove beneficial, it
 must be mainly by causing maceration of the false membrane
 by the free secretion of mucus about and beneath it, aided by
 the vomitive effort induced for its expulsion.  Mucus  is not
 known to be a solvent of the exudate, nor is it by any means
 certain that its presence greatly accelerates  its separation.  It
 is, however, generally abundant in the throat when it  is the
 seat of the deposit.   A  loosened membrane or  one but par-
 tially detached  by the  physiological process, and  irritating
 or obstructing the  larynx and  glottis, is not infrequently
 expelled  by the vomiting caused by  its presence in such
 localities, and when such a  state of the membrane is known
 to exist and  does not occasion the necessary vomiting, it is
 reasonable and  proper to cause it  by irritating the fauces
 with  a feather or  the   finger carried  far back  into the
throat. 
96
DIPHTHERIA.
  The debilitating effect of antimony  and ipecac, especially
the former, is well known, and their use is  therefore not to
be thought of in states of prostration such as are usually seen
in diphtheria.   Even the exertion of vomiting, in eases  of
great debility, is to be feared, and avoided if possible.
  If in any emergency, the use of an emetic seems imperative,
the patient should be guarded from harm by being previously
placed under the influence of an alcoholic stimulant, or a sup-
porting dose of morphia (one sixteenth to one sixth of a grain),
or both combined;  and even  then it  will be  necessary to
select only such emetics as act quickly and briefly.   Those
least  objectionable  are,  doubtless, powdered mustard seed
in doses  of  one or  two  teaspoonsful in  a wine-glass of
tepid water, and the sulphates of zinc and copper.
   The copper salt may be given in doses of  from two  to  ten
grains, mixed with powdered sugar, every ten or twelve min-
utes until it acts : the zinc dissolved in  tepid water in  doses:
often grains  for children, to sixty for adults, and may be re-
peated in five minutes.  Bretonnau,  for reasons  given, pre-
ferred the copper ; J.'R. Cormack advises the zinc. Opinions
differ, and the  practitioner has  abundant authority  for  his
choice.   About the only valid reason that can be assigned for
the administration of an emetic in diphtheria, let it be under-
stood, is to get rid of the annoyance and danger of detached
or partly loosened membranes  irritating or obstructing the
larynx.   They  are not believed to  occasion its  loosening  if
given before that process is at least partially effected through
the ordinary process of inflammation.
   The tincture  of the perchloride of iron, and quinine  are the
two remedies more generally employed at  the  present time
than any others, though upon what principle it  is not easy to
decide.   They  are variously classed by writers as tonics, re-
storatives, specifics, recuperatives. and antiseptics, or as be-
longing to two or more of these classes.
   From the  fashion in the medical profession at the present 
                CONSTITUTIONAL TREATMENT.             97

time of prescribing one or both of these valuable remedies in
every case of diphtheria and in every stage, it  is necessarily
inferred that they are regarded as  specifics.   They are pre-
scribed as uniformly in this disease as are any of the known
specifics in the diseases they are known to arrest.   If judged
in this light, in view of the slightly diminished rate of mortal-
ity since the times  of Bard and Bretonnau, with bleeding,
mercury and blisters, they must, with these discarded rem-
edies, be regarded as flat  failures.
   Among a respectable minority who regard iron as possess-
ing no special utility in this disease, West, in his Diseases of
Children, has the following:   " Neither have  I found  it to
vindicate in my hands its claims to that special specific virtue
for which some practitioners have given it credit."  Flint, in
his Practice of Medicine,  speaks most decidedly on  this sub-
ject, saying :  " The tincture of the  chloride of iron does  not
exert a specific influence as some have supposed."
   If it is not as a specific that iron is prescribed, it is probably
as a restorative tonic.  Here, in diphtheria, markedly in  its
early stages, the acknowledged indications for its administra-
tion are  usually noticeably lacking.  M. Bretonnau wrote in
1826 :   '• At the onset of diphtheria the organic functions and
those which belong  to the life of relation, are so little dis-
turbed that children who are already dangerously affected by
malignant angina, generally retain.their habitual appetite, and
continue their  play"—an observation  very  applicable  to
numerous cases at the present time.  The  nutritive fluid is
not impoverished, as the  appetite  and digestion are as  yet
but slightly impaired ; neither anaemia nor emaciation being
manifest, but  only such  depression of the vital powers  as
results from the toxaemia.  The rational indications  in this
condition seem rather to call for nutrients and  alcoholics, or
specifics, to fortify the system against the progressing ravages
of the disease, or to counteract and eliminate its virus, than
for iron as a restorative.   It is not rendered even probable by
     7 
9S
DIPHTHERIA.
 the state of the patient that the  blood is suffering from any
 want of iron in the composition, but as before intimated, from
 the effect  of a  specific  poison for which  iron  is not even
 claimed to be an antidote.  This systemic condition calls  for
 support till the disease is overcome by the recuperative ener-
 gies and its germs eliminated, or else for specific treatment,
 and iron quite certainly meets neither of these requirements.
   I am permitted to make the following quotation from  an
 unpublished thesis of  an esteemed medical friend :
   '•' The tincture  of the chloride of iron  is by many regarded
 almost  if not quite in the  light of  a specific in diphtheria.
 Its admirers and  upholders, aside from considering that it de-
 stroys or neutralizes the  specific poison to which the disease is
 due, advocate its use  on the ground that it is a tonic, an
 astringent, an appetizer, and  an  antiseptic.  All of these
 qualities, except that of  a specific, the remedy under consid-
 eration  most unquestionably does possess.   Its  action as a
 specific  is certainly not  well  supported.  As a tonic and re-
 storative, iron is unquestionably one  of  the  best.  It is one
 of  the  great triad of restoratives,  quinia  and cod-liver  oil
 being the  other  members.  But is  tonic  and  restorative
 action required, as a general thing, thus early in diphtheria ?
 And when  required, is iron the best  agent to employ ?  The
 patients are  generally young and vigorous, often plethoric,
 and tonics are often  strongly contraindicated.   And when
 required, beef-juice, eggs, milk, cream, egg-nog, and nutrients
generally, fulfill the indications better than iron.
  " As an astringent, tincture of iron has the same proper-
 ties as  MonselTs  solution, intensified in degree, and is more
 irritating.   In common  with astringents as a class, it checks
secretion by constringing the mucous surfaces with  which it
comes in contact.  But  in diphtheria the indication is  to get
increased action of the mucous glands, as the restoration of
 the normal secretion facilitates the separation of the pseudo-
 membrane ; and astringents are contraindicated. 
CONSTITUTIONAL TREATMENT.
99
   " The mucous glands under the membrane are either acting
abnormally, or not acting at all.  This perversion or suspen-
sion of their function must be rectified, and the normal secre-
tion restored  if we would imitate our great teacher, Nature,
and favor the separation  of the pseudo-membrane in the
natural manner.  And  in  the inflamed condition  of the
throat the  local application of an  irritant is anything but
beneficial.   As  an  antiseptic it does  not rank as  high as
many others that are far less irritating in action.
   •• Appetizers are  hardly  needed in  the commencement of
the malady, and in  children, with  whom we  have most fre-
quently to deal in treating  this disease, the  tincture of iron,
by its  disgusting taste, begets a loathing rather than a long-
ing  for food.   Its  exhibition  is pushed in  diphtheria; full
doses frequently repeated being the rule.  But no less an au-
thority than Pareira says that when swallowed even in medi-
cinal doses it readily disorders the  stomach.  Hence it de-
feats its own object.
   " In diphtheria the fever  is often very marked, and there
is a tendency  to fibrinous deposits not only in the throat, but
in the  cavities of the heart, and embolism is not infrequent.
Iron certainly will not abate the fever, and is not  known to
have any power to arrest  membranous, or to prevent or ar-
rest fibrinous  coagulation in the chambers of the  heart and
the blood-vessels, and therefore is  not indicated.  After the
high fever has passed away and the vital forces of the patient
are very  low, seems to be a  more  reasonable time for the
employment of  this  remedy.   And there  are arguments
against its use even here.  In Wood's Materia Medica we
find the  following :  Analogy has suggested its employment
in other adynamic affections, such  as diphtheria and pyaemia,
but its value in  these diseases is much more than doubtful.
   " According to Stille, iron is contraindicated  in congestion
and inflammation, which  would go to exclude it from our list
of diphtheritic remedies. 
100
DIPHTHERIA.
  "Iron  is generally  administered  in large and  increasing
doses, from  the first  to the last visit of the attending physi-
cian, to adults in doses of 3 ss to 3 i every two or three hours
diluted with water and glycerine, and to children in propor-
tionate doses ; or the following to a child of five years :
           IJ,     Tinct. ferri chloridi,
                  Potas. chlorat. aa 3 ij,
                  Syr. simp. § iv, misce.
  A teaspoonful every one or two hours. (Smith.)
  These  doses are  often considerably increased.  If the case
be malarial or  malignaut. quinia and whisky  are far more
rational."
  Quinia may be sometimes required as  indicated, but is
neither known  nor supposed by the  writer to possess any
peculiar therapeutical properties that render it any more effi-
cacious in diphtheria  than in any other  febrile disease in
similar conditions.   Its great value  as a remedy has led too
many practitioners into its indiscriminate  use in the most
diverse and contradictory conditions, apparently upon no well
settled therapeutical principle ; but as being the first thing
to  suggest  itself  as possibly possessing  some  indefinable
property to meet  almost  every emergency, local  or general,
acute or  chronic, that may occur in. practice.
  The very general administration of quinia in this  disease
can only be accounted for, first, from its being regarded as a
specific.   This  deduction seems  almost a  necessity,  as it is
given, as is  iron,  early and late  in the disease ; when symp-
toms are sthenic or asthenic ; adynamic, malignant, or benign ;
laryngeal, nasal, or faucial; and  with the  same uniformity
with  which it  is  given in  intermittents. for which  it is  an
acknowledged specific; or second, for its supposed tonic proper-
ties, in view  of which it may at  times be  beneficial.  Be it
remarked, however, that no small proportion of the  cases of
diphtheria are characterized for the first twenty-four or forty-
eight  hours  by high arterial action  and  a  correspondinc 
CONSTITUTIONAL TREATMENT.
101
increase of temperature, and that the effect of quinia in ordi-
nary medicinal doses is to increase the heart's action and  the
body heat.   It is consequently more rationally prescribed
in states  of great exhaustion  and  debility.    Any means
which,  in these sthenic states, has so direct  a stimulating
effect, cannot  be other than hurtful, as the high action  is a
chief agent in consuming or exhausting  the  vital  powers,
which at this  stage should doubtless be conserved by a cau-
tious lowering of the temperature  and calming the circula-
tion by tepid sponging, or a few doses of aconite or veratrum
in connection with the chloral treatment.
   Two to four grains of quinia every two  or three hours in
such sthenic states, which is common  practice, theoretically
should  be, and doubtless is, pernicious.   If given at all in
such states it should be in anti-pyretic doses of ten grains to
a child of five years, and twenty or thirty  grains to an adult,
and promptly  suspended, if, at most, two or three doses at
intervals of three  hours do not effect the desired reduction in
body heat and pulse rate.....Quinine may be given, third, as
a mere matter of routine, or a blind concession to writers whose
recommendations  are regarded  as sufficient warrant for the
practice.  Quinia  is  a most  valuable remedy, as  are  also
mercury and atropia, but it does not follow that they  should
be  given to all persons in all diseased  conditions.   Their
power for good, when indicated, is no less potent for evil when
contraindicated.   What, for  example, can  be expected from
such  practice as  the following, reported, but not sanctioned,
by Prof. J. L. Smith in the  immediate connection with  the
remark " that  quinia does not  exert any  special or peculiar
action in diphtheria, and is beneficial in the same way and no
further than  in  other acute infectious diseases, is, I think,
generally admitted by the profession ; for  large doses do not
exert that controlling effect, which we  would expect  from a
specific, as is shown by cases like the following, which are not
infrequent during severe epidemics : 
102
DIPHTHERIA.
   '■C.  aged four years, male, was examined by me in con-
 sultation,  on February 10th,  1S76.   I  learned that he had
 apparently contracted diphtheria from  the escape of sewer
 gas through a defective trap in the little room where he slept,
 and that the  disease  began after midday  on February 6th,
 with fever ; at 10 P. 31. of the same day, when visited by the
 family physician, the temperature was 103°, and the fauces were
 red, but without any pseudo-membrane. Four grains of quinia
 were ordered to be given every two hours,  and ten drops  of
 the tincture of the chloride of iron, with two grains of the
 chlorate  of potassa, to be given three  times hourly.  On the
 7th the exudation covered  both tonsils and the half arches ;
 temperature 102^°;  evening,  temperature  100° ; pulse 12S.
 8th.  is playful; pulse 100 ; has  slight swelling of the cervi-
 cal glands ;  evening, some extension  upward of the pseudo-
 membrane ; has  vomiting.  9th, Pulse  144; vomits  often.
 10th, at 3 P.  31. began to grow worse ; phanynx and nostrils
 covered with exudation."
   Forty-eight grains of quinia and one  and one half ounces
 of the tincture of the chloride of iron  a day for four con-
 secutive  days to a child of four years, or  a  total of 193
 grains  of the former and six ounces of the latter ! !   What
 physician will wonder that, with the recuperative powers  so
weighed  down and  embarassed  with  such an  amount  of
nauseous drugs, the little one should grow worse day by day,
should vomit on the  third day, and die  on the fourth  of
"toxaemia ?"
           '•Drugs are medicines when they cure.
           But poisons when to death they lure."
  Prof. Smith in commenting upon this case says:
  "It was impossible,  at the time of my visit to obtain any
of the patient's urine for examination, and death occured a
few hours afterward from the toxaemia.   Forty-eight grains of
quinia  administered daily, from the first day, had no appreci-
able effect in staying the fatal progress of the malady, had 
CONSTITUTIONAL TREATMENT.
103
no such  effect as would be likely to follow, were  its action
specific or antidotal.  But there are two advantages from the
quinia treatment, which explain the confidence reposed in it
by the profession :  1st. It has an antipyretic effect in doses of
from three to five, or more, grains.   2d. In moderate doses it
is one of the most  reliable tonics.   But high febrile move-
ment,  requiring  an antipyretic,  I  have seldom  observed in
diphtheria, except in the first forty-eight hours ; and if, during
this time, the febrile movement  be such that an antipyretic
is required,  quinia in the large doses  is preferable, in my
opinion,  to any other remedy.  In its subsequent use, namely,
as a tonic, two grains may be administered every two to four
hours.  But other bitter mixtures,  which have been found to
be the most  useful  tonics in general practice, perhaps would
meet the indication nearly or quite as well."
  In the history  of medicine  no remedy has been so much
abused,  or brought  into  such  undeserved discredit by its
advocates, as quinia; if only we except mercury and blood-
letting, the panaceas of the age just past.   "It will certainly
cure malarial intermittents,  and hence,  as they are febrile
diseases,  it  is probably  remedial   in  all other  fevers," is a
process of reasoning that answered well enough for the facile
quack who,  after  failing  to  cure  his ague by lobelia  et al,
was forced by suffering,  against  what he  thought  his better
judgment, to resort  to quinia, and being promptly cured, became
so strongly converted that he not only prescribed it for every
disease,  but  adopted it  as  an article  of diet,  and  daily
sprinkled with it his potato  and bread-and-butter.  Such a
philosophy is quite too prevalent,  as  is easy to see, in the
practice  of some regular  physicians.   An army  physician
once prescribed quinine for a subordinate afflicted only with a
sore toe.   Such  aimless, senseless,  routine practice  may  not
often endanger  the  patient, but is certainly  a reproach  and
disgrace  to  physicians  so afflicted with  mental or moral
stupidity. 
104
DIPHTHERIA.
   As a general tonic the claims of quinia, although strongly
contested, are for the present conceded ; and hence we regard
it as remedial in states incident to diphtheria, but know  of
nothing entitling it to  rank here as a specific.   --As a rule,
however," says 3Iackenzie, -quinia  is more useful  after the
more serious  symptoms have abated, when it  may be very
suitably  combined with iron and  a mineral acid.   3Iorphia
and chloral are occasionally necessary to combat continued
sleeplessness,  and to ward off  the exhaustion  which is its
invariable consequence."'
   Chlorate  of Potash.   This salt,  usually classified among
diuretics, has since its introduction by Hunt in 1S47 for the
treatment of cancrum  oris, achieved a cosmopolitan reputa-
tion in the  treatment of ulcerative diseases of the mouth and
throat.  3Iany practitioners hold that it, as well as chloral,
possesses aplastic powers, or the  property of checking the
formation of an exudation, and it is doubtless more generally
prescribed  in croup and diphtheria than  almost any other
remedy.  West is said  to have been the first to formulate its
use  in membranous stomatitis,  which occasionally exhibits
pseudo-membranous patches on the gums and buccal surfaces.
We do not,  however, class  ulcerative  stomatitis among the
membranous diseases.   Subsequent observers have not only
confirmed the favorable reports of Dr. West, but have con-
ferred  upon this remedy the character  of a specific in the
treatment of this hitherto refractory affection.   Its mode  of
action is not understood, but its almost universal efficacy  in
ulcerative stomatitis is one of the  few established facts  in
clinical medicine.
   Having achieved such a reputation,  how naturally comes
the  suggestion  to test its utility in other diseases more
uniformly attended with membranous exudation.  Bluche  is
supposed to have been the first to try its efficacy  in diph-
theria.  The results were  not as  emphatic as  in ulcerative
stomatitis, but were encouraging.   '; Since then, cases  have 
               CONSTITUTIONAL TREATMENT.            105

multiplied in all quarters,  and the facts  authorize us to con-
sider chlorate of potash, as a remedy, perhaps not sure, but
at least able to render some service  in this grave disease.
But in this respect we must make an observation.   Croupous
angina  (diphtheria)  has  very various  degrees  of gravity,
according as it  appears sporadically or as an epidemic, and it
would be supremely irrational to draw conclusions from thera-
peutic  experience in cases so unlike.   If it is true that  in
malignant angina,  especially when  epidemic,  chlorate  of
potassium generally fails, as most treatment does fail,  it can-
not be denied tbat the same remedy has procured success  in
quite different circumstances, that is,  when croupous  angina
presented chances of curability.   In this respect the obser-
vations made at  the children's hospital, or published by a
large number of  physicians  at  Paris and in the  country,
scarcely permit a  doubt.   We will say, then, with Isambert,
that the  usefulness of chlorate  of potassium, in  cases  of
medium intensity, seems to us proved, not only by a real and
definite success, but by its special and almost elective action
upon the  pharyngeal mucous membrane, identical with that
which is observed in membranous stomatitis.  The return  of
the rose red color, the fall of the false membranes, the low-
ered pulse,  are often in a space of time which is sensibly the
same in both cases.  This observer  adds that cauterization,
employed concurrently,  does not seem  to him to hasten the
action of the chlorate  at  all,  but  sometimes to impede it."
(Trousseau.)
   In as much as clinical facts are more to be trusted than the
most elaborate theories without such confirmation, and as like
testimony to the utility of  this medicine in diphtheria is borne
by nearly all observers, everywhere, it must be accorded a place
among  the  tried and useful remedies in  diphtheria.  Its dose
is from two to ten grains, in aqueous solution,  every hour,
and should be given  in conjunction with from  one  to five
grains of chloral hydrate.  (Form. Nos. 22 & 23 at end  of vol) 
106
DIPHTHERIA.
  The internal  treatment of Dr. J. L. Smith, which is very
generally followed by American physicians, is the administra-
tion in alternation of  formulae  Nos.  19 & 20. which he  de-
clares he has found to constitute the most  satisfactory  inter-
nal treatment.   He also advises citrate of iron and ammonia,
alone, or in combination with carbonate of ammonia, in two
grain doses, dissolved in simple syrup,  in place of the latter,
when the inflammation of the fauces has considerably abated,
or is moderate.  As a disinfectant to be applied within  the
nostrils, he advises carbolic  acid, gtt. xxiv, glycerine § ij,
and water  | vi; to be injected every four hours.  Also  lime-
water spray in laryngeal  cases.
  Mercury was  considered  by Bretonneau and others as  the
most  important of remedies in the  constitutional treatment
of  diphtheria,  and  Dr.  Bard  wrote '-Although I  consider
mercury  the basis of the cure, especially in  the begining di-
sease.  I do not by any means intend to condemn or omit  the
use of proper alexipharmics and antiseptics."'
  Very few practitioners of the present time prescribe this
agent in any other way than as a laxative in the early stages
of the disease.   Its  specific effects are now known to increase
the asthenia and adenitis, without  any compensator}* effect to
neutralize or to eliminate the specific poison ;  hence mercury
is practically and deservedly expunged from the list of anti-
diphtheritic remedies.
  Sulphide of potassium,  regarded by Swiss  physicians as a
valuable specific, probably does more harm than good, and is
only mentioned to be condemned.
  Bromine and the bromides have also failed  to vindicate  the
expectations of their advocates, and are practically abandoned
except in laryngeal cases.
  Carbolic  and salicylic acids,  and the  sulphites have  been
vaunted since the promulgation of the  bacterian theory,  as
constitutional as well as local remedies of great value for  the
destruction of those  minute  low organisms of  which Eberth 
CONSTITUTIONAL TREATMENT.
107
has said :  " Without micrococci there can be no  diphtheria."
These remedies, or some of them, doubtless do possess in a high
degree, bactericide  properties; and, were the  theory true,
would be genuine specifics for diphtheria, at first locally, and
afterward systemically, through the  medium of the  blood.
These remedies I have formerly often used very early in the
disease, both locally by careful application to the entire  in-
flamed faucial surfaces; and internally, either at the same time
or subsequently, without any apparent modification of the pro-
gress of the disease.  Other observers have had similar ex-
perience of their inutility.  J. Lewis Smith expresses himself
upon this point as follows :
   c; But experience, if sufficiently extensive, is the safe guide
in therapeutics, and, according to  my observations, internal
antiseptic measures have not  seemed to  exert  any marked
controlling effect on the course of diphtheria."
   As bearing upon this subject he refers to a case of a four
years old child, who took " Almost from the beginning of the
sickness, a mixture of potassa and iron on the first hour, two
grains of quinine on the  second hour, and three grains  of
salicylic acid on the third hour, and this treatment was con-
tinued night and day, and yet this child, having from the first
taken sixteen grains of quinine, twenty-four of  salicylic acid,
beside the potash and iron daily, died after eight days with
profound blood poisoning, having had many extravasations of
blood."
   3Iackenzie says :  " I have not employed carbolic acid my-
self as an internal remedy, but the  sulphocarbolates as rec-
ommended  by Dr. Sansom have often proved of service  in
my hands, in the secondary poisoning of diphtheria.  In the
primary septicaemia, these remedies have appeared to me quite
useless."   (Form.  No. 26.)
  Balsam of copaiba and cubebs, so well known for their action
on the mucous membranes, have been used both as specifics
and as expectorants in diphtheria, and are well spoken of by 
108
DIPHTHERIA.
very reputable  observers.   3Iackenzie  says :  he has  found
distinct benefit  in catarrhal cases  from perles of copaiba,
but is of the opinion that neither copaiba nor cubebs can lay
claim to anything like a certain and specific action.  Dr. Be-
verly Robinson, one of the  physicians  of Charity Hospital,
New York, following the teachings of Trideau, is an advocate
of the treatment  by freshly powdered cubebs, (American Jour-
nal of Medical Sciences, July, 1576.)   Its action he considers
to be that of a stimulant to the mucous surfaces, both by con-
tact, and by elimination through the respiratory mucous mem-
brane and the kidneys.  To a child of five years he gives gr. x
in sweetened water every two hours.
   Senega alone or in combination with carbonate of ammonia,
has also been found useful, probably by promoting secretion
by the mucous and salivary glands.  By increased secretion
beneath the false membrane its separation may possibly be
promoted,  and the pharyngeal congestion  in some  degree
relieved.
  Of expectorants  it has been said no other is  equal in effica-
cy in diphtheria to  pilocarpin.  Dr. Guttman. of Cronstadt,
has recently treated sixty-six cases  with this  remedy,  with
most satisfactory results.   •■ Fifteen of these exhibited the
worst symptoms of diphtheria, of which  at least two-thirds
according to previous experience,  would have died ;  thirty-
three bad cases had extensive  membrane, the others   slight.
He gave pilocarpin to all,  and in the  first cases  associated
this treatment with quinine and gargles only,  they recovered
in periods, as a rule, varying from twenty-four hours to three
days :  of the fifteen worst cases, two recovered  in nine and
eleven days, the rest in two to five  days.  All patients  who
came early under treatment, while the  pseudo-membrane was
still loosely adherent, without exception were cured in twen-
ty-four hours.  The doubt that these eases were not  truly
diphtheritic is not to be raised, since   they  were  examined
with the utmost care, and, in the worst cases,  the  contagion 
CONSTITUTIONAL TREATMENT.
109
could be distinctly traced.   Under the action  of pilocarpin
not only were the membranes and infiltration dissolved in the
salivary flow, but also the violent inflammatory  condition
yielded to its  influence,  the deeply  reddened,  dry mucous
membrane soon became moist, pale red, and  in every respect
of normal appearance."   (Boston Medical and Surgical Journal,
Oct. 6th, 1SS1.)
   For his mode of administering the remedy, see formulae
27 and 2S, each dose to be followed by " a small amount of
generous wine."  Others who have used this remedy  in a
similar manner report favorably of its effects.
   An eminent American author (Flint) has asked the following
simple question :  " Is there any known specific remedy for this
disease ? " and replies that " the question  must be answered
negatively, unless we give credence to the doctrine advanced
by Dr. E. W. Chapman, namely, that the special  morbid con-
dition of the blood is antagonized by alcohol.  Dr. Chapman
claims that by the early administration of alcohol, as freely as
it  is  tolerated without  alcoholic excitation, in  conjunction
with quinia, the disease is  curable.  He bases this doctrine
on the results of a pretty large clinical experience.   He em-
ploys alcohol, not as a sustaining remedy, but as an antidote,
comparing its efficacy to that which  it has in cases  of ven-
omous snake bites.   The  claim in behalf of this method of
treatment is not irrational, and it should be tried sufficiently
to test its value.   To the usefulness of alcohol in  the  treat-
ment of this disease the author (Flint) can add his testimony
to that  of  others.  The tolerance  of alcoholics is,  in some
cases, notably increased by the disease.  It should be  given
to the extent to which it is tolerated  without  any manifesta-
tion of its  toxical  effects.  The novelty of Chapman's doc-
trine is  that its  utility depends on its antidotal effect, and
that, therefore, the earlier in the  disease it is given, it is bet-
ter, not waiting for evidence of  failure of the vital powers.
A French author, 31. Sanne, considers alcohol the most effec- 
110
DIPHTHERIA.
tive of antiseptics  which are administered  internally, and
that it is indicated in proportion to the intensity of the infec-
tion."
  It is believed by the writer that the experience of the med-
ical profession thus far, fails to  support the claims set up
for alcoholics to antidotal or specific virtues in diphtheria,
and that they are only of value as in other asthenic diseases
or exhausted states of the  bodily  powers.   Under such con-
ditions of prostration as often occur in diphtheria their ex-
hibition  is  imperative, but not more so than if the cause be
typhoid fever or any other exhausting disease.   The symp-
toms believed to indicate, and which should govern their use,
are  given elsewhere in  this treatise,  and are, therefore, dis-
missed for the present.
  Dr. Aitkin answers the question by saving : "We have no
specific treatment which can cure the disease or eliminate the
poison," and Dr.  Hartshorne  declares that  "no  specific
remedy having been discovered, we must be governed  in our
tentative treatment by our idea of its  nature, while conclud-
ing upon its therapeutics finally through experience.   Noth-
ing, it must be confessed, is very satisfactory as yet in the
management of bad cases."  Jacobi expresses himself as fol-
lows :  " I know of no specifics for diphtheria, and recommend
no  uniform  treatment for all persons and all cases."
  These quotations no doubt  truthfully and  lucidly express
the prevailing convictions of the medical profession ;  and yet
are logical intimations of the belief that a specific may exist,
and a hope  that careful observation and research may reveal
it.   It is certainly no less probable that such may exist for
this particular form of blood-poisoning than for such others
as the malarial and syphilitic.  Then, the continued trial of
new remedies, indicating unrest and dissatisfaction with the
result of every therapeutical resource hitherto applied; are
eloquent and logical, even if only inferential  proofs of a be-
lief in the probable existence of  some such remedy. 
CHLORAL TREATMENT.
Ill
  The result of the writers  experience and convictions is
that he  can truthfully reverse the negative reply  to Prof.
Flint's question, " Is there any known specific remedy for this
disease ? " and confidently intrust his affirmation to the severe
scrutiny and crucial tests  to which such a claim must be sub-
jected by the medical world.
                 CHLORAL TREATMENT.

   To set forth the claims of chloral hydrate to specific virtue
 in  the treatment of diphtheria, is the  main  object of this
 monograph, and  the  sole excuse  for adding  another to the
 long list of books on this subject.  Frequent references have
 already  been made to this treatment, especially in the chap-
 ter on local treatment.   A farther canvas of the  claims of
 chloral as  a constitutional remedy will  necessitate more or
 less of repetition, for which the forbearance of the  reader is
 solicited.
  The merit of the discovery of chloral,  in 1S32, is accorded
 to  Baron  Liebig, and its production and composition deter-
 mined by him and Dumas.  The remarkable antiseptic, dis-
 infectant, and deodorizing powers of this invaluable remedy
 might reasonably be inferred from the materials employed in
 its  manufacture, viz ; dry chlorine gas and absolute alcohol.
 " In the  experience of Dr. Squibb, ninety-two pounds of alco-
 hol required the  continuous generation  of chlorine gas for
 twenty-eight  days, using about 1% tons  of mixture of man-
 ganese  binoxide  and common salt, and yielded about  160
 pounds of  crude  chloral." (National Dispensatory.)
  Chloral  hydrate  is not,  however, merely  condensed  and
 solidified chlorine gas, although it possesses many qualities
in common with both it and alcohol; but is a new substance,
having qualities not known to exist in either, or in both com-
bined in any other way.   In its power to allay  pain and pro- 
112
DIPHTHERIA,
duce sleep it may be said to somewhat resemble opium.   Its
control of pain is less  positive, and  the sleep induced more
like natural sleep.   It  seldom produces the  untoward effects
of opium, such as nausea, dryness of the fauces, constipation,
anorexia, dysuria, headache and  giddiness  or malaise.   On
the contrary it is a valuable remedy in nearly all these states.
Its efficacy is especially exhibited  in exhausted and debili-
tated conditions ; as from overtaxing the brain by  prolonged
mental application or emotional  excitement; or the debility
occasioned by acute disorders ;  and also in various nervous
diseases  caused by anaemia or exhaustion; in  puerperal
convulsions, mania, chorea, delirium  tremens, and tetanus in
advanced  stages.
  Its sensible effects, when  taken by  an adult in doses of 15
to 30 grains, are exhibited usually in from five to ten minutes,
by a feeling akin to mild  intoxication, accompanied almost
from the first by a desire for  quiet repose.   The face is a  lit-
tle  flushed,  and the frequency of respiration and the pulse-
rate somewhat diminished.    The sleep induced is generally
natural and  refreshing.  Its anti-pyretic effects, in  cases of
exalted temperature, are marked,  while its sedation of cardiac
excitement and irregularity is nearly  as noticeable as its calm-
ative effect upon the brain and nervous system.  The stom-
ach, too, is quieted by its operation,  nausea diminished,  and
the toleration of food and medicine  improved.  These are a
few of the  better  known  constitutional effects of  chloral
hydrate.
  Besides its topical virtues in diphtheria (see chap. XVI.) it
is  highly  esteemed as an antiseptic  dressing in surgery and
in the  treatment of various  local and skin diseases.  Few
remedies of  its years are  so honored  and esteemed by intelli-
gent observing physicians.
  Its power to prevent putrefaction and to destroy or prevent
putrid  emanations is well known,  and has led to its  employ-
ment for the  preservation and deodorization of pathological 
CHLORAL  TREATMENT.
113
  specimens and bodies for dissection.  Its power also to disin-
  tegrate, or in some manner to destroy, the diphtheritic false
  membrane during its vital connection, has been so often  ob-
  served by the writer as to preclude doubt, and is  as  strongly
  affirmed by other observers.  (See local treatment.)
    Diphtheria, iu the opinion of the author, is never primary
  in any locality; its local lesions are only the visible manifesta-
  tions of the destructive effect upon the blood of the invisible
  intangible miasm  traversing  its  channels, unbalancing  its
  equilibrium, and destroying its vital and nutritive  properties,
  as shown by increasing debility, with corresponding  increase
  of the  infiltration of the glandular and other tissues  with
  plastic  material  that  may also occasion coagulation in the
  cavities of the heart, with fatal  results.  All this  infiltrated,
  exuded, or coagulated  plastic matter, wherever it exists, is
  abstracted from the blood.
   In suddenly fatal cases, the decomposed condition of the
 blood indicates so violent an action of the toxic agent that
 the blood was immediately so changed in its properties as  to
 render it incapable of coagulation and of  supporting life.
 In such cases it is obvious that  no treatment can be of any
 avail.
   What is chiefly  required  of a  remedy in diphtheria  is,
 then, so to  act upon the blood, or the specific virus in it,  as
 to correct its constantly evinced tendency to coagulation and
 loss of  its fibrin.  In  the rapidly fatal  cases noticed, its
 coagulating power (which is what is usually meant when we
 speak  of its  vital properties) is immediately  destroyed, and
 restoration placed beyond the reach of medicine.
  Has chloral any such power over the  tendency of tiving
blood to coagulation ?
  Blood within its natural  channels in health  shows no such
tendency; when  withdrawn and exposed  to the air, and  in
this way depriy*ed of its vitality, coagulation speedily ensues.
If an ounce of healthy human blood, as it flows from an open
     8 
114
DIPHTHERIA.
vein, be caught in a wine glass or vial containing one-fourth
of an ounce of a ten percent solution of chloral hydrate of
the same temperature as the blood,  and stirred sufficiently to
intermix the two, no proper coagulation will afterward occur.
IS the vial be corked no apparent change in color or consis-
tency occurs thereafter.   In appearance it is like carmine ink,
and flows  from the pen  as  freely, making a bright red mark
like fresh  arterial blood.
  This  action of chloral upon  human blood  may be called
specific  or antiseptic, or by the votaries  of the  bacterian
theory it might be called bactericidal, as it has been shown to
be fatal to these low organisms.  To whatever class it may
be assigned, or whatever be the rationale of its operation, the
fact is, in my mind, well established, that it exerts a similar
influence upon the living blood in the body.  Prof. Bartholow
makes the following pertinent and  suggestive remark  as to
the therapeutical  properties of this remedy.  -Besides  its
powers to allay the spasms (in croup) it is one of the few re-
medies which possess the property to check the formation of
an exudation."   He is here  discussing the systemic treatment
of croup,  and hence  must necessarily refer to the effects of
chloral upon the blood, by virtue of which effects it limits or
arrests the tendency  to local exudation within  the larynx.
Upon this point  this erudite writer speaks as one possessed of
positive convictions,  if not  positive knowledge  of the  fact
affirmed, namely, it is one of the few remedies known to possess
the property to check the formation of an exudation.  It checks
this tendency, then, of necessity, by correcting the  dyscrasia
in the blood ; or, in other words, counteracts or antagonizes
the abnormal tendency to separation, as well as to coagulation
of its fibrinous elements.
  Prof.  Bartholow is  an acknowledged authority in therapeu-
tics, and  we cordially accept his teaching on this subject, as
it confirms our own convictions long since expressed, and now
confirmed by a very large experience. 
CHLORAL TREATMENT.
115
  In no other disease is the tendency to membranous exuda-
tion so strong  and so general as in  diphtheria.   As before
stated, it is likely to attack and complicate any abrasion of
the common integument,  or irritated  portion of the  mucous
membrane;  and in most cases of  the  disease  the thick-
ness and extent of the membrane are  considered the index to
the proportionate violence of the  disease.   The disease not
being primary  in any  locality, and uniformly  the result of
a specific poison in the blood, rapidly destroying its integrity
and life, it is  apparent  that  the indications for treatment
would not be met if limited to the indispensable resources of
the kitchen,  no matter how systematically administered; nor
by  merely  tentative treatment.  A remedy is needed  more
rapid in  action than the destroying virus, and potent enough
to limit its ravages or to antidote its toxic agency.
  The effects of chloral in solution follow quickly its introduc-
tion into the stomach,  from which it is almost instantly ab-
sorbed, and appears in the blood in its identity, and not, as
formerly taught, changed  into chloroform.  Its specific effects
upon the blood are, therefore,  speedy, and no doubt are also
in proportion to the amount taken up.  The amount tolerated
and necessary to its best effects is to be judged by the degree
of somnolence  induced, which should never be profound or
comatose, but  mild and constant,  and continued only till its
office is  performed, generally till the disappearance of the
membranous exudate.
  The conservative character of the effects  produced are to
be  judged  by  its effects on blood  freshly drawn ;  and its
further specific  effects by the deductions of experience.
  Up to  the latter part of 1S75 I treated diphtheria as others
did and many still do,  mainly with iron and quinine, and my
losses  tallied with theirs, being from 25 per cent, to 33^ per
cent., which  the records of mortality show to be its present
rate under  ordinary treatment.   To  say  I had become dis-
gusted by what is called the intractable nature of the disease, 
116
DIPHTHERIA.
and its fearful fatality, is too feeble language to express my
feelings.   I wished most earnestly that I could be excused
from ever seeing another case, and lost all confidence in the
modes of treatment employed,  and determined to try some
other.  I am still in  very great doubt, as are also many
others, whether there is not more harm than benefit resulting
from the drugs usually employed.
  The astringent preparations, of iron, for example, if taken
into  the  blood, must  increase its tendency  to  coagulate.
Chloral preserves  its  fluidity, and thus limits or prevents
fibrinous separation and exudation, and diminishes greatly the
danger of extension of the exudate into the larynx and nares ;
indeed, so great is its power of preserving the fluidity of the
blood, that the vessels of anatomical specimens injected with
it by Dr. Keen, were found  after several months to contain
semi-fluid blood, instead of the dirty pasty mass usual.
  Iron is apt to derange the  digestion, according to Pareira,
whose views are  confirmed by common  experience ; and to
create disgust and nausea, rather than to promote appetite.
Chloral,  instead of interfering with the digestive  function,
allays nausea, and thus promotes appetite.
  Iron raises the arterial tension and the temperature, hence
increases  fever.  Chloral diminishes the arterial tension and
efficiently lowers the temperature in febrile states, and  di-
minishes the force and frequency of the pulse.
  Iron increases nervous irritability, while chloral  allays it.
Iron both constringes and irritates the mucous surfaces of the
fauces, thus diminishing local secretion.  Solutions of chloral,
passing over the  inflamed and irritated surfaces, disinfect
them, and both by its local and  constitutional  effects favors
healthy secretion.
  Under ferruginous treatment, the opiates required to obtain
the needful rest often materially interfere with the normal se-
cretions ; under chloral, abundant natural refreshing  sleep is
obtained without the vital functions being in any way inter- 
CHLORAL TREATMENT.
117
fered with, or secretion arrested ; hence  albuminuria is  ren-
dered less frequent.
  Iron manifests no particular effect on  the toxaemia,  while
chloral, by antagonizing the  specific poison, diminishes  the
toxaemia and consequent prostration,  and renders  paralytic
sequelae less frequent... . Chloral is by many writers and prac-
titioners regarded an unsafe remedy in debilitated states, in
which we have shown it is specially beneficial, from fear of its
paralyzing effects upon the heart.  It is yet to be proven that
pure chloral in medicinal doses is a  depressant;  it  is  more
easily  proven  to be a conservator of  nervous  and muscular
power by its sedation of nervous excitement, and the refresh-
ment which results from the repose of quiet sleep, induced by
its use.  Its effects upon the pulse and temperature cannot
come of induced debility, for the reason that no  debility re-
sults from its use ; which fact is apparent to the  dullest per-
ception ;  as it occasions  no  delirium, no  pallor, no blueness
of the  skin, no muscular tremor, nor unsteady action of the
heart, no sighing respiration, no clammy perspiration, nor any
other symptom of resulting weakness or paralysis.   On the
contrary the mind is calmed ; pallor diminished by  equaliza-
tion of the circulation; the tremors even of dipsomania calmed ;
the gait is steadied ; the pulse is rendered  soft and  full ; the
secretions are not arrested, but promoted,  and  some,  notably
of the  mucous and salivary  glands, are  increased.  Quite
probably chloral will repeat the history of  digitalis, which but
recently was thought by all writers to be only a substitute for
the lancet, and to reduce the action  of the  heart  only by
weakening it; but has now become the standard  tonic in af-
fections of this organ.   No increased debility of the heart or
any  other organ ever results from  the proper  medicinal use
of chloral hydrate.   Nine grammes (nearly  140 grains)  were
given without harm by Laseque to produce sleep in  a patient
sufferino" from rheumatismal meningitis, in which belladonna,
quinia, and other remedies, had failed. Sleep ensued, and the 
118
DIPIJTIILRIA-
patient recovered. (Trousseau.)   Several hundred  grains, in
doses of from twenty to sixty grains, are frequently given by
the best physicians, in a few hours, in diseases of great debil-
ity, as puerperal eclampsia, puerperal mania,  &c., not only
without harm, but with the happiest results.
   Trousseau advises a first dose of 4 grammes (gr. 60) in puer-
peral eclampsia, to be followed by fresh doses of one gramme
as soon as the action becomes feeble. Yerneuil advises chloral
in large doses, and to the extent of 8 to 12 grammes daily, in
traumatic tetanus.  Trousseau reports fourteen cases  of slow
tetanus, treated with one and one-half to  three  drachms of
chloral daily, and continued from twenty-four to sixty days,
with eleven  cures ; a better showing than can be claimed  for
any other treatment.  In none  of these cases is debility claim-
ed or proven to be a contraindicatioa to or result of  its  use.
But, were the results of such extreme doses less favorable, or
even fatal, they could not with any sense be claimed to prove
that ordinary medicinial doses, continued for a few days, were
dangerous.  Atropia, strychnia, and arsenic, are given in me-
dicinal doses with impunity  and benefit  for long periods,
although it  is certainly known that they  are deadly poisons
■when  administered  in  too large doses.  Even  gluttonous
meals of wholesome food  are  sometimes fatal, yet  nobody
would be so senseless as to base upon  such occurrences an
argument against rational eating.   No more would the  evils
resulting from the abuse of chloral, or from an idiosyncracv,
militate against its legitimate use in disease.
  The treatment of diphtheria with chloral hydrate as a chief
or I might say as a specific remedy, was  first employed  and
advocated by the writer in 1S75.   Since that time he has em-
ployed it in  more than  five  hundred  cases of well  defined
diphtheria, with a mortality of less than two per cent.  Like
other well attested specifics for other diseases,  the earlier  in
the disease the administration is commenced in any case,  the
better; for,  as a rule, the toxaemia is rapidly progressive, and, 
CHLORAL TREATMENT.
119
beyond a certain limit, will overwhelm the vital powers,  and
defy any treatment.
  Chloral is advised in all cases, (see formulae 22, 23 and 24)
in the place of the irrational  iron  and quinine  mixtures in
general use, and is given in small doses to the  extent of
inducing  a quiet somnolent state.  A moderate  hypnotic
effect is, in my experience, essential to the best results, as at
this point, if not before, the temperature and pulse rate are
reduced, and worry, headache, and nausea  disappear.   We
know, too, by this effect, that the  remedy has been absorbed
into the blood in  sufficient quantity to produce upon it spe-
cific effects.
  Occasionally it  is found best  to begin treatment with a
much larger  dose  in order  to reduce the temperature and
pulse, and to obtain a night of repose, as in  the  following
case.  Oct. 27th, 1881, Mrs. H., aged thirty-five years, and in
ordinary health, whilst away from  home on a social visit, ob-
served in the early part of the day that swallowing caused
acute pricking pain,  and  soon after an attending sense of
fulness and soreness.  The  preceding  night her  sleep  had
been interrupted and unrefreshing.  As the day  advanced,
headache and backache came on, followed, after a hearty
dinner,  by  nausea and  vomiting, with  violent  pains in
the  head,  neck  and  throat, with  sensations of  violent
general  sickness,  and  severe chills alternating with brief
paroxysms  of high  fever.  She  was  conveyed home  late
in the  afternoon.   At 8 p. m. she was visited  and the  pre-
ceding  history of  the attack elicited.  The pulse was  now
115 and bounding; temperature 104t}° ; eyes suffused ;  skin
hot; tongue moderately coated and dry,  and  purplish red
in the  centre ; nostrils stuffed and violently congested;  de-
glutition  difficult  and painful;  tonsils,  uvula and  velum
swollen, with  patches of false membrane upon both tonsils ;
submaxillary and cervical glands  swollen and tender ; bow-
els  constipated.   Ordered twenty grains each of soda bicarb, 
120
DIPHTHERIA.
and  calomel, to be  taken immediately, and followed at 9
o'clock by IJ Chloral hyd. 3 ss. tr. opii deod. gtt. xv, in half an
ounce of well sweetened water.   The  throat  to  be covered
with a light linseed  poultice, and  enveloped in soft flannel,
and  the  patient to  be allowed to rest for the night without
further medication.   2^th,  a. m.—Patient  had quiet sleep
during the  night, and  this  morning  two  fecal  dejections.
Pulse 84. temperature 90°, tongue  moist :  some  increase in
exudation, but  less faucial and  nasal  congestion :  glands of
neck still swollen, but less tender.   Ordered formula  No. 22,
which with  a few  slight variations was kept up till Novem-
ber 2d, when the patient was discharged — cured.   After the
night of  the 27th,  only  dry soft  flannels  were  applied
externally.
  To a child of five years suffering from a moderately severe
attack of  diphtheria, about  thirty-two grains of chloral hy-
drate in twenty-four hours is the usual quantity administered ;
in combination with an equal amount of chlorate of potash,
(Form. No. 23) in  syrup  and water,  and  administered  in
drachm  doses hourly, except  during refreshing sleep.  The
quantity should be increased or diminished  in proportion to
the age of the patient, and according to the  exigencies of the
case  : and if marked somnolence be produced, the  frequency
of administration  may be somewhat diminished.    The ad-
ministration  is uniformly commenced on the first  visit, and
continued till all exudation has disappeared, and longer, in
diminished quantity, if the toxaemia or local  manifestations
demand it.
  Should the irritability of the stomach seem to preclude the
present  administration of chloral, it will generally be found
to be controlled  by the  laxative before mentioned, and  if
necessary, recourse may  be had to such other means as are
generally employed to allay nausea.
  Should the febrile manifestations be very  marked, a few
doses of aconite or veratrum may be administered, but in 
NASAL DIPHTHERIA.
121
most cases the chloral is the only febrifuge required.   If, on
the contrary, malignant or typhoid symptoms are manifested,
the administration of pure rye or bourbon whisky, or pure
brandy, in milk punch or egg-nog, or other eligible forms, is
indicated, and if well borne, continued  in increasing quanti-
ties, up to the limit of toleration.  While administering alco-
holics, the chloral  mixture should generally be continued in
alternation.
  Experience has  shown that the excessive use of alcohol is
seldom required in connection with the chloral treatment; ifj
however, it be indicated, as above, its use is emphatically en-
dorsed.
  If headache or pharyngeal or other pain be complained of,
these generally  subside within a few  hours  after the  com-
mencement of the chloral treatment.
  The mouth and faucial and pharyngeal surfaces are effect-
ually   disinfected  by each  dose, and as the  local action of
the remedy is also desirable, no drink should be permitted for
several minutes afterward.  In most cases no other local treat-
ment  is required.  For other local treatment see chapter XVI.
  The patient  should be  allowed  abundance  of agreeabtej
refreshing, and nutritious drinks, as  cold water, milk, lemon-
ade, barley or rice water, toast  coffee, beef tea, or milk and
raw egg.  For further directions with regard to nourishment,
see chapter XIV.
                    CHAPTER XVIII.

                  NASAL DIPHTHERIA.

  Nasal diphtheria is much more frequent in some epidemics
than in others, and is so designated solely on account of the
implication of the nasal passages, either as the  primary seat
of the  local affection, or as the consequence  of  its extension
to the  nares from the pharynx. 
122                    DIPHTHERIA.
  The nares are,  however, but seldom at the first invaded by
the diphtheritic inflammation, or the original seat of the mem-
branous exudation.   The affection is generally secondary, the
result of the extension of like  processes  from the pharynx.
The disease, or, rather, the complication,  is usually at first
shown by a yellowish or  brownish  ichorous discharge from
the nostrils.  The mucous membrane is  congested  and red-
dened, and the passages soon become occluded  by  swelling
and the membranous deposits, which, at times extend contin-
uously from the posterior nasal orifices to the anterior,  oc-
casioning great embarrassment of respiration.
  In some cases we observe, however, only scattered deposits
on the mucous surfaces of the septum or turbinated bones.
  The general treatment of this form of diphtheria  is  in all
respects the same as in other forms of the disease.  The nasal
passages should be  frequently cleansed  and  disinfected in
order to prevent putrefaction and secondary blood poisoning
by absorption of septic matter thus formed.
  In my observation, paralysis of the pharyngeal muscles is,
doubtless  as a result of neglect to cleanse  these  surfaces,
more frequent in  nasal, than in other forms  of  the  disease.
It is, therefore,  of the first importance to keep these pas-
sages as thoroughly  cleansed  and  disinfected   as  possible.
This is to be accomplished  by the abundant injection of weak
pure soap-suds two or three times  daily,  followed by  weak
solutions of chloral hydrate (three to  fifteen percent), car-
bolic  acid, lactic acid,  permanganate  of potash, alum,  cr
tannin.  Preference is given to the chloral solution.
  The nasal as well as  the  pharyngeal surfaces  may  be
effectually  treated by inhaling the  vapor exhaled by  slack-
ing lumps of lime in a three percent  solution of chloral
hydrate, in a wide mouthed bottle.   This  should be repeated
every three or four  hours.  The vapor  may  be  rendered
aromatic by adding a small amount  of any agreeable per-
fume  or essential oil to the liquid used. 
LARYNGEAL DIPHTHERIA.
123
  Should epistaxis occur, and it is  not very unusual, it may
be controlled by  injections of Monsell's solution diluted with
four to six parts of water,  or by the use  of a snuff com-
posed  of persulphate  of iron one  part,  and starch three
parts.

                     CHAPTER XIX.

               LARYNGEAL DIPHTHERIA.
  Laryngeal diphtheria,  denominated also diphtheritic croup,
has been fully  described in chapter X, to which the reader is
referred.
  Its differential  diagnosis from that other form  usually  de-
nominated pseudo-membraneous laryngitis, or true croup, is
not generally difficult, and yet may at times be nearly or quite
impossible.  To the  general practitioner the conflicting argu-
ments for and against their identity, are of little  value or in-
terest, only as they may possibly influence his treatment of
the case.  Fortunately he is rarely placed under circumstances
of so equivocal a nature as to occasion serious  doubt,  and
should such conditions occur, he can derive little  aid from
controversial writings.  The following observations will  ma-
terially aid  in properly classifying any given case.
  A case is diphtheria, 1st. When it is the result of extension
of diphtheritic inflammation and exudation from the pharynx
or nares.
  2nd.  When it  can be clearly traced to  diphtheritic infec-
tion, and is  ushered in or preceded by constitutional pyrexial
symptoms such as characterize attacks of diphtheria.
  3rd.  If the  case occurs during the epidemic prevalence of
diphtheria, and is attended with swelling of  the  tonsils,  the
parotids, submaxillaries,  or the cervical lymphatic glands, any
or all  of them.
  On the other hand, the case is croup, 1st. If it be without
constitutional symptoms other than those attributable to laryn- 
124
DIPHTHERIA.
geal inflammation and exudation, as  partial aphonia, croupy
cough, slight fever, and embarrassed respiration.
   2nd.  In the absence of diphtheritic exposure, if the disease
be sthenic in its symptoms, and primarily locally limited to
the larynx.
   The treatment of this class  of cases is not shown to  have
been very satisfactory hitherto, as by far the largest part of
those attacked have died.   The prevention of laryngeal  com-
plications, by early and efficient constitutional and local treat-
ment is. no doubt, much more effective than any means that
can be employed after the larynx is invaded.   But suppose
laryngeal symptoms to arise in any case, the earlier they are
detected, the more hopeful may we be of favorable results.
   It behooves the physician therefore to keep a careful watch
in every case of diphtheria, in order to detect the approach of
laryngeal complication, which, as shown in chapter X. is or-
dinarily heralded by greater  or less vocal  impairment; as.
slight hoarseness of the voice, and croupy cough: or by slightly
stridulous breathing.  All these symptoms are magnified by
increase of the laryngeal tumefaction and exudation, till by
occlusion of the larynx the act of efficient respiration is ren-
dered impossible.
   The general medication in such cases need not be  material-
ly modified except to be pressed with a  vigor commensurate
with the danger.  The same is also true of the external  local
treatment, which at most need only be supplemented by effi-
cient fomentation by means of flannels wrung out of hot weak
solutions of chloral, changed even* fifteen  minutes.  Have
two sets of flannels, in order that the throat  may not be ex-
posed in changing.  Light flaxseed poultices are likewise to
be commended.
  By far the most important and promising item in  the treat-
ment at this period consists of the administration  by inhala.
tion of fluids vaporized by slacking lime, or  atomized by an
atomizer.  For this  purpose Mackenzie advises the use of lac- 
LARYNGEAL DIPHTHERIA.
125
tic acid (gr. xx in § i), to be used at least  every hour, and
continued for five minutes.   Prof. Smith gives preference to
limewater for this purpose, and advises its constant use.
  Having myself had no experience with the lactic acid spray,
it is sufficient to  say that it is strongly advocated by so high
an authority as Dr. Mackenzie.  I have had experience with
limewater spray,  but  in  my hands it has proven  less  useful
than a three per cent, solution of chloral hydrate, and I have
found its use troublesome on account of incrustations forming
upon the parts of the atomizer,  so as, sometimes at a critical
period, to prevent its working.
  Believing, therefore, that chloral  is a better disinfectant
and destroyer of the  diphtheritic exudate than is limewater,
as well  as more  convenient  in  practice, I advise its use for
ten or fifteen minutes hourly. The vapor of lime and chloral,
as advised (see R, 17) is specially recommended.
  There must be no relaxation in the administration of nu-
trients and stimulants, which, if necessary,  may be given  in
enemata.
  These measures must  be reasonably persisted  in till the
stridor and hoarseness are relieved, and the false membrane
destroyed or expelled.
  If this treatment is not successful, there now arises one of
the most difficult questions the  physician is ever called upon
to decide ; namely, the propriety of tracheotomy.  Out of the
greatest perils there is no doubt a few have, by this means
been rescued; and from perils apparently  equally great, a
larger proportion have recovered by the persevering use of
means less violent.  I know of  no satisfactory statistical  or
other basis for the clear  solution of this grave problem.   It
must therefore be largely a matter  of individual judgment,
aided, if possible, by the best available counsel.
  Time, to confer and debate the problem  at  the bedside, is
in every case exceedingly brief, from the very nature of the
case.  It may be that  even a few moments of apparently 
126
DIPHTHERIA.
unavoidable delay or doubt will prove  fatal;—instantaneous
decision  and  corresponding  action are  all  that  remain
In the writer's judgment the propriety of the operation in
any case of general infection is exceedingly doubtful, and un-
fortunately, such systemic infection exists in every  case of
undoubted diphtheritic pseudo-membranous laryngitis.
                     CHAPTER XX.

      TREATMENT OF DIPHTHERITIC PARALYSIS.

  Diphtheritic  paralysis,  the only frequent sequel of this
disease, is not ordinarily attended with great danger to life.
Its mode and period of development, and its attending phe-
nomena are  described in chapter X. which see.
  Although rarely fatal, and tending to spontaneous recovery,
it by no means follows that medical treatment is unimportant
in these cases.
  When the paralysis is slight, and  limited to the pharynx
and soft palate, as is most frequently the case, little is needed
to be done, save careful nursing, with the tonics appropriate
to this stage of convalescence; and here, if at all, in diph-
theria, is an appropriate sphere for iron.   Quinine and cod-
liver oil are also needed.
  In  the  graver cases of muscular paralysis, there is in
addition, a need to call to their aid other therapeutical anents.
If there be marked loss of power of the pharynx and oesoph-
agus or epiglottis, rendering swallowing difficult or  impossible
in the former, and dangerous in the latter; the administration
of nourishment  per rectum may become a  necessity.  For
this purpose milk with raw egg beaten in it, or strong beef-tea,
with milk and brandy,  are to be used, with  the addition of
a few  drops of tincture  of  opium  to  prevent   immediate 
MEDICAL PROPHYLAXIS.
127
expulsion.   These  may also  be made the vehicles for the
administration of remedies, as strychnia, iron, and quinine,
which are  now needed.  The feeding and administration of
medicines may also be effected by means of the stomach tube.
One or both of these modes  may  be a necessity to prevent
death from starvation.
  If  the paralysis  prove severe  or obstinate,  we should,
regardless of its seat, resort, in addition, to electricity, friction
with the flesh brush or the naked hands, and local stimulants,
as tincture of capsicum, or ammonia.
  The writer has been well pleased with  the effects of the
magneto-electric current, though the other electric currents
in a mild form are recommended.
                     CHAPTER XXI.

                MEDICAL PROPHYLAXIS.
   If the views entertained by me of the chloral treatment of
diphtheria are well founded, as I believe them to be, and if,
as I also believe, its effects are produced primarily on the
blood, and through its medium only, the following sequence
is, to say the least, logical.
   The effects of chloral  being  antagonistic to  the systemic
poison, or in  other  words, antidotal thereto in the  more
advanced  stages, it  is likely to be equally  so during the
stage of incubation, and therefore an efficient theurapeutical
prophylactic.
   That it is such I  have often demonstrated in practice,  to
my  perfect  satisfaction.  It manifests a  remarkable  power
over the diphtheritic poison in every stage of its develop-
ment.
   When given to  persons exposed, in the doses heretofore
advised,  three or four times in twenty-four hours,  I have 
128
DIPHTHERIA.
almost uniformly observed that if they contracted the disease
at all, its form was mild.  In most instances its protective
influence has  seemed positive, and its use for the purpose,
though new to most practitioners, is earnestly recommended,
A little  experience in  its  use  will dispel incredulity,  and
prove the value of this new departure. 
CROUP.
                      CHAPTER I.

  In its aetiology  croup has little  in  common  with diph-
theria.   Croup generally has  its origin  in colds, and rarely
occurs  except  in Winter and Spring, during the prevalence of
inclement weather,  and is neither contagious nor epidemic ;
whereas diphtheria originates from a subtile blood poison,
prevails at all seasons of the year, and is  both contagious
and epidemic.  Pathologically their relationship consists in
the development in both of a similar exudation ; in the former
always within the  larynx, in the latter almost  universally
upon the pharyngeal surfaces, from which its extension into
the nares and larynx, as well as its development upon  any
abraded surface of  the body, is not rare.  We regard both as
forms of toxaemia, for the reason that common acute inflam-
mation never, or very rarely, leads to a membranous exuda-
tion.
  Just what the antecedent or coexistent cause of the blood
poison of croup  may be, aside from the catarrh by which it
is ordinarily introduced and seemingly induced, is not known;
we are only  familiar  with the course and phenomena of the
disease.  These differ as widely from  diphtheria as they do
from  fibrinous bronchitis.  All three of these diseases  are
characterized  by an identical membranous exudation, but are
not therefore  even  suspected of being one disease.   There is
no  better reason for suspecting the identity  of croup and
diphtheria than there is for  reckoning  all  three to be  one,
and simplifying the  nomenclature by calling all diphtheria.
     9                     0-'9) 
130
CROUP.
Indeed, Sir J. R. Cormack  has suggested that plastic bron-
chitis may be a variety of diphtheria, and numerous other
writers of great distinction treat croup and  tracheal diph-
theria as identical.   Nevertheless  the  very wide clinical dif-
ferences observed by all, are sufficient to distinguish them as
separate diseases, having the one characteristic, a lamellated
membranous  exudation, in common.
  Their histories are as distinct  as their clinical differences.
and both alike disprove their identity. .  .  .  The common
membrane, it  must  be admitted, is suggestive of a  similar
effect being produced upon the blood by the causes which
call into existence these separate affections.  Although com-
mon forms of inflammation never produce such an exudation,
it does not follow  that the different causes of these  diverse
maladies may not, to some extent, similarly affect the blood,
and be amenable to like treatment.
  Fibrinous exudations prove either such an affection of the
blood as predisposes  to coagulation, or a  peculiar form of
local inflammation,  producing  topically, in  croup and plastic
bronchitis, a condition that in  diphtheria has  been  shown to
be systemic.  Either  may be admitted, or both,  without  ma-
terially influencing the treatment, for the  reason that, in the
presence of so great danger, no topical or  general treatment,
known to have a favorable influence  is  likely to  be disre-
garded, whether it exactly fits  our philosophy or not.
  The disease now under consideration is given a variety of
appellations,  as pseudo-membranous laryngitis,  croupous or
plastic  laryngitis, cynanche trachealis, membranous croup,
true croup, etc., to  distinguish  it from other  varieties of
laryngeal inflammation.  The  term croup, which  was first em-
ployed by Sir Francis  Home, has long been applied  to  this
malady, and  is expressive of  its earliest  symptoms, hoarse-
ness and stridor.  Its derivation is  uncertain and  unimpor-
tant, while its true  meaning  is expressive  and significant.
" Croupy cough" and " croupy breathing'' are popular ex- 
CROUP.                      131
pressions that are never misunderstood nor disregarded by
medical men, and very seldom by the laity.  They inspire the
popular and the professional mind alike with a well-grounded
sense of impending suffering and imminent  peril.
   The disease is  essentially a plastic  laryngitis, dependent
largely for its origin upon exposure in inclement weather,
and in some degree  perhaps upon  specific causes, and  also
upon peculiar personal or family susceptibility ; and not upon
any peculiar contagium.
   Croup is essentially  a disease of childhood,  between the
ages of two and seven years, but occasionally occurs  outside
of these limits.  It prevails mostly during Winter and Spring
and is  only exceptionally observed  during  Summer and Au-
tumn.  Its occurrence  as a consequence of or in  immediate
connection with common acute catarrh, so masks its stealthy
invasion that its serious character is often unsuspected : the
patient is thought only to have •• caught a cold."
   Early symptoms and diagnosis.  First Stage.   Pseudo-mem-
branous  laryngitis in its  early stages is with difficulty diag-
nosed from simple  or ordinary catarrhal inflammation.   Its
symptoms are such as depend solely upon laryngeal obstruc-
tion. This obstruction is at first, as in all the other forms of
laryngitis,  due to  sub-mucous infiltration, or inflammatory
swelling.   An inflammatory stage, as in diphtheria, precedes
the exudation or the period of membranous formation.  Then
as croup is, unlike diphtheria, neither  epidemic nor  conta-
gious, no  reliable  diagnosis can be  based upon its epidemic
prevalence, or upon  exposure  depending upon the presence
of others affected  by the  disease.   The slight roughness or
hoarseness of the  voice  and clanging  or barking cough, as
before intimated, are  no more, often less, marked in the croup-
ous than in simple catarrhal or accute forms of  laryngeal in-
flammation.  Auscultation  shows that both the inspiratory
and  expiratory  sounds  are a little  prolonged, and that the
vesicular murmur is more  or less marked by laryngeal stri- 
132
CROUP.
dor.  The supraclavicular, intercostal, and precordial spaces
are somewhat  depressed during inspiration, the depression
being in proportion  to  the  obstruction.   Xeither rigor, pro-
dromic  symptoms, nor peculiar form of fever, indicates the
true nature of the attack, any more than do the character of
the voice and cough.  Xo characteristic expectoration or fau-
cial inflammation or adenitis are so manifest as to enable the
anxious practitioner to surely solve the problem  of diag-
nosis.  Is its solution then impossible ?  It is only just to
confess that, in the early stages, it sometimes is  impossible.
With  physicians of experience and culture, and quick percep-
tion of cases, a diagnosis is often like an intuition or a super-
added sense, and is  no  more  communicable to a novice  by
words than are the most difficult  problems  of geometry.
This superadded sense or ready  interpretation of the physi-
ognomy of disease is a large element of medical proficiency,
and either is, or underlies, skill.  What, then, we inquire, are
the best communicable instructions to aid junior members of
the profession to fix upon a diagnosis in the early stages or
first period of  croup, as a basis for the treatment of this
most deadly foe of children ?
  1st.  Remember that the characteristic symptoms are gen-
erally (not always,  it must be confessed.) more slowly devel-
oped than in the simple  inflammatory or spasmodic  forms of
laryngeal obstruction. The cough and stridor are less marked
and more insidious  and prolonged in this early period, than
in the usually  harmless  spasm  of  the glottis, whether
accompanied or not by some degree of  inflammation.
  2d.  Fever is induced alike in the simple and the croupous
forms of laryngitis, and  hence is not pathognomonic.  It may
be said often to appear earlier, and at  first with greater vio-
lence,  in the simple form of laryngitis than the croup.
  3d.  The differential diagnosis, to be  reliable, must depend
upon the discovery of the pseudo-membrane.   If we are able
to make visible the  interior.of the larynx by means of the 
CROUP.                       1^3
laryngoscope,  the presence or absence of this formation will
remove all doubt.   This method is not always practicable,
and with timid children, suffering often as much from fright
as from dyspnoea,  is very generally impossible.  " If,"  says
Prof. Flint, " the demonstration by this method fails, the pres-
ence of a  false membrane is to be inferred, first, from the de-
gree of obstruction being greater than in simple acute laryn-
gitis, provided the patient be a child; and second, from the pres-
ence of an exudation in the pharynx, which is determinable by
inspection of the throat. The latter is by far the more reliable.
Clinical observations go to  show that, in the  great majority
of cases,   an  exudation visible  in. the pharynx accompanies
pseudo-membranous laryngitis exclusive of the occurrence of
the latter as a complication of diphtheria.   There  are, how-
ever, some cases in which this evidence is wanting.  In these
cases a positive diagnosis cannot be made independently of the
laryngoscope,  until portions of the false membrane have been
expelled by coughing.   In all cases the expectoration  should
be carefully examined with reference to this point.   The por-
tions  of false membrane expectorated are  sometimes rolled
together with the mucus into a mass which must be carefully
unrolled in water, in order to determine its membranous char-
acter.   This evidence of the  affection is rarely  obtained if the
patient be under five years  of  age  on account of the expec-
toration being swallowed."
   These remarks by this great teacher  serve  more to show
the  difficult  character of the  problem  under  consideration
than to aid in its solution; although it must be acknowledged
they are as truthful as they are characteristically frank  and
instructive.
  Let  us  call  to our aid a clinical example.   E. S., aged five
years,  contracted  a  cold  from exposure  Nov. 12th,  1880.
Family are constitutionally predisposed to croup, two children
having previously  died of the disease.  Parents  and  living
children  constitutionally  sound except the  predisposition 
134
csou:'.
above mentioned, which  has also been manifested by several
violent  attacks  of diphtheria.  Sanitary surroundings  and
other circumstances reasonably good.   When  called on the
15th the patient appeared but slightly ill; for three days had
had a cold and been moderately but increasingly hoarse, with
croupy cough keeping pace with the hoarseness, appetite im-
paired, fever so  slight that of itself it would not attract at-
tention ; had a rather restless night, respiration slightly stridu-
lous and distinctly audible.  No view of the interior of the
larynx could be obtained ; epiglottis and adjacent parts con-
gested and coated partly with what appeared to be condensed
mucus,  no dysphagia nor  glandular swelling.   diagnosis
membranous laryngitis.
  If in this stage any doubt may have existed, the subsequent
history showed unequivocally the correctness of the diagnosis.
  At this early period of the disease, the symptoms as epito-
mized by Bartholow, are as follows.  The attack of the croup
usually but not  invariably begins as an acute catarrh of the
larynx ; there  is a feeling of heat and irritation in the organ,
and the voice is  a little husky; there is cough with something
of stridor about it; and  fever, restlessness,  thirst, anorexia,
and  disturbed sleep accompany the  evidences of laryngeal
mischief.  When the fauces are inspected,  more or less red-
ness, sometimes dusky  redness,  will be observed, and also
small patches of a thin pellicular exudation of  a grayish-yel-
low color, studded over  the  palate, tonsils and pharynx.
These patches presently coalesce and then form a dense mem-
brane several  lines in thickness (?). of a yellowish gray or
ash color.  As huskiness of voice was one of the initial symp-
toms, the same patches of pellicular exudation are forming in
the larynx.
  Evening exacerbations, followed, as morning approaches, bv
remissions, are, during this period, extremely common, but are
at most only suggestive,  and not to be considered diagnostic.
Says Prof. Mackenzie:   " In children it is  sometimes very 
CROUP.
135
difficult to distinguish catarrhal  laryngitis of a  severe  form
from croup.   Indeed, in the early stages it is often impossible
to differentiate the two maladies."
   On the other hand J.  Lewis Smith (Diseases  of  Children)
writes :   " The diagnosis of true croup is ordinarily easy.  It
might be mistaken for spasmodic laryngitis, but more frequent-
ly spasmodic laryngitis  is mistaken for  it.   The differences
which will aid in the differential diagnosis are the following :
Commencement abrupt and at night in the one, gradual in the
other; presence in one and absence in the other of pseudo-
membrane upon the surface of the fauces ; fragments of mem-
brane in the sputum in one ; character of the cough, course of
the disease growing gradually in one, in the other,  with few
exceptions, rapidly improving."  Trousseau speaks of the lia-
bility to error of diagnosis in these cases in which spasmodic
laryngitis is associated with pseudo-membranous pharyngitis.
" Few physicians hesitate to designate as true croup these cases
in which there is a croupal cough in connection with false mem-
brane upon the surface of the fauces, and yet the laryngitis,
under such circumstances, may be merely spasmodic.   This
coexistence of pseudo-membranous pharyngeal and of spasmo-
dic laryngeal inflammation is, however, probably rare, but its
occasional occurrence should be borne in mind."
   Just  how Prof. Smith has rendered the  " diagnosis of true
croup easy "  in the preceding quotation is not easy to see, as
he has failed entirely to notice the difficulty of differentiating
the disease from catarrhal laryngitis,  which Mackenzie truth-
fully  declares " is often  impossible."  Much of  the apparent
clearing up of the diagnosis of true croup comes from its be-
ing considered by Trousseau, Mackenzie, Bartholow, and others
as identical with diphtheria ; hence the frequent reference to
the discovery of .membranous deposits on the  pharynx as
diagnostic of croup: it is, however, more commonly pathogno-
monic of diphtheritic infection, and its  appearance is  excep-
tional and rare in uncomplicated true croup.  A certain diag- 
136
CROUP.
nosis at an  early period of the disease is  frequently simply
impossible.
  Later Symptoms.  As the disease advances the skin becomes
hot and dry,  the face flushed, eyes suffused, breathing more
hurried and stridulous. cough more hoarse and frequent until
it becomes toneless, a mere spasmodic expiration; the labored
and  hoarse  phonation is nearly, and  finally entirely extin-
guished.  The patient,  already suffering from asphyxia, be-
comes  alternately  dull,  and  fretful and passionate.  Then
occurs a lull, respiration somehow is a little easier, probably
in consequence of relaxtion of the laryngeal structures, the
effect of the increasing carbonic acid toxaemia, and the patient
not only breathes better, but from better oxygenation of xhe
blood becomes temporarily less  stupid, and for a very brief
period seems quite himself again.  Yery soon, however, as the
irritability of the laryngeal structures is revived, spasmodic
stricture is again added to the organic obstructions, the dys-
pnoea returns with increasing violence;  the lips  and nails be-
come blue, every respiratory muscle seems to exert its utmost
power to obtain the required air, inspiration is prolonged and
stridulous. the intercostal spaces  are depressed:  the veins of
the face and neck become prominent,  and a profuse perspira-
tion bursts from every pore.   Expiration, though obstructed
and often prolonged in proportion to the amount of air exhaled,
is less painful, because not accomplished in so great a measure
by the direct labor of the exhausted respiratory  muscles.
  The effects of the intense labor,  and the accumulated  car-
bon in the blood, soon again produce exhaustion and  insensi-
bility, and the patient again  falls asleep.   A brief  period of
restless repose and labored breathing is soon  succeeded bv
another paroxysm even more violent than the preceding.  The
cough does not increase in violence as the disease progresses
on account of the muscular debility, and is rarely of sufficient
force to raise the mucus  from the air passages,  or to detach
and  expel the loosening portions of false membrane.  The 
CROUP.
137
paroxysms of coughing  not only do not afford relief,  but on
the contrary, by lifting the thick mucus or detached portions
of membrane to the rim of the glottis, add to  the existing
obstruction,  occasioning increased spasm,  and may thus pre-
cipitate a  fatal termination of the case.  The voice  during
this period is usually extinguished, or so  great  is the effort
necessary to  speak, or so  painful, that only a feeble whisper
or sign can be elicited.
  The appetite for food  is entirely lost, the thirst incessant,
and deglutition not generally difficult.  The tongue is  heavily
coated with a thick white fur except the tip and edges, which
are often intensely red.  The fauces are red, or ash colored, and
occasionally  show traces of membranous  exudation,  but af-
ford no index to the violence of the disease.
  During the third stage, which now supervenes, the exacerba-
tions grow less violent as the natural forces  decline,  and the
intermissions fail to recur,  while the respiratory  effort is con-
stantly taxing to the utmost the waning vital and muscular
force.   The cough  grows more feeble or ceases entirely ; the
breathing apparently less laborious is feeble and  sibilant.
  The head is forced backward as in opisthotonos, the larynx
depressed and alternately moving up and  down in aid  of the
respiratory efforts, which with the co-operation of the abdomi-
nal muscles causes the chest to heave violently to increase its
capacity,  and  force  the  entrance of air.   The  countenance
grows livid and anxious, the eyes dull and pale,  the skin dry
or clammy and the extremities cold.  The  pulse becomes very
feeble and rapid, the respirations irregular or intermittent: the
patient throws himself about upon the couch, often clutching
the throat in frantic fruitless efforts to remove the obstacle to
breathing.   The agony increases, the countenance gradually
relaxes, and  either increasing dyspnoea, coma, or convulsions,
hasten the tragic scene to a close in death.
  Death may occur  at  almost  any period of  the disease.
Fatal cases  rarely run a longer period than two weeks, or a 
138
CROUP.
shorter than two days.  In the earlier periods sudden death
is often, no doubt, the result  of spasmodic  closure  of the
glottis.  Later it may result from the great extent and thick-
ness of the membrane, or from detached portions lodging  in
the chink  of the  glottis.  Still another cause of death  may
be found in the bronchial obstruction, caused by mucus and
pus, which the feeble patient has been unable to  expectorate ;
and yet another cause of death may be the imperfect aeration
of the blood from imperfect respiration, and the consequent
gradual accumulation therein of carbonic acid.
  Pathology.  The  post-mortem appearances  are in  accord
with the disease phenomena heretofore delineated.  As death
rarely occurs during the first period, few opportunities are af-
forded of determining the anatomical characters which  then
exist, but as the hoarseness and croupy cough are  primarily
due to inflammatory congestion and  tumefaction, during the
first period, only the evidences of such action are known  to
exist.  These  consist of intense injection  of   the  larynx,
either uniform or in patches, swelling, and a scanty secretion
of tenacious mucus, or elementary pseudo-membrane.  In its
later stages, after the hyperaemia has  attained its maximum
intensity, the disease is characterized by the appearance upon
the inflamed surface of a grayish-white  semi-transparent  pel-
licle or rudimentary false membrane, which rapidly increases
in thickness, and which presents much the  same  physical and
chemical properties as the pseudo-membrane  formed in  well
marked cases of diphtheria.   It is not of uniform density,
and is found more firmly adherent at some points than  at
others ; often it is found loose, or being  only  partially de-
tached hangs in shreds or fringes.  Its  thickness varies from
a mere pellicle to several lines.   Its location is chiefly in the
interior of  the larynx, coating the vocal cords, the ventricles,
and lower surface of the  epiglottis.   It is occasionally visible
upon  the pharyngeal surfaces, but probably less frequently
than is often estimated. 
CROUP.
139'
   The formation of the pseudo-membrane  in the trachea is
 also  common, and may  extend downward to  the  minutest
 bronchi, so completely obstructing the passage of air as to
 have induced emphysema or atelectasis.  According to Guer-
 sent, in  120 cases, the false  membrane was limited  to  the
 larynx and trachea  in  78, and in 42 extended also into the
 bronchial  tubes.  It is seldom  so  abundant in the larynx as
 to completely close it against the entrance of air, but  on  the
 contrary, necropsy often  reveals there merely a transparent
 pellicle.   The dyspnoea which during the first period was due
 solely to inflammatory tumefaction, was subsequently,  in such
 cases, probably due to spasm of the  glottis, excited  by  the
 presence of the pseudo-membrane,  just as any foreign particle
 causes such spasm in health; for it should  be borne continu-
 ally in mind that the most violent paroxysms of dyspnoea,
 are in nearly all cases, largely due  to spasm.
   The pseudo-membrane,  then, surrounded generally with epi-
 thelial debris and mucus and pus, is the peculiar characteris-
 tic of croup, as seen  by the anatomist, and in the absence of
 this, no pathologist could venture to pronounce a case pseudo-
 membranous laryngitis.
   Treatment.   When we consider the great  danger from  the
 rapidly increasing obstruction to respiration ill this disease, by
 the increasing congestion of the  larynx and the  deposit of
 plastic matter upon its walls, in  connection with the natural
 narrowness  and sensitiveness  of the chink  of the glottis in
 young children, in whom slight turgessence of its mucous
 membrane  is often sufficient  to cause stridulous breathing
 and  alarming  spasmodic  closure,  the importance  of early
 treatment can hardly be exaggerated.
   Indications.   The arrest of inflammatory  congestion, limit-
 ing or preventing the adventitious deposit, or  if already
formed  effecting its  disintegration or  expulsion   and the
prevention  of spasm  are the chief  therapeutical indications.
While  pursuing  these  objects,  the necessity  for  properly 
140
CROUP.
 supporting the patient's  strength  so  that  he may be  able
 to withstand  the  progress  of the disease, must of course
 be borne in mind,  and is to  be effected by suitable nutrition,
 and  avoidance of  such measures of  treatment  as tend  to
 induce undue depression.
   Of remedial measures having the sanction of most authors
 we first notice emetics.  Their effects  are, 1st:   To diminish
 the local congestion by occasioning copious secretion and ex-
 pulsion of mucus.  2nd:   To  detach  the pseudo-membrane
 by increasing  the secretion  beneath  it, and softening it,
 and by the expulsive efforts  occasioned, to effect if possi-
 ble  its dislodgment  and ejection with  the  matter vom-
 ited.   Emetics are, therefore, generally considered the proper
 initial of rational treatment.  As it is manifestly important
 to consider the  strength of the patient, that he may be able
 to bear up against  the ravages of the disease, and be able in
 the  succeeding  periods thereof,  by  vigorous  cough   and
 repeated administrations of  the remedy if needful, to effect
 the object  in view ; it  is essential  to select  such emetics as
 occasion the last prostration.   Their  repetition, to vigorous
 patients, as often as three to five times  in twenty-four hours,
 it is  thought,  is often beneficial.   Antitnonials, which were
 formerly much in vogue, are therefore  manifestly improper,
 and must  be rejected.   Ipecacuanha in substance, or  in  the
 form  of sirup or wine, although less  depressing, is yet  ob-
jectionable  unless with robust  subjects, because of the con-
 tinued nausea and  resulting debility.    Sulphate of aluminum
 in doses of a teaspoonful suspended in sirup or honey, given
 every ten or fifteen minutes till free emesis  is produced is
 highly commended  by Prof. Meigs of Philadelphia and others,
 and is one  of the best  of this  class of remedies ;  the large-
ness of the dose is the only objection to its use.   Sulphate
of copper is another of the most prompt and least objection-
able of emetics in croup.   It is conveniently administered
powdered with an equal weight of ipecac, and suspended in 
CROUP.
141
sirup so that each drachm may contain four or five grains of
the mixture, and  is given in teaspoonful doses every five
minutes till it operates.  It has been administered as often
as every two to four hours with apparently good results.  So
frequent administration is not generally to be advised.  The
yellow  sulphate of mercury in two or three  grain  doses,  to
a child of two years, is highly praised by  Dr. Hubbard, Prof.
Fordyce Barker,  Prof. J. L. Smith, and others.   Dr.  Barker
gives the remedy without delay, and claims not to have lost a
patient thus treated for several years.   The  dose should  be
repeated in ten or fifteen  minutes if the first dose  does  not
produce emesis.  Its employment is sanctioned by  the  very
best authors, and is commended by the writer, although par-
tial to sulphate of copper.
   If there be  any degree  of constipation, mild  cathartics
should be early administered.
   After emesis, resort  must be had to those remedies  known
to prevent or diminish plastic exudations, acting through the
blood  ; also to  the topical  use  of such  as  tend to  remove
such exudate by effecting  its separation or  solution.  The
chief remedies of this class are mercury, chlorate of potassa,
chloride of ammonium, quinia, bromide  of ammonium  and
chloral hydrate.
   Mercury.  This  remedy, which is usually administered in
the form of calomel, has been highly recommended  by nearly
all  reputable authors  of the  past  century.   " Dr.  Samuel
Bard  states that  Dr. Douglas of Boston, who  published in
the  year 1736 an account of the angina suffocativa, was the
first to recommend the  employment  of  mercury  in croup.
Bard says that he was induced to try mercurials after read-
ing  Dr. Douglas's little essay, and adds, - The more freely I
have used  them, the  better effects I have  seen from them.'
To patients three  or four years old he gave thirty or forty
grains  in five  or  six  days, 'not  only without any  ill effects,
but to the manifest advantage  of my patient;  relieving the 
142
CROUP.
difficulty of breathing, and promoting the casting off of the
slough beyond any other medicine.'  He advises  the first
dose or two combined with opium, and  considers mercury
the basis of cure in croup." (Meig5-)
   We certainly know that calomel has the effect of increasing
and attenuating the expectoration, but whether it also in-
creases  the  secretion  within the  larynx and beneath  the
pseudo-membrane and  thus assists in its detachment, is  not
so easily  demonstrated nor generally conceded.   But this
remedy has  also an ancient and honorable reputation  as an
anti-phlogistic  and alterative.   On account of the  former
property it  has been,  and still is to a considerable extent,
reputed to be  the great antagonist to  inflammation :  hence
it has generally been advised to  continue its administration
till the  inflammation subsides, or the mouth becomes con-
siderably affected.
   As an alterative its effects are produced through the medium
of the circulation.  By its effects upon the blood or the dis-
ease elements, it is well known in some maladies,  as syphilis.
to have the power so to modify it as to effect a cure.
   This power of producing an alterative effect upon the blood
bas been  invoked in the  treatment of croup.   Its reputed
efficacy  in so modifying the blood as to diminish or prevent
membranous exudation, has been  sustained by the  ablest
writers.   Prof.  West, of St. Bartholomew's Hospital, London.
"wrote, "Calomel seems  to have a twofold utility;  it counteracts
the tendency to the formation of false membrane in the air
passages, and prevents or subdues that inflammation of the
lungs which is so frequent and so fatal  a complication of  this
disease.''  Says Coley. of London,  • One or two grains of
chloride of mercury must be given immediately, and repeated
every hour, until the inflammation has subsided, or the mouth
has become sensibly affected."'  Prof. Meigs says. -It (calomel)
ought to be  given early in order to produce upon the blood its
■defibrinizing effect, and thus prevent, or at least limit, the ex- 
CROUP.
143
tension of the deposit."   Such evidence of the utility of mer-
cury in croup,  from eminent authors,  might be made to em-
brace  almost the entire  list of medical  writers up to a very
recent date.  If to the mass of writers, we add the oral testi-
mony  of a great multitude of living eminent practitioners, a
strong case is  certainly made in favor of the use of mercury
in this disease, and it is not too much to concede the proprie-
ty of its employment.
   The approved  mode of administering  this potent remedy
may be thus epitomized.   To a child one or two years of age
give from gr. ss to gr. i, either alone or combined with enough
pulv.Dov.  to prevent  its cathartic effect.   At the age of five
or six  years the usual dose is gr. i to gr. ij.   These  doses are
usually repeated  at intervals of two  hours, and in violent
cases are given hourly.  Prof. Meigs  affirms that of nine cases
so  treated by  himself, six  recovered ; while of  seven cases
treated without mercury, five died ; showing a balance in favor
of mercurial treatment of 50 per cent, in the proportion of re-
coveries.   It should be borne in mind that with mercury the
other approved adjuncts, as emetics,  moist  air, &c, were con-
joined.
   Notwithstanding the affirmed utility and high repute so
long enjoyed, of mercurial medication in croup, the title to its
venerable reputation is at the present time greatly questioned.
Prof. 3Iackenzie omits even its mention among the  reputable
remedies, whilst by some  other recent writers it is noticed only
to distrust, or to condemn.  Neither the theory  upon which
the practice is based nor the practice itself is any longer re-
garded as invulnerable.  It must be confessed that the finest
theories of medical scientists are at the mercy of clinical facts.
Let it  be proven as stated by Meigs  and others that fifty per
cent, more cures are obtained by this treatment than by any
other,  and we shall soon see that an improved version of science
will furnish an improved  theory.  If on the contrary, careful
observation shall  prove the superiority of more recent modes 
144
CBOUP.
 and remedies, no reverence for antiquity,  nor list of worship-
 ing admirers, can save this venerable giant from humiliation.
   Chlorate of potash is very generally prescribed in some way
 in pseudo-membranous  laryngitis, although  both its  modus
 operandi  and the benefits resulting from its use, are questions
 still far from being satisfactorily settled.  It  was first pro-
 posed as a remedy in croup by Chaussier in IS 19. but  soon
 fell into  complete  disuse.  It was revived again by Blache,
 and has ever since been used,  in connection with other reme-
 dies, with more or less belief in its beneficial effects.   It is re-
 garded  by Trousseau as  -having a general influence over the
 system  opposing the reproduction of plastic exudations.' and
 he adds. -Nothing forbids the use of this remedy in so dread-
 ful a disease as croup,  without, however, placing  exagge-
 rated confidence in its virtues, and especially  without using
 it to the exclusion of other treatment of proved (though per-
 haps limited) efficacy."
  Its excessive use is thought to induce inflammation of the
 kidneys with albuminaria.  Its possible  dangers,  therefore,
 and equivocal benefits in croup, should guard  against its too
 liberal administration.
  Ammonium Chloride, administered internally,  has  long en-
joyed the  reputation of having a specific tendency t • the mu-
 cous membrane of the air  passage-, improving its tone and
 favorably  modifying its secretion.  --The idea which 1ms  ap-
peared chiefly to direct its use in medicine is. that it tends to
render all  the secretions freer and more abundant, while it at
 the same  time  lessens the plasticity of the  blood,  in other
words, that its operation is. in some respects,  identical with
that of mercury.'' for which it has been by many physicians
 extensively substituted in practice.  Notwithstanding the sug-
 gestiveness of  its reputed physiological  action, it has  but
 recently assumed an important rank  in the  therapeutics of
 croup, and in this disease is now used  to a considerable  ex-
tent both  in private and hospital practice.  Prof.  J. Lewis 
CROUP.
145
Smith  writes  of its use in  Bellevue Hospital, as  follows
(Diseases of Children, p. 511) :  " Calomel has been much used
in times gone by for its supposed antiplastic action, and more
recently muriate of ammonia and chlorate of potassa as in the
following formula.
                R  Potas. chlorat.    3 i.
                   Ammon. muriat.  3ss.
                   Syr. simplic.      § ss.
                   Aquae            3 ij.     Misce.
Give one teaspoonful every half hour or hourly.
  " Since  the  discontinuance of the  calomel  treatment, thisr
mixture has been largely used in New York, but is now being
superseded by the atomizer, or it is being employed along with
the atomizer."
  Quinia and bromide of ammonium are accounted most valu-
able remedies in croup, especially by Bartholow.   Quinia in
full doses of gr. iii to gr.  v with children, inducing and main-
taining cinchonism  as fully as possible, is thought to effect
the arrest of plastic exudation.  Bromides, by their elimina-
tion by the bronchial and faucial surfaces, no doubt  exert a
beneficent local effect in  addition to their  efficacy as anti-
spasmodics in controlling the laryngeal spasms.  The bromide
of ammonium is given the preference, and is recommended in
full doses in alternation with quinia.
  Chloral hydrate is believed by the author  to  have proven
itself more efficacious in the treatment of croup than any other
individual remedy.   For seven years it has been  freely used
in every case treated by him, with much better results than
had hitherto been obtained without its use.   In  eight cases
since 1876, of such  gravity as is usually  thought to  demand
tracheotomy, six, by its persistent use, terminated in recovery j
and in no single instance since its introduction has  resort to
this formidable operation been thought advisable.
  The spasmodic affection of the larynx,  which constitutes so
dangerous a complication in this disease, is  so perfectly con-
     10 
146
CROUP.
trolled by chloral as to be almost eliminated from its danger-
ous  symptoms.  This effect  might reasonably be  expected
from its well established efficacy in other spasmodic affections.
  It will be observed that chlorine is  an element in aU the
reputed antiplastic remedies employed in croup, and from the
immense amount of this element employed in the manufact-
ure of chloral,  it might on this ground reasonably be  sup-
posed to be superior to them  alL  Having already, when pre-
senting its claims to  specific  action in diphtheria, shown its
effects upon the blood to  preserve its fluidity and to prevent
or arrest the tendency to fibrinous coagulation or exudation, it
is sufficient in the present case to refer the reader to that part
of this volume, with the remark that its therapeutic efficacy
in croup is bebeved to be as rational and as well established
as in that disease.
   It is believed its use in the treatment  of croup originated
with the writer about the time of its introduction by him in
the treatment of diphtheria, and so far as known, Prof.  Bar-
tholow alone among standard authors, has  arrived at similar
views, or commended its use  in this disease.  He says (Prac-
tice of Medicine, p.  437), u Besides the agents  above advised.
quinia and the bromides—for the  laryngeal spasms chloral is
to be commended.   The author has preferred to give chloral
and bromide of ammonium together, and the quinia separate-
ly.  Besides its power to allay  spasms, chloral is one of the
few remedies which possess the property to check the forma-
tion of an exudation."
   To assure its greatest efficiency, it should not only be  given
early in the disease, but should  be given  freely and persist-
ently.  To a  patient two or three years  old either of the
formulae, 23 or 24. may be employed in appropriate doses  every
hour or oftener when awake.  For older  patients the dose
should be proportionately large, and in any case increased or
diminished according to circumstances, special reference being
had to the soporific effects of the  chloral.  If the tendency to 
CROUP.
147
 sleep is strong, a less dose is indicated.  Its employment does
 not in any way interfere with the administration of emetics
 when indicated, nor with any other measures deemed necessary.
   Moist air being more easily respired in this disease than
 dry, it is advised that the atmosphere inhaled by the patient
 be impregnated with steam, either alone or medicated.   Chlo-
 ral and lime  in the form of vapor or spray is regarded the
 most important.   An eligible and economical mode of sup-
 plying the vapor  consists in slaking  lumps of fresh lime in
 an open-mouthed bottle, or in a coffee-pot closely covered and
 rendered tight by placing wet cambric beneath the lid, and so
 held as to compel the patient to inhale the vapor as it arises
 or is  discharged from the spout, or  rubber tube attached.
 A  coffee-pot,  or  any  similar vessel, with the spout  placed
 near  the top, is  to be preferred, as it  furnishes a more
 dense  vapor, which  can be easily directed to the nostrils  of
 the patient.   The  water used for slaking the lime  should
 contain  from ten to twenty  grains of chloral hydrate dis-
 solved in each pint.  The vapor may be  made aromatic by
 adding to the water  a small quantity  of  some  agreeable
 perfume.  The inhalations should be commenced  as  soon
 as  the disease is recognized,  and continued as  long  as the
 hoarseness persists.   Each inhalation  should continue ten to
 fifteen minutes, and  should be repeated every hour or oftener
 in the early stages, and less frequently  as the  disease subsides.
   No case of croup can be efficiently  treated so as to afford
 the patient the best chance of recovery, without  resort being
 had to inhalations of either the above or similar vapors, or of
 atomized fluids possessing like qualities.  The old method of
 slaking lime in open vessels, thus filling the sick-room with
 the vapor, is both awkward and wasteful,  as  well as disagree-
 able and dangerous to the attendants, rendering them exceed-
 ingly liable to take cold upon going into the  open air.
  Spray inhalations, though believed  to  be  less efficacious,
may be used instead of the above.  Those of lime-water and 
148
CROUP.
chloral, separate or  combined, the author considers  most
efficacious.  (Nos. 10, 11, et seq.)
  For use in this way Mackenzie recommends lactic acid (16).
  J. Lewis Smith recommends the nearly constant use of
lime-water four  parts, and glycerine one part, only intermit-
ting its use every second hour long  enough to inhale one
ounce of No. 14.
  When portions of false membranes are thought to be  loose,
or the passages are greatly obstructed by mucus, prompt  emet-
ics  are indicated,  and if not  successful in dislodging and
expelling the obstructing matter, recourse may be had to the
use of a small soft probang or brush for the purpose.
  The local application of cold water and of ice have been
advised, but are uncomfortable to the patient, and  hence re-
sisted by him, and opposed by the attendant friends as  being
a harsh and hurtful expedient.
  Emollients rendered antiseptic,  as glycerine  with chloral
hydrate (grs. v  to x in 3 i), or  camphorated oil,  or  light
warm linseed poultices,  are preferred by the  writer, and
are recommended.
  The patient should be well nourished, and allowed  agreeable
beverages.  Milk and beef juice or essence, with soft farina-
ceous preparations, as panada, arrowroot, cornstarch, &c, with
custards and syrups,  may be given according to the judgment
of the practitioner and the taste of  the patient.
  Finally, the grave  question  of tracheotomy  may  be forced
upon the attendant physician from the  apparent failure of the
timely and persistent use of the best remedies at his  com-
mand ; for it is certain that this grave issue must occasionally
be faced,  despite  the important addition of chloral to the
therapeutics of this dangerous disease.  The indications that
call for the performance of this operation are solely  such as
relate to the respiration.   In brief, it is necessary and justifi-
able after all  other remedies  have  failed,  and impending
suffocation can only be averted by  making an artificial  aper- 
CROUP.
149
ture into the windpipe in order to render respiration possible.
This  procedure,  surely  to be followed  by the  death of a
large majority of its subjects, can never be justified upon the
plea of conservation, in order to forestall and anticipate dan-
gers which either may or may not occur,  but only, as it were,
in the presence of death itself, with all it implies.  Since using
the chloral  treatment I have witnessed  a larger  proportion
of recoveries from conditions usually thought to demand the
operation, but in which it was not performed, than is shown
by the most  favorable statistics to have resulted from its per-
formance.  Six out of eight  such  cases I have seen recover
from the use of therapeutical measures  alone, while the best
results obtained in the best institutions, by  the most experi-
enced and  skillful  surgeons,  in this country  and  Europe,
scarcely average  a  single recovery  in less than five  cases
operated upon.  Between the years 1S49  and 1858. according
to Trousseau, 466 cases operated on in the Children's Hospital
in Paris, 126 recovered,  and 340  died.   In 1863, so  far as
ascertained by careful research, the  proportion of recoveries
at the Hospital cles Enfants Malacles, was one in four ;  at the
Hospital Sainte Eugenie, one in six.  In the latter, from 1S54
to 1875 inclusive,  one in four and  fifty-four  hundredths,  and
in the former, from 1851  to 1S75  inclusive,  one in three  and
eighty-two hundredths. The statistics of Paris probably repre-
sent the best results attainable by  this operation  in croup by
the most skillful and experienced operators.
   In England and America the results  are not known to be
more encouraging ;  practically they  are  identical and  hence
need not be repeated.
   We repeat then, only the gravest conditions can justify so
equivocal a procedure. The conditions demanding and justify-
ing such an operation are those relating to the degree of laryn-
geal obstruction.   It is manifest that occlusion of the trachea
below the  point of operation,  or of the bronchi, not only
could not be remedied by tracheotomy, but contraindicate its 
150
CROUP.
performance.  The degree of laryngeal  obstruction is indi-
cated by the greater or less respiratory stridor,  and is still
further  evinced by being  accompanied by evidences of insuf-
ficient aeration of the blood, as blueness or lividity of the lips
and finger tips.  When such evidences of asphyxia exist and
can in no other way be relieved, then it is clearly time to have
recourse to tracheotomy.  To delay in the presence of these
portentous symptoms is even more dangerous than the opera-
tion.  Therefore it is now clearly a duty to open a passage for
respiration, or it must cease.
  It is advisable that this extremity, which may occur sud-
denly and unexpectedly, should be anticipated by careful pre-
paration for prompt action.  Have  in readiness  one or more
double canulae, in addition to the instruments for making the
incision, which are usually  found in every surgeon's pocket
case.  Every physician liable to be called upon to perform the
operation is supposed to  have familiarized himself with its
details,  its dangers, and subsequent management, by a knowl-
edge of the teachings of the  best surgical authors.
  For succinct advice  and  directions  regarding  this proced-
ure (tracheotomy),  attention is  likewise called  to chapter
XXIII, which has been kindly furnished for this volume by an
able, skillful, and experienced operator,  R. A.  Vance, A. M.,
M. D., late  Professor  of Operative Surgery  and Clinical
Surgery in  the  Medical Department  of the  University  of
Wooster. 
TRACHEOTOMY.
151
                    CHAPTER XXIII.

                     TRACHEOTOMY.
                 BY R. A. VANCE, A. M., M. D.

   Systematic writers describe three operations for the relief of
obstructive disease of the air-passages — laryngotomy, laryn-
go-tracheotomy and tracheotomy.  In laryngotomy the open-
ing is made through the crico-thyroid membrane.  Laryngo-
tracheotomy involves  an incision  into  the  crico-thyroid
membrane  primarily,  followed by  section  of the cricoid
cartilage and adjacent rings of  the trachea.  In tracheotomy
the surgeon opens the trachea  by a vertical incision in  the
middle line of the neck.  There is no department of surgery
in which more erroneous notions prevail than in that which
pertains  to operations upon  the  windpipe.   These  errors
relate not only to the supposed facility with which the  air-
passages can be  opened,  but extend even to the  regions in
which the operation should be performed.  Thus, laryngotomy
and  laryngo-tracheotomy  have been extolled as measures
adapted for the relief of  suffocative angina, whether catar-
rhal, croupous or diphtheritic'  Anyone versed in  anatomy
knows that laryngotomy and  laryngo-tracheotomy can be
readily performed in the adult.   The  experienced surgeon
shrinks from their execution under any circumstances owing
to the dangers that attend and follow  them.   Any interfer-
ence with the  structures of the larynx may develop distress-
ing spasm of the glottis, or  initiate fatal inflammation: in
patients fortunate enough to escape the immediate dangers
of these  procedures,  necrosis  of  the  laryngeal  cartilages
frequently ensues, while permanent impairment of the voice
is an almost  inevitable consequence in those who recover.
The readiness, with which  laryngotomy and laryngo-tracheot-
omy can be  performed upon the adult has  originated an idea 
152
TRACHEOTOMY.
that these measures can be effected with equal facility upon
the child.  That they can be performed, even upon an infant.
no one denies — that they can be easily executed in a child,
no one who has attempted either procedure, even upon the
cadaver, will maintain.  The small siz? and rigid walls of the
air-passasre at the points where it must be opened, as well as
the  difficulties attendant  upon the  performance of  these
operations and the dangers  associated  with them, should
prevent laryngotomy. or laryngo-tracheotoiny being resorted
to for the relief of  suffocative angina.
   Tracheotomy is the operation  that, as a rule,  should be
resorted to in such  cases.   But even  this procedure  has not
escaped misrepresentation.  Some years since a distinguished
physician, the Professor of Practice  in the University  of
Louisville, spoke of tracheotomy as the most simple thing in
the world, which anyone might perform easily with a razor !
Well might Dr. S.  D. Gross  say. that,  had this gentleman
ever opened the trachea he would never have made  such an
erroneous statement: and add — - the amputation of a limb,
the extirpation of a glandular tumor, lithotomy and even the
perineal section  are  trifling  matters  in  comparison  with
tracheotomy in a short,  thick-necked and  restive child."  To
such statements a- the one  reprobated by  Dr.  Gross,  the
sacrifice of many lives and  the humiliation of many operators
are due.  The erroneous impiv-sion  that  tracheotomy  is not
difficult, that little anatomical knowledge, and no  surgical
experience is demanded for its performance, has led many an
inexperienced practitioner to attempt the opening of the
wind-pipe — attempts that but too frequently have cut short
the patient's life and injured the reputation of the physician.
   Various complicate!  appliances  have  at  different  times
been recommended as mechanical devices that would rid this
operation of danger and render its execution easv.  It is need-
less to spend time in  their enumeration, for. to the  inex-
perienced operator they would be  a snare: to the experienced 
TRACHEOTOMY.
153
surgeon  they would  be useless.  A  knowledge ot anatomy
and  a reasonable degree of surgical skill are all that are
demanded  for tracheotomy :  the experienced surgeon  can
open the trachea successfully with no other implements than
a sharp knife, and such other  aids as can be improvised  at a
moment's notice in any house.  Retractors, tenacula, artery
forceps,  scalpel, sharp  and  blunt-pointed  bistouries,  and
tracheotomy  tubes, comprise  an outfit  that supplies  the
surgeon with all the instruments he will be likely to  need in
the vast majority of cases.
   The use of anaesthetics in the operation is a question to be
decided by no hard and fast rule, but a problem to be solved
independently for each individual case.  The duration of the
disease, the condition of the respiration and  circulation, the
general state of the patient, and the wishes of the individual
to be operated  upon, are all elements to be taken into  con-
sideration  in arriving  at  a  decision.   It  can  be stated
emphatically, however, that  the pain of the operation  is
slight, and that by  employing  local anaesthesia, or simply
benumbing  the  skin  over  the trachea  with  ice,  even  this
suffering can  be materially reduced.  The objections  to ether
or chloroform in suffocative angina are very great.
   In order to  open the wind-pipe  satisfactorily, the light
must be good, and the patient properly placed with reference
to it, in the supine posture, and should  have his  shoulders
supported by one pillow, his head  by another, and his neck
made prominent by a hard roll of cloth between the two.  In
adults it is occasionally desirable to  operate with the patient
in a sitting position—the patient should then support his
head on the  back of the chair.  The assistant who is  sub-
sequently to have charge of the sponges now uses the ether
spray, or ice, and  benumbs  the integument  over  the point
where the trachea is  to be opened.   This done, the surgeon,
who stands behind  the  patient, if sitting, or at his right side,
if in the recumbent  position, steadies the integument with 
154
TRACHEOTOMY.
the fingers of the  left hand, and makes an incision through
the skin an inch and a half, or two inches long, the center of
the cut resting over the third tracheal ring.   This  incision is
carried down until  the fibrous bands uniting  the muscles on
either side of the mesial line are exposed.  Any blood-vessels
exposed  in  the  procedure are either drawn  to one side, or
ligated at two points and cut between.   A few strokes of the
knife loosen the central attachments of the  muscles,  and
permit them  to  be drawn aside.   The handle of the  scalpel
may now clear the  anterior surface of the trachea of all over-
lying structures save the layer of firm fascia in immediate
contact with  it.   If the thymus gland projects  upward, it
can  be drawn down; if the thyroid isthmus projects  down-
ward,  it can be  drawn up ; vessels can be pulled  to  one
side — in a word any structure the surgeon d<*>es not wish to
cut can be loosened and removed out of the way.   The fascia
covering the trachea should now be incised, the latter  is thus
exposed, and if  the subsequent  incisions have all been made
the  length  of the original opening in the  skin, and  the
hemorrhage  has ceased, the surgeon  is ready to open the
wind-pipe.   In order to  do this, the trachea is steadied with
a tenaculum, and one ring cut through with a  sharp-pointed
curved bistoury ; a blunt-pointed bistoury is  passed through
the  opening, and the incision enlarged  to a degree sufficient
to admit the tracheotomy tube — if no tube be at hand an
elliptical piece is cut from the anterior portion of  the trachea
and pains  taken  to  keep the edges of the  wound  widely
separated by some kind of improvised retractors as wire-
bent to suitable  shape.  If a tube is to be inserted, so soon as
the  opening  in the trachea has been enlarged to  a sufficient
extent, the surgeon passes his finger  into the trachea,  and at
once follows it with the tracheotomy tube, the finger sen-ins:
as a guide to pilot the tube into the air-passage.  Should the
patient be able to  breathe through  the tube,  all that remains
to be done  in ordinary cases is to fasten the  flanges of the 
TRACHEOTOMY.
155
outer tube around the neck by means  of tapes, and give
directions for the after treatment.
  The incision into the trachea should be of such a size as
to fit snugly the tube when the latter is in  place.   Inasmuch
as the opening in the skin is much longer than that in the
wind-pipe, it may  be necessary to draw  the  edges of the
latter together with  sutures after the tube is introduced.
Yet I have not  always found  this good  practice :   on the
contrary, if the parts between the trachea  and  flange of the
canula be filled with absorbent cotton, it will serve  a three-
fold purpose — hemorrhage will  be guarded  against;  the
wound will be protected from the irritating influence of the
tracheal discharge ; and  the opening into  the wind-pipe will
be the sooner consolidated to such an extent as to permit the
removal of the tracheotomy tube.   It  generally takes three
days for  the wound to assume such a state that it  remains
patent when the tube  is withdrawn.  During  this time the
outer tube should not be disturbed ; if accidentally displaced,
the  surgeon himself should  return it.   The inner tube can
be removed for cleansing at any time it may seem necessary,
and this  duty  can  be  performed by  the  nurse.   When the
trachea is opened  the  patient  generally struggles for air —
the insertion of the tube and change of the patient's position
afford relief.  In a short time tracheal mucus of an adhesive
stringy character begins to be voided.  After a while it may
accumulate to such a degree  that even frequent removals of
the  inner  tube  no  longer suffice to keep the passage-way
clear : in these cases, in addition to washing the inner tube
in hot water every  fifteen  minutes or so, the nurse will have
to use feathers to extract  the mucus that accumulates below
the canula.  In all cases where tracheotomy has been per-
formed, surgical aid should be close at hand for the  first two
days after the  operation.   Immediately  after the  tube  is
introduced and it is  seen  that the patient breathes well,
blankets may be hung about the bed in  such manner as to 
156                PLASTIC BRONCHITIS.

isolate the  patient and permit his being subjected  to the
action of steam without filling the whole room with aqueous
vapor.  The tube may have to  be taken away  before the
wound has  had time to consolidate ;   under such  circum-
stances retractors  must be  used to keep the edges asunder
until  the opening is rendered patent  by plastic  material.
For  the  first few days the patient's diet should consist of
fluids : there is no objection, however,  to the administration
of such  drugs as  the physician may deem necessary for the
proper medicinal treatment of the case.
                    CHAPTER XXIT.

                  PLASTIC BRONCHITIS.

   Plastic Bronchitis, denominated also  fibrinous  bronchitis.
 croupous bronchitis. &c. is a distinct disease which is believed
 to  have its seat primarily in the bronchi of the third and
 fourth order.   Its remarkable and diagnostic feature is the
 formation, or. rather, exudation, upon the interior of the air
 passages, below the  trachea, of  a membrane  in character
 identical with that  described in pseudo - membranous laryn-
 gitis as located upon the walls of the larynx;  and  in  diph-
 theria, in the pharynx and elsewhere.  These diseases, although
 very diverse in their other characteristics, exhibit by this sim-
 ilarity, a relationship which is at least very suggestive in re-
 gard to their classification and therapeutic management.  On
 account of the identity of the membranes. Sir John Rose Cor-
 mack •• suggested that plastic bronchitis may be a variety of
 diphtheria "; and numerous writers of great distinction. Mack-
enzie with others, for the same reason, teach that croup is truly
and only laryngeal diphtheria ; while Niemever has  called it
bronchial croup.  Such doctrines indicate the recognized rela-
tionship, based on the plastic phenomenon, common to each of 
                    PLASTIC BRONCHITIS.                157

 these diseases ;  which, however, is quite insufficient, as shown
 in the previous  pages of this work, to establish their identity;
 their distinctive features are too numerous, uniform, and em-
 phatic to be reconcilable with such an  idea.  In systems of
 nosology,  however, classes are  formed upon  analogies  less
 apparent, and no good reason exists why these three  distinct
 diseases, thus related, should not  be grouped as a separate
 class, to be denominated Membranous diseases.
   The class thus formed, though small, is  second to none in
 importance, and this last of the series, although much  less
 common, is hardly less grave than its predecessors.
   It is observed both as an acute and chronic affection ; most
 frequently  in young adults, although  no period of life is
 known to be entirely exempt.
   Niemeyer mentions the case of a girl fifteen years old who
 had almost daily,  for years, coughed up almost a complete
 cast of the left bronchial tree.
   Causes.   Of the  causes of plastic  bronchitis we know as
 little or less than is known of those of laryngeal croup.   The
 type of the inflammation is thought to be  similar in the two
 as their products are identical, and also from the tendency of
 both to extend  downward from their original sites, and the
 general absence of symptoms,  except such as depend  upon
 the local disease.
  The more rapid progress of croup is thought to depend upon
 its location at the  fountain head of  the respiratory current,
 and upon the  exquisite sensibility of the larynx, which  can-
 not be made tolerant of the foreign body (the membrane) as
 are the lower  air passages.
  Inhalation  of cold air,  and  bodily  exposure we know
 aggravate the symptoms of this disease, but their influence
 in its causation can  only be inferred.  It is proper here to
remark that the  disease is neither contagious nor epidemic;
and so rare as  to  afford little opportunity to investigate its
nature or causes. 
158
PLASTIC BRONCHITIS.
   An idiosyncracy, or peculiar state of the blood, as causative
agencies are suggested by the membranous  deposits and its
analogies to croup noted above.
   Anatomical appearances.  i: In primary independent croup-
ous bronchitis (i. e. plastic bronchitis) the same  condition of
the bronchial mucous membrane is found, and with the same
coagulated exudation upon it. which we have  described as
existing upon the mucous membrane of the larynx in laryngeal
croup.   In the larger bronchi the caliber of the  canal is not
usually completely  occluded; and  the coagula  are  tubu-
lar ;  but in the smaller bronchi they form cylindrical plugs.
Croupous bronchitis is seldom spread over the  whole lung.;
generally it is partial, and confined to a  small number of
bronchi; but to this rule there are exceptions."  (Niemever.)
   The larynx and trachea, it is beheved, are never involved
as in croup and diphtheria.
   Symptoms and  diagnosis.—These,  as before stated, depend
largely upon the local disease ; the constitutional perturbation
whatever it may be, is  not declared by known phenomena
except the exudation, the existence of which is only deterniin-
able  by portions expectorated.  If suspicious  coagula  appear
in the  sputa, they should be  carefully rinsed in water  and
soaked in dilute  acetic acid ; if only condensed mucus  they
will sin-ink and be rendered firmer, and  the case is ordinary
bronchitis ; if fibroid, they will swell and soften  and indicate
the plastic type.
   Symptoms of acute inflammation, fever and pain, are gen-
erally slight or entirely absent.   When,  however, these exist
continuously, with extreme dyspnoea, they indicate an exten-
sive, acute, and very dangerous form of the disease that may
terminate in fatal asphyxia.
   More or less febrile action, however, is excited, even in
chronic cases, by the violent and prolonged cough and labored
breathing attendant upon the separation of masses  of the
exudation; which, with the cough, quickly subsides when the 
PLASTIC  BRONCHITIS.
159
mass is expectorated.  Bloody sputa, more  or less abundant,
often precedes and generally follows, for a few days, these
occasions ; during which  the cough and dyspnoea increase to
fearful yriolence, and the patient appears in the greatest danger
of suffocation.
  When the affection is acute, the casts are quickly renewed,
and the course of the disease is limited to a few weeks at most,
and is said to prove fatal in about fifty per cent, of the entire
number of cases.
  In the chronic form the casts are also often reproduced and
the affection may continue for years with but little danger to
life.
  The membranous casts when expectorated, may be in convo-
luted masses or in the form of branching tubes with clean cut
edges, or as solid branching rods if formed  in the bronchi  of
finer caliber.   When  expectorated  in masses, if placed in
water and unfolded, they exhibit most interesting models of
portions of the bronchial tree ; the trunk being sometimes
from a tube of the third or fourth degree, with branches
diminishing  in size with the successive divisions, to mere
capillaries.
  The patients generally suffer from dyspnoea in proportion
to the extent of the obstruction.  The respirations are quick-
ened from the same cause and in the same ratio.   Cyanosis
is apparent at times, due  to the imperfect aeration.
  The cough, except about the periods of expulsion of mem-
branes, is dry and harassing.
  Auscultation and percussion furnish almost  no aid in the
diagnosis of fibroid bronchitis and are of as little service in
its treatment.  So long as the bronchial  obstruction is com-
plete the respiratory murmur is destroyed over the pulmonary
area deprived of respiration ; and enfeebled if the obstruction
be only partial.
  Partial bronchial obstruction, according to its  degree, also
occasions correspondingly varying sibilant sounds.  A coarse 
160
PLASTIC BRONCHITIS.
flapping rale is observed sometimes, and attributed to partially
detached membranes fluttered by the respirator}- currents.
  The resonance on percussion and the vocal fremitus are
not noticeably changed, except from collapse of the lung sub-
stance ; or from solidification from localized pneumonia, which
sometimes happens, and in either case  more or less dullness
is occasioned.   In diagnosis none of these sounds are at all
distinctive  until after  their significance has been shown by
the expectoration of fibrinous clots or casts.
  The respiratory movements  of  the  chest are  perceptibly
diminished if the obstruction cuts off a  due supply of air from
any considerable portion of the lungs.   This is only percept-
ible upon one side, when the disease, as is common, is limited
to one lung.
  The most frequent complications of  plastic  bronchitis  are
phthisis  and pneumonia,  which reveal themselves  by  the
superaddition of their appropriate well known symptoms.
  Treatment.  The recognized analogy of fibrinous bronchitis
to croup, has led, as might be expected, to  a  corresponding
similarity of medical treatment.   '• The treatment  is to be
conducted upon the principles laid  down for the management
of laryngeal croup."  (Niemever.)  To effect the speedy sepa-
ration and expectoration of the casts, the inhalation of warm
steam is regarded as of undoubted utility, as are also  vapors
or sprays containing chloral hydrate (f£. 9, 10,11), lactic acid
(K .10). or lime (rj .IS).  The vapor of lime and chloral (fy .17),
is recommended.
  Emetics are also used when the obstruction has become con-
siderable, to promote the  dislodgment  and expulsion of the
casts.  Those advised  for croup are especially  appropriate,
(See  croup.)
  "Rugel and other German authors recommend especially
the muriate of apomorphia as an especially appropriate emetic
in consequence  of the  promptness  of its operation with  but
little  nausea, and the absence of unpleasant after  effects." 
PLASTIC  BRONCHITIS.
161
 (Flint, see also Ziemsen's Cyclopedia, vol. 4, p. 467.)   In this
 country it is rarely employed, and, on account of the danger-
 ous depression  sometimes following its exhibition and  the
 difficulty of preserving it, it is not to be recommended.  The
 mechanical emetics, i. e. the sulphates of copper and zinc, yellow
 sulphate of mercury, alum and mustard are equally prompt
 and more safe, and therefore preferable.
   " Aside from the treatment having immediate  reference to
 the removal of the casts, measures for the relief of the bron-
 chitis are indicated.  For this object the iodide  of potassium
 has been found  especially useful."  (Flint.)  "I have never
 observed  any benefit resulting from its action in this disorder."
 (Niemeyer.)   " This remedy is said  to  have been  employed
 with success." (Prof. A. T. H. Waters, Liverpool.)
   I have  used iodide of potash faithfully in a chronic case of
 this anomalous affection, without being able to discover any
 beneficial effect.  The same case, when later put upon arsenic,
 iron  and  cod-liver oil, convalesced and complete  recovery
 resulted, though  not speedily.
   Admitting the importance of those measures of treatment
 to effect the separation  and expulsion  of the  casts, and aU
 such also as are employed " for the relief of the  bronchitis,"
 and these embrace all measures of acknowledged efficacy in
 other forms of bronchitis, it  is observed that writers on this
 affection are quite as conspicuous by the omission of all ref-
 erence to  a possible primary  constitutional implication, as by
 the constant suggestion, if not positive affirmation  that  the
 disease is of local origin; a  partial  or  limited, specific form
 of bronchial inflammation.
  The question, Is the disease a specific form of inflammation,,
or, the result of constitutional causes ? although apparently
overlooked, cannot be ignored by the  thoughtful clinician.
This much can be  positively affirmed :—the ordhiary  causes
of bronchial inflammation do not induce fibroid exudation 'r
else this phenomenon would  be as common as other  types of
     ll 
162                PLASTIC  BRONCHITIS.
bronchitis.  If the affection be then a specific form  of local
bronchitis, not from ordinary causes, yet as it probably does
not exist without cause, that cause must be special; and from
its infrequency, is most likely personal and systemic.   Such
exceptional manifestations are no  doubt connected with, or
caused by. a constitutional vice, or, what amounts to the same
thing, a disordered state of the blood.  This view is further
confirmed by the  almost uniformly pale and cachectic appear-
ance of the patients (at times cyanotic from imperfect breath-
ing): and, its acceptance by writers may also  be argued from
the use of such constitutional remedies  as iodide of potash.
arsenic, iron and cod-liver oil.
  None of the remedies employed for the cure of this disease
are known to possess aplastic properties,  or efficacy in antago
nizing in the  blood, the tendency to part with its fibrine, so
clearly exhibited  in this and the other membranous  diseases.
Certainly  one of the clear indications of treatment, is to cor-
rect the  constitutional affection by such remedies as  "are
known to possess the  power to limit or prevent an exuda-
tion."
  At the head of this  class of remedies we place chloral hyd-
rate, either alone  or conjoined with bromide of ammonium or
chlorate of potassium,  substantially as shown in ]J. 22, 23.
These remedies are advised, in  plastic bronchitis, mostly on
theoretical grounds; no sufficient opportunities having occur-
red to the writer, since the introduction of the chloral  treat-
ment, to fully test their efficacy in typical cases of this disease.
as has been done in diphtheria and croup.  In chronic  forms
of disease, there is manifestly no occasion  to push these rem-
edies as advised in acute forms, in which the progress is rapid
and the perils immediate.
  Ample nutrition is a part of the treatment of every case
of plastic bronchitis, not to be overlooked, nor considered of
secondary importance. 
FORMULA.
  The formulae here  given  may be variously  altered to adapt
them to various ages,  degrees of violence, and stages  of disease,
and  to the tastes, susceptibilities and tolerance of patients, and the
judgment of the practitioner.   It is believed,  however,  that  in
the main  they  will, as written, meet the indications for their use.
  They are not all original, but have been gleaned  from various
authentic sources, and are  not  presumed to represent  all the
remedies needed in the treatment of the membranous diseases.
       Local Remedies.
              l.
IJ . Pot.Permanganat. gr. x a xx.
   Aqua:             3 i.   M.
  Useful in gangrene, &c.
  Apply  to  fauces  with large
camel's hair brush.
  For atomizer reduce \.
\\ . Chloral Hyd.    3 ss a 3 iss.
    Sir. Cort.Aurant. 3 ss.
    Aquae           3 i.    M.

   Or,
              3.
]$. Sol.Ch.lor. Hyd.(-tr.40to = i) - ss.
   Tr.  Iodin. C.           3m.
   Glycerin.               3 ss.
   A 1. Menth. Pip.     ad - ij.
                         m.'
  For use as No. 1  in fauces,
for  effect  upon false membrane
and disinfection.
 \j.. Chlor. Hyd.        3 i.
    Tr. Iodin. C.       3 i.
    Glycerin.
    Aquae          aa | ss. M.

  Or,
              5.
 I£ . Chloral Hyd.       3 i.
    Tr. Iodin. C.
    Glycerin.
    Tr. Gaulth.
    Aqua?          aa 3 ss. M.
  For external use in glandular
and other swellings.—Apply  4
times a day, and keep the parts
well covered  with  dry,  soft
flannel.
163 
164
FORMULA.
              6.
IJ . Chloral Hyd.    gr.xaxxx.
   Spt. Gaulth.    3 i.     M.

  Or,
              7.
IJ. Chloral Hyd.    gr. x a xxx.
   Sol. Sod. Borac.(gr.ia 3 i)
   Aq. Menth. Pip.     aa 3 ij.
                        M.
  For injecting into nasal  pas-
sages to cleanse and disinfect.

  Or,
              8.
IJ. Acid.Carbol.      gtt. xxiv.
   Glycerin.         3 ij.
   Aquae            3 vi.  M.

       For Atomizing.

              9.
IJ. Pot. Permang.     gr. v.
   Aquae            3 i.   M.
  To be used  in  atomizer  for
disinfecting. Instead of the Pot.
Permang. in 9, use. if preferred,
5 grains  each of Chloral Hyd.
and Pot. Chlor.
Or,
             10.
IJ. Chlor. Hyd.
   Spt. Gaulth.
   Aq. Pur.
   Aq. Calc.
   gr.x.
   3 i.

aa - iss. M.
  Or,
IJ. Chlor, Hyd.        gr.x.
   Acid. Carbol.       gr. xv.
   Aq. Calc.
   Aq. Gaulth.     aa 3 iii. M
11.
IJ. Ammon. Brom.
   Potas. Brom.   aa gr. v a x
   Aquae             3 iss. M.

  The last three useful in laryn-
geal diphtheria and croup, every
1, 2, 3 or 4 hours  for  15  min-
utes.

              12.

IJ. Acid. SalicyL
   Sod. Borac.      aa gr. v.
   Aquae              § i. M.
Or,
13.
IJ. Acid. Salicyl.
   Glycerin.
   Aq. Calc.

  Or,
14.
Or,
16.
3 ss.

l'vx.M.
R.. Acid. Carbol.     gtt. xxii.
   Glycerin.          " ij.
   Aquae             r vi.  M.

  Or,
             15.
IJ . Acid. Carbol.     gtt. xxii.
   Pot. Chlorat.      3 iii.
   Glycerin.          r iii.
   Aquae             - v.  M
gr.xx.
 = i.   M.
IJ. Acid. Lactic.
   Aquae
  Recommended  also in laryn-
geal  diphtheria and croup. 
FORMULAE.
165
  The following are appropriate
quantities of the medicines named
for each ounce of water for spray
inhalations.
  Many other  medicines  and
various combinations  are   also
employed in this manner, as the
judgment of the practitioner or
accredited  authorities  may  in-
dicate.
  If a hand ball atomizer, which,
when well constructed, answers
every purpose, is  employed, let
the fluid be warmed  to  100° F.
or upwards.
Acid. Tannic.        gr. iii a v
  "   Lactic.        gr. xx.
  "    Carbol.        gr. iii.
Ammonium Brom.   gr. v a x.
Aq. Calc. (undiluted)
Chloral Hyd.        gr. v.
Fer. Perchlor.        gr. iii.
 "   Sulph.          gr. iii.
Potas. Permanganas. gr. v.
  "   Chloras.      gr. xx.
  "   Bromidum    gr. xv.

      Vapor Inhalations.

              17.
IJ. Fresh Lime             lb i-
    Water  containing Chlo-
       ral Hyd. 3i       0. i.
  Or,
              18.
IJ. Fresh Lime           lb i-
    Water                 0. i.
  Put the lime in lumps into a
coffee-pot,  open mouthed bottle
or fruit jar, pour upon it the
fluid (to the spout of the coffee-
pot or similarly constructed ves-
sel may be attached a piece  of
rubber  tubing  of  convenient
length when desired), and when
tlie vapor begins to rise direct
it  into the patient's face so it
must be  freely  inspired;   use
every hour  in laryngeal" cases
and croup.  Of inestimable value.

      General Remedies,

              19.
IJ, Pot. Chlorat.       3 ij.
   Amnion. Mur.      3 i.
   Glycerin.           3 ij.
   Aquae              3 vi. M.
   Given in cases of croup, &c,
in one  or  two  drachm doses
every hour,  according to age.

              20.
fj. Quin. Sulphat.      3 ss.
   Elix. Tarax. C.     3 ij. M.
   Dose,  teaspoonful every two
hours  for  a child of 5 years,
and alternated with

              21.
IJ. Tr. Fer. Chlor.      3 ij.
   Pot. Chlorat.       3 ij.
   Sir. Simp.          3 iv. M.
   Dose, same as 20.

   Prof. Smith declares  this in
his hands "the most satisfactory
treatment" in diphtheria.
              22.
IJ. Chloral Hyd.
    Pot,  Chlorat.   aa gr. xcvi.
   Spt, Gaulth.   vel.
   Spt. Month. Pip.    3 i.
   Aquae
   Sir. Simp.       aa 3 ij. M, 
1G6
FORMULAE.
  Of great value in diphtheria.
Dose for an adult two tea>]>oon-
fuls every hour when awake.
  No drink  to follow  the ad-
ministration for * or 10 minutes.
The  degree  of somnolence  is
somewhat a measure of the effect
of chloral,  and should influence
accordingly.
  The  pungency  of this  and
the following Chloral mixtures
should, by varying their strength,
be adapted to the different fau-
cial sensibility of patients, which
can be judged by the complaint,
if any,   of pain  following the
administration.

              23.
IJ. Chloral Hyd.
   Pot. Chlorat.    aa gr. xlviii.
   Spt. Gaulth. vel.
   Spt. Menth. Pip.   3 i.
   Sir.  Simp.
   Aquae           aa 3 ij. M.
  Give   a  teaspoonful  or  tea-
spoonful and  a half every  hour
when awake to a child from 5 to
10 years of age.
See also remarks under  IJ. 22.

              24.
^. Chloral Hyd.
   Ammon. Brom. aagr. lxxx.
   Spts. Chloroform. 3 i a ij.
   Sir.  Simp.
   Aquae          aa 3 ij.   M. 1
  Give  to adults  two teaspoon-
fuls every hour, and to children
above 10 yrs. one, in laryngeal
diphtheria and croup.
  For younger children use the
following:
              25.
U. Chloral Hyd.
    Ammon. Brom.  aa gr. 1.
    Spts. Chloroform.   3 i a ij.
    Sir. Simp.
    A^uae           aar'x]. M.
  Give a teaspoonful every hour
when awake.
  These  are cases of the gravest
danger, and demand the utmost
vigilance in the use of both local
and general treatment.

              26.
IJ • Sod. Sulphocarb.   3 ij.
    Sir. Simp.
    Aquae           aa^i.  AT.
  For a  child of five years, tea-
spoonful every 3 hours.

              27.
IJ . Pilocarpin.        gr. -J a f.
    Pepsin.            gr. i a i^.
    Acid. Hydrochlor.  gtt. ij.
    Aquae             = ijss.
                           M.
  Give a teaspoonful  hourly to
children.

              28.
IJ . Pilocarpin.          gr. iss.
    Pepsin.            gr. xxx.
    Acid. Hydrochlor.   gtt. viii.
    Aquae              = ijss.
                            M.
  Give a teaspoonful  hourly to
adults. 
INDEX.
 Abscesses of lymphatic glands in diphtheria,  59.
 Aitkin, 85.
 Alcohol, use of, in diphtheria, 80, 109, 121.
 Albuminuria in diphtheria, 7, 32, 34, 35.
 Aluminum, sulphate of, in croup, 140.
 Ammonium bromide in croup, 145.
             chloride in croup, 144.
 Antimonials in diphtheritic laryngitis, 140.
 Antiquity of diphtheria, 9.
 Antiseptics in  diphtheria, 53.
 Atmosphere, influence of, 37.
 Atomizer, use  of,  in laryngeal diphtheria, 124.

 Bacteria, 21, 72.
          germs, 27.
          in diphtheria, 29.
          in non-diphtheritic  states, 29, 30, 72.
 Bacterian theory untenable, 25, 26, 37.
 Ballard, 41.
 Balsam of Copaiba in diphtheria, 107.
 Bard, 14.
 Baths in diphtheria, 81.
 Blood, the, in diphtheria, 75, 76.
 Blood-poisoning in diphtheria, 30, 32,  35, 58, 60.
                symptoms of, 68.
                secondary, 58.
 Brain, the, in diphtheria, 75.
 Bretonneau,  18, 39.
 Bristowe, 84.
 Bromides in  diphtheria,  106.
 Bromine in diphtheria, 106.
Bronchitis, plastic, or fibrinous, 129.
                               (167) 
168
IXDEX.
Catarrh a predisposing cause of diphtheria, 42, 55.
Cathartics, use of, in croup, 141.
                  in diphtheria, 94.
Causes of death in croup, 138.
                in diphtheria, 08.
Causes of croup. 129.
        of diphtheria. 20.
        predisposing, of diphtheria, 39.
Caustics, use of, 87,  58.
Chapman, 109.
-Chloral in croup, 145 et seq.
        in diphtheria, 87 et seq., Ill et seq.
        exists in the blood as chloral, 115.
        not depressant, 117.
        prevents coagulation of the blood, 113.
        used in all cases, 119.
Chlorate of potassium in the treatment of croup, 144.
                                      of diphtheria, 104 et seq.
■Climatic and atmospheric influences, 37.
Coagulation of the blood prevented by chloral,  113.
Constitutional nature of diphtheria, 7,  30.
              treatment of diphtheria, 92.
Contagium of diphtheria, 26.
Convalescence, 59.
Copaiba in diphtheria, 107.
Copper, sulphate of, in croup, 140.
Creasote, use of, 85.
•Croup,  129.
        and diphtheria,  symptoms compared, 123.
        and laryngeal diphtheria, identity or non-identity of,  129.
       aetiologv of, 120.
        aphonia in, 136.
       asphyxia in,  136.
        causes of death in,  138.
       cough in, 131, 136.
       -examination  of sputa in, 133.
       exudate in, 134, 138, 139.
       membrane in, 130.
       nature of, 131.
       nomenclature of, 130. 
INDEX.
169
Croup, pathology of, 138.
       respiratory sounds in, 131.
       symptoms and diagnosis, 131 et seq.
       treatment of, 139.
       use of chloral in, 145 et seq.
       use of laryngoscope in, 133.
       voice in, 136, 137.
Croupous diphtheria, 51.
Cubebs in diphtheria, 107.

Deglutition, difficulty of,  caused by  paralysis, 62.
Diagnosis between diphtheria and membranous laryngitis, 65.
                             and quinsy,  66.
                             and scarlatina, 65.
                             and thrush, 65.
Diagnosis of diphtheria, 64.
Diphtheria a constitutional disease,  7, 30.
           age when it occurs,  39.
           albuminuria in, 49.
           causes, 20.
                  predisposing, 39.
           constitutional nature of,  7, 30.
                         predisposition to, 40.
                         treatment of, 92.
           definition of, 7.
           diagnosis of, 64.
           feeding in, 78.
           gangrene in, 54, 70.
           hemorrhages in, 54.
           history of, 8.
           incubation of, 42.
           laryngeal, 51.
           malignant, 46.
           mortality in, 67, 115.
           nasal, 52, 121.
           of Eustachian tubes, 52.
           of lachrymal duct, 52.
           of rectum, 53.
           of vagina, 53.
           of wounds,  7, 53. 
170                          INDEX.

Diphtheria, predisposing causes of, 39  et seq.
           prognosis in, 69.
           prophylaxis and prophylactics in, 44
           sequelae of, 60, 63.
           sewers and, 41.
           sex in, 40.
           skiu eruption in,  55.
           symptoms of, 45 et seq.
           synonyms of, 8, 11.
           temperature in, 56.
           treatment of, 77 et seq.
           unfavorable symptoms in,  69.
           uraemia in, 68.
Diphtheritic croup, 51.
            exudate, 50.
            laryngitis and membranous croup, 15, 66, 123L
            membrane,  50, 70.
                        mode  of production of, 71.
            membranes, separation of, 57.
            paralysis, 60,  126.
                      causes of, 63.
                      electrical applications in, 127.
                      frequency of, 63.
                      statistics of, 61.
                      treatment of, 126.
Duration of incubation of diphtheria, 42.

Eberth, 24, 72.
Emetics in croup, 140.
        in diphtheria, 95.
Epistaxis in diphtheria, 123.
Eustachian tubes, diphtheria of, 52.

Feeding in diphtheria, 78.
Fibrinous or plastic bronchitis, 129,130, 156.
          exudations, 130.
Fomentations, use of, 91.
Formulas. 163.

Gangrene in diphtheria, 54, 
INDEX.
171
 General treatment of diphtheria, 77.
 Glands,  swelling of the, in diphtheria, 36, 74.
 Guttmann, Dr.,  108.

 Heart affections in diphtheria, 74.
 Hemorrhage in diphtheria, 54.
 History  of diphtheria, 8.
 Hydrargyrum in the treatment of diphtheria, 106.
 Hydrochloric acid, use of, 85.

 Ice in diphtheria, 90, 91.
 Incubation of diphtheria, duration of, 42.
 Infection of diphtheria, manner of, 40. 41.
 Inhalations of steam in croup, 147.
 Inoculability of diphtheria, 40.
 Ipecac in diphtheritic laryngitis, 140.
 Iron in the treatment of diphtheria, 96 et seq., 116.

 Kidneys, symptoms connected with, 32, 76.

 Labadie  Lagrave, 56.
 Lachrymal duct,  diphtheria of,  52.
 Lactic acid, use of, in diphtheria, 125,
 Laryngeal diphtheria, 123.
                     treatment of, 124.
 Laryngoscopic examination in  croup, 133.
 Laryngotomy, 151.
 Laryngo-tracheotomy, 151.
 Lime water in diphtheria, 86, 122, 125.
 Local treatment in diphtheria,  84.
 Lung affections in diphtheria, 74.

 Mackenzie, 32, 36, 37.
 Measles and scarlatina predisposing causes, 42.
Medical prophylaxis,  127.
Membrane, diphtheritic, 35.
           in croup, 134, 138, 139.
           seat of, in diphtheria, 35. 
172                         INDEX.
  Membrane, decay of, 53.
  Membranous croup, 129.
                     diagnosis of, 131~et seq.
                     treatment of, 139.
  Membranous deposits in larynx, 134, 138, 139.
  Mercury in treatment of croup, 141 et seq.
                      of diphtheria, 106.
  Micrococci, 22 et seq., 29.
  Microzymes, 28.
  Mode of propagation in  diphtheria, 39.
  Moist air in croup, 147,
  Mortality in diphtheria,  67,  77,
  Muguet and diphtheria, 65.

  Nasal diphtheria, 52, 121
                  epistaxis in,  123.
                  treatment of, 122.
 Nitrate of silver in the treatment of diphtheria, 86.
 Nomenclature,  2.
 Nourishment in diphtheria, 73.

 Oertel, 23, 86.

 Paralysis diphtheritic, 126.
                      affecting vision, 61.
                      frequency of, 63.
           of extremities, 62.
           of heart, 62.
           of muscles of neck, 62.
           of muscles of trunk, 62.
           of pharynx, 61.
           of sphincters. 62.
Pilocarpin, use of. in diphtheria, 107.
Potassium  chlorate, in diphtheria, 104 et seq.
           sulphide, use  of, 106.
Plastic bronchitis, 156.
Poultices, use of, 80, 91.
Prognosis in  diphtheria, 66.
Prophylaxis, medical, 127. 
INDEX.
 Propagation, mode of, in diphtheria, 39.
 Pyaemia, 53.

 Quinia in croup, 145.
        in diphtheria, 96, 100.

 Rectum, diphtheria of, 53.
 Rokitansky, 89.

 Salicylic acid in diphtheria, 106.
 Secondary blood-poisoning, 58.
 Senega in diphtheria,  108.
 Septicaemia, 73.
 Sex in diphtheria, 40.
 Silver nitrate in diphtheria, 86.
 Sinapisms, 80.
 Skin eruption in diphtheria, 55.
 Spray inhalations in croup, 147.
 Sputa, examination of, in croup, 133.
 Sulphide of potassium, 106.
 Sulphites, use of, 106.
 Sulphur, 87.
 Symptoms of diphtheria, 36.
           unfavorable, in diphtheria,  68.
 S3Tnon3*ms of diphtheria, 8, 11.

 Thrombi in diphtheria, 68, 75.
 Tonsils,  ulceration of,  59.
 Tracheotomy, 148, 150.
              anaesthetics in, 153.
              in diphtheritic larjmgitis, 125.
              mode of operation, 153.
              statistics of, 149.
 Treatment of diphtheria by chloral,  111 et seq.
                        constitutional, 92.
                        general, 77.
                        local, 84.
                        therapeutic, 81.
Trousseau, 41, 60, 105.
Tympanum, perforation of,  52. 
174
INDEX.
Ulcers of tonsils and fauces, 59.
Urea increased in diphtheria, 33.
Urine,  casts in, 23.
       albuminous, 32.

Vaginal diphtheria,  53.
Vance, 151.

"Wounds, diphtheria of, 7, 53. 
 
 
ERRATA.
ige 2D.	line 2.		read,	scantiness.
• 54.	"	30.		comatose.
■ 74.	a	24.		coauubv.
• si.	u	2.">.		quotation ( " ) after violenc
■• Sl'i.		29.		irritating.
• 102.	'•	17.		pharynx.
■■ 116,	:<	15.		Kces.
:; 131,		35.		masked.
- 132.	u	31.		in the croupous.
• 164.	;(	•j.	insert	in Ij. 6. Aq. 1 ij.
 
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