READ BEFORE THE 
Detroit Medical and Library Association 
FEBRUARY 6, 1893. 
AN INQUIRY INTO THE CAUSES OF THE MORTAL- 
ITY OF DIPHTHERIA, AND SOME SUGGESTIONS 
WITH REFERENCE TO THE TREATMENT OF DIPH- 
THERIA. 
BT 
ALONZO BRYAN, M. D., 
Detroit, Michigan. READ BEFORE THE 
Detroit Medical and Library Association 
FEBRUARY 6, 1893. 
AN INQUIRY INTO THE CAUSES OF THE MORTAL- 
ITY OF DIPHTHERIA, AND SOME SUGGESTIONS 
WITH REFERENCE TO THE TREATMENT OF DIPH- 
THERIA.* 
BY 
ALONZO BRYAN, M. D., 
Detroit, Michigan. 
I speak witji candor. Therefore permit me to say that, according to my 
understanding and convictions, I believe that many noble-minded and sincere 
thinkers in our profession are unwittingly impeding the proper evolution of the 
treatment of diphtheria by certain grievous and most unfortunate errors, in 
which they repose a blind and implicit faith. They are doubtless honest, but 
also dreams are honest, and they are none the less fanciful for that. 
I believe that the frightful mortality of diphtheria is due almost altogether 
to its constitutional treatment as adopted by physicians at large. In the treat- 
ment of diphtheria there are deleterious medicinal agents in extensive use. In 
my opinion the two most destructive of these, and employed blindly as remedies, 
are alcoholic liquors and corrosive sublimate, given internally. I believe that 
both of these so-called remedies are in many instances deadly when given in 
cases of diphtheria. For these death-bearing agents a most strange fascination 
possesses the minds of a very large number of medical men at the present day. 
Hardly anything has been known like it since the palmiest days of venesection. 
If the infatuation progresses, more persons are liable to die under the baleful 
influence of this ghastly constitutional treatment than succumbed to the murder- 
ous management of wounds which preceded the advent of Park's methods in 
surgery. In this arraignment I am convinced that I use no extravagant terms. 
They are indeed not so strong in their expression as the bier and the coffin which 
appear before our eyes every day; and these latter are phenomena which should 
arrest the attention of every thoughtful man. According to the formal and 
systematic reports of authorities to-day, nearly one-third of all the persons 
affected by diphtheria die of the malady. And, according to the statements of 
medical journals and standard books, nearly all the cases of diphtheria are sub- 
mitted to the alcoholic treatment, and to this is often added the treatment by 
the ingestion of corrosive sublimate. 
Let us proceed to examine these deleterious agents lauded as remedies. Should 
* In this note it is a matter of extreme regret on my part to be compelled to say that 
during the preparation of this paper I ascertained that a peculiar circumstance had deprived 
me of the pleasure of obtaining a record of the ultimate and collected results of my treat- 
ment of diphtheria for many years past. For my record I had relied on the books of the 
Detroit health office. When I came to look into them I found there the name of another 
physician named Bryan, and whose initials are just the same as mine. Therefore, for the 
most part I was unable to distinguish the record of my own cases from that of his. However, 
from all sources, I have identified enough cases to show that the mortality in my own treat- 
ment of diphtheria is rather less than ten per cent. The general mortality of diphtheria in 
this city is a mean of about thirty per cent. 
A. B. 2 
I be permitted to advise, I would counsel a physician when he is confronted by 
a case of diphtheria, to not become excited as in the presence of a fire, but to 
view' the circumstances with equanimity; and above all, to take a deliberate and 
quiet survey of the nature of the remedies which his imagination proposes; and 
let him on such an occasion be not too much filled by a deferential reverence for 
the sanctity of authority; for it is often reverence in medicine that jeopardizes and 
destroys the life of the patient, and retards a progressive evolution in the art of 
healing. Some old man with the garb and mien and thought of a recluse, may 
have immagined that it is a good thing to fill a delicate system with corrosive 
sublimate, and then to wash the poison out again by means of internal ablutions 
of whisky. Some fanatic may have had a disordered dream and then adopted 
it into practice. I have always said, and I say now, beware of the ancients; and 
notwithstanding them, let the torch of your reason ever cast its beams in front 
of you. Therefore, let the alert and thoughtful physician, when brought into the 
presence of diphtheria (or of any other adynamic disease) look up a much neg- 
lected book, namely, "Taylor on Poisons" (newest edition). Let him read 
therein what that author says on the subjects of alcohol and of corrosive subli- 
mate as poisons. It is well to do this before having struck the first blow at the 
patient. The unfortunate one is already stricken by the disease, therefore let 
the medical attendant forbear until he shall have thought at least twice. 
I cannot here adduce all that Taylor has said on the subject of alcohol as a 
poison. Suffice it to abstract, and paraphrase, a few of his oonclusions. They 
are these: " Small quantities of alcohol frequently kill children; and larger quan- 
tities often destroy adults. In all the cases there is intense congestion of the brain 
and lungs. There is usually great damage to the mucous membrane of the stom- 
ach ; it may be found congested, inflamed, ulcerated. Either with or without death, 
there may be delirium, coma, paralysis. In acute alcoholic poisoning death 
may be the sequel of continuous symptoms, or there may be a remission closely 
followed by a renewal of the symptoms and by a fatal termination. After the 
acute poisoning, a prostrated and enfeebled condition of the general system 
may endure for days or for weeks when the dose has not been sufficient to kill, 
or if so, when death is long delayed. In numerous instances there is granular 
degeneration of the kidneys." [In the cases of chronic poisoning the list of 
symptoms is long and painful to contemplate, but their citation is not essential 
for the purposes of this paper.] " The alcohol that is eliminated escapes through 
all the emunctories. Every excretory gland exerts itself to rid the economy of 
the poison." Such knowledge on this subject, and much more, do we get from 
" Taylor on Poisons." 
Richardson (than whom there is no higher authority), in his " Ten Lectures 
on Alcohol" (delivered before the Society of Arts, London), says that alcohol 
increases the pulse-rate many thousands of times in the twenty-four hours. How 
exhausting then, must alcohol be in adynamic diseases ? It is this powerful- 
and in adynamia-deleterious, agent that has been brought forward in vaulting 
and dithyrambic style, as the sovereign balm for those who are in pain, in fear, 
and in danger of death, on account of diphtheria. Just think about it. Its 
advocates say just have the patients swallow some corrosive sublimate every two 
hours, and at the same time give them plenty of liquor to wash it out with. 
Now let us examine the subject of corrosive sublimate. Refer to " Taylor on 3 
Poisons," and turn to the article " Corrosive Sublimate," in that standard author- 
ity. In evidence it will be found there that all forms of mercury (even in few 
and minute doses, and cautiously given) wherever there is a granular state of the 
kidneys, with albuminuria, are especially dangerous and destructive. In such 
cases there are ulceration and gangrene of the throat, destruction of bones, maras- 
mus and death, as frequent occurrences. I am informed upon respectable 
authority that fully twenty per cent, of all the cases of diphtheria treated in a 
certain large and well regulated hospital show the symptom of albuminuria. In 
that hospital they say that " whenever one of our diphtheria patients gets gangrene 
of the throat he is sure to die." In that same hospital corrosive sublimate and 
whisky are the " sheet-anchors." Just think about all that. In that hospital 
they have two " sheet-anchors," corrosive sublimate and whisky. They have 
provided well there, for hardly any ship carries more than one of those steadfast 
arrangements. But the history of medicine affords an account of other " sheet- 
anchors." Bleeding was once a " sheet-anchor," immersing amputated limbs in 
boiling pitch was a 11 sheet-anchor." I have no doubt that a large number of the 
cases of gangrenous diphtheria found in that hospital are of the cases wherein 
there is a complication of albuminuria, and to which corrosive sublimate or 
some other form of mercury has been given. The medical chemists say that 
corrosive sublimate principally passes away from the system with the urine. 
Think of those great emunctories, the kidneys, being filled up and impeded in 
their operation by albumen, and then, of the system behind them loaded with 
corrosive sublimate that has been given perhaps every two hours for many days. 
Per force of such dreadful and unfortunate circumstances a patient must needs 
die. In that hospital the mortality of diphtheria is said to be about thirty per 
cent. I do not believe the mortality, when the cases are treated properly, should 
be more than ten per cent. Nay, it should be rather less. 
Now, before having proceeded further in the investigation of these questions, 
it will be well to note the forms of death which supervene in the disease; for 
such note will throw light upon the value of the medicines employed. I believe 
that asthenia is conceded to be by far the most frequent cause of death. The 
asthenic condition gradually deepens; the whole muscular system fails, fails; 
the heart becomes weaker and weaker, flutters, and finally stops; the scaleni and 
intercostals, and the diaphragm, become utterly exhausted; and the laryngeal 
muscles themselves become wearied unto death, permitting fatal occlusion of 
the glottis by collapse. I say I believe that it is commonly conceded that gen- 
eral asthenia is the most frequent cause of death in diphtheria. Then there are 
the paralyses proper that either directly or indirectly cause death. They are 
sudden in their appearance. The heart may be paralyzed, whereupon life will 
instantly cease; the muscles of the larynx may be paralyzed, whereupon the 
patient may die of sudden asphyxia, the immediate result of collapse of the 
glottis. Or, there may be paralysis of the diaphragm, or of any of the external 
muscles of respiration, in which case the effects of fatal asthenia are immensely 
hastened by a prostrating stress thrown on the other muscles of respiration, 
inducing gradual (asthenic) asphyxiation. Also there may be paralysis of the 
oesophagus, or of the laryngeal muscles, rendering deglutition difficult or alto- 
gether impossible; in which case the patient may die of inanition, or of asthenia 
brought on by the complication. But, in diphtheria which is not disastrously 4 
treated, I believe that these paralyses are rare. And, beyond all peradventure, 
the so-called direct paralysis of the heart is, in fact, usually asthenic cardiac fail- 
ure, or asthenic failure of some other organ or organs equally important. Still, 
in the malignant forms, paralysis may appear within the first week or ten days. 
Also, death by lethargy, and by coma, is especially liable to ensue when large 
quantities of liquor are given. In a number of cases the lethargy of the brain 
prevents supplementary voluntary power in breathing, and thereby assists in the 
induction of gradual asphyxia. In small children especially, asphyxia is often 
brought about by occlusion of the larynx by false membrane, and in such cases 
alcoholic lethargy rapidly hastens the fatal climax. 
Also for the purposes of this article, it is valuable to note certain particular 
and formidable general phases of diphtheria. The cases with these phases may 
be designated as the malignant. I would characterize septic, and the so-called 
" gangrenous '' forms, and the nasal, as malignant. I believe that there is no 
specific difference in the poison that produces malignant diphtheria and that 
which produces the milder forms. It is the particular state of the seat of the 
intromission of the germ that determines whether the case shall be mild or severe. 
All the malignant cases, the complete history of which I have been able to 
obtain, have given an account of a previously diseased condition of the part 
attacked. The worst cases are those that have been, and are, coincidentally 
affected by chronic catarrh of the throat and nares. And, it is here as we should 
expect, patches of mucous membrane are denuded of epithelium, and there is 
often superficial ulceration. In scorbutus a similar condition is seen. I believe 
that it is these raw surfaces that yawn to receive the germ. Furthermore, the 
hypertrophied lymphatics in the neighborhood are patent conduits, eager to 
take up and carry the germs and their ptomaines abroad from the gates of entrance. 
I believe therefore that the epithelium is the (perhaps perfect) wall against 
the specific germ of diphtheria. Hence, preserve the epithelium both before 
and after the invasion of the disease. More than all, do not destroy any of it 
either by means of escharotics, or by alcoholic applications, or by mechanical 
denudation. And do not institute an exfoliation of this protective covering by 
the specific and constitutional effects of mercury; do not, I pray you. 
Another very important question presents itself. Why do the germs run a 
course in the system and disappear? They complete a cycle of life in the system 
and are no more. Why is this? So far as I am aware we do not know. They 
may possibly be destroyed by their own ptomaines. But all is conjectural. 
However, seemingly the germs follow the path of a cycle, and then their exist- 
ence is at an end. It is the knowledge of this cycle of germ-existence that is of 
vast importance in the treatment of diphtheria. I shall call attention to it again. 
And, to me, what seems a highly important possibility, is this: I have a very 
deep impression that the mild forms of diphtheria are those where there are no 
solutions of continuity of the epithelium. In such instances the specific micro- 
cocci do not perhaps at all gain admission into the general system; but their 
ptomaines may be absorbed somewhat and thereby produce mild systematic 
effects. I believe that such instances furnish a vast majority of all the cases 
put together. They will end towardly with almost no treatment at all. Be 
careful not to break the epithelium, and if there is a wound upon the body keep 
it dressed in a thoroughly aseptic manner. Prevent if possible the intromission 5 
of germs into the system at large. I will also say that I do not believe that 
moderate swelling of the contiguous lymphatics and of other soft structures is 
much evidence that the germs have gained admission to the general circulation; 
for those parts may swell by turgescence, and by a stress lain on common absorp- 
tion. Nearly all the cases just indicated will get well if not too much interfered 
with by meddlesome medicine. They should not be thrust into great peril by 
mechanical abrasions, by escharotics, or by alcoholic and mercurial destruction 
of the epithelium. I repeat, do not, I pray you, become the unwitting fomenters 
of a dreadful mortality by the employment of dangerous and deadly agencies in 
these mild cases, whose numbers are vast. Do not convert a great number of 
these simple, and comparatively innocent cases into malignant forms by virtue 
of your treatment; for simple and cautious antisepsis alone will cure nearly all. 
Now let us revert to the alcoholic treatment of diphtheria, and to the treat- 
ment of diphtheria by the internal administration of corrosive sublimate. I do 
not believe that alcohol, or any alcoholic leverage, can take a curative part in 
the medical treatment of diphtheria. Upon the other hand, I believe alcohol to 
be dangerous and destructive. I believe that alcohol is one of our most powerful 
anaesthetics. In the lethal stage of diphtheria some of our friends give it in 
extravagant doses to arouse the patient from a condition of torpor. Taylor, in 
his indisputably authoritative work on " Poisons," affirms that in cases of death 
from the effects of alcoholic poisoning " the lungs, or brain, or both, are intensely 
congested," and that " the fatal termination can be almost invariably traced to 
that cause." Now, in the cases of diphtheria where there is a dangerous con- 
gestion of the lungs, brought on by protracted dyspnoea, our friends just pour in 
the alcohol. Yes, pour it in and make the fire blaze as high as possible! Fan 
the congestion into an inflammation! Dr. Richardson, (that renowned and 
sincere investigator) says that full and continuous doses of alcohol reduce human 
temperature to below the normal standard. Our friends, when a patient's heat 
falls to an imminently dangerous subnormal reading, just swim him in alcohol. 
Some zealous advocates give to an adult, so affected, a fluid ounce and more of 
strong whisky every two hours, so long as his life lasts. When such cases have 
fallen into my hands I have had the pleasure of rapidly increasing their tempera- 
ture by forbidding any more alcohol to be given. As I have already said, Dr. 
Richardson's investigations prove that alcohol increases the pulsations of the 
heart many thousands of times in the twenty-four hours, doubtless tending to 
induce its gradual exhaustion thereby. The investigation also proved that alco- 
hol brought on general muscular weakness, which was only a confirmation of 
what Franklin had demonstrated about a hundred years before. Our friends 
of alcohol say, in diphtheria u support the strength," therefore give whisky ad 
infinitum. Truly, reason is of all shades and degrees. 
All intelligent persons are aware that profound coma can be easily induced 
by alcohol. Suppose that we increase the lethargy incidental to partial asphyx- 
iation in diphtheria by the abundant administration of alcohol. Why, we lose 
the supplementary volitional power of the brain over motion. The patient sleeps, 
and all is-not so well; we get cyanosis, then palor, then death. Or, if coma 
does not supervene, the additional stress of labor which the system puts upon 
itself to rid it of the alcoholic poison, wears it out unto death. The muscles, which 
else might have borne up against the depressing cycle of diphtheria successfully, 6 
fail certainly, gradually, and fatally. The muscles of respiration yield; and the 
heart stops. According to my belief, that is the way that alcohol " supports the 
strength." Such results as alcohol accords afford the grimmest sarcasm against a 
false but widely spread theory. 
As to alcohol in diphtheria, as well as in all other adynamic diseases, I 
believe it to be a delusion and a snare. I believe it to be a dangerous and useless 
agent when employed, as it often is, in the condition of shock incidental to 
grave surgical injuries. In such instances it anaesthetizes instead of revives the 
appalled and stunned economy. An eminent authority (Kottmann) has lately 
declared against its use in shock; so of others; others follow and the tides turn. 
Now, once more as to corrosive sublimate, that most virulent of the mercu- 
rials. Some medical people give it internally for the cure of diphtheria. They 
give it from the incipiency of the disease until its termination. They say that 
wherever a refractory germ persists in its course, and enters the circulation, it 
shall be met by a fatal dose of corrosive sublimate circulating in the blood, and 
already prepared for it. And each and every germ must be so met, and then 
their dead carcasses floated out of the system in a perfect flood of whisky. 
Everything is excited, and the dead germs, ptomaines and all, are carried away 
in a hurry, and the sinking patient is 11 supported " at the same time. A few 
days ago I saw a man going along the street in a zigzag fashion; it was cold 
and his gait was uncertain; so I offered him support of another kind (external), 
saved him from a policeman, and landed him among his friends. This man had 
had only a part of the treatment, the alcoholic. If I am irreverent it is because 
I have a safer and more rational treatment to offer; and it is one which I have 
proven over and over again. The corrosive sublimate people are wrong; their 
remedy is very dangerous, and often fatally destructive. 
In diphtheria the function of the kidneys is frequently oppressed by albu- 
minuria. Many years ago Dr. Craigie and Sir R. Christison (of England), 
made extensive observations which proved conclusively that persons affected by 
granular kidney, with albuminuria, are particularly liable to the dangerous and 
fatal impressions of mercury. Persons with such an affection of the kidneys, 
who take mercury, are liable to gangrene of the throat, necrosis of bones, and 
death; and these fearful results may follow from one to a few alterative doses, 
or applications, of the drug. Bartholow has said that "important changes 
occur in the kidneys (in diphtheria), and at a very early period of the disease. 
They are swollen, intensely hypersemic in the severe cases, but little so in the 
mildest; but, in all cases changes occur in the Malpighian tufts and in the 
tubules. The tufts are haemorrhagic, contain micrococci colonies, and are sur- 
rounded by lymphoid cells; the epithelium of the tubules is cloudy, granular, 
and swollen, and is often detached in the form of casts with epithelium adher- 
ent." Let those who wish to reason put Bartholow's statements, and those of 
the eminent pathologists named, and that of the aforesaid authoritative toxicolo- 
gist, together. The inference will be at once impressive and conclusive. 
Certain so-called septic cases are doubtless often produced by mercury, in the 
form of corrosive sublimate or otherwise, which agent cannot be eliminated by the 
already incapacitated kidneys. Taylor says that bichloride of mercury is mostly 
eliminated by the kidneys; and that when they are oppressed and unable, the 
poison is thrown back upon the system with the destructive results already 7 
described. I have no doubt that under such circumstances, gangrene and putre- 
faction often occur independently of the specific nature of diphtheria, and that 
common septicaemia ensues as a matter of course; the mercury being the prime 
mover in the dreadful train. Nay, in these cases there is doubtless more than 
this: altogether there are the septic effects of mercury, the septic effects of the 
microbe of putrefaction, and the septic effect of the diphtheria microbe-the 
mercury having perhaps thrown open the door for the entrance of the two latter 
forms of poisoning. 
As a proper interpolation, permit me to say that the older disastrous methods 
of treatment, in civilized places, have faded away. Blood-letting, catharsis, 
repeated emesis-and tartarized antimony in " broken doses," lobelia, and such 
like, are matters of ancient history, to be reverted to as remarkable curiosities. 
But the days of those remedies had their 11 graver and more fatal epidemics." 
The mystery of the gravity of such epidemics may often be solved by studying 
the gravity of the remedies employed 1 An evil and blind genius may sometimes 
fall upon the times. 
In conclusion, permit me to present the proper and rational treatment of 
diphtheria, in so far as I am able to conceive it. If I have been prolix in saying 
what not to do, I will be brief in saying what to do. 
The first thing to consider is that diphtheria is produced by a specific germ 
(or, as is remotely possible, by a variety of specific germs), and that the germ 
runs a cycle and disappears. At present, as I believe, there is no known means 
of preventing this occurrence. Our germicides certainly do not reach all the 
germs. Those that are external we are only able to decimate; those that are in 
the lymphatics and in the system at large we cannot attack at all. While this 
cycle is in progress what shall be done? Why, conserve, and add to the strength; 
and resort to the best and strictest antisepsis, both externally and internally. 
Give the patients nutritious and easily digested foods; predigested foods if pos- 
sible. Malted milk is excellent for the purpose, and there are other excellent 
foods of the same class. In cases wherein deglutition is impossible on account 
of paralysis, inject absorbable foods and fluids into the rectum. I regard the 
injection of fluids through the oesophagus into the stomach as being very danger- 
ous in diphtheria, on account of the great liability to spasm of the larynx. I 
believe that spasm of the larynx in such cases usually causes fatal prostration 
and sudden death; therefore, do not resort to it at all, for the paralysis of the 
muscles concerned in deglutition, will, in all probability, be transient; and in the 
meantime considerable efficient nutriment may be administered per rectum. 
As to antisepsis, if the patient's strength will permit, the first thing to do is 
to cleanse him from head to foot with warm soap and water. Then the face, 
head, neck, and forearms should be washed with a suitable disinfecting solution; 
say a proper solution of the bichloride of mercury, or of the peroxide of hydro- 
gen. The interior of the throat, and of the nose should be washed out not 
oftener than once every two hours with a solution of the peroxide of hydrogen. 
This destroys some of the diphtheria germs and lessens the liability to septicae- 
mia. If the patient is very weak do nqt disturb him so often as every two hours, 
once in three will do. If the symptoms are not too Urgent let the patient rest 
undisturbed from 12 o'clock midnight until 6 in the morning. I believe too 
frequent disturbance to be a great cause of death. A strong mixture of quinine 8 
and syrup of yerba santa, or of liquorice, may be given in doses every two to four 
hours. Quinine is a mild germicide, and when so given disinfects gently the 
primae vise. The tincture of iron mixed with syrup, and given, acts in a similar 
manner, with the additional power of being a tonic for the blood. In case that 
apnoea threatens by reason of occlusion, or of stenosis, of the larynx, a surgeon 
should be called, and requested to make an opening in the trachea. However, I view 
this as an unfortunate contingency, for I regard tracheotomy as increasing the dan- 
gers from sepsis. I would advise the surgeon to use a cautery (if such a means 
is practicable), so as to sear the edges of the wound as he proceeds; for in this 
way the intromission of germs and ptomaines into the lymphatics and blood-ves- 
sels at the seat of the operation might be prevented, at least for a time. After 
tracheotomy I counsel the same mild measures that I have already indicated. 
As to intubation, I have had no experience in the observation of its effects; but 
where there is dangerously oppressive occlusion or stenosis of the larynx it might 
subserve a good purpose. But it is my opinion that all such cases as those which 
are reduced to so low an estate as to require an operation, are not liable to recover 
at all. 
The paralyses of diphtheria are almost invariably transient. They appear sud- 
denly, and after a brief duration disappear as suddenly as they come. Their 
transient nature is a phenomenon worthy of thought and comment. According 
to my observation, when paralyses occur in the acute stage of diphtheria there is 
a coincidental subnormal temperature. This fact points out to me that perhaps 
the paralysis is brought about by the slowing of the rate of nervous conduction 
by a lessening of the natural caloric of the body; for it is a principle well known 
that a depression of temperature will decrease the velocity of nervous force. It 
is my belief, therefore, that to sustain the heat of the body is a prophylaxis 
against paralysis in diphtheria. The application of external heat is perhaps the 
best means. When there is a subnormal temperature large and frequent doses of 
alcohol will still further rob the system of its heat and thereby greatly facilitate 
the supervention of paralysis-perhaps paralysis of the heart, which of course is 
instantly fatal. Upon the principle urged the application of heat will tend to 
shorten the duration of, and cure, the paralyses of diphtheria. 
The inhalation of oxygen, immediately before and after an operation is doubt- 
less valuable. 
Abscesses of the neck, and also of the middle ear, sometimes oocur in the 
malignant cases of diphtheria, and they should be treated with extreme wisdom 
and caution. The opening of a diphtheritic abscess by surgical means is a very 
grave matter, and should not be lightly undertaken. It is my opinion that the 
abscess should always be opened by means of the actual cautery, so that no 
blood-vessels or lymphatics may be lain open, and that secondary infection may 
be avoided thereby. The cavity should be instantly washed out with a very effi- 
cient antiseptic solution; and great care should be taken not to lacerate the pyo- 
genic membrane, and thus avoid sepsis from a source of violence.- 
If from any cause septicaemia supervene, I still recommend the same mild, 
gentle, and cautious treatment as that which I advocate in the cases of less grave 
import. And I here affirm solemnly that I do not believe in the alleged efficacy 
of alcoholic liquors in any form of septicaemia. In common surgical septicaemia 
I eschew them, as I certainly do in all other adynamic diseases. Most for- 9 
tunately, however, when a kindly and cautious treatment is adopted from the 
beginning in diphtheria, septicaemia does not by any means so often occur. 
The so-called 11 gangrenous " phase of diphtheria I regard as being simply an 
almost certainly fatal extension of an already grave septicaemia. Mild measures 
are unavailing, though they paliate; heroic measures but hasten the tragic end. 
And now, with extreme sincerity and candor, I leave the contents of this 
article to the gracious consideration of those who may honestly and conscien- 
tiously differ from me on so momentous a subject; and to those whom I hope to 
convert to a belief in the doctrines expressed. And if I have any sympathizers 
who think and feel as I do myself on this intricate but humane question of sci- 
ence (and involving for the most part but charitable labor), to imagine their 
existence and presence is a most grateful thought indeed.