Chapter XLII: Part II: , Showing Predominance of Malarial Element . . . . 617 (41)

{685} MORBID ANATOMY.--Either the membrane or the granular infiltration is characteristic of diphtheria. The statement that the former occurs only when atmospheric air can gain access thereto, as A. d'Espine and C. Picot still hold,[35] is plainly contradicted by its appearance on the mucous membrane of the lower intestines. The condition of the membrane is not unalterable, any more than the clinical symptoms of the disease, for, according to different circumstances, epithelium, mucus, blood, and vegetable parasites are added thereto. The membrane can either be lifted from the mucous membrane on which it lies or is imbedded into and underneath it. In the first instance, it consists to a great extent of fibrin, the result either of epithelial changes or derived directly from the exuded blood-serum. E. Wagner, who makes no anatomical distinction between croup and diphtheria, considers epithelial changes the principal source. The pavement epithelium becomes altered in a peculiar manner. It becomes turbid, larger, dentated, and dissolves into a network; it is at first uninhabited, but serves later as the vehicle of newly-formed cells; there also occurs a considerable infiltration of the mucous membrane pus-cells and granules; besides, the cellular tissue is studded with granules, the granular degeneration resulting sometimes in necrotic destruction, which is looked upon by Virchow as the most important element in severe forms of diphtheria. The several conditions or degrees may occur independent of each other, associated or in succession. Classen shares Wagner's views, but, according to Boldygrew, the pseudo-membrane consists of successive coagulations of a fibrinous fluid which exudes from the diseased surface. Steudener also opposes the views of Wagner. He does not believe in the probability of an exclusively endogenous origin of the cellular elements of croup membrane; in fact, he doubts the occurrence of an endogenous formation of pus-globules in epithelium. Croupous membrane, according to him, is formed by the migration of numerous white blood-globules through the walls of the vessels in the mucous membrane, and by a direct formation of fibrin from the transuded plasma. In addition to this, the mucous membrane is stripped of its epithelium (except at the mouths of the acinous glands) and infiltrated with migrating cells. Fresh croupous membrane consists of a delicate network of homogeneous structure and shining appearance, in which numerous cells and the epithelium of the various layers of the trachea are imbedded. In old membranes the cells are destroyed by granular degeneration and general maceration. Tenacious mucus with pus-cells and detritus are then found. C. Weigert looks upon the deposits as analogous to those on serous membranes. Every inflammation yields an exudation which may coagulate when the coagulating ferment is added. This latter is probably produced by the white blood-cells when in disintegration. But he does not say why it is that there is no such coagulation in suppurative processes, where the leucocytes are more numerous. He believes himself justified in establishing pathological differences of croup, pseudo-diphtheria, and diphtheria. A croupous inflammation means destruction of epithelium, which gives rise to a fibrinous exudation upon the surface, while the cellular tissue remains intact. The only difference between it and the pseudo-diphtheritic inflammation is looked for in the larger number of emigrated white {686} blood-cells. The superficial deposit consists, to a great part, of them and the fibrinous exudation. When there are but few leucocytes the deposit is a network of fibrillæ (croup). When there are many, the masses are more solid and voluminous (pseudo-diphtheritis). When, however, the tissue is changed into a hard substance resembling coagulated fibrin, when the exudation does not exist on the surface, but takes place into the mucous membrane, the process is diphtheria. Zahn also establishes three varieties--viz. 1st, such as result from a peculiar degeneration of pavement epithelium; 2d, such as originate in the solidification of a muco-fibrinous, and, 3d, of a fibrino-purulent, exudation. Each of these varieties may contain colonies of micrococci, but these organisms are neither essential nor are they constantly found.

[Footnote 35: _Man. prat. des mal. de l'enfance_, 1877, p. 81.]

The diphtheritic process does not merely consist of the membranous changes in the pharynx and air-passages. Its fatal cases have afforded marked evidence of the implication of most of the organs. Reimer's 17 cases give the following post-mortem results: the lungs were hyperæmic in 8 cases, twice the seat of pneumonia, and three times of embolic infarctions; in addition, emphysema in 12, oedema in 6, atelectasis in 7, subpleural ecchymoses in 7, pericardial ones in 4. The heart-muscle had undergone fatty degeneration in 6, and was the seat of ecchymoses of the size of a pin's head in 3. In addition to frequent hyperæmic conditions of the abdominal viscera, emboli of the liver in 3 (with capillary hemorrhages of the peritoneal covering in 1), emboli of the spleen in 5, desquamative nephritis in 7 (in 6 of which there were colonies of micrococci in the uriniferous tubules), cellular hyperplasia of the cervical and mediastinal glands in 14 (complicated in 6 with capillary hemorrhages in the glandular tissue). The blood was frequently normal, very often watery and dark, at times leucocythæmic. Thus the disease exerts its influence everywhere.

Rindfleisch defines diphtheritic inflammation as that form of inflammation which produces a coagulating necrosis in the tissues by the immigration of schizomycetæ. The coagulating necrosis differs from the usual form of necrosis in this, that the change from life to death is accompanied with the coagulation of fluid albuminoids. This process takes place mainly in the interior of cells and other parts of tissues, and therein differs from the coagulation of fibrin. In the cells there is taking place a peculiar homogenization of protoplasm; at the same time the nuclei disappear, and are changed into irregular masses liable to cohere and form membranous conglomerates, which owe their peculiar wax color to the invasion of a solid albuminoid endowed with a strong tendency to refract the light. Coagulating necrosis is found in circumscribed localities, and gives rise, in the neighborhood, to a marked amount of inflammation and suppuration, which leads to the expulsion of the necrotic part, with more or less loss of substance--either mild or phagedenic ulceration.

Leyden describes a gray degeneration of the muscular tissue which he believes to be truly inflammatory, and Unruh has lately published an account of some cases in which myocarditis occurred. In Leyden's cases, the muscular nuclei were increased, became atrophied, and underwent fatty degeneration, giving rise thereby to extravasations, softening, dilatation and debility of the heart, with general debility, collapse, {687} and--probably by reflex action on other branches of the pneumogastric--vomiting. Micrococci he found neither in the heart nor in the kidneys.

In the heart, particularly on the right side, numerous thrombi are frequently found in various stages of development; its muscular tissue is often in a state of fatty degeneration or the seat of parenchymatous inflammation and hemorrhages. Bridges first called attention to the occurrence of endocarditis in diphtheria.[36] This complication, which, however, occurs more frequently with rheumatism, puerperal fever, diphtheria of wounds, pyæmia, and old valvular affections than in the course of an acute diphtheria, does not, as found in the latter affection, consist simply of a fatty degeneration and subsequent ulceration, but is considered a genuine diphtheritic process (Virchow), affecting the mitral valve more frequently than the tricuspid or pulmonary valves. It begins with hyperæmia and the exudation of plasma in the cellular elements, so that they appear larger and darker. The granulations which form are frail and easily destroyed, so that ulcers form on which fibrin is deposited, and whence it is conveyed as emboli into the terminal arteries (Cohnheim) of the spleen, nerves, brain, and eye. Infarctions may also occur in the valveless veins of these organs, giving rise rather to small multiple abscesses than to large purulent collections. Suppuration but rarely takes place in the heart; the granular mass found there resists the action of æther and alcohol, and spreads throughout the cardiac parenchyma, so that perforation of the septum and of the right auricle and aorta has been observed.

[Footnote 36: _Med. Times and Gaz._, ii. p. 204.]

Bouchut and Labadie-Lagrave, out of 15 cases of diphtheria, met in 14 with a plastic endocarditis, which became the source of emboli. Thus, there were infarctions of the lungs, at times in their centre colorless, at other times in a state of purulent degeneration; superficial thrombi of the small veins of the heart, subcutaneous connective tissue, pia mater, brain, and liver; and in addition, moderate leucocytosis.

The lungs exhibit (post-mortem) all sorts of inflammatory and congestive conditions, with their consequences, as oedema, catarrh, broncho-pneumonia, atelectasis, emphysema, ecchymoses, and large infarctions.

The spleen (and occasionally the liver) is frequently large, congested, and friable, and studded with infarctions to a greater or less extent.

The kidneys are either simply congested or the seat of nephritis or infarctions. The same forms of inflammation which accompany scarlatina--to wit, the desquamative and the diffuse--are here observed. The diffuse form is not of so frequent occurrence as in scarlatina, but is sometimes extensive and dangerous.

The muscles occasionally exhibit ecchymoses, and are at times the seat of parenchymatous inflammation, gray degeneration, and atrophy.

The lymphatic glands are frequently inflamed and swollen, either hard or doughy, oedematous or congested. Large abscesses are rare. It is more especially the gland tissue, and less the connective tissue of the glands, which takes part in the pathological process. The periglandular tissue very soon becomes involved, however. Necrotic foci have been described by Bizzozero. When the entire surface of the mucous membrane of the mouth and of the air-passages, from the nose to the trachea, is the seat of the disease, there is an impregnation of the mucous membrane, from the epithelial surface to the submucous tissue, of the entire {688} tongue, borders of the lips, and frequently of the lips and cheeks, as well as of the tonsils, the lower portion of the nasal cavities and the upper, and especially the anterior, portion of the larynx. The fossæ Morgagni and the posterior aspect of the soft palate are more frequently affected in the same way than the anterior aspect. Small isolated spots are found on the tonsils and occasionally on the posterior wall of the pharynx. The so-called croupous form--that is to say, the one in which the membranes deposited may either be removed in large patches or lie macerated in the profuse secretion of subjacent mucous glands--is found partly in the nasal cavities, on the posterior surface of the soft palate, and also in the trachea and its subdivisions.

The character of the mucous membrane varies with the locality. Its different elements, as the epithelium, the basement membrane, the connective tissue mingled with elastic fibres, the blood-vessels, the nerves from the cerebro-spinal and sympathetic systems, and the papillæ and ducts of numberless glands, all influence the pathological process going on upon the surface. Their distribution in the oral cavity and the respiratory organs is a very interesting study, and in a table already published,[37] I have exhibited it in a condensed tabular form.

[Footnote 37: _Treatise on Diphtheria_, p. 126.]

Where elastic tissue predominates, diphtheritic impregnation is slow to take place, and recovery is also slow when the tissue has finally submitted. Pavement epithelium yields the easiest foothold to diphtheritic membrane. Thus it is that the tonsils, not from their prominent situation alone, favor the reception and development of the infection. But the elastic and connective fibres when once affected are apt to harbor the disease a long time. Still, there is another reason why the diphtheritic process should favor the tonsils. For Th. Höhr has demonstrated that their epithelium exhibits interruptions in its continuity. Through them round cells may emigrate. Wherever the epithelial covering of the integuments (skin or mucous membrane) is intact and unbroken, diphtheria takes hold with difficulty. But where a defect is established, large or small, diphtheritic formations will be apt to take place according to the size of the abrasion. This is one of the modes of the formation of small diphtheritic deposits on the tonsils, which it has been the tendency of many, both practitioners and authors, to honor with special names.

Ciliated epithelium is not so liable to be affected. It occupies a higher rank in the scale of animal formations, has a more complex function and a greater power of resistance. The presence of a large number of mucous glands impedes, as a rule, by the presence of the normal secretion, an extensive destructive action upon the tissues. The secreted mucus assists in removing epithelial masses, and even fibrinous exudations, from the surface. Thus it is that the deposits in the respiratory portion of the nasal cavities are frequently cast off through the nostrils, and in a similar manner the membranes that have formed in the trachea are ejected in a semi-solid condition through the opening made by tracheotomy. The large number of mucous glands in the larynx and trachea is unquestionably the reason why the lymphatic vessels of the mucous membrane are not influenced by the overlying loosened masses, and will not absorb; hence laryngeal and tracheal diphtheria, when not complicated, have decidedly a local character, and are usually devoid of constitutional symptoms. For the {689} same reason the usual form of tonsillar diphtheria is a mild disease. On the other hand, the large number and size of the lymphatic ducts of the Schneiderian mucous membrane, as well as their direct communication with the lymphatic glands of the neck, accounts for the dangerous character of nasal diphtheria.

Diphtheria of the intestinal canal is characterized by fibrinous deposits on the surface and in the tissues of the intestine, with subsequent granular degeneration. It is mostly preceded by a catarrhal process. The same condition is found in the urinary organs.

There are but few autopsies of cases which have died of, or during, diphtheritic paralysis. In some instances there was considerable thickening of the spinal nerves at the junction of the posterior and anterior roots, with hemorrhages. The superficial connective tissue in these places exhibited a diphtheritic exudation (Buhl). There was in the sheath of the nerves of the cerebral and spinal meninges and in the gray substance of the cord voluminous nuclear infiltration; in one case there were extensive hemorrhages in the spinal meninges, with nuclear proliferation in the gray substance of the cord (Oertel). Disseminated meningitis with perineuritis of the neighboring roots, characterized by infiltration of nuclei between the nerve-fibrillæ was found by Pierret; and degeneration of the palatine nerves and fatty degeneration of the palatine muscles by Charcot and Vulpian. Dejerine, in five autopsies, records an atrophy of the anterior roots secondary to a myelitic degeneration of the ganglia of the anterior horns. E. Gaucher found the same in the case of a boy who died with paralysis of the muscles of deglutition, of the extremities, and of the trunk. In a child of two years with paralysis of the palate and extremities the autopsy was negative. In two cases Dejerine reports finding changes in the intramuscular nerves, such as liquefaction of myelin and loss of axis cylinders.

Thus, Buhl, Charcot, Vulpian, and Dejerine are unanimous about an affection of the peripheric nerves and muscles. Oertel, Dejerine, and Gaucher believe in a disease of the spinal cord. It is true that a disease of the gray substance would fully explain the symptoms of the bad cases, but what we know of poliomyelitis anterior, with which this affection would be identical, precludes the idea of the rapid and almost certain complete recovery. Therefore, in most cases, diphtheritic paralysis consists of a trophic affection of the motor system, almost always seated peripherally in the nerves and muscles, seldom, if ever, in the centres. This affection must be compared, in most of its relations, with the degenerative processes taking place in the muscular tissue after typhoid fever, or in the renal epithelium after infectious diseases, both of which give rise to serious results, with usually a favorable termination.

DIAGNOSIS.--The characteristic sign of diphtheria is either the membrane or the gray infiltration, with more or less injection of the surrounding parts. In regard to this greater or less injection, I will say that pharyngeal congestion, when it is uniform, may or may not point to imminent diphtheria. When it is local, confined to one side mainly, it is either traumatic or diphtheritic. White spots which are easily washed away, or which can be removed with a brush, or squeezed out of the follicles of the tonsils, into which a probe can be introduced sometimes to the depth of one-half inch, soon announce their true character--viz. either a {690} simple catarrhal secretion or suppuration. Even though the superficial deposit contain oidium or leptothrix in considerable numbers, it can easily be removed; I have only known the totally inexperienced to mistake muguet (thrush) for diphtheria. In the larynx muguet is, moreover, very rare indeed, and always circumscribed. It is sometimes seen on the true vocal cords. The gray discoloration of superficial follicular ulcerations, as observed in the ordinary form of stomatitis follicularis, can hardly fail to be recognized. Such patches are very numerous in the fauces and on the lips and cheeks--never on the gums, except in ulcerous stomatitis (which is not follicular). They are accompanied, too, by vesicles containing more or less serum which have not yet ruptured. It must be remembered, however, that the mucous membrane, when deprived of its superficial covering, is liable during an epidemic of diphtheria to become infected, like every other wound. I have seen cases in which stomatitis and diphtheria existed side by side, the latter having invaded the surfaces exposed by the former. The examination of the entire throat is not always easy. Very young children vomit frequently and persistently before the whole surface is exposed to view, and not infrequently repeated examination with the spatula is absolutely necessary. In general, however, the slight attempts at vomiting suffice to cause a great part of the swollen posterior portion of the tonsils to become visible. I have heard that the pale surface of old hyperplastic tonsils has been mistaken for diphtheria; I merely mention the fact. When a discoloration happens to be the result of a deposited flake of mucus, a drink of water will remove it.

Fever is not always a prominent symptom; as a rule, simple diphtheria of the tonsils is accompanied by very little fever. Still, there are plenty of exceptions. But the differences of temperature are not more striking than in most other infectious diseases, whose either mild or severe invasion may offer an obstacle to immediate diagnosis. As the height of the fever does not absolutely determine, or even indicate, the character of the subsequent course of the disease, but little importance is to be attached to the temperature unless there be a very marked elevation. A sudden rise frequently occurs with lymphadenitis. High fever in the beginning may render the diagnosis difficult or may postpone it.

The absence of glandular swelling does not exclude the diagnosis of diphtheria, for when the tonsils are affected by the disease there is usually little or no swelling of the neighboring glands. Swelling of the glands enables us to locate the affection in a mucous membrane richly endowed with lymphatic vessels. It is very marked when the nose is affected. A few hours' duration of nasal diphtheria suffices for the development of a severe lymphadenitis, especially at the angles of the jaw. When the latter condition is found to exist, the throat should be examined with the idea of finding a membrane extending upward; nasal diphtheria is very liable to complicate an affection of the uvula and arches of the palate. The membrane cannot well be seen by looking through the nostrils; highly serviceable for this purpose is a very short, broad rhinoscope reaching upward to the bony structure of the nose. However, nasal diphtheria may frequently be diagnosticated some days before the membrane becomes visible, by the rapid development of lymphadenitis; this may be done even where the sweetish, musty odor of certain forms {691} of diphtheria is absent. Still, nasal diphtheria may occur without much lymphadenitis; as, for instance, when the blood-vessels are very numerous and superficial, and thereby give rise to slight hemorrhages at the very beginning of the sickness. In such cases the lymphatic vessels are little, if at all, required to transmit the poison, the open blood-vessels replacing them in the function of absorbing. Naturally, there are cases in which an ocular examination cannot be satisfactorily made. In the journals we read of brilliant results of rhinoscopic and laryngoscopic examination; in practice we see but few. This holds good especially for the cases of dyspnoea accompanying laryngeal diphtheria, where the diagnosis may be doubtful when no membrane can be detected in the fauces; even if membrane be observed there, symptoms of suffocation may still arise from a laryngeal stenosis independent of membranous deposits in the larynx. If aphonia and difficulty of both inspiration and expiration be present at the same time, there is certainly membranous occlusion. If aphonia appear late, or even toward the very last, and only inspiration be impeded while expiration is comparatively free, there is an oedematous saturation of the ary-epiglottidean folds and of their copious submucous tissue, and consequently of the posterior attachment of the vocal cords. Although a general oedema glottidis in connection with diphtheria is of exceedingly rare occurrence, the above condition is not at all uncommon, and has forced me to tracheotomize many times; but, again, a comprehension of the true condition, where it occurred in not very severe cases, has on several occasions enabled me to avoid an operation. This local oedema may sometimes be detected by palpation in the region of the swollen posterior wall of the pharynx.

One of the diagnostic symptoms of membranous laryngitis, believed in and referred to by Krönlein, does not exist--viz. the swelling of the lymphatic glands, which in his opinion is pathognomonic. Not only is that not the case, but the absence or scarcity of lymphatics on the vocal cords and in their neighborhood renders the absence of glandular swellings a necessity, provided the latter do not depend on complicating diphtheria in other localities. In uncomplicated diphtheritic laryngitis I expect no lymphadenitis. The character of the laryngeal pseudo-membrane does not depend at all on the condition of the pharynx. The latter may have membranes of any description or consistency without permitting the diagnosis of the condition of the larynx. I lay stress on this fact because no less a writer than Krönlein believes that where there is but little or no membrane in the pharynx, that in the larynx is rather loose and movable.

One of the diagnostic symptoms of diphtheritic laryngitis, or membranous croup, is the relative absence of fever. Catarrhal laryngitis, or pseudo-croup, is a feverish disease. A sudden attack of croup with high temperature, provided there is no pharyngeal or other diphtheria present, yields a good prognosis; without much fever, a very doubtful one.

The diagnosis of diphtheritic paralysis offers very little difficulty in most cases. Its occurrence after an attack of diphtheria, its beginning in the fauces or in the muscles controlled by the ciliary nerves, the immunity of the sphincters, the gradual development, the irregularity of its progress, are good diagnostic points. Examination by the interrupted or continuous current is not conclusive. Very frequently in the {692} beginning the response to the interrupted current is normal, sometimes deficient; to the continuous current, exaggerated. After some time the power of both to excite contraction is diminished. When we reflect on the numerous causes which may underlie diphtheritic paralysis, and that we have not to deal with one and the same anatomical change in all cases, it becomes apparent that no reliable conclusions can be based upon electrical examination.

PROGNOSIS.--In general, the prognosis in diphtheria is favorable when the affected surface is of small extent and where such parts are the seat of disease as have little communication with the lymphatic system. To the latter class belongs simple diphtheria of the tonsils. Marked glandular swelling, particularly if arising suddenly, is always an unfavorable sign, and calls for the utmost caution in prognosis, especially if the region of the angles of the jaw be speedily and markedly infiltrated. This, as we have seen, is particularly apt to occur with nasal diphtheria, whether developed primarily, (and then accompanied by a thin fetid discharge), or, as is more commonly the case, secondarily from an affection of the pharynx and palate which ascends into the posterior nares. With the appropriate local disinfection this form of the disease is neither so alarmingly dangerous as Oertel depicts it, nor so assuredly fatal as Roger but a few years ago taught in his clinique, or as Kohts appears to believe,[38] yet it is ever grave. With energetic treatment many cases will, however, get well. Diphtheria of wounds, complicating diphtheria of the pharynx, is always an unfavorable sign; that of the mouth and angles of the mouth, associating itself with a previously existing diphtheria, having an indolent course, and producing more frequently a deep impregnation of the tissues than a thick deposit, causes a painful and serious condition. Diphtheria of the larynx, whether it be of primary origin or the result of extension from the fauces, is nearly always fatal. In severe epidemics the mortality is 95 per cent. Tracheotomy, too, saves but few of those who take the disease at such a time. In fifty consecutive tracheotomies from 1872 to 1874 I did not see one recovery. In the last few years I have seen few good results. In average epidemics tracheotomy will save 20 per cent. A pulse of 140 to 160, and high fever immediately after the operation, render the prognosis bad; so does absence of complete relief after the operation. An almost normal temperature the day after the operation is an agreeable symptom, but does not exclude a downward extension of the diphtheritic process, and hence cannot be looked upon as assuring a favorable prognosis. A marked elevation of temperature is apt to indicate a renewed attack of diphtheria or a rapidly-appearing pneumonia, and is an unfavorable symptom. A dry character of the respiratory murmur some time after tracheotomy indicates the approach of death within from twelve to twenty-four hours from descent of the membrane; so does cyanosis, whatever be its degree of intensity. Diphtheria of the trachea, which ascends to the larynx, is positively fatal. It has a rapid course, and tracheotomy only postpones the end for a little while, if at all. The general health and strength of the little sufferer have no influence whatever.

[Footnote 38: Gerhardt, _Handb. d. Kinderkr._, iii., 2, p. 20, 1878.]

Thick, solid deposits need not of themselves render the prognosis so unfavorable as do septic and gangrenous forms. Even in the nose they {693} are not of as serious import as the thin, putrid discharge. I have seen recovery ensue in cases where I was obliged to bore through the occluded nasal cavities with probes and scoops. Fetid, putrid discharges are unfavorable, but in no wise fatal; conscientious disinfection accomplishes a great deal. Slight epistaxis indicates the possibility of rapid absorption through the blood-vessels; but here, too, the final result depends on whether the disinfection be equally rapid and thorough. The same holds true for the sweetish, fetid odor of the breath, whether of the nose or mouth, which, on the one hand, demonstrates the significance of the disease, while, on the other hand, it indicates the possibility of infection by inhalation.

The height of the fever is not in proportion to the danger in any individual case; some have a favorable, some an unfavorable termination, without fever of any account. Simple catarrh of the pharynx and larynx frequently begins with a sudden and marked rise of temperature; diphtheria in the same parts but rarely. There are cases, however, in which the height of the fever and the deposited membranes are in inverse proportion to each other. In these cases the fever may subside rapidly, owing to a speedy elimination of the poison. Young children only are in danger of death from convulsions or a rapid tissue-degeneration due to hyperpyrexia. If the temperature rise suddenly after some days of sickness, either a complication or a fatal termination is to be apprehended. Yet, there are as many deaths in cases with comparatively low as with very high temperatures. Whether collapse has resulted rapidly or slowly, the patient dies often with low temperature. Thus, a rapid elevation is hardly a more unfavorable sign than a rapid fall. The pulse, too, may be very variable. True, a small, rapid, and irregular pulse is always unfavorable, because it indicates a weakening of the cardiac function; yet as long as it retains an approximately normal relation to the frequency of respiration a rapid pulse gives no cause for alarm. Moreover, the pulse is not always rapid when the strength gives way. It occasionally becomes slower, and sometimes very slow, and may then become a dangerous symptom.

Every complication adds to the danger. Bronchitis and pneumonia are not infrequent, yet I have seen cases of laryngeal diphtheria recover in which I had suspected pneumonia before performing tracheotomy, and was enabled to diagnosticate it after operating. Albuminuria in the early part of a diphtheritic attack with high fever is of little significance; nephritis, later in the course of the disease, partakes of the character of scarlatinous nephritis; cases of acute diffuse renal disease are fortunately infrequent, and the remainder are very submissive to treatment. The cases of diphtheria complicated with endocarditis in my practice have ended fatally. An early affection of the sensorium, not dependent on pressure upon the jugulars by greatly swollen glands, is an unfavorable symptom. Purpura, with profuse hemorrhages and a livid hue of the skin, is ominous; icteric discoloration, together with marked glandular and periglandular tumefaction, is absolutely fatal.

Most cases of diphtheria of the pharynx and of the tonsils have a favorable termination, yet a positive prognosis can in no case be given with certainty. Still, even in malignant epidemics the mortality is not very great, for even though there be a large number of severe cases in {694} any one epidemic, yet it is greatly overbalanced by the number of moderately severe and mild ones. True, not a few cases end fatally in several days, owing to the high fever, or to septic absorption, or nephritis, or croup, but the majority of cases end in recovery in one or two weeks. Yet diphtheria does not always take so regular a course; not infrequently, after the pulse has become stronger, the appetite improved, and the pharynx cleared, and the patient is apparently on the high road to recovery, another attack occurs accompanied by fever, as before, and a rapid formation of membrane. Occasionally two or three such relapses may occur in the course of three, four, or five weeks; not to speak of the fact that those who have once suffered from diphtheria are more susceptible to the action of the poison than those who never suffered before.

TREATMENT.--Every case should be treated on general principles; thus, it is not possible to lay down a routine treatment for every individual case. High fever should be reduced by sponging and bathing, quinia, and sodium salicylate; collapse speedily treated, and severe reflex symptoms, as vomiting, etc., checked at once. Whether to employ for this purpose ether, wine, cognac, champagne, or coffee must be decided by the physician in individual cases. The administration of the remedy, whether by mouth, by injection into the bowels, or subcutaneously, as I have employed cognac, ether, alcohol, and camphor dissolved in ether or alcohol, in some cases with decided and rapid success, must depend on the condition of the organs and on the urgency of the case. However, all the above remedies are frequently of no service, because administered too late and in too small doses. If I have ever had cause to feel contented with the results of treatment in diphtheria, it is owing to the fact that I lost no time. No medicines, however, must be resorted to which are apt to derange the digestion of the patient; alcoholic stimulants must be given in fair dilution only, for that reason. The nourishment of the patient is a matter of very great importance. On general principles it is true that care must be taken in regard to food administered to febrile patients, but we must bear in mind that, when the lymphatic vessels are kept empty and no new and proper material is introduced into them, the absorption of locally-existing poisonous substances is proportionately increased. Hungry lymph-vessels are the organism's fiercest enemies.

I dwell particularly on the foregoing remarks for the reason that in diphtheria, unlike certain diseases having a typical course and those of a simple inflammatory character, expectant treatment should not be indulged in. Oertel's advice, that when neither high fever nor complications are present we should quietly wait, and "act only when new and most alarming symptoms present themselves," is decidedly perilous. A mild invasion does not assure a mild course. Never has a "possibly superfluous" tonic or stimulant done harm in diphtheria, but many a case has a sad termination because of a sudden change in the character of the disease, putting the bright hopes of the physician to shame. Only the philosopher may be a passive spectator; the physician must be a guardian. When I again read, in the work of the same meritorious author, "that when in exceptional cases, in children and young people, death is imminent, not from suffocating symptoms in the larynx and trachea, but from septic disease and blood-poisoning, it is necessary to resort to {695} powerful stimulants," it strikes me that he is frequently too dilatory with his remedies, and, furthermore, that his experience concerning the terrible septic form of diphtheria which is so frequently met with in some epidemics must have been very limited at the time he was writing. In New York, during the past twenty-five years, for every death from diphtheritic laryngeal stenosis (membranous croup) there have been three from diphtheritic sepsis or from exhaustion.[39]

[Footnote 39: We have to improve somewhat on the plan of Thomas Wilson, though his general instructions be good (as laid down in his _Tentamen medicum inaugurale de cynanche maliqna_, Edinb., 1790, p. 24): "Cum hactenus nullum inventum est remedium quod contagionem in corpus receptam suffocare possit; cum medicamenta pleraque quæ putredinem corrigere dicuntur, corpus ejusque functiones manifesto roborant; et denique cum hunc morbum comitantur virium prostratio, et, etiam ab initio, summa functionum debilitas, qualis evacuantia omnigena prohibet, indicationem curandi unicam, scil. debilitatis effectibus obviam ire, proponam. Hinc corporis conditioni obviam itur præcipue tonica et stimulantia administrando." (As no remedy has yet been found which can extinguish the contagion after it has been received into the body; as most medicines which have the reputation of correcting putrefaction are roborants for the body and its functions; and, lastly, as this disease is attended with great prostration and such debility of functions as to preclude the use of all sorts of evacuants,--I propose but this one indication for treatment--viz. to meet the effects of debility. This is fulfilled by the administration mainly of tonics and stimulants.)]

In regard to the dose of stimulants, it is a fact that there is more danger in diphtheria from giving too little than too much. When the pulse barely begins to be small and frequent they must be administered at once. A three-year-old child can comfortably take thirty to one hundred and fifty grammes (fl. oz. j-v) of cognac, or one to five grammes of carbonate of ammonium, or a gramme of musk or camphor (gr. xv) and more, in twenty-four hours. In the septic form especially the intoxicating action of alcohol is out of the question; the pulse becomes stronger and slower, and the patient enjoys rest. In those cases in which the pulse is slow, together with a weak heart's action, the dose can hardly be too large. The fear of a bold administration of stimulants will vanish, as does that of the use of large doses of opium in peritonitis, of quinia in pneumonia, or of iodide of potassium in meningitis or syphilis. I know that cases of young children with general sepsis commenced immediately to improve when their one hundred grammes (fl. oz. iij) of brandy were increased to four times that amount in a day.

The remarks I have made in reference to the general treatment of diphtheria naturally render superfluous a discussion of the value of abstraction of blood. To be sure, it could only be a question of local bleeding. For nobody would dare to resort to jugular venesection, as our predecessors did in the last century. It may be safely asserted of the latter that it has no influence on the process, but frequently increases the local swelling and makes the patient more anæmic. There is no case in which a resort to it would not be criminal. I can distinctly recall the time when bleeding and calomel formed the groundwork of the treatment. Until the year 1862 the death-rate in Rupert, Vermont, from diphtheria was 90 per cent., according to the reports of the local physicians, and particularly of my pupil, Dr. Guild, who at that time finished his studies in New York and commenced practising. When, in the same epidemic, bleeding and calomel were replaced by stimulants and iron, with the chlorate of potassium, 90 per cent. recovered.

That attention must be paid to the general condition mainly during a {696} retarded convalescence from previous sickness is self-evident. Any complications, too, must be subjected to early treatment. Diarrhoea must be mentioned among these; it reduces the patient's strength very quickly; likewise, the early appearing nephritis, which may suddenly end life.

In this connection I must allude to the great danger of self-infection, which may occur in every variety of cases, severe or mild. The poison is diffused by expiration and expectoration. Though care may have been taken to disinfect the linen, towels, handkerchiefs, the bedstead and bedding, chairs and wall-papers, and carpets and curtains, even the clothing of the attendants will be infected. While the patient is getting well he will be infected again, and have a more serious relapse; and a third one, and succumb. I have met with such cases often, and with some which went from one attack into another, and would certainly have perished but for their removal to a distant part of the town. Where there are vacant rooms the indication is to change rooms every few days and to thoroughly disinfect (with sulphurous acid) that which has been used and infected.

One important axiom must be borne in mind--namely, that prevention is easier than cure. I do not refer simply to the removal of the healthy members of the family beyond the danger of infection or to the isolation of the patient. If the latter becomes necessary, the first indication is his removal to the top floor of the house. There are, in addition, however, certain prophylactic measures which will prove valuable in the hands of every good physician. It is necessary under all circumstances that the mouth and pharynx of every child be constantly kept in a healthy condition. Eruptions of the scalp must be treated at once, and glandular swellings of the neck caused to disappear. Some cases of laryngeal diphtheria have been traced directly to the presence of suppurating bronchial glands, with or without perforation.[40] The same rule applies to nasal and pharyngeal catarrhs, the treatment of which should be commenced in warm seasons, when general or local remedies yield better results. Enlarged tonsils should be resected, or, where that can not be done, scraped out with Simon's spoon, at a time when no diphtheritic epidemic is raging. It is important that this take place at a time when, even though sporadic cases of diphtheria occur, the danger of infection is not great; for during the height of an epidemic every wound will give rise to general or local infection. This holds good for any part of the body as well as of the mouth. I avoid, therefore, an operation at such a time, provided it can be postponed.

[Footnote 40: Weigert, in _Virch. Arch._, vol. lxxvii., p. 294, 1879.]

Prevention, after all, is not the business of the physician only, but just as much that of the individual or the complex of individuals--viz. the town, the state, and the nation. Those sick with diphtheria must be isolated, though the case appear ever so mild, and, if possible, the other children must be sent out of the house altogether. If that be impossible, let them remain outside the house, in the open air, as long as feasible, with open bedroom windows during the night, in the most distant part of the house, and let their throats, and those of their nurses, be examined every day. The watching eye of a father or mother will discover deviations from the norm, so that the physician can be notified. Let the temperatures {697} of the well children be taken once a day, toward evening. Ten minutes of a mother's time are well paid by the discovery of a slight anomaly which may require the attention of the physician. Happily, there are now many mothers who keep and value a self-registering thermometer as an important addition to their household articles. The attendant upon a case of diphtheria must not get in contact with the rest of the family, particularly the children, after his visiting and handling the patient, for the poison may be carried, though the carrier remain well or apparently well. Unnecessary petting of the patient on the part of the well ought to be avoided, and kissing must be forbidden; the bed-clothing and linen should be changed often and disinfected, the air of the sick-chamber should be cool and often changed, and if possible the chamber itself should be changed every few days.

The well or apparently well children of a family that has diphtheria at home must not go to school nor to church. The former necessity is beginning to be recognized by the authorities and teachers, and also, in consequence of partially enforced habit, by parents; the latter will be resisted longer. Schools ought to be closed entirely when a number of cases have occurred. Even when the school-children have not been affected to a great extent, but an epidemic of diphtheria has commenced in earnest, it will be better to close the schools for a time. If that be not advisable, the teacher ought to be taught to examine throats, and directed to examine every child's throat each morning, and to send home every one with even suspicious appearances.

In times of an epidemic every public place, theatre, ball-room, dining-hall, or tavern ought to be subjected to supervision. Where there is a large conflux of people there are certainly many who carry the disease with them. Disinfection must be enforced by the authorities at regular intervals. Public vehicles must be treated in the same manner. That it should be so when a case of small-pox has happened to be carried in them appears quite natural. Hardly a livery-stable keeper would be found who would not be anxious to destroy the possibility of infection in any of his coaches. He must learn that diphtheria is, or may be, as dangerous a passenger as variola. And what is valid in the case of a poor hack is more so in that of railroad-cars, whether emigrant or Pullman. They ought to be thoroughly disinfected in times of an epidemic, at regular intervals, for the highroads of travel have always been those of epidemic diseases, and railroad officers and their families have often been the first victims of the imported scourge. Can that be accomplished? Will not railroad companies resist a plan of regular disinfection because of its expensiveness? Will there not be an outcry against this as despotic and as a violation of the rights of the citizen? Certainly there will be. But so there was also when municipal authorities began to compel parents to keep their children at home when they had contagious diseases in the family, and when a small-pox patient was arrested because of endangering the passengers in a public vehicle. In such cases it is not society that tyrannizes the individual; it is the individual that endangers society. And society begins at last, even in America, to believe in the rights of the commonwealth, and not in the rights of the democratic person only. The establishment of State and National Boards of Health proves that the narrow-hearted theories of the strict constructionists {698} have not only disappeared from our politics, but also from the conscience and intellect of society.

The sick room must be kept cool, the windows kept open--more or less--by night as well as by day, the floor frequently washed, the linen soaked at once, the excrements removed. Dead bodies ought to be kept moist, for infectious material, chemical or otherwise, will spread more easily when dry. Attendants must not talk unnecessarily over the mouth or diphtheritic wounds of the patient, and will do well to carry a little dry loose cotton--to be changed often--in each of the nostrils, for it aids in protecting those who are necessarily exposed to infection.[41]

[Footnote 41: Wernich, in _F. Cohn's Beitr._, iii., 1859, p. 115.]

A very important mode of prevention consists in disinfection. The experiments of Schotte and Gaertner, and of Sternberg, prove the inefficiency of small doses of most of the disinfectants in common use. The popular idea, sometimes even shared by physicians, that the faint odor of chloride of lime or of carbolic acid in a sick room or in a foul privy is evidence that the place is disinfected, is entirely erroneous. Particularly in regard to the latter agent, it may be stated at once that its employment for disinfecting purposes on a large scale is impracticable, both on account of the expensiveness of the pure acid and the enormous quantities required to produce the desired effect. For in regard to its efficiency it does not rank very high in comparison with a great many other articles, as may be seen from a table of the disinfectant properties of different chemicals published by Miquel in the _Semaine Médicale_.

For practical purposes I know of no better or simpler rules for disinfection than those published by the National Board of Health. In its _Bulletin_ No. 10, of September 6, 1879, the following instructions for disinfection were published: Deodorizers, or substances which destroy smells, are not necessarily disinfectants, and disinfectants do not necessarily have an odor.

"Disinfection cannot compensate for want of cleanliness nor of ventilation.

"I. Disinfectants to be employed:

"1. Roll-sulphur (brimstone) for fumigation.

"2. Sulphate of iron (copperas) dissolved in water in the proportion of one and a half pounds to the gallon; for soil, sewers, etc.

"3. Sulphate of zinc and common salt, dissolved together in water in the proportion of four ounces sulphate and two ounces salt to the gallon; for clothing, bed-linen, etc."

Carbolic acid is not included in the above list, for the following reasons: It is very difficult to determine the quality of the commercial article, and the purchaser can never be certain of securing it of proper strength; it is expensive when of good quality, and experience has shown that it must be employed in comparatively large quantities to be of any use; it is liable by its strong odor to give a false sense of security.

"II. How to use disinfectants:

"1. In the sick-room.--The most available agents are fresh air and cleanliness. The clothing, towels, bed-linen, etc. should, on removal from the patient and before they are taken from the room, be placed in a pail or tub of the zinc solution, boiling hot if possible.

"All discharges should either be received in vessels containing copperas {699} solution, or, when this is impracticable, should be immediately covered with copperas solution. All vessels used about the patient should be cleansed with the same solution.

"Unnecessary furniture--especially that which is stuffed--carpets and hangings, should, when possible, be removed from the room at the outset; otherwise they should remain for subsequent fumigation and treatment.

"2. Fumigation with sulphur is the only practical method for disinfecting the house. For this purpose the rooms to be disinfected must be vacated. Heavy clothing, blankets, bedding, and other articles which cannot be treated with zinc solution should be opened and exposed during fumigation, as directed below. Close the rooms as tightly as possible, place the sulphur in iron pans supported upon bricks placed in wash-tubs containing a little water, set it on fire by hot coals or with the aid of a spoonful of alcohol, and allow the room to remain closed for twenty-four hours. For a room about ten feet square at least two pounds of sulphur should be used; for larger rooms proportionately increased quantities.

"3. Premises.--Cellars, yards, stables, gutters, privies, cesspools, water-closets, drains, sewers, etc. should be frequently and liberally treated with copperas solution. The copperas solution is easily prepared by hanging a basket containing about sixty pounds of copperas in a barrel of water.

"4. Body- and bed-clothing, etc.--It is best to burn all articles which have been in contact with persons sick with contagious or infectious diseases. Articles too valuable to be destroyed should be treated as follows:

"A. Cotton, linen, flannel, blankets, etc. should be treated with the boiling-hot zinc solution; introduce piece by piece; secure thorough wetting, and boil for at least half an hour.

"B. Heavy woollen clothing, silks, furs, stuffed bed-covers, beds, and other articles which cannot be treated with the zinc solution, should be hung in the room during fumigation, their surfaces thoroughly exposed and pockets turned inside out. Afterward, they should be hung in the open air, beaten, and shaken. Pillows, beds, stuffed mattresses, upholstered furniture, etc. should be cut open, the contents spread out, and thoroughly fumigated. Carpets are best fumigated on the floor, but should afterward be removed to the open air and thoroughly beaten.

"5. Corpses should be thoroughly washed with a zinc solution of double strength; should then be wrapped in a sheet wet with the zinc solution, and buried at once. Metallic, metal-lined, or air-tight coffins should be used when possible; certainly when the body is to be transported for any considerable distance.

"It might have been added here that no public funeral must be permitted."

In this connection I have to speak of a remedy which I class among the prophylactic agents--namely, the chlorate of potassium or the chlorate of sodium. I cannot say that I rely on either of these remedies as curative agents in diphtheria, and yet I employ them in almost every case. The reason lies in the fact that the chlorate is useful in most cases of stomatitis, and thereby acts as a preventive.

There are very few cases of diphtheria which do not exhibit larger surfaces of either pharyngitis or stomatitis than of diphtheritic membrane. There are also a number of cases of stomatitis and pharyngitis, {700} during every epidemic of diphtheria, which must be referred to the epidemic, sometimes as kindred diseases, and sometimes as introductory stages only, which, however, do not, or do not in the beginning, show the characteristic symptoms of the disease.

When, in 1860,[42] I wrote my first paper on diphtheria, I based it upon two hundred genuine cases, and at the same time enumerated one hundred and eighty-five cases of pharyngitis, which I considered to be brought on by epidemic influences, but which, the membrane being absent, could not be classified as bonâ fide cases of diphtheria.

[Footnote 42: _Amer. Med. Times_, Aug. 11th and 18th.]

Such cases of pharyngitis and stomatitis, no matter whether influenced by an epidemic or not, furnish the indication for the use of chlorate of potassium. They will usually get well with this treatment alone. The cases of genuine diphtheria, complicated with a great deal of stomatitis and pharyngitis, also indicate the use of chlorate of potassium; not, however, as a remedy for the diphtheria, but as a remedy for the accompanying catarrhal condition in the neighborhood of the diphtheritic exudation. For it is a fact that, as long as the parts in the neighborhood of the diphtheritic exudation are in a healthy condition, there is but little danger of the disease spreading over the surface. Whenever the neighboring surface is affected with catarrh or inflammation, or injured so that the epithelium gets loose or thrown off, the diphtheritic exudation will spread within a very short time. Thus chlorate of potassium or sodium, the latter of which is more soluble and more easily digested than the former, will act as a preventive rather than as a curative remedy. Therefore it is that common cases of pharyngeal diphtheria will recover under this treatment alone; and these are the cases which have given its reputation to chlorate of potassium as a remedy for diphtheria.

The dose of chlorate of potassium for a child two or three years old should not be larger than half a drachm (2 grammes) in twenty-four hours. A baby of one year or less should not take more than one scruple (1.25 grammes) a day. The dose for an adult should not be more than a drachm and a half, or at most two drachms (6 or 8 grammes), in the course of twenty-four hours.