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.
The effect of the chlorate of potassium is partly a general and partly
a local one. The general effect may be obtained by the use of
occasional larger doses, but it is better not to strain the
eliminating powers of the system. The local effect, however, cannot be
obtained with occasional doses, but only by doses so frequently
repeated that the remedy is in almost constant contact with the
diseased surface. Thus, the doses, to produce the local effect, should
be very small, but frequently administered. It is better that the
daily quantity of twenty grains should be given in fifty or sixty
doses than in eight or ten; that is, the solution should be weak, and
a drachm or half a drachm of such solution can be given every hour or
every half hour or every fifteen or twenty minutes, care being taken
that no water or other drink is given soon after the remedy has been
administered, for obvious reasons.
I have referred to these facts with so much emphasis because of late
an attempt has been made to introduce chlorate of potassium as the
main remedy in bad cases of diphtheria, and, what is worse, in large
doses (Seeligmüller, Sachse, L. Weigert, C. Küster, Edlefsen.)
{701} Large doses of chlorate of potassium (2 drachms daily to an
adult I claim to be a large dose, particularly when its use is
persisted in for many days in succession) are dangerous. In several of
my writings I have given instances of its fatal effects.[43] I have
seen fatal cases since, and scores have been published in different
journals. The first effects of a moderately large dose are gastric
and, more especially, renal irritation; the latter it was which I
experienced when I took half an ounce twenty-five years ago. Fountain
of Davenport, Iowa, experienced the same before more serious symptoms
developed, of which he died.[44] The symptoms are those of acute
diffuse nephritis, with suppression of urine, or scanty secretion of a
little black blood, and uræmia deepening toward death in fatal cases.
My earlier cases I considered as primary diffuse nephritis, and I have
even been inclined to attribute the frequent appearance of chronic
nephritis, amongst all classes and ages, in part to the influence of
the chlorates, which have become a popular domestic remedy and are
found in every household. But the experimental researches of
Marchand[45] and others prove that, at least in many instances, the
extensive destruction of blood-cells is the first and immediate result
of the introduction into the circulation of the chlorate, and that the
visceral changes are due to embolic processes.
[Footnote 43: _C. Gerhardt's Handbuch der Kinderkrankheiten_, vol.
ii., 1876; _Med. Record_, March, 1879; _Treatise on Diphtheria_,
1880.]
[Footnote 44: Stillé, _Therap. and Mat. Med._, 2d ed., 1874, p. 922.]
[Footnote 45: _Sitzungsber. d. Naturforsch. Ges. h. u. Halle_, Feb. 8,
1879, and _Virch. Arch._, vol. lxxvii.]
Special Treatment.--The first axiom in the treatment of diphtheria is
that there is no specific; the second, that in no other disease the
individualizing powers of the physician are tested more severely.
The treatment is both internal and external. The local remedies are
either such as dissolve the mucous membrane, or such as thoroughly
modify the mucous membrane from which the pseudo-membrane has been
removed, or real antiseptics, with the power of destroying either
chemical or parasitic poisons.
The number of remedies recommended in diphtheria is immense. No other
proof of its dangerous nature is needed. In the following I shall
review those which I consider it worth while either to reject or to
recommend.
Steam is used partly to soften the membranes, but principally to
increase the secretion from the mucous membrane, and thereby throw off
the superjacent membrane. This can be done to advantage only where
there is a natural tendency to it; that is, where there are a great
many muciparous follicles under a cylindrical or fimbriated
epithelium. This is the condition on part of the pharynx, but not on
the tonsils; and in a small portion of the larynx, in the trachea and
bronchi, but not on the vocal cords. Wherever there is pavement
epithelium on the normal surface, and where the membrane is imbedded
into the tissue, steam can hardly be expected to do good. In the other
cases it will. Thus, the locality of the diphtheritic process
determines to a great extent whether steam is indicated or not. If it
be used, the necessity of a full supply of atmospheric air must not be
disregarded. Steam, with an overheated room and without pure air, is
liable to be as injurious as steam in pure air is beneficial in a
number of cases.