individualizing, and the impossibility of treating all cases alike,
than the fact that many will do well under steam treatment, and others
are certainly injured by it. I have repeatedly had the joy of seeing
children with croup become less cyanotic after their removal from an
atmosphere of vapor, and I can readily see that pure atmospheric air
would be more agreeable and wholesome to a child with stenosis of the
larynx than an atmosphere laden with steam. Of course this remark does
not apply to cases of pseudo-croup and bronchitis, which are generally
benefited by a warm, moist atmosphere. Those, however, who deem it
judicious to employ steam as a vehicle for carbolic acid, salicylic
acid, chloride of sodium, chlorate of potassium, or lime, had best
resort to the atomizer for applying these remedies. It can be used
without trouble; most children are sufficiently intelligent to allow
the spray to be directed upon the fauces and larynx every ten or
fifteen minutes in case of necessity. When it is deemed advisable to
administer steam, I warn against the use of gas stoves. They require a
great deal more oxygen than an alcohol lamp, which ought to be
preferred when a stove or slaking lime or hot iron or bricks immersed
in water are not available.
Water may be made serviceable in different ways. Its effect on the
skin, when taken in large quantities, under normal or abnormal
circumstances, is a matter of daily experience. Copious perspiration
is its immediate result. The very same effect is produced on the
mucous membranes. In diphtheria, besides professional hydropathists, I
know of but one[46] who favors the plentiful use of water, 100-200
grammes (3-6 ounces) every hour or oftener, either by itself or mixed
with an alcoholic beverage.
[Footnote 46: C. Rauchfuss, in _C. Gerhardt's Handb. d. Kinderkr._,
iii. 2, 1878.]
Severe inflammatory symptoms, such as redness of the throat, great
pain, swelling of the glands, require cold applications, either an
ice-bag or ice-cold cloths well pressed out and frequently changed.
They must, however, be placed where they can do most good--in
laryngeal diphtheria around the neck, in pharyngeal diphtheria with
glandular swelling over the affected part. In the latter, therefore,
the flannel cloth which covers the whole of the application must be
tied over the head, and not behind. When ice-bags are used, care is to
be taken lest they should be too large; if so, they will not affect
the desired spot at all. Small pieces of ice frequently swallowed are
greatly relished by the patient; water-ices in small quantities will
render the same service; ice-cream, in half-teaspoon or teaspoon doses
every five or ten minutes, adds to the necessary nutriment. When the
fever is high and the surface hot, sponging with tepid or cold water,
or water and alcohol, will mitigate both. For the cold bath or the
cold partial pack (trunk and upper part of the thighs) the general
indications hold good. As a rule, I favor the latter, for many cases
have such a tendency to debility and collapse that sometimes the
circulation of the surface of the body is badly interfered with by
cold bathing. Therefore, a contraindication to cold bathing must be
found at once in cold feet, either before or after a bath. When,
unfortunately, the feet do not recover their normal temperature in a
very short time, they ought to be warmed artificially, and the cold
bath not repeated. In such cases the cold pack, however, is still
indicated. A linen or cotton cloth, {703} large enough to cover the
trunk and half of the thighs, is dipped in cold water, well pressed
out, and the body of the patient wrapped tightly in it. The arms
remain outside; the whole body is then wrapped up in a blanket; the
feet may be warmed meanwhile when necessary, and the cold pack
repeated as often as required to reduce the temperature--viz. once
every five minutes, every half hour, every hour.
The contraindications to the use of cold have in part been alluded to.
Very young infants bear it but to a limited extent. The beginning of
recovery contraindicates it, unless for some local cause; for
instance, an inflamed gland. The extensive use of cold water or ice is
also forbidden when there is no fever, where there is perhaps an
abnormally low temperature, where we have to deal with the septic or
gangrenous form of diphtheria, where the vitality is low and the
mucous membranes pale or even cyanotic. In such cases, on the
contrary, while unlimited internal stimulation is required, the hot
bath, or hot pack and hot injections into the bowel, will be found
beneficial.
Lime-water, glycerine, lactic acid, pepsin, neurin, papayotin,
chinolin, and pilocarpine are all solvents of pseudo-membrane, but
whether there is sufficient time and opportunity to produce a curative
effect by every one of them is a question open for discussion. Of
lime-water and glycerine I have employed a mixture of equal parts in
considerably more than a hundred cases after the completion of
tracheotomy, directing the remedy through an atomizer into and below
the canula, but cannot say that the descent of the membrane into the
trachea or bronchi was prevented by it. Lime-water may be used in the
nose and throat as an injection, spray, or gargle, but its solvent
effect is greatly diminished by the action of the carbonic acid of the
breath on the lime. I have no doubt that if water alone was used with
the same persistence as lime-water, its effects would be nearly the
same. Still, what little effect the minute dose of lime (1:800) in the
lime-water may have may just as well be utilized. What I object to is
the omission of more powerful agents. If lime is to be used, slaking
lime frequently in the presence of the patient is attended with vastly
more benefit, inasmuch as by that proceeding a large amount of
powdered lime is projected into the air of the room and the mouth and
respiratory organs.
Lactic acid also, in from ten to twenty-five parts of water, has
yielded no better results in my hands. Those cases of tracheotomy
which I afterward treated with lactic acid spray terminated no better
than such as were treated with lime-water and glycerine. Of the
solvent effect of pepsin I have not been able to convince myself so as
to recommend it. The accounts of neurin have not encouraged me to try
it at all. Chinolin (tartrate) has been used locally by O.
Seifert,[47] Müller, and others. It is said to remove the membranes
and relieve the fever. For a gargle it is dissolved in five hundred
parts of water, or it is mixed with ten parts of water and alcohol
each, and applied by means of a sponge. To relieve the burning
sensation ice is swallowed afterward. The local applications of
alcohol have the same drawback. There are but few patients who do not
suffer intensely from its local contact.
[Footnote 47: _Berl. klin. Woch._, Nos. 36, 37, 1883.]
Papayotin has been recommended by Rossbach for the purpose of
dissolving membranes in a one-half per cent. solution. It peptonizes
{704} albuminoids, and macerates meat, intestinal worms, and croup
membranes in both neutral and feebly alkaline solution. In
concentrated solutions it has a caustic effect. It is recommended, not
as an anti-diphtheritic, but merely as a solvent remedy.[48] Whatever
reliance may have been placed upon it has, however, been jeopardized
by Rossbach's remarks[49] on the variability of the preparations in
the market. Not only are the specimens very unequal, but each of them
is variable, easily spoiled, and particularly affected by moisture.
[Footnote 48: _Berl. klin. Woch._, March 10, 1881.]
[Footnote 49: _Transactions of the Congress for Int. Medicine_, 1883,
p. 162.]
Muriate of pilocarpine was recommended for this purpose three years
ago. It was praised by Juttmann as a specific, and has failed. The
quackish recommendations of the drug have, indeed, earned for it a
certain amount of distrust which it does not deserve in all cases. It
is expected to increase the secretion of the mucous membranes to such
an extent as to float the pseudo-membranes. It sometimes succeeds in
so doing, but only in those cases in which the membrane is deposited
upon the mucous membranes. When the tissue is impregnated the drug
fails. It also fails in septic cases, and mostly for the reason that
it diminishes and paralyzes the heart's action. It ought, therefore,
never to be given unaccompanied with large amounts of stimulants.
Where the patient is strong, and the heart healthy, it may be tried; I
know that a few cases of moderate laryngeal diphtheria improved with
pilocarpine, steam, and turpentine inhalations. The dose is 1/30
grain, dissolved in water, every hour.
Turpentine inhalations were recommended by C. Edel.[50] Fifteen drops
of oil of turpentine are inhaled from a common inhalation apparatus,
which is placed at a distance of three inches from the mouth of the
patient, for a period of ten minutes every hour. He claims recoveries
in from twelve to forty-eight hours. I allow the patient to remain in
his bed, and keep water boiling constantly on an alcohol lamp, on the
stove, or over the gas. A tablespoonful of turpentine, more or less,
is poured on the water, care being taken that nothing is spilled in
the fire. Thus the room is constantly filled with a penetrating odor
of turpentine, which is not at all disagreeable, even when in great
concentration. The effects are very satisfactory indeed. Where
circumstances allowed or required it I have raised a tent over the
bed, large enough not to give inconvenience to the patient and to
admit either the whole apparatus or the tube containing the mixed
vapor of water and turpentine.
[Footnote 50: _Med. Rev._, Jan. 19, 1878.]
Ammonium chloride may sometimes be used to advantage for its softening
and liquefying effects. Its internal administration in bronchial and
tracheo-laryngeal catarrh is so old that it has several times been
obsolete. Of late, more stimulant effects have been attributed to it
than it actually possesses. But its liquefying action, in cases where
the secretion of mucus is defective and expectoration scanty and
viscid, is undoubted. Thus it proves valuable in many cases of simple
catarrh, both when administered internally and inhaled. The latter
mode I have often resorted to, and believe that its macerating
influence has been of service to me in cases of laryngeal diphtheria.
Half a teaspoonful of the pure salt is spread on the stove or burned
over alcohol {705} or gas. It evaporates immediately, and fills the
room or the tent with a white cloud, which, when dense, excites
coughing. But it does not irritate to any uncomfortable degree, and
the process may be repeated in an interval of an hour or more.
Not all cases of diphtheria are septic or gangrenous, nor are all the
cases occurring during an epidemic of the same type. Some have the
well-pronounced character of a local disease, either on the tonsils or
in the larynx. The cases of sporadic croup met with in the intervals
between epidemics present few constitutional symptoms, and assume more
the nature of an active inflammatory disease--very much like the
sporadic cases of fibrinous tracheo-bronchitis. These are the cases in
which mercury deserves to have friends, apologists, and even
eulogists. Calomel, 0.5-0.75 gramme (gr. viij-xij), divided into
thirty or forty doses, of which one is taken every half hour, is apt
to produce a constitutional effect very soon. Such doses, with minute
doses, a milligramme or more (gr. 1/60), of tartar emetic, or ten or
twenty times that amount of oxysulphuret of antimony, have served me
well in fibrinous tracheo-bronchitis. But the mucous membrane of the
trachea and bronchi is more apt to submit to such liquefying and
macerating treatment than the vocal cords. The latter have no
muciparous glands like the former, in which they are very copious. And
while the tracheal membrane, even though recent, is apt to be thrown
out of a tracheal incision at once, the pseudo-membrane of the vocal
cords takes from six days to sixteen or more for complete removal.
Still, a certain effect may even here be accomplished, for maceration
does not depend only on the local secretion of the muciparous glands,
but on the total secretion of the surface, which will be in constant
contact with the whole respiratory tract. Thus, either on theoretical
principles or on the ground of actual experience, men of learning and
judgment have used mercury in such cases as I detailed above, with a
certain confidence.
If ever mercury is expected to do any good in cases of suffocation by
membrane, it must be made to act promptly. That is what the blue
ointment does not. In its place I recommend the oleate, of which ten
or twelve drops may be rubbed into the skin along the inside of the
forearms or thighs (or anywhere when their surface becomes irritated)
every hour or two hours. Or broken doses will be useful, such as given
above, or hypodermic injections of corrosive sublimate in 1/2 or 1 per
cent. solution in distilled water, four or five drops from four to six
times a day, or more, either by itself or in combination with the
extensive use of the oleate, or with calomel internally. Lately, the
cyanide of mercury has been recommended very strongly. I hardly
believe that it will work more wonders than any other equally soluble
preparation. Within the past few years the internal administration of
bichloride of mercury has been resorted to more frequently and with
greater success than ever before. My own recent experience with it has
been encouraging, and so has that of some of my friends. Wm.
Pepper[51] gave 1/32 grain of corrosive sublimate every two hours in a
bad form of diphtheritic croup, with favorable result. But in this
very bad case, desperate though it was--child of five years, resp. 70,
pulse 160--large membranes, "evidently from the larynx," had been
expelled before the treatment was commenced on the {706} seventh day
of the disease. The remedy ought to be given in solution of 1:5000,
and in good doses. A baby a year old may take one-half grain every day
for many days in succession, with very little if any intestinal
disorder and with no stomatitis.[52] A solution of the corrosive
chloride of mercury in water is frequently employed of late as a
disinfectant. It acts as such in a dilution of 1:20,000. As healthy
mucous membranes bear quite well a proportion of 1:2000-3000, any
strength between these extremes maybe utilized. A grain of the
sublimate in a pint or more of water, with a drachm of table-salt,
will be found both mild and efficient. As a gargle or nasal injection
it will be found equally good. But it has appeared to me that frequent
applications give rise to a copious mucous discharge; hourly
injections into a diphtheritic vagina became quite obnoxious by such
over-secretion, which ceased at once when the injections were
discontinued. Thus, when it is desirable not only to disinfect but
also to cleanse the diseased surface, the injections with corrosive
sublimate appear to yield a result inferior to less irritating
applications.
[Footnote 51: _Trans. Am. Med. Ass._, 1881.]
[Footnote 52: _Med. Record_, May 24, 1884.]
Chloride of iron is undoubtedly a valuable remedy in diphtheria, but
in its administration it must by no means be forgotten that small
doses at long intervals are out of the question. I have not the least
doubt but that the failure of the remedy may be attributed in most
cases to the fact that the doses were too small and administered too
seldom. A dose of from five to fifteen drops, properly diluted, every
fifteen minutes, half hour, or hour is indispensable for a proper
estimation of its effects. Gargles are not of much service, for the
simple reason that they do not come into sufficient contact with the
affected parts, and reach at the utmost to the anterior pillars of the
soft palate. A direct application of the remedy to the mucous membrane
of the pharynx may also be desisted from, thereby avoiding any
irritation, the internal administration at short intervals causing the
pharynx to be sufficiently influenced by local contact with the
remedy. It must, of course, not be expected that the chloride will
remove the membrane, but it can frequently be seen to reduce the
hyperæmia and swelling and prevent the reproduction of exuded
material. The chloride of iron exerts a decided influence on the vital
contractility of the blood-vessels. This increased contractility
certainly assists in diminishing the rapidity of absorption of putrid
fluids through the blood-vessels, which constitutes the principal
source of danger from the disease.
It cannot yet be positively asserted that the chloride of iron exerts
a direct effect on the lymphatic vessels. Naturally, this was claimed
when the remedy was recommended, in the treatment of diphtheria, on
account of its therapeutic effects in erysipelas, with the
accompanying inflammation of the lymphatic vessels of the skin.
Although we know of no direct compression of the lymphatic vessels due
to the action of the chloride, yet it may be assumed that perhaps the
compression of the blood-vessels exerts a similar influence upon the
neighboring lymphatics. In consequence of this there would be an
impediment to the absorption and further development of poisonous
substances in the lymph. The chloride, like the sulphate of iron, is a
tolerably powerful disinfecting agent. If this observation be correct,
it may go very far toward explaining the action {707} of the chloride
of iron in septic diseases, which are accompanied by an exalted
activity of the lymphatic vessels and an increase of the white
blood-corpuscles. Furthermore, Saase has endeavored to show that the
ferrous salts possess the power of converting oxygen into ozone. They
share this power with the blood-globules exclusively, and could hence,
to a certain degree, supply a deficiency of the latter. Pokrowsky,
too, has shown that iron increases the process of oxidation in the
body by demonstrating that in health there is an elevation of
temperature and an increase of the percentage of urea in the urine
during its administration. In anæmic persons, to whom iron has been
given for the purpose of increasing the amount of blood, the above
phenomena may be observed before this object is accomplished. Thus
iron appears to replace the blood-corpuscles to a certain extent. Now,
in infectious disorders of the blood, where the red globules are
perpetually menaced with destruction, it seems plausible that the
preparations of iron should exert an antiseptic action.
Finally, it has been found that of all the preparations of iron the
chloride possesses the greatest power of stimulating the nervous
system. Possibly this effect may be traced to an increase of the
arterial pressure in the nerve-centres. It has been said that this
effect has been vividly illustrated in certain forms of chlorosis. If
this be true, iron would be all the more indicated in diphtheria,
since it would act as a prophylactic against a series of nervous
phenomena that so frequently present themselves, both during and
subsequently to the diphtheritic process. Thus it is that for many
years the muriate of iron has constituted the main element, with me,
of internal medication in most cases of diphtheria, both of the mild
and the most dangerous septic type. A common formula is, for a child
of two years,
Rx. Tinct. Ferri Chloridi fl. drachm ij;
Potass. Chlorat. gr. xx;
Aquæ fl. oz. v;
Glycerin. Pur. fl. oz. j. M.
S. A teaspoonful every fifteen, twenty, or thirty minutes.
Carbolic acid exerts a powerful influence on the vitality of all
living elements, and hence also on rapidly proliferating epithelium,
which constitutes a part of the diphtheritic membrane. It is of great
advantage for local use. Its local effect, undiluted or diluted with
equal or larger parts of glycerine or alcohol, in shrinking and
removing membranes, is sometimes very useful; in mild solutions in
water (1/2, 1, or 2 per cent.) it is very efficient in nasal
injections or for external applications or mouth-washes. Rothe's
prescription for external use is carbolic acid and alcohol each 2
parts, water 10, tincture of iodine 1. Its internal administration to
the extent of five to twenty grains daily, given largely diluted, in
small and frequent doses, is of less positive value.
Salicylic acid, in a solution of 1:30-50, is caustic. A milder
solution, 1:200-300 relieves or removes foul odor from the nose or
throat, but it does not detach membranes or shorten the duration of
the disease, apparently. Internally, it acts no longer as a
disinfectant, but is changed into a salicylate and is an antipyretic.
It is then better to replace it by the sodium salicylate. With its
administration (for a child of 2 years 3 grains every hour until 20 or
25 grains are taken) it ought not to be {708} forgotten that serious
brain troubles, collapse, and irregular and paralytic breathing, as
well as gastric and intestinal disturbances, may follow its use. It
ought not to be given without careful watching and the simultaneous
free use of alcoholic stimulants.
Binz found, as the result of experiments with solutions of pure quinia
varying from one part in a hundred to one in a thousand, that the
latter sufficed to prevent the development of bacteria in fluids
capable of undergoing putrefaction; but even estimated thus, a patient
with eighteen pounds of blood would require one hundred and
thirty-eight grains of quinia circulating therein in order to satisfy
the conditions of Binz's experiment. If Binz considers two grammes
(half a drachm) of quinia per day sufficient for an individual
weighing one hundred and twenty pounds, his calculation is founded on
experiments with dogs, in which septicæmia was avoided by the
injection of quinia. It is also necessary to bear in mind that Binz
makes a distinction with regard to the preparations of quinia
employed. He warns against the use of the bisulphate as being the most
inactive. No matter which preparations are used--I prefer the
muriate--I have come to look upon quinia as of no great service in
reducing the temperature in infectious fevers. The main indication for
its use can only be found in inflammatory fevers. When it is given,
however, salicylate of sodium may be added for a short time to obtain
a speedier effect.
On the part of bromine Wm. H. Thompson claims the following
advantages: 1. When applied locally, it promptly arrests fetor by
arresting directly the gangrenous process, and thus lessens risk from
absorption. 2. It acts as an anti-putrefactive likewise in the fluids
of the body generally--_i.e._ blood, interstitial circulation, and
secretions--owing to its high rate of diffusibility, equal to that of
sodium chloride itself. 3. It locally destroys the communicable
property of the discharges, shown by the immunity of attendants from
any sore throat when it is used, and from its checking the spread of
the disease in the locality. He orders two solutions to be used: the
first of equal parts of Lawrence Smith's solutio bromini and of
glycerine, applied with a hair pencil to the membrane, as gently as
possible. Sometimes he uses the solution full strength. The brush
should be washed at once in water, and does not last more than one
day, owing to the action of the bromine on the hair. If, however, the
membrane be very extensive and the parts much swollen or difficult to
reach, he resorts instead to douching with a Davidson syringe, using
half a drachm to one drachm of the solution to a pint of warm water.
By beginning gently with the stream directed against the buccal mucous
membrane, the child soon becomes accustomed to the current and allows
it then to play against the deeper parts.
Internally he orders from six to twelve drops of the solution in a
half ounce of sweetened water, every hour, two, or three hours,
according to the urgency of the case, and continuously.
The most convenient way of making Smith's solution is: Take two ounces
of a saturated solution of potassium bromide in water; add to this,
very slowly, in a bottle and with constant shaking, one ounce of
bromine. It is better to add a part, and then let it stand a while
before adding the rest; then fill up gradually, and with constant
shaking with water, until it measures four ounces.
{709} Ozone has been used as an anti-fermentative in inhalation during
three or five minutes every hour or two, by Jochheim.