Entered according to Act of Congress, in the year 1864, by
H. C. G. LUYTIES,
In the Clerk's Office of the District Court of the United States,
For the Eastern District of Missouri.



PREFACE TO THE SECOND EDITION.
In offering the Second Edition of this volume to
the Profession, the Author would state that he has
endeavored to make such alterations and corrections as the present state of our knowledge of Diphtheria demands, and has expunged and modified
other portions of the work according to the experience of the best practitioners of the Homceopathic
School. A considerable number of pages, treating
of the Surgical management of Diphtheria, have
been omitted, and their place supplied with other
matter which will probably be of more service to
the generality of practitioners; enough, however,
has been allowed to remain to give the reader an
idea of the utility of such means and the opinions
of others as to their expediency. The whole chapter on the "Treatment," has been re-modeled, and
all the newer medicines been added to the list of
remedial agents which have been found serviceable
in the affection. Sections on the "Manner of Recovery," and "Manner of Death," with some hints
as to the further Pathology, have been incorporated
with the text.
With such modifications and corrections, the Author would again claim the indulgence of his professional friends, for the many imperfections of
this treatise, relying, in a measure, on the favor
with which the first edition has been received, and
trusting that what has been added will increase
the usefulness and practical value of the work,
No. 209 PINE ST.,
St. Louis, Mo. Sept. 5th, 1864.






DIPHTHERIA.
CHAPTER I.
SECTION I.
Synonyms employed at different eras to designate the
dispease.
The term Diphtheria is of Greek derivation, the
terms J~'~.pa and /Je'Orpepc having both the same
signification — the prepared skin of an animal.
aJ,&porric and AJe&poaw. both signify that which is
covered with skin.
The terms that have been used at different periods
to designate the disease are- -
I. MALUM EGYPTIACUM, as described by Aretreus
the Cappadocian, also called by him Ulcus Syriacus.
II. MoRBus SUFFOCANS, described by Villa Real,
as the disease appeared in Andalusia in 1590-91,
the title of the work being "(Joannis de Villa Real
de Signis, Causis, Essentia, Prognostico et CzurationeMorbi Suffocantis.)  Compluti 1611."
III. GARRoTILLo-described by Fontecha —the
title being "(Disputationes Medicwe super ea quce
Hippocrates, Galenus, Avicenas, necnon et alii Grceci,



1It              DIPHTHERIA.
i'rabes et Latini, de Anginarum naturis, speciebtus
causis et curationibus scripsere diversis in locis; et
circa aft ctionem hisce temporibus vocatam GARROTILLO. Opus Doctoris Johannis Alphonsi de Fontecha, &c. Compluti 1611." Also described under
the same name by Herrera, early in the seventeenth century —De Essentia Causis, Nlotis, Prcesagio,
Curatione, et Prcecautione Faucium  et Gutturis
Anginosorum  Ulcerum, Morbi Suffbcantis, GARROTILLO Hispane appellati, &c.  Authore, Doctore
Christophero Perez de Herrera, &c. Matriti, 1615.
IV. EPIDEMICUS STRANGULATORIUS —as it appeared in 1618 at Naples, the popular name of the
disorder being "male de canna," disease of the
trachea-described by Nola Carnevale, Syambiti
and others.
V. GULAE MoRBus-as it was known in Sicily in
1600-25-described by Cortesius-"Joannis Baptistee Cortesii, Miscellaneorumz Medicinaliunm Decades
Denoe, p. 696, Messana, 1625."
Vi.. ULcus SYRIAcUS-as it was seen in Syria and
C:clo-Syria, by Alaymus (lMarci Antonii Alaymi,
(onsultltatio, pro Ulceris Syriaci nunc Vagantis curation e, p. 54, 1632.)
VII. MIoRBus  STRANGULATORIUS — noticed in
London in 1739-1746, by Dr. Forthergill —the title
being " An account of the Putrid Sore Throat, by
JOHN:EFORTHERGILL,   M. D., pp. 32, 34.  Fifth
edition. London: 1769."
VIII. ANGINA SUFFOCATIVA - as:described by
rr. Bard, of New York-his work being "An in~uiry into tfe nature, cause and cure of the Angina



DIPHTHERIA.              11
Stufocativa or Sore Throat Distemper, by SAM'L BARD,
M. D."
Transactions of the American Philosophical Society, vol. 1, pp. 388, 404. Philadelphia: 1789.
IX. DIPHTHERITE —as described by M. Bretonneau, of Tours, in two memoirs, in 1821, also in
1825-26-as the disease appeared in different parts
of France.
X. PSEUDO, MEMBRANOUS PHARYNGITIS, ANGINA
PSEUDO MEMBRANOSA —as described by Churchill,
"Diseases of Children," p. 468; Meig's Diseases of
Children, p. 208, and other modern authors.
XI. DIPHTHERIA-Of the nineteenth century.
SECTION II.
Remarks: History of the different Epidemics;
Antiquity of the Disease.
In the whole range of disorders that the physician
encounters, there is none more calculated to deceive
the inexperienced practitioner-both as to its course
and termination-than Diphtheria. Its ravages have
made its name a dreaded word in civilized communities in all parts of the globe-the insidious
nature of the complaint having rendered it the
terror of parents and the' dread of the medical
practitioner.
Can there be to the mind of the humane man any
thing more sorrowful, than the knowledge that tells
of the certain and speedy death of a beautiful child
who was but yesterday stricken with disease?



12              DIPHTHERIA.
There she sits, her breathing (during her waking
hours) not much impaired, playing with her toys,
swallowing food and drink readily; nay, standing
upright upon her feet, and moving as either inclination or command dictates. Yet Death has set his
seal upon her brow. You know it from the appearance of the face; from a peculiar lustre in the
bright blue eye; from the horrible rattling breathing while:she sleeps; from  the slight venous
congestion in the cheek; from the alternate and
almost periodical nature of the pains in the limbs;
from the occasional ringing cough; and your duty
calls you to reveal that which your feelings would
gladly conceal —Death, certain and speedy —perhaps
torturing, suffocating death.
Such cases are vivid in my mind, and I have
been dismissed from the patient as forming a rash
and harsh diagnosis-while others have been called
whose more favorable prognosis for a time rekindled the dying hope, only to be suddenly and
fearfully blotted out forever.
HISTORY.-For the last few years the medical
periodicals have all been fruitful in papers, essays,
etc., upon Diphtheria. Some of these possess much
merit, and others are but the records of ordinary
cases of diphtheritic sore throat, which usually
prevail at the same time with true Diphtheria,
and which may readily pass into the more malignant form of the disease.
Diphtheria is no new disorder in the literature of
medicine, although it really is so to many medica
practitioners of this century. It has made its



DIPHTHERIA.                 13
appearance in many parts of the world, and has
received the attentive observation and study of
cultivated minds. Its great antiquity cannot be
doubted. In the Fiske Fund Prize Essay upon
Diphtheria,* Dr. Slade remarks, "That there is
reason to suppose that we can trace back the history
of this affection to a period almost cotemporary
with Homer." Whether this be the case or not,
certain it is that ten centuries after, we find distinct
descriptions of a form of malignant sore throat in
the writings of Aretseus, under the name of Egyptian or Syrian Ulcer.
At Rome, A.D., 380, a similar epidemic occurred,
and to such an extent, that propitiatory offerings
were made to the Gods: "Ut populus Romanus,
morbo qui angina dicitur, promisso voto, sit liberatus."
In the years 1337 and 1557 the disorder prevailed
in Holland; and in 1576 some parts of France were
visited by the disease. According to Greenhow,t
Fontecha, whose work was published in 1611, (vide
section 1,) had seen the affection as early as 1581;
and adds, that it prevailed as an epidemic in 1599
and 1600.
Villa Real records the presence of the disorder
in Andalusia and other parts of Spain in 1590 and
1591.
"- Diphtheria-Its Nature and Treatment. By Daniel Denison Slade, M. D.
Philadelphia: 1861.
t On Diphtheria. By Edward Headlam Greenhow, M.D. Bailliere Bro.:
1861.



14                DIPHTHERIA.
The earliest mention, however, is that made by
Aretmus, who writes of its appearance in Egypt,
Syria and Coelo-Syria, and alludes to the foetor from
the mouth, the regurgitation of fluids through the
nostrils, hoarseness and aphonia, which certainly
are among the symptoms noticed.
According to Villa Real (who designated Diphtheria as morbus suffocans) hemorrhage from the
nose and mouth was invariably fatal; and Herrera,
speaking of the Spanish epidemic, describes eight
varieties, which are said to correspond nearly to
what has been observed during the present century.
Of the epidemic which invaded Sicily, where the
disorder received the name guilc morbus, Cortesius
notices the frequent occurrence of several fatal
attacks in the same family; and Alaymus states
that the invasion was most generally noticed upon
the tonsils, or in the fauces, and occasionally in
the nostrils.
A disease termed morbits strangulatorius had been
observed in London in 1739, which continued
periodically until 1746, when it broke out in an
alarming manner at Bromley, in Middlesex, and at
Greenwich. Dr. Fothergill published in 1748 " An
account of the sore throat, attended with ulcers,"
which, from the description, evidently must have
been diphtheritic in its character.* His pamphlet
was the earliest notice of the disease that appeared
in England. In 1747 Ghisi noticed an epidemic
*- MM. Rilliet, Barthez aiid Greenhow concur in this view of the matter, although Churchill, in his Diseases of Children, p. 468, beli.:ves the disorder, described by Dr. Fothergill, to have been a species of gangrenous pharyngitis.



DIPHTHERIA.               15
sore throat of a diphtheritic character prevailing at
Cremona. A disease, resembling and designated
Croup, appeared at Chesham in Buckinghamshire
in 1793 and 1794, which, like the Cornish epidemic
forty years earlier, appears to have been really
idiopathic diphtheria.
In Sweden, an epidemic diphtheria appeared in
1755, where it raged for ten years. It was found
in Stockholm in 1757-58; in Rasbo in 1761-62.
Dr. Samuel Bard, in a paper entitled "An
Enquiry into the nature, cause and cure of Angina
Suffocativa, or sore throat distemper," published in
the Transactions of the American Philosophical;Society in 1789, describes an epidemic disease, the
nature and seat of which lead to the conclusion that
it must have been Diphtheria, as it appeared in 1771
in New York. Greenhow quotes at length from
this, but the limits of this chapter forbid any
further mention save the insertion of a small
paragraph, viz.: "Out of sixteen cases attended
with this remarkable suffocation in breathing, seven
died, five of them before the fifth day, the other two
about the eighth. Of those who recovered, the
disease was carried off in one by a plentiful salivation, which began on the sixth day; in most of the
others by the expectoration of a viscid mucus."
The New Hampshire Observer, in 1828, published
an account of a new and "curious disease," then
prevailing, which has been supposed to be the
same as that known by the name of Diphtheria. It
was described as follows:
"Within the last three weeks, Mr. Alvah S.



16                 DIPHTHERIA.
Crafts, of Middelfield, has lost all his three children by a disease without a name in this country.
The first symptoms show themselves in a cankerous humor near the root of the tongue; inflammation ensues, and the subject finally dies in all the
agony of croup."
From these facts, it is plainly evident that Diphtheria is anything but a new disease, and that those
physicians who state such news to their patients, or
their students, are not certainly as well versed in
the history of the disorder as they would have
either their patrons or their pupils believe.
Again in this the nineteenth century the ravager
stalked forth, slaying its hundreds and thousands,
causing terror and  dismay wherever it passed,
awing the hardest hearts of the laymen, and stupefying, by its intractability, the most learned and
scientific physicians. It would be needless in this
work to enter upon the history of this last course of
the disease. Interesting as the subject may be, the
want of space alone would forbid further historical
notice. It has been so prevalent that there are few
who have not seen it -none who have not heard of
it.  In all the periodicals, both Allecopathic and
Homeeopathic, the symptoms are detailed; and the
public journals have called the attention of the laity
to the fearful nature of the affection by many notices of awful mortality.
Men read such paragraphs as these with terror:
DIED —In Etna, Tompkins county, January lst, of'Diphtheria, Emma Ophelia,
aged 4 years and 6 months.
Also, January 2d, Prudence Eliza, aged 10years and 17 days.
Also, January 4th, Hiram, aged 12 years, 5 months and 12 days.
Also, January 5th, Allen Benjamin, aged 7 years, 7 months and 20 days.



DIPHTHERIA.                         17
Also, January 6th, Pauline R., aged 20 years, 11 months and 10 days.
Also, January 8th, Polly Elizabeth, aged 18 years, 9 months and 22 days: all
children of Daniel and Elizabeth M. Sherwood.
In another paper:
On the 11th instant, Henry, aged 13 years, 10 months and 4 days.
On the 12th, Edward, aged 14 years, 10 months and 3 days.
On the 17th, William, aged 4 years, 10 months and 11 days
On the 18th, Daniel, aged 9 years and 5 months.
On the 20th, Jacob, aged 10 years and 5 months.
All of Diphtheria. Children of Mr. Jacob Palmer, of Mountjoy Township, this
county.
These paragraphs are inserted merely to demonstrate the devastation that may be made in a very
short period of time, by the diphtheritic poison, and
to show the great necessity of prompt remedial
measures in its treatment.
In the next chapter, I shall give the disease as
I have carefully observed it in many cases that
have come under my own observation, as well as
of those which I have seen under the care of my
professional friends, and at the end of the work,
when we come to an important point-the pathology
of the disease-will be found the results of experiments and post mortem examinations, which may
be of interest to all whose minds are interested in
this important matter. After the description, a
case or two in detail shall follow, for the benefit of
the student.
I never shall forget the first case of Diphtheria
that came under my own observation. It was in
this city, (St. Louis,) 1859. I was called in consultation to see the disease at its advanced stage. I
only heard the breathing, saw the suffocation,
recognized the whistling cough and labored respiration, at once pronounced the disorder to be that



DIPHTHERIA.               19
own observation, is by no means a pathognomonic
sign. I have known children die of Diphtheria,
who, from the first onset of the disease until it was
very far advanced, had not the slightest difficulty
in swallowing; and, in other instances, have observed
that severe pain in deglution may be an early
symptom, and may entirely disappear before death.
Three cases are now vivid in my recollection, in
the which, a few hours, nay, in one instance, a few
minutes before a fatal termination, the patient
swallowed morsels of food of considerable size.
During these periods if the excrements be examined,
the stools are found frequently covered with mucous,
and the urine, in most cases, loaded with albuminous
matter. Periodical and severe pains in the limbs
are often present. An examination of the fauces
(and in many instances this is by no means an easy
matter) reveals patches of membranous exudation,
very small, whitish or of a yellowish or a tawny
hue, deposited mostly in the irregularities of the
amygdalke, and in the palatine arch, more frequently
in the former than in the latter locality; the tonsils
may be either enormously swollen, or not much enlarged. Salivation, which may have been noticed
earlier in the progress of the disorder, continues:
the pulse is still quick; the system generally announces that prostration which is so marked a feature
in the whole course of the disease. A foeter is now
noticed from the mouth-a foeter so peculiar that
many physicians, and those, too, of high repute,
regard it as pathognomonic of the disease. Dr.
Ludlam* lays particular stress on this symptom,
* A Course of Clinical Lectures on Diphtheria, by R. Ludlam, M.D., p. 12.



20               DIPHTHERIA.
and others have recorded cases wherein a diagnosis
was made out by the peculiarity of the odor emitted from the mouth. The effluvia is per se-indescribable, but immediately recognized after having once
become acquainted therewith. The diagnosis is then
perfect, a case of true Diphtheria has commenced.
The friends and relatives of the patient are anxious,
the physician is aroused to the nature of the fearful
adversary he has to encounter, and marks with
watchful eye the progress of the complaint. If convalescence begin here, if the remedial measures
properly chosen, appear to exercise a beneficent
action, a refreshing slumber, a copious diaphoresis, a
diminution of the swelling of the glands, an arrest
of further membranous formationt and the gradual
disappearance of that already noticed, a slower
pulse and returning appetite, announce the welcome
tidings: if otherwise, the symptoms are as plainly
marked. Perhaps there may be no further increase
in the exudation, but the nostrils begin to discharge
a watery fluid. The eye —and that organ alone will
often tell the tale, as it increases in its brilliancy
and watches with never ceasing vigilance the motions
of those who are fruitlessly endeavoring to soothe
the anguish of the moment —is somewhat brighter;
the face assumes a bluish, waxy appearance, resembling, to my fancy, the complexion of females
when in the commencement of serious puerperal
convulsions; the breathing is labored and rattling,
always much worse when the patients attempt to
t For a description of the MANNER in which the exudation disappears, s'ide
Section III of the present Chapter.



DIPHTHERIA.               21
sleep; the voice is impaired; the exudation has
considerably increased, and even invaded the roof
of the mouth, and extreme prostration results. In
such cases as these, there is still some hope, and
such have made good their recovery. But the disease may advance notwithstanding every barrier
that science and art can place to oppose its progress.
The stridulous breathing increases, cough-a hollow,
croupy, metallic, whistling cough-tells that the
larynx is invaded. The discharge from the nostrils
continues; fluids taken into the mouth return by
the nose. The cheeks have here and there some
slightly congested spots; an enlarged capillary vein
spreading throughout their surface. Periodical and
severe pains occur in the limbs; hemorrhage from
the nose or mouth may be very troublesome; new
and larger patches of false membrane are found
upon the fauces. The labor of respiration continues;
the patient grasps at the neck or the clothing to
endeavor to gain air. The blueness of the face
increases-that horrid ghastliness of countenance
which, when once seen, is never forgotten —and
death comes at last to end the fearful suffering.
Or deglution may improve; the swelling of the
glands subside; the membrane disappear from view;
and just as those not conversant with this insidious
form of the affection may suppose that improvement
is about to commence, the sufferer sinks to death
without a sigh or a groan, overwhelmed by the constitutional poison. Death by the latter method is
certainly the most easy both for patient and attendant, for there is nothing more heart-rending than



22              DIPHTHERIA.
the imploring look of those who die from such
torturing suffocation.
It is well for us to recollect that this coma of
which we have spoken may be so extreme as to
simulate death.  This fact was forced upon my
mind from the following sad circumstance:
In a neighborhood in which Diphtheria had prevailed to a considerable extent, a little girl was
taken suddenly, and died in a very short time: the
family fearing that some contagion might emanate
from the body, rather hastened the funeral. After
the child had been buried two days, a second in the
family was attacked with the disease in its most
malignant form, and soon succumbed to the poison.
The parents desiring that both their children
should occupy the same grave, had the former
child exhumed. When the coffin lid was removed,
the little one had altered her position-one hand
was thrown up, and a stream of blood had trickled
down from the nostril; these appearances giving
evidence that interment had taken place before life
was totally extinct. The horrible nature of the
revelation may be imagined-and the physician
should guard against such unfortunate results by
carefully ascertaining that life no longer exists.
SECTION II.
Bretonnea~u's Diphttheria.
It may not be amiss, after noting the symptoms
of the disease as they have come under our own
personal observation, to record the characters of



24              DIPHTHERIA.
more apparent than at the beginning; often portions of concrete matter are effused into the substance itself of the mucous membrane; there is
observed also a slight erosion, and sometimes
ecchymosis in points which, bytheir situation, are
exposed to friction, or from which the avulsion of
the false membrane has been attempted. It is especially about this time that the concretions, which
have become putrid, give out an offensive odor.
If the concretions are circumscribed, the cedematous swelling of the cellular tissue immediately
around makes the former appear depressed, and,
judging from this appearance only, we might be
tempted to believe that we had under observation
a foul ulcer, with considerable loss of substance.
"If, on the contrary, they are extended over considerable surface, they become partially detached,
and hang in shreds more or less putrefied, and simnulate the last stage of sphacelus; but when we
open the bodies of those who, several days sick,
have succumbed to tracheal Diphtheritis, we shall
find in the air-passages all the shades of inflammation from its first degree, as shown in the portions
just invaded, up to that which has by its deceptive
appearance led us for a moment to dread the supervention of gangrene."
SECTION III.
The Manner of Recovery.
Attention should be directed to the slow nature
of the convalescence after severe attacks of Diph



DIPHTHERIA.               25
theritic disease, and the peculiar manner in which
this recovery may occur. A few years since, when
we were not so far advanced, either in our knowledge of the disorder, or the remedial means that
were most effectual in its treatment, it was impossible to observe many of the minutiae which since
have become quite well established. Among these
peculiarities of recovery is, the softening of the
membrane, which I affirm may take place in two
very different ways: 1st. By actual decomposition
of the structure, with feetor and salivation. Or,
2dly, by its assuming a semi-fluid consistence, and
being either expelled through the mouth and nostrils by expulsive cough, or ejected at will by the
patient. I have seen recovery from diphtheritic
disease by both these methods, and I would therefore call attention to the appearances presented.
Let us suppose a severe case of Diphtheria;
such an one as is termed by many, malignant
Diphtheria. The physician is called in the evening, finds the patient with high fever and slight
congestion of the fauces, an enlarged parotid, and
slight epistaxis. Diphtheria has been prevailing in
the neighborhood, and is certainly suspected. The
physician prescribes the appropriate medicines, and
finds in the morning a patch of membrane from
tonsil to tonsil: not a small isolated spot here and
there, but a formation of from one to two inches in
length. The patient, perhaps, is covered with an
niform redness in various parts of the body, and
has screamed through the night with pains in the
bones. The same medicines are continued, the



26              DIPHTHERIA.
practitioner understands his business and the disease
which he would vanquish. Upon examining the
fauces in the evening, the membrane has thickened and extended; the pulse is very quick; the
breathing is so much impaired that the child can
rest but a moment or thereabouts, and then starts
up in his sleep with frightful dyspnoea. The rash
has increased and the vigilance of the eye is well
marked. Still, the well selected medicine is continued, and by morning, though there is no perceptible change in any symptom, yet there has been no
increase in the exudation. Medicines are exhibited
at longer intervals. In the evening, the peculiar
odor has given place to the death-like smell of that
putrefaction which occurs in living things. When
the fauces are examined, the yellowish membrane
has become darker and grayish, and has shriveled
slightly around its edges. In twelve hours more,
the odor has become so palpable that it pervades,the whole room, and small particles of a dark, decomposed substance have been cast off. This process of mortification may continue until the whole
exudation has been removed, accompanied with
profuse salivation. In the second variety, a yellowish, slimy substance, about the consistency of
thick starch, is expelled by coughing, both from
the mouth and nose. It is often a matter of surprise to remark the immense amount of this peculiar semi-fluid which has been thrown off. It
may accumulate in the cavities until it threatens
suffocation, and then with a severe expulsive effort
be ejected. A diagnostic mark I have observed is



DIPHTHERIA,                27
the following: That when recovery takes place by
the latter method, the material. which is thrown
off possesses the Diphtheritic odor, while, as has
been before mentioned, the decomposing process is
necessarily accompanied wuith fetor. These processes may occur also in the same patient. In the
former cases I have often given the greatest relief
to the sufferer by removing with the dressing forceps those portions of the exudation that appear
friable and loose, recollecting never to use any
force in such proceeding, as the tearing away of the
membrane not only increases the tumefaction of
the parts, but the raw surface in a few hours will
certainly become again coated wuith the exudation.
SECTION IV.'Unfavorable Symptoms and Manner of bDeat7h.
There are certain symptoms which in Diphtheria
mnust always be regarded -as unfavorable, and too
much stress cannot be laid upon their importance
to the physician in his prognosis. And first of all
in point of danger must be rememberedThe invasion of the larynx and trachwe as evidenced
by the croupy cough. There -are several varieties
of cough that may be present in this disease; indeed, there are few cases that are not accompanied
with a dry and somewhat irritating tussis; but the
ringing, rattling, croupy sound, that tells of the
invasion of the larynx may, so far as my observations and.those of.my professional friends tend, be



28               DIPHTHERIA.
laid down as almost invariably a fatal symptom.
2d. Ulceration of and discharge from the nostrils.
This symptom may be present in the milder forms
of the affection, but it must be regarded as unfavorable when the discharge is fetid and acrid to such
a degree as to cause excoriation of those parts to
which it is applied.
3d. Hemorrhagefrom the nose and mouth. When
we consider the causes that are most likely to produce such hemorrhage, we cannot fail to perceive
that the symptom must, in the majority of cases,
be regarded as rather unfavorable in the prognosis.
Certain children are more liable to epistaxis than
others, and its recurrence in such will not be so
unfavorable as in those who are not accustomed to
such attacks, but in the majority of cases the hemorrhage is occasioned by necrosis of the blood and
great anvemia, together with general prostration.
Sometimes the bleeding is quite intractable, but
from personal observation I am disposed to believe
that a profuse hemorrhage that ceases, or can be
controlled, is not as unfavorable as the constant
trickling of defibrinated blood from the nose or
the mouth: it is the latter variety that is the most
unmanageable; and I have observed that when it
is accompanied with great enlargement of the parotid gland, that the case has assumed a very unfavable aspect, although it may not be considered as
entirely hopeless.
4th. Coldness of the surface, is another symptom
that does not generally receive that attention which
it deserves. The nature of the diphtheritic poison



DIPHTHERIA.               29
is such that it affects always, to a greater or less
extent, the nervous centres, occasioning those
symptoms of collapse among which we find the
cold, clammy skin, which is so marked a feature
in cholera and its typical diseases. Coldness of
the surface in this disease generally indicates that
the system is laboring under the most virulent
diphtheritic poison, and even where it is unaccompanied by any other bad manifestations, should
place the physician upon his guard, as trouble may
certainly be anticipated.
5th. Albzuminzuria, will be noticed in another portion of this work.
Other symptoms are, diarrhoea and vomiting at
an advanced stage of the disease; passage of the
pseudo membrane per rectum; convulsions; petechive, rigors, etc.
Sudden death is by no means unfrequent. There
are instances recorded of patients believing themselves much improved, who have walked a considerable distance, and then expired. In others, death
has come so suddenly that medical advice has not
been summoned at all, the post mortem examinations
revealing the true nature of the disease.
Of those who succumb to diphtheritic disease,
about an equal number die of suffocation and of
zymosis, although many have been known to perish from exhaustion, from hemorrhage and convulsions. If the presence of the membrane within
the larynx cause severe suffocative paroxysms, they
are easily recognized, but if the gradual poisoning
of the system is to terminate in death, a very dif



30               DIPHTHERIA.
ferent train of symptoms is manifest, and may tend
to lead astray the inexperienced. The exudation
may have become less in the fauces, the pulse and
breathing perhaps be more regular, although the
latter is still accompanied with the rattling noise,
but the patient appears to be in a deep and perhaps
quiet sleep, from which it is difficult to be aroused,
but when fully awake is extremly bright and understands all that is said to him, but soon falls
back into a state of stupor, which becomes more and
more intense, may last from six to thirty hours, and
will certainly terminate in death. There is no use,
when such manifestations are present, to delude
either oneself or the friends and family of the
patient with the idea of recovery; such a course
only tends to ultimate dissatisfaction to both parties.
"Death," says Greenhow,* "from syncope or the
accession of collapse, fatal in a few hours after
exertion, has so. often happened when patients have
appeared to be recovering satisfactorily, that convalescents from Diphtheria cannot be considered
out of danger, until some time after the throat is
well, and the very marked anwemia produced by
the disease has disappeared."
Again, death may occur suddenly from cardiac
spasms, or from imperfect closure of the valves of
the right heart, the symptoms of which may easily
be detected by auscultation. Such a case has very
lately come under my personal observation. No
* Treatise on Diphtheria, p. 129.



DIPHTHERIA.                33
SECTION I.
Differential Diagnosis between Parotitis and Diphtheria.
The preliminary symptoms of mumps and of
Diphtheria, are, in many instance of a similar
character, indeed they do not differ in their
generality  from  the precursory manifestations
exhibited by any acute disorder; there is chilliness and fever, general langour, indisposition
and loss of appetite, with considerable thirst, and a
coated tongue. After these symptoms have continued for some time, the others present, and it is
worthy to remark how nearly the two diseases may
simulate. The essential nature of parotitis is swelling of the parotid gland to a greater or lesser extent, the sub-maxillary glands also enlarging from
sympathetic inflammation. In very many cases of
Diphtheria a precisely similar condition of things
may exist. Dr. Madden notices this fact, he speaks
"of an unusual amount of swelling of the glands,
the enlargement being quite as perceptible externally as internally."
Dr. Preston mentions several cases where there
was great swelling of the glands of the neck.
Mr. Adams, of England, records cases in which
the glands of the neck were much enlarged.
Mr. Moyce, of Rotherfield, in stating his own
case, remarks: "There was much external swelling."



34              DIPHTHERIA.
Dr. Bristow, in the report to the Pathological
Society, of London, records a case wherein "thlere
is great tumefaction, hardness and tenderness in
the upper part of the throat, chiefly in'the parotid
and sub-maxillary regions, and more on the right
side than on the left;" and, again, in referring to a
post-mortem examination, says: "The parotid and
sub-maxillary regions were much swollen and
hardened, especially on the right side, where, also,
the integuments were studded with congested and
livid spots," and, again, in another case, "the external fauces on the right side are much swollen,
very tense and tender, but not discolored."
Greenhow says, that great swelling of the glands
is noticed, and is generally an unfavorable symptom.
Trousseau mentions enormous swellings of the
glands of the neck as belonging to the worst forms
of Diphtheria.
From these facts, therefore, we perceive that, in
many cases of Diphtheria, the parotid gland may
become much enlarged, thereby presenting the
pathognomonic sign of parotitis.
Again, pain in the ear is often complained of by
children affected with cynanche parotidea, and the
same symptom is noticed in Diphtheria. M. Bretonneau mentions this symptom, and Dr. Beardsley, of Milford, Conn., has noticed that such
suffering, in his section of country, was generally
present. Here, again, a similarity exists: what,
then, are the diagnostic symptoms? In Diphtheria
we have the hollow, croupy, barking cough, with



DIPHTHERIA.               35
the peculiar breathing, particularly during sleep,
but more especially the presence of the exudation
itself, which may be revealed upon examining the
mouth, or may be ejected during the cough.
Scarlatina and Diphtheria.
When Diphtheria first makes its appearance, it
may be accompanied with a rash, resembling, in
some respects, that of scarlet fever; and the occurrence of the two disorders together, even as
epidemics, in the same localities, at the same
periods of time, or the one succeeding or preceding
the other, gave rise to the opinion that Diphtheria
wag but a modified form of scarlatina; in other
words, the sore throat strongly developed on account of the non-appearance of the eruption.
Another circumstance which favored this belief,was
the presence of albuminuria in both.
The differential diagnosis between the diseases is
well described in an editorial note to Dr. Preston's
article on Diphtheria, which is so pertinent that
we quote it enitire.  It reads thus: "Invasion,
generally more insidious in Diphtheria, more violent
and sudden in scarlatina (Valleix). It may, however, be foudroyant, and death has even anticipated the formation of false membrane. The swelling of the lymphatic glands of the neck, which is
sometimes so enormous as to extend beyond the
jaw, is altogether out of proportion to the intensity
of the faucial affection. Join to this acute pain in
the head, intense fever, excessive frequency of the



DIPHTHERIA.                37
doubt of the non-identity of the two diseases, and
but little difficulty found in rendering, after careful
observation, a correct diagnosis.
Croup and Diphtlheria.
With reference to the diagnosis between croup and
Diphtheria, Dr. Ranking, in his lectures, writes:*
"The great distinctive mark between diphtherite
and croup, properly so called, is to be found in the
locality chiefly affected. In both, it is true, the main
feature is the presence of an exudation, but in the
one disease it commences in the fauces, and only
reaches the windpipe by extension, and in a certain
number of cases; in the other, that of true croup, it
commences in the larynx and trachea, and does not
necessarily affect the soft parts above the glottis.
As a consequence of this, a marked difference is also
found in the symptoms of the two diseases. In
Diphtheria the uneasiness is first referred to the
parts subservient to deglution; in croup, on the contrary, the earliest symptom is that of stridulous
voice and breathing-a symupton which in the former
indicates the final development of diseased action."
There is, however, another distinction which should
be remembered, and that is: in croup we believe
the membrane to be distinctly Jibrinous, while in
Diphtheria it is albumnzinous in its character.1- Again,
we may notice a fact that bears some relation to
~ London Lancet, January, 1859.
t Vide Chapter 3d, Section II.



DIPHTHERIA.                 39
deglutition, with swollen palate and adynamia;
and the fifth, by the peculiar wash leather deposit
and great prostration.
Dr.Dake, of Pittsburg, classifies his cases into
six varieties;t and the Lancet Sanitary Commission,
appointed to report on D)iphtheria, make three distinct forms of the affection, viz.: simple, croupal
and malignant Diphtheria.4
_My friend, Dr. Ludlam, of Chicago, writes thus:
"Practically speaking, I am of opinion that we
should recognize but two forms of this diseaseviz., the simple and the malignant —Diphtheria Sim.
plex and Diphtheria Maligna."  Although, on page
86, he further says: "Under all its forms and varieties, the disease is essentially. the same. In
one family we may have pharyngeal, laryngeal,
palpwebral, cutaneous and vulvular deposit of pseudo
membrane". And he then quotes the following
from Trousseau: "It is with Diphtheria as with
variola, which, confluent or distinct, mild or malignant, is always variola."
It appears, however, that these distinctions
really embarrass the beginner in practice, as the
one may often assume strong features of the other
varieties, or a single case may exhibit more or -less
of the peculiarities of all.
Certain it is, that when, upon examination, the
buccal cavity presents an inflamed appearance, with
swollen salivary glands and patches —be they ever
t N. A. Journal, Vol. X, p. 422.
t Science and Art, or the Principles and Practice of Medicine, p. 576.



40                DIPHTHERIA.
so slight -of membranous formation, it behooves
the physician to look well to his work, for trouble
may be anticipated.
Diphtheria is generally conceded to be an endemic and epidemic disorder, not contagious, as a
general rule, but subject, in its propagation, to those
peculiar extesions and exarcerbations, which, in
some instances, might lead to the supposition of its
spread by contact. On this subject my friend, Dr.
Dake, thus writes:
"' 1. There is a common cause or morbific influence, which pervades a particular part or region of
country, resting equally upon all the inhabitants
thereof. So far it is epidemic.
"2. There is a peculiar state or diathesis of
constitution-a condition of health -which makes
some of those inhabitants more susceptible to the
common cause, or morbific influence, than others.
So far the disease is endemic, or peculiar to certain
persons.
"' 3. There are certain influences, such as sudden
changes in the temperature or weight of the
atmosphere, errors in diet, over-exertion of mind
or body, which serve as exciting causes,, which bring
the common and predisposing causes more closely
together, thus rendering them at once operative."
Dr. Preston, in an elaborate article on this subject, after discussing certain questions relative to
the nature of the affection, thus writes:* "I conclude that Diphtheria is essentially an epidemic,
* United States Journal of Homoeopathy, Vol. I, p. 236.



non-contagious disease, rarely, in certain favoring
localities, becoming endemic by concentration of the
epidemic- influence."  This is, no doubt, a fact, for
there are few physicians who have paid attention
to the subject, who have not, either from personal
observation or from the perusal of medical periodicals, noticed several in one family, in one house, or
in one particular locality, successively affected. I
have in one instance seen five children attacked, in
another four, and frequently two or three in the
same family exhibit the diphtheritic exudation.
This, of course, would not prove the communica..
bility of Diphtheria, although Bretonneau and.
others supposed the disease contagious by means
of contact with the exudation, and not through the
surrounding atmosphere. There are some facts
that would tend to substantiate these premises, but
there are many others that would contradict them.
Dr. Leonard and Dr. Morris, while attending cases
of Diphtheria, both suffered from a variety of
ophthalmia, which they attributed to the contact of
the exudation, which was thrown into their eyes by
the spluttering of fluids from the mouths of the
patients while undergoing local treatment. This is
no proof whatever. If nitrate of silver, or perchloride of iron, or muriatic acid, be injected into the
eyes, whether from the mouth or from a syringe,
the probability is that ophthalmic symptoms will.
present.  Greenhow  says on this point,  "A1l
thought I have no proof that Diphtheria is commua.
nicable by means of the exudation, many facts have
fallen under my notice which convince me that the



44              DIPHTHERIA.
patients had, from birth, been accustomed to the
comforts and luxuries that competence or wealth
could procure. There can be no doubt that those
means which always favor the spread of disease, as
dampness, poor ventilation, bad food, improper
attention to cleanliness, exposure, &c., will certainly influence the spread of this as well as other
disorders; but, from my own observation and
experience in the disease, I am convinced we must
look elsewhere for the true causes of Diphtheria.
There have also occurred many sporadic cases of
Diphtheria; and most physicians have heard of or
witnessed cases of the disease, when there has been
no prevailing epidemic.
I have now in mind an instance related to me by
a gentleman of this city, in which his child, after
being extremely ill for a number of days, and being
given over to death by the physicians in attendance (who frankly stated their inability to form.
any diagnosis), ejected from the mouth and nostrils
"a thick skin," as it was termed, which expulsion
gave immediate relief, and the patient recovered.
This case occurred a number of years since, long
before Diphtheria was generally known to the profession or the community.



48               DIPHTHERIA.
curious coincidence, which has lately been noticed,
I attended two children for measles; they both did
well until about the sixth day, when scarlet fever,
of a malignant character, appeared in the one, ancd
Diphtheria, in its worst form, attacked the other;
both died, and both had been exposed to p ecisely
the samee contagious influence. The couse of the
Diphtheria in this case was extrem-ely rapid.  I
discharged the child cured of the measles-through
which she passecd without an untoward symiptomon Thursday.  On Saturday night, I perceived the
first diphtheritic deposit; and on Monday morning
she was a corpse. A third child was takern witlh
scarlet fever, and recovered very slowly; a servant
ix the family also suffered from the same disease.
The existence of Small Pox and Diphtheria at
the samne time in the same system, was, for a time,
a matter of doubt, but I have had, very recently,
an opportunity of observing the two diseases developed simultaneously in the case of a young man
of nineteen years. The pustules of the eruptive
disorder were perfect and numerous, and the pseudomembrane also exhibited as complete a forinatior
as is ever found in diphtheritic disease,.
SECTION IL
Ifemorrkhage.
Villa ReaI, whio designated lDiphtheria as nmorbus suffocans, has alreacdy, in years long passed,
called attention to the fact of hemorrhages occur



DIPHTHERIX.                49
ring concomitant with the disease, and its import
in assisting to form a prognosis in the affection.
As a general rule, the blood most frequently comes
from the nares, although in some cases it has been
observed to proceed from the gums, mouth, and
rectum. It may be considered upon the whole as
an unfavorable symptom, although in persons who
have been subject to epistaxis, or in those of a
hemorrhagic diathesis, it would not be regarded
with the same degree of importance as in those
who had never or rarely been obnoxious to such
bleedings. When we take into consideration the
peculiar dclefibrination of the blood that results in
the more malignant forms of the disease, it is rather
a matter of surprise that hemorrhages are not even
of more frequent occurrence than they appear to
be. Of the varieties of hemorrhage that take place,
epistaxis is certainly the most frequent, bleeding
from the buccal cavity next, and rarely, if ever, is
proctorrhoea noticed.
I have seen these different varieties, and in different grades of violence, and so far as my experience goes, I believe that the passive hemorrhages
are always the more dangerous, not on account of
the loss of the vital fluid, but as exhibiting a more
highly poisoned organism by the diphtheritic virus.
A slight, but constant trickling of thin, watery, defibrinated blood from one or both nostrils, I have
always found to belong to the worst cases of the
disease; and in fatal cases the symptoms may
frequently be observed.
Again, the hemorrhage which occurs late in the



50               DIPITHERP IA.
progress of the affection, is indicative of more
serious disturbance than a violent effusion of blood
at the invasion; indeed, in the latter instances, it
is not impossible that relief may be experienced
from the discharge.
In many instances, these hemorrhages, be the.y
active or passive, profuse or otherwise, are very
difficult indeed to check, and in illustration we would
here insert a case read before the St. Louis Homoeopathic Medical Society, at its meeting in February, 1864, by my friend Dr. T. G. Comstock:
"On the 27th of ~Nov., 1863, at 9 P.M., I was
called to see a female child of two and a half years,
in the Lindell Hotel, attacked with what seemed
to be spitting of blood, or at least hemorrhage from
the cavity of the mouth. The mother's statement
was: While she was at tea, the child being left in
the care of the hurse, she had suddenly bled profusely from the mouth, she had also seemed all
day somewhat unwell, and at times a little feverish.
"When I first saw her, she appeared only slightly
feverish, the pulse was quick and somewhat excited, but she was apparently quiet until aroused by
me to examine her, and then she was so irritable
I could not examine the throat or cavity of the
mouth. I saw the blood on the child's clothes in
quite a quantity, and the nurse stated  that it
was at first coughed and spit up, and then
that it trickled for some time from the mouth.
Under the circumstances, I naturally concluded the
bleeding must have come from the nasal passages,



DIPHTHERIA.                01
and regarding the case therefore as not in the least
serious, prescribed-R. Arnica, 1st, every 2 hours.
"About 1 o'clock at night, I was called up, again
to see the same child. The father informed me
she was again bleeding from  the mouth, and the
throat was evidently very sore, and she cou ld not
swallow.  He insisted  his child was certainly
near her end. I hastened at once to the bed-side
of the little patient, and found that she really had
bled a second time, and was still bleeding from the
mouth.
"The source of the hemorrhage was to me the
first question. I examined the throat, and found
the tonsils very much swollen, looking very red,
lacerated and spongy; one tonsil being covered with
two or three small exudations evidently diphtheritic in character, and the other tonsil having only
one upon it, and more or less blood still oozing
from it. The posterior wall of the pharynx seemed also to be coated with a diphtheritic exudation
or deposit. The child breathed heavily and swallowed with great difficulty; pulse 120, and fever
decided, although not higoh. I had never before
met Diphtheria complicated with these symptoms.
The source of the hemorrhage was certainly from
the tonsils. I ordered the tonsils touched at first
with vinegar, which happened to be handy, and
small pieces of ice to be given the child to swallow
or melt in the mouth, according to the inclination
of the patient; they were taken without difficulty,
owino to the child's thirst.  ilLriatic acid and
Belladonna, were given internally through  the



52              DIPHTHERIA.
night. The next day she seemed better, having
been very much relieved in her breathing; had no
more hemorrhage, and could evidently swallow better; she appeared however very weak and languid,
coughed a great deal, and rattled in the throat when
breathing; the tonsils, palate and posterior wall of
the throat looked much the same, except the sanguineous secretion upon the tonsils had disappeared.
"The same treatment was continued, and milk
punch, with ice in it, was freely given. The second night, the child had a tranquil sleep for two
hours or more, and on the morning of the third day
seemed improved, and the throat looked better;
still, a profuse secretion of a dark, greenish color
could be seen behind the uvula. These symptoms
continued much the same for nearly a week, the
child  being up a little on the fourth or fifth
day, but fretful, languid and feverish at night.
"The swelling of the tonsils had abated somewhat on the third day, when Deutoiodide of'Mercuzry
was given instead of Miuriatic acid in alternation
with Belladonna; but, on the sixth day, Hepar
Sulphzur was given for two days, and this followed
by the Muriated tinctzre of Iron, four drops, three
times daily. The child remained somewhat languid, but the appetite improved a little, and on
the twelfth day she was quite well.
"According to Villa Real, in Diphtheria, hemorrhage from the mouth or nose always proves fatal.
As this was the first case of the kind I have ever
met with, I desire to r'ecord it, and inquire of my



DIPHTHERIA.                 53
professional brethren if they have observed simil-.ar cases?
"I have seen (May'64) two cases of hemorrhage
in Diphtheria, since the report of the above case.
One case of a boy at 5, had a dangerous attack of the
disease; hemorrhage from  the nose and mouth
took place on the sixth day of the attack —the
child recovered entirely at about the ninth day.
"In another case of apparently the mild form of
the disease, bleeding from the nose set in on the
seventh and tenth days. This was readily controlled, but the child died on the seventeenth day. We
consider hemorrhage in Diphtheria as a very
serious complication; and Dr. Jacobi, in the Amer.
Med. Times, Vol. I, p. 114, speaks of it as such.
"The remedies for this form of the disease are:
01. Terebinthi., Arnica, Hamnmamelis and Crocus. As
to the remedies applied locally, such as Muriated
tinct. of Iron, solution of the Per-sulphate of Iron,
Altum, 01. Terebinthine and Creosote, we sometimes
resort to one of them; but limit ourselves to one or
two or perhaps four applications; if, after this, the
exudation still forms, we use no local applications
other than salt and water,  or claret wine and
pounded ice, as I am convinced that stronger preparations, persisted in, can do more harm than good.
"In some cases of Diphtheria where the convalescence is protracted and the patient enfeebled,
we have used with the best success Pyro-phiosphate
of _Iron. It is, withal, the pleasantest, safest, and
most agreeable of any of the ferruginous preparations, and seems to possess more analeptic proper



54                DIPHTHERIA.
ties than the muriated tincture, protoxide, or the
carbonate. It is perfectly soluble in water, and I'
have found no child over two years old refuse to
take it.  It may be given in solution.  R. Aq.
distill., oz. ij.; Pyro-plzosphlate of Iron, grs. xv.
M. etft. sol. Dose, from a half to one teaspoonful
every three hours."
SECTION III.
Other Concomitants.
Rke,,natismi. - Rheumatic  affections, of the
m:ost serious  character, sometinmes accompany
the disease, and the attacks of pain are generally
periodical in character.
Pleuro-Pneumonoia.-Inflammiatory- action has been
known to extend along the larynx and trachme to the
lungs; and both single and double pneumonia
have been found coincident. Phrenitis has also been
noticed by observers, and has in cases proved not
only a very obstinate, but in some instances a fatal
complication.
Venous Congestion.-There is scarcely a malig-'lant case of Diphtheria which does not, in some
of its stages, present appearances of this kind on
some portion of the surface of the body. I believe
lthat the peculiar mottled, bluish, or indeed sometimes purplish hue of the cheek, that is sometimes
observed, even in the first stages of the affection,
is always a serious symptom, and one indicating approaching trouble. It arises from the thorough con



DIPHTHiFERIA.              55
tamination of the venous system by the poison, and
a patient cannot be too closely watched who presents
the appearance in question. It is rather a remarkable fact that so many acute observers of the disease have overlooked this symptom, which is certainly often present in malignant diphtheritic disease.
CHAPTER ~.-SEQUELME.
The majority of the sequelwe of Diphtheria are
those belonging to the nervous system; perhaps,
t.hree-fourths of all the complaints that follow severe diphtheritic disease cah be traced to -the action
of the virus upon the nerve centres, all tending to
impress upon the mind the profoundness with which
the human system may be affected by the poison,
and serving to illustrate the difference of diagnosis
between the disorder in question and others, which
in their premonitory or later symptoms may bear
to each other quite a striking similitude. It is astonishing also to observe the tendency that the
glandular systeml appears to exhibit during convalescence, to stupptiuration.
In my own practice, I have observed many of the
latter, particularly suppuration in glands, and in the
cavities of the nose and ear, also of the lungs; and
have also observed aphonia, sometimes complete,
sometimes partial, with great prostration, continue
for weeks after a severe invasion.



56               DIPHTHERIA.
Cinvulsionsb-Cases are upon record where most vio.
lent enclampsia has been present during the course
of the disease-a most distressing and prolonged
case of the kind having fallen under the care of my
friend Dr. Temple. The records of the whole case
have been published in the Western Horneopathic
Observer.
Mr. Gravely, of Newick, mentions the case of
his own son, aged two years, in whom singular
paralysis of the muscles of the neck occurred; the
head rolled about by its own weight in all directions, and, when once fixed, appeared immoveable,
In two cases under my own supervision, the
head has been drawn to one side, and remained in
such position from one to several months.
Impaired vision has also followed the disorder,
cases of which Greenhow records, and which very
recently I have observed, accompanied with a
peculiar nasal twang of the voice-supervening
upon one of the most violent attacks of Diphtheria,
which it has yet been my fortune to witness.
Aphonia. —Perhaps this symptom  is the most
common of all the diphtheritic sequelae, and is indeed often difficult to overcome.  In  several
instances, patients have been known to lose the
voice for weeks and months together, and in others
a singular paralytic condition of the muscles of' the
palate has been observed, which almost entirely
prevented deglutition of liquid aliment.
Strabismus.-Squinting, both of the convergent
and divergent varieties, often occurs, but I believe
is not generally a permanent symptom.



DIPHTHERIA.                  57
Dr. J. F. Merrit,  of Staatsburg, New  York, *
mentions a case of Diphtheria following erysipelas
after vaccination; and very many have noticed
affections of the spinal marrow as sequels of the
disease.tM. Roger has investigated the history of the
numerous cases of diphtherite which have occurred during 1861, in the Children's Hospital, at
Paris, for the purpose of ascertaining the relation
of paralysis to this affection. Of 210 cases thus
observed, paralytic accidents have appeared in 31,
or in about one-seventh of the whole number; but,
as many of the patients are removed from the
hospital before the period of paralysis arrives, and
as many also die early of the diphtheritis, the
proportion is probably much greater; in fact, about
one-fourth.  M. Roger also found that secondary
paralysis is rare after other acute maladies. Diphtheritic paralysis appeared most frequently between
the ages of four and six; 21 times in the female,
and 17 in the male sex.  The season of the year did
not appear to have any influence over it.  The
paralysis almost always began at the pharynx and
soft palate; in 2 out of 10 cases, the paralysis
reached the lower limbs.ij
Dr. Dake notices as sequelse-coughs, glandular
abscesses, otorrhoea, ozcena, erysipelas and paralysis.
* North American Journal of Homoeopalthy, No. XXXSI, page 485.
t For an interesting cure of such a case, see U. S. Journal of Homceopathy,
August, 1861.
+ American Medical Times: New York, 1862.



58               DIPHTHERIA.
The most peculiar and the most frequently
recurring sequela is the peculiar prostration that
remains after a severe attack of the disease; and
this is so well marked as to deserve especial
attention of the practitioner. All the movements
of the body are uncertain and tottering; the skin
assumes a peculiar pallor; the muscles of the
tongue appear to lack the power they should possess;
severe pains occur in the limbs; strabismus may
be present; the hearing be impaired; and, in fact,
idiocy threaten the patient.
The presence of albumen in the urine will be
noticed in the chapter upon pathology, where, according to the ideas of the author, it properly belongs.
To illustrate the course of the disease, and its
sequelae, the following case of rare interest is
appended, because surgical treatment was necessary and efficient in the treatment, and because the
pywamia which resulted was remarkable from the
immense amount of pus that was discharged, and
the number of times that paracentesis was resorted
to for the relief of the patient.
On January 14th, I was called to visit a child,
aged between three and four years, who had been
suddenly attacked with symptoms of convulsions.
I found the little patient almost comatose, with
burning red cheeks, glistening eyes, slight dyspnuea,
pulse 130, and at irregular intervals some twitches
of the facial muscles. Supposing that, as on the
evening previous there had been a large company
at the house, the symptoms resulted from dietetic



60              DIPHTHERIA.
the dyspncea, and that its excision would allow
time for the medicines to act, and might also remove
a portion of the exudation. I accordingly took off
a portion of the amygdalse, and was gratified to
perceive evident temporary relief. Ordered a desert
spoonful of beef tea to be administered every hour,
and presented the first trituration of the Chlorate of
Potash in water, a teaspoonful every half hour.
Was summoned again at 5 o'clock, A. M., and
found the exudation increasing, the breathing more
impeded, pulse more depressed, but very quick,
and every symptom becoming aggravated. I then
determined to try the treatment of Dr. Madden, as
published in the British Jorurnal of Homoeopathy, and,
with some difficulty, succeeded in touching the
exudation with the tincture of the Mzuriate of Iron.
It was noticed that, wherever the solution was
applied, the edges of the isolated portions of the
diphtheritic formation appeared to shrivel; and in
about an hour, a quantity was thrown off. R. Ammonizum causticunm 1~ (in solution); a teaspoonful
every half hour.
Upon my return later in the morning, although
no improvement was manifest, still the symptoms
had not increased in violence. A nutritious diet
was recommended, and the. same medicine continued, at longer intervals. In the evening, the
topical application was renewed, and the caustic
Ammonia still prescribed. At twelve o'clock at
night I visited the patient again, and found the
breathing about the same, exudation not increased,
and the prostration very great. At this juncture,



DIPHTHERIA.              63
to make the abscess, if such it was, point at the
intercostal spaces. The child, however, continued
to lose around daily, and it:was thought that
perhaps the thorax might cautiously be opened
by the application of the caustic-a method preferred by many excellent surgeons at the present day;
but as yet there was no perceptible fluctuation, and
the difficulty of positively determining the character of the fluid remained the same. The caustic Potash was used daily for three days, but with no
success, andthe little emaciated sufferer complained
so bitterly of the pain consequent upon its application that I determined to hazard the operation.
During the last few days of the treatment, the
swelling on the left side of the thorax had become
rather more prominent, and it was very evident
that the life that had been ebbing away for months
was very soon to terminate.
On Thursday, the 10th of May, I visited my
patient as usual, in the morning, and informed the
family that, at 12 o'clock (noon), the operation of
paracentesis would be performed. To this procedure objections were raised by some members of the
family, they being unwilling that the patient should
undergo any farther treatment.
Drs. Temple and Adams accompanied me to the
house at the time appointed, and found the patient
in a sinking condition. Indeed, the breathing was
difficult, there was scarcely any pulse, and that
weak and intermittent, and the voice was altering
to such an extent that the expediency of the
operation was doubted. However, after some con



64               DIPHTHERIA.
sultation, I passed a trocar between the last true
and first false rib, and had the satisfaction of seeing
pus discharge through the canula. The flow at first
was not very profuse, but by withdrawing the
canula, it passed out in quite a stream. About
three teacupfuls were discharged, when, from the
exhausted condition of the patient, it was deemed
best to allow him to rest. He was laid upon his
back, and fell into a quiet slumber, such an one as
the poor little fellow had not known for months.
He wakened in about two hours, asked for nourishment, and passed a good night. In the morning,
however, a violent cough was presented, and upon
examining the wound, it was found closed.  I
opened it again, and about four teacupfuls of matter
of the same character was discharged during the
day. Throughout this period, the medical treatment consisted chiefly in the exhibition of Arsenicurn, Calendula and China.  The cough was not
much relieved, and the suppuration for a week was
so profuse as to threaten life once more. Upon
referring to a paper published in the British
Journal of Ilomoeopatlhy, on the effects of Iodine
injected into serous cysts, and from the analogy of
the cases therein mentioned, and the great success
of Iodine injections after the operation for hydrocele,
it was concluded to try the expedient. I therefore
injected a solution composed of one part of Iodine to
four of water into the cyst, at two different periods,
and although the irritation and pain were for s6me
moments considerable, yet, during the day, the pus
became changed in character, while the cough



66              DIPHTHERIA.
the true nature of the disease, but as absolute
facts from which, perhaps, correct deductions as
to the nature of Diphtheria may be drawn.
SECTION I.
Post-Mortem Examinations.
AUTOPSY I.-Performed March 17th, 1860. The
subject, an infant (one of twins), had died within
three days, of malignant Diphtheria. The usual
incisions, to expose the trachea and larynx, were
made, the sternal muscles divided, and the thyroid
body brought to view, and turned aside. A longitudinal incision was then made through the anterior
face of the larynx and trachea, the mucous lining of
the passages being thus exposed. A circumstance
here occurred which for a time caused some perplexity of mind: so soon as the knife had penetrated
the cartilaginous rings of the trachea, a watery
fluid gushed from the wound. This transudation was
sanious and frothy in character, and, floating in it,
small particles of membrane were noticeable. The
membrane had partly covered the inside of the
larynx, and was greatest on each aloe of the thyroid
cartilage. Some patches were noticed lower down
on the cricoid; but none within the trachea, although the lining membrane of that tube presented
high inflammatory appearances. Within the sacculi
laryngis, (the ventricles of Morgagni,) there was a
much more tenacious deposit. This examination
was not satisfactory, as it was made in some haste,



DIPHTHERIA.              67
and the fear of marring the appearance of the body
prevented the incisions being sufficiently extended
to bring fully into view either the trachea below or
the rima-glottidis above. The adynamia in this
case was probably the cause of death; but the
escape of so much fluid from the vwindpipe, and the
increased deposit within the ventricles of Morgagni,
made an impression upon my mind.
AUTOPSY II.-On the 24th day of August, 1861,
a second opportunity offered for an examination.
There was immense tumefaction of the parotid
and sub-maxillary glands, the latter so much enlarged as almost to fill the whole digastric triangle.
The number of veins branching from the inferior
thyroid, with an anomalous course of the anterior
jugular, also were worthy of remark. The thyroid
gland was swollen to a size considerably greater
than usual, and appeared to be rather softer than
natural. In this instance, I resolved to take out
the trachea and larynx, instead of allowing them
to remain and exposing their interior by a longitudinal incision-a course pursued in the last
autopsy. By such method, besides submitting the
air passages to a more minute examination, I might
extend the inquest to the mucous lining of the
oesophagus. Dissection was therefore made above
the hyoid bone, and the palato-pharyngeus and palato-glossus muscles divided as high up as possible.
The posterior wall of the pharynx was then cut
through, and the structures thus loosened drawn
forward and dissected from the faces of the vertebrae as low down as possible, and then both trachea



68              DIPHTHERIA,
and cesophagus divided and withdrawn. During
this dissection, as soon as any part of the trachea
or larynx was opened, a fluid, similar in character
with that observed in the first post-mortem examination, was thrown off; but the quantity was very
much greater than was noticed in the former case.
The larynx and trachea presented the following
appearance: the exudation had almost disappeared
from the lateral half arches of the palate, and the
uvula was free, but directly anterior to the epiglottis, there was a great deposit of false membrane;
the mucous surface was almost obliterated, and the
epiglottis itself, instead of standing upright, was
thrown partially backward over the rima-glottidis.
A division was then made longitudinally of the
Esophagus from behind, and it was found in a
healthy condition. The trachea and larynx were
then cut through from below, upward, on the posterior face of the tube, through the large diameter
of the cricoid cartilage. The membrane that covered the arytenoid cartilages was tumefied and purple; the vocal chords could not be all seen, for the
coat of exudation; but there was no trace whatever
of membranous formation within the trachea. The
examination ended here, no other organs being subjected to investigation, because the body of the
child had already been laid out, and the hour of
burial was close at hand.
AUTOPSY III.-Conducted on the morning of the
15th February, 1861, one of the graduates of
the college assisting in its details. I was very
anxious to ascertain if the ideas that had forced



70              DIPHTHERIA.
small slit, which was further encroached upon by
the cedema of the parts. The trachea and larynx
were then divided from behind, and the layers of
thick tenacious membrane that lined the wings of
the thyroid cartilage were truly surprising. No
vocal chords were visible, and the sacculi between
them could not be distinguished until the membrane had been withdrawn with comparative force.
No trace of exudation was found in the trachea,
though the lining membrane thereof bore marks of
inflammatory action.
These examinations had made considerable impression upon my mind, and I was anxious that
another occasion should offer, when I could make
further investigation into the pathological states
exhibited after death by Diphtheria. The desire
also to obtain some of the transuded fluid, if it
should occur again in other dissections, was quite
insatiable. Here, in three autopsies, I had witnessed after death the fluid that has been mentioned; had found the most deposit on the anterior
face of the epiglottis, and in the ventricles of Morgagni; and I wished to ascertain if the false membrane was generally located in these parts.
AUTOPSY IV.-This post-mortem examination
took place on the afternoon of the 2d of March, Dr.
Luyties assisting. The incision was made from the
insertion of the genio-hyoid muscles to the extremity of the ensiform cartilage. The origins of the
sterno-cleido-mastoid were divided, the muscles on
the anterior face of the windpipe dissected back,
and the sternum removed. By passing the scalpel



DIPHTHERIA.               71
upward and backward (dividing the muscles connecting the hyoid bone with the tongue), we
separated the anterior and posterior lateral half
arches of the palate, and divided the pharynx. The
next incision was made above the left innonminata
vein,transversely across the trachea and esophagus.
Here, again, we noticed the escape of the fluid,
somewhat thicker in this instance, on account of the
admixture of a little venous blood, which escaped
from the inferior thyroid vein, that was necessarily
cut across; but still so profuse that we were obliged
to absorb it before proceeding with further dissection. Some of this transudation I preserved for
experiment. Drawing forward the trachea and
cesophagus, they were taken out, and presented the
following appearances: a pseudo-membranous
growth, was firmly attached to the glosso-epiglottidean folds, which had, as in the third case detailed,
pressed backward the epiglottis. This cartilage
itself was much swollen, very convex on its anterior
aspect, with a corresponding concavity on its
laryngeal side. In this cavity was a deposit of
false membrane more tenacious in character than
any I had previously had an opportunity of observing. The cEsophagus was then divided by a
longitudinal incision on the posterior face of the
tube, and the mucous lining thereof wes found
somewhat thickened, though presenting no trace of
inflammatory action. The windpipe was then laid
open also from behind, and the exudation was found
to be in positions similar to those noticed in other
examinations, viz.: on the aloe of the thyroid, and



72              DIPHTHERIA.
particularly in the ventricles of Morgagni. These
sacculi could not be at all perceived until, with the
forceps, I drew out the membrane that completely
filled them. The covering of the arytenoid cartilages were much swollen, the tumefaction extending
throughout the whole rima-glottidis. There was
but slight trace of inflammation in the trachea;
indeed, none beyond the two or three superior
rings of the tube. The lungs were much collapsed
and very white in appearance, but became somewhat darker after they had been exposed for an
hour to the atmospheric air. In many lungs that
I have had an opportunity of examining, such great
and peculiar pallor has not been observed. The
pericardium was natural in appearance, and it
contained fluid rather greater in quantity and more
dense than usual. The heart was then taken from
the media-steinum, by dividing the great vessels
high up; and as we raised it from the body, a
slight shred hanging from the aorta attracted
attention. This was so unusual that, following an
impulse without thought, I drew it out. It measured, as I have since ascertained, two inches in
length, and an eighth of an inch in breadth. How
far it extended within the left ventricle, my thoughtless act, of course, prevented me from ascertaining.
The cavities were next examined; and inserting the
scissors below the opening of the inferior cava, we
divided the wall of the right auricle, in the course
of the sculcus transversalis. Upon exposing this
cavity, an object of intense interest presented itself.
A mass of substance resembling a polypus filled



DIPHTHERIA.               73
nearly the whole auricle; was somewhat firmly
attached to its walls, and sent shreds or processes,
if we may so term  them, between the musculi
pectonati of the appendage. But surprise did not
end here. This abnormal formation extended into
the right ventricle (the external wall of which was
now carefully divided), through the ostium venosum, preventing the proper closure of the tricuspid
valve, and was firmly attached to the columnse
carneme. It was also adherent to the extreme tip of
the ventricle, and then followed a direction upward
toward the pulmonary artery. The ventricle was
then laid open by another longitudinal incision,
and, extending to the semilunar valves, this peculiar
structure continued; or, perhaps, to give a more
definite idea of its position, the foreign substance
was V-shaped, with the apex pointing to the
extremity of the ventricle, and extending downwards from the auricle to the tip of the ventricle,
and upwards to the valves guarding the pulmonary
artery: in other words, it followed the exact course
of the current of venous blood within the right
heart. The left auricle and ventricle, with the
valves, were normal, and nothing unusual was
presented in them excepting the shred of membranous formation, which has already been noticed.
The whole heart, with its contents, weighed two
ounces and two drachms. It measured five and a
quarter inches around the auricles, and three and
a quarter inches from the top of the right auricle to
the tip of the ventricle on the same side. From
the margin of the tricuspid valve to the extremity



DIPHTHERIA.              75
examined, the exudation was invariably found in
these localities-in the one instance, to such a degree as to shut down the valve of the larynx, and
in another, to pull it backward to a considerable
extent. When, moreover, we recollect the hoarseness and aphonia that remain for weeks and months
after patients have recovered from the severer
forms of the disease, the presence of deposit and
great unhealthy action between the clhordae vocales
cannot be doubted.
Similar observations have been made by others.
Greenhow writes: "The epiglottis besides being
covered above and below, or on both sides with
exudation, is likewise of ten swollen' so as to contract the entrance of the windpipe."
Dr. Sanderson found, in an autopsy performed by
him, the upper surface of the tongue healthy as far
back as the base of the epiglottis, where there was
found a small path of exudation.  The mucous
membrane of a cavity behind the left tonsil (pillar
of the fauces) contained a creamy exudation.
Mr. Simon found the membrane on the posterior
surface of the soft palate.
Mr. Solly records a case in St. Thomas Hospital
in which the soft palate, uvula, the tonsils and
pillars of the fauces were covered in many places;
the base of the epiglottis being very thickly overlaid.



DIPHTHERIA.              77
long and careful examination," and that it contains
the principles of which the false membrane is
afterward formed.
II.-Upon the 16th of February, the day after
the third recorded autopsy had been made, at quarter before 10 o'clock P.M., I placed a portion of the
membrane preserved from that examination on a
slab of porcelain, and poured thereon about fifteen
drops of strong Perclloride of Iron. This preparation had been highly recommended as a solvent of
the exudation, and I was anxious to perceive its
effect. In about two minutes, the diphtheritic formation to which it was applied shriveled slightly,
and then appeared to harden. At twelve o'clock
the same night, the hardness had increased; and
on the next morning, the substance was black, dry,
and perfectly tanned.
III.-A solution was next prepared of one part
of pure Nitric acid to two of water, and a portion of
exuded membrane subjected, by immersion, to its
action. In twenty-six hours, it was partly decomposed and much whitened; and in thirty-six hours,
the continuity was destroyed, the substance being
separated into flakes.
IV. —Muriatic acid, diluted in the same manner,
was then used, with the effect of rather hardening
the membrane, but at the same time contracting its
proportions considerably. In eight hours, the continuity of the substance was entirely destroyed by
the addition of a little more pure acid.
V. —Sulphuric acid, in the same proportions as
above, softened the exudation, somewhat reddened



78              DIPHTHERIA.
the solution, and threw down a slight precipitate,
not, however, decomposing the structure.
VI.-Benzoic acid and PFluoric acid (the former
diluted as above, the latter pure,) produced in a
longer space of time, an effect similar to that mentioned as following the use of Nitric acid.
VII.-I next prepared a solution composed of
equal parts of caustic Ammnonia and water, and immersed therein a portion of the pseudo-membrane.
In seven minutes, it commenced to dissolve, and in
twelve minutes, no trace remained of the substance
but a slight cloud within the vial. This appearance continued unchanged for thirty-six hours, and
then the matter sank to the bottom of the glass on
the addition of tannic acid.
VIII.-A portion of the membrane was next
subjected to quite a strong solution of caustic Potaslh.
For about an hour, the substance floated in the
liquor, and then began to separate into particles,
which gradually deposited themselves at the bottom
of the glass. On the morning following, no trace
of membranous formation could be observed.
IX.-A solution, composed of one part of Iycdrocyanic acid, and two parts of water, dissolved the
substance in about thirty minutes, leaving no traces
excepting a whitish deposit.
X.-A preparation of chloride of Zinc (one I have
used to preserve bodies for anatomical purposes,
made by dissolving the granulated chloride in
water, or one part of the disinfecting fluid of the
Pharmacopeia to eighteen of water) preserved the
membrane, and hardened and somewhat blackened



80               DIPHTHERIA.
I was rather gratified at the speedy action of
caustic Ammonia, because I had prescribed the medicine frequently with benefit, but had never used it
locally. Attention was particularly directed to this
agent, during 1860, by the perusal of some extreme
cases of Diphtheria, which had been cured by its
exhibition, and which were published in the British
Journal of IIomoeopathy.*
Hydrochloric acid has also been highly recommended as a local application by both Allopathic
and Homceopathic writers upon Diphtheria. Some
have spoken loudly of its peculiar virtues, and
others have seen no effects from its application;
but, be this as it may, I am certain that it possesses
the power of dissolving the membranous exudation
of Diphtheria.
In a strongly written article on "Diphtheria and
its Treatment," Dr. Thos. P. Helsop thus writes:t
"I have also applied daily, sometimes twice a day,
by means of sponges, a solution of Hydrochloric acid,
but little weaker than the dilute acid of the London
Ph7armacopceia, and have always enjoined a regular
use of weaker gargles of the same acid. This, with
the constant administration of stimulants, beef-tea,
milk and jellies, has constituted my treatment;
and I repeat here, what I have already stated in
other quarters, that since I have become aware of
the value of this medication, nearly ten months
ago, I have not lost a single case." This gentleman, whose veracity cannot be doubted, in other': No. LXXI, p. 159.
t- Medical Times and Gazette, May 29th.



82                DIPHTHERIA.
he  membrane from the fauces. To this matter,
however, allusion will be made in another portion
of this work.
SECTION III.
The Composition of the Membrane.
Madden believes the membranous formation in
Diphtheria to be distinctly albuminous; and from
the observations I have made, I believe his deductions to be correct. And as recent experiments in
physiology have proved that such an organization
can be composed of albumen, without any fibrin,
we may argue that the disease consists in an albuminous condition of the blood.*
It has been asserted by some, that false membrane must be composed of fibrin, as this is the
only plastic or organizable element in the liquor
sanguinis. This is contradicted by Lehmann,^t
who states that plastic exudations are sometimes
entirely devoid of fibrin; and by Peasly, who
argues that it is impossible that any single immiediate principle can be the source of all the tissues,
since all of the latter consist of several principles
combined, and that albumen and fibrin both have
the different necessary ingredients of structure
associated with them. Moreover, the tissues are
said to be developed and nourished by fibrin only,
because all plastic exudations contain fibrin. If
* For further pathological views of the affection, the reader is referred to
Section IV. This being the first step in the investigation.
t Physiological Chemistry, Vol. II., p. 290.



DIPHTHERIA.                 83
this were true, we might also remember that they
contain albumen. This fact, taken with the assertion of Lehmann, already quoted, may prove that
fibrin cannot be the only organizable element in the
liquor sanguinis, as albumen must be organizable in
exudations containing no fibrin. And if so in such
cases, it is probably in all, for we find no exudation
not containing albumen. These ideas are somewhat
contradicted by Gluge,* who writes, "The organization of fibrin into fibres and cells is a matter of direct
observation." We are all aware that simple coagulation of fibrin produces fibres; but there is no
proof, as yet, that cells are the product of that
substance, for, in his chapter on Cytology, Peasly
writes,t "The cell wall is formed of simple membrane, and of course is an albuminous compound,
but is not fibrin;" p. 115, "The fluid contained in
the cells is almost invariably transparent, or nearly
so: in the blood corpuscles, however, it is of a
bright red color: in chemical composition, it varies
extremely, being usually an albuminous compoundin part at least;" p. 117, "The membranous wall
of the nuclei is an albuminous compound certainly,
and probably but little, if at all, different from the
younger cell membrane." And further, on p. 157,
he writes, "they [the cells] are probably never
developed from fibrin, but from  albumen rather,
fibrin never rising to a higher organization than
mere simple fibre." And still, on the same subject,
he writes, in speaking of false membrane, "It
Pathological Histology, p. 50.
t Histology, p. 114.



84               DIPHTHERIA.
must therefore be something else that is converted
into cells and tissues, and we can assign no other
element than albumen. In respect, therefore, to
the tissues, albumen, and not fibrin, is thle plastic
element of the blood plasma."
That the membrane is albuminous may be verifiedIst, by the albuminous precipitate resulting from
the addition of Nitric acid to the transudation which
had been preserved from the-last autopsy.
2d, by the same deposit being thrown down by
tannic acid.
3d, by coagulation upon the application of heat.
4th, by the solution of the foreign substance in
caustic alkalies.
5th, perhaps by the presence of the exudation
within the right heart.
6th, the membrane found within the right heart
was not fibrinous. Fibrin from the veins is rather
different in formation from the same substance
taken from arterial blood; and according to Draper,"
the former may be dissolved in a warm solution
of nitrate of potash, while the latter cannot. A
portion of the cardiac exudation was subjected to
this test, without the slightest effect being produced, while caustic ammonia immediately dissolved
it.
7th, fibrin is dissolved by cold, concentrated
muriatic acid, and if kept at a cool temperature
for twenty-four hours, the solution acquires a
M ~edical Chemistry, p. 390.



DIPHTHERIA.               85
dark indigo-blue color. Albumen, similarly heated,
acquires a violet hue.*  Many portions of Diphtheritic exudation were submitted to this test, under varying circumstances, and the violet hue was
always developed.
SECTION IV.
Deductions.
From all these circumstances, I believe that
Diphtheria is certainly a malignant blood disease.
The zymotic action greatly affecting the nervous
centres, prevents the conversion of albumen into
fibrin, and the virus still being carried to those
localities whereon it appears to have the most especial action, causes, in the majority of instances, the
membranous deposit to appear in those parts of the
human system. As the fibrin in the blood is obtained in part from the chyle and lymph, and in all
three of these fluids comes from their albumenas we are aware that certain poisons, those of malignant typhus and glanders, for instance, prevent
the coagulation of the blood by the destruction of
thlefibrin, so I believe, the diphtheritic poison prevents by its action the conversion of albumen into
fibrin; and hence the nature of the deposit, which,
as has been remarked, can of itself become organized from albumen alone. But there is another
circumstance that forced itself upon my mind
while thinking of the pecular endocardial deposit
X Todd &'Bowman, Physiology, p. 55.



88               DIPHTHERIA.
found an albuminous deposit in the riglht heart, following the direct course of the venous circulation;
2d, that fibrinous deposits are most generally discovered in the left heart; 3d, that, from actual
experiment, the vital fluid in the arteries uniformly
contains and deposits fibrin; 4th, that Lehmann
has asserted the fact that the aeration of blood
within the lungs converts albumen into fibrin; 5th,
that, so far as our observations have gone, the
greatest exudations in Diphtheria are noticed in
such positions as effectually impede the ingress of
atmospheric air to the lungs; 6th, that we know
the blood poisons of certain diseases likewise prevent the transformation of albumen into fibrin; and,
7th, that the exudations themselves, in Diphtheria,
are conceded to be distinctly albuminous —may we
not arrive at the conclusion that the diphtheritic
poison, first within the blood, prevents the necessary
transformation of albumen into fibrin? that the
false membrane is thrown off in localities, which
(if Lehmann's theory be correct, and which Simon's
experiments, already detailed, appear to prove,)
still further prevents this necessary change,
wherefore the tissues not being supplied with their
pabulum, waste from imperfect nutrition? and that
excessive prostration is the result-a prostration so
rapid and excessive that life is proof against it, in
some instances, but a few hours?
There are also other circumstances that tend
strongly to force upon my mind the correctness of
the theory in reference to the albuminous nature,
not only of the membrane, but of the blood of
diphtheritic patients.



90               DIPHTHERIA.
in cyanosis, in diabetes, etc. etc."  He then goes
on to remark that experiments of Bareswil, C1.
Bernard, Brown-Sequard and Dr. Hammond, all
go to prove that albumen may exist in the urine
without any structural change in the kidney, or
without producing any symptoms of ansemia.
The question then arises, What are the causes
of albumen being noted in the urinary secretion of
those suffering from Diphtheria. In the first place,
we are all now well aware of the high position that
albumen bears in the process of digestion; and in
fact, as has been mentioned already, the fibrin in
the blood, chyle and lymph, first comes from their
albumen; or, according to Lehmann,* who thus
speaks: "After what has been said of the occurrence of albumen, it seems scarcely necessary to
adduce any further proof of its utility. informing
and renovating the nitrogenous tissues of the animal body. In fact, the whole theory-of nutrition rests
upon this postulate." Now, we know very well that
there are certain, zymotic diseases that prevent the
transformation of albumen into fibrin, and although
we agree in a measure with the views expressed
by Dr. Fletcher,t in reference to the revival of
humoral pathology, still we must give due credit to
the more recent investigations in  pathological
science, which are expressed by the editors of the
said volume in a foot-note of considerable length.
Diphtheria is most certainly one of these disorders,
and the zymotic process going on in the system
* Physiological Chemistry, Vol. I, p. 309.
t General Pathology, pp. 84, 85.



DIPHTHERIA.               91
does not allow the albumen to be transformed into
the renovating tissues, and:consequently the blood
is loaded with the compound. Again, we have
already adverted to the fact, that Lehmann has
proved, by direct experiment, that proper oxidation
of the blood is necessary to transform albumen into
fibrin. To this he alludes again in the following:
*"gNo one can doubt that the albuminous substances
in the blood undergo a gradual oxidation, before
they can be employed'in the formation or renovation
of the tissues," etc. Now, in very many cases of
Diphtheria, we are aware that the membrane is
so deposited as to prevent the free ingress of air
to the lungs, which would be but another reason
for supposing the blood to be unable, through this
channel, to throw off its albumen; therefore, we
may perceive why the kidneys, the great enmunctories of the system, should be called upon to assist
in a measure, at least, in depriving the system of
that albumen with which the circulating fluid is
overcharged.
Albuminuria may also be explained by the action
of the diphtheritic virus upon the ganglionic system
of nerves supplying the kidneys. The well known
action of this peculiar poison upon the nervous
system, as evinced by both the symptoms and more
particularly by the seque1ae of the disease, would
lead certainly to the belief that the renal nerves
could not be exempt from the action of the virus.
A general nervous condition may also so disarrange the system as to give rise to what Dr.
* Lehmann's Physiological Chemistry, Vol. II, p. 356.



92              DIPHTHERIA.
Clark terms, a passive congestion of the kidney.
He says on this point: "The consequence of this
congestion is, to reduce the kidney to a condition
in which it can no longer separate the urea from
the blood in the usual quantity of urea.
Therefore, it appears that we may find, without
looking further into the matter, quite sufficient reasons for the presence of albumen in the urine of
those persons affected with Diphtheria, when we
understand the true pathology of the disease. 1st.
Diphtheria is a zymotic disease, the virus changing
the character of the blood, and that very mutation
tending to overload the circulating fluid with albumen. 2d. The action of the poison on the nerves
of the kidneys, as well as the whole nervous system, as has been proven, will produce the appearance
of albumen in the urine. So far, then, for the appearance of albumen without structural change. When
such organic disease exists, then there need be no
difficulty in explaining the-appearance presented in
the urine. The only important question then
arising being, Does the structural change belong to
the Diphtheria, or was it existing prior to the invasion of the diphtheritic attack. I am inclined to
believe that in by far the greater majority of cases
of Diphtheria, no such structural renal disease,
exists, and in those few post-mortem examinations
that have shown an altered kidney, the disorder
had been present before the patient had been
attacked with Diphtheria, or at least a latent renal
disease had only been aroused into action by the



DIPHTHERIA.               93
general poisoning of the systen by the diphtheritic
virus.
Greenhow makes a difference between Diphtheria
and scarlet fever-by the early appearance of albuminuria in the former and its later development in
the latter.
Casts of the tubuli uriniferi have been seen in
the urine; but I have often known great albuminous
deposit to be present, and not uriniferous casts.
The same fact is mentioned by Drs. Helsop and
Haughton, of England. On this subject, Greenhow
says: " The presence of albumen in the urine must
always be regarded as a serious circumstance in
Diphtheria; and of course, more so, if the albumen
be in large quantity. But neither is its presence
an absolutely fatal symptom, nor does it always
coincide with great severity in the other symptoms."
In the second report of the Medical Officer of the
Privy Council, Dr. Sanderson says, that albumen
was found in the urine in all cases except one in
which it was sought for. Dr. Webb found it in
every case in which he examined the urine. At
Crowle, albumen was frequently found in the urine;
but in some severe and fatal cases, it could not be
discovered.
It must be confessed, however, that the subject
is, as yet involved in much obscurity, and demands
much enterprise, experiment and experience to
substantiate the true pathology of the affection.



94               DIPHTHERIA.
SECTION VI.
Other Pathological Views.
The connection. of Diphtheria with a parasitic
fungus, mentioned by writers on the subject, deserves to be noticed. From  the observations of
many, not much reliance can be placed in the appearance of the oidium albicans in the diphtheritic
exudations. For a confirmation of this assertion,
we may refer'to a note to, Dr. Preston's article on
Diphtheria, published in the United States Journcal
of HomOeopatly; and to the experience of Dr.
Wilks,  who states, that, in the cases that had
passed under his own observation, the fungus was
always present, and that at first he was disposed
to believe this peculiar growth constituted the true
character of the malady.  He says also, "My
attention being directed to this matter, I took the
opportunity to examine the films which occasionally form on the mouths of those sick with various
diseases, and upon submitting them to a microscopic test, felt some surprise in witnessing in all,
fungous growth which I have not been able to distinguish from that of Diphtheria."' He mentions
the case of a woman who had died under his care
with acute cerebral and spinal meningitis, upon
examining the pharynx after death, a pellicle was
found composed of the parasitic growth. Several
other instances are recorded in which the same
* Medical Times and Gazette, p. 354.



DIPHTHERIA.              95
growth was detected, when there was no diphtheritic disease, properly so called; and Greenhow
remarks, "Low forms of cryptogamic plants are
occasionally found on the exudation, which gave
rise to the belief that the disease is of parasitic
origin. This opinion is disproved by the facts, that
on the one hand, the supposed parasite is not
invariably present in Diphtheria, and on the other,
that it is frequently found on unhealthy mucous
surfaces, which are not of a diphtheritic nature."
There have been other ideas suggested by postmortem examinations as to the pathology of Diphtheria; some have supposed its main centre to be
in the kidneys, and that from these organs the
origin of the disorder may be traced.
Dr. Gull suggests, the spinal cord as the original
seat of the disease, and adduces, from this, an
explanation of the paralytic symptoms which are
noticed at a late stage of the disease, or as sequelke
of the affection.
CHAPTER VII. —TREATMENT.
Some members of our school have been very
successful in the treatment of Diphtheria, managing hundreds of cases without a single death, while
others have not been as fortunate. I belong to the
latter class, and have had under my care some
cases that proceeded from bad to worse without a
single favorable symptom, rushing onward un



96              DIPHTHERIA.
checked by every means that were used to arrest
the progress of the disorder, and terminating fatally in from three to seven or fourteen days.
Before proceeding to state the internal medicines
for Diphtheria, it may not be amiss to say a word
in reference to topical applications; and to offer a
few remarks upon the methods of examining the
fauces.
SECTION I.
Exanzination of the Mouth, &c.
In adults, it is not generally a difficult matter to
obtain a view of the inside of the buccal cavity,
because they readily can understand the necessity
for such examination; for their own welfare they
do as they are bidden, and permit the spoon handle,
or other instrument for depressing the tongue, to be
inserted within the mouth; but in certain cases of
disease, even the separation of the jaws is effected
with much pain, and when inflammatory action has
stiffened and swollen the tongue, and the muscles
at its base, quite severe suffering is often engendered by the requisite examination of the parts.
In such instances the patient should be made to
sit facing as strong light as possible, and if the
disease prevents wide separation of the jaws, a
small mirror may be used to throw either reflected
light from a candle, or lamp, held by an assistant,
or the rays of the sun, within the mouth; then, by
inserting the handle of a spoon or the ordinary
tongue depressor-the shape and size of which are



DIPHTHERIA.               97
familiar to all-as far back as possible, pressure
should be made downwards, slight at first, but
gradually and steadily increasing, until the spasm
of the muscles at the base of the tongue is overcome, and a satisfactory view of the parts in question
obtained. This method will succeed in the majority
of instances, when the patient has arrived at an age
sufficient to comprehend the necessity of the operation; but in young children, there is not one of
the minor duties of the physician which requires
so much patience, and which is often so unsuccessful as the simple examination of the fauces.
There is danger of children being thrown into
convulsions by the force actually required to effect
an opening between the tightly clenched teeth,
and I have known relapses to occur from the same
cause. The child, on such occasions, sets its teeth
firmly together, and persuasion, entreaties, bribes,
punishment, or pain, are alike unavailing.  In
such instances, the better plan, after patient and
gentle entreaty has been tried in vain, is to take
the nostrils firmly between the forefinger and
thumb of the left hand, and holding the depressor
(whichever kind be selected) in the right hand,
patiently wait for an inspiration; the ingress of
air by the nostrils being prevented, the child will
slightly gasp, when, with a rapid and dexterous
movement, the instrument is gotten partly into the
mouth; but at this period the teeth again are firmly
closed upon the depressor, and a little more patience
is required. It is not well either to wrench the
instrument, or to try to prize open the mouth by



98              DIPHTHERIA.
force-teeth are broken and gums lacerated by such
proceeding; the better method is to hold the nose,
as before, and forcibly blow into the mouth through
the slight aperture on either side of the spoon
handle; another gasp is the result, and by quickly
slipping back the instrument to the fauces, a
choking sensation is produced; the child gags, the
curtain of the soft palate is raised, and the whole
isthmus of the fauces brought to view. Another
method, if the child will listen to reason, is to have
the mouth open; request the patient to project the
tongue outward as far as possible, and to say loudly,
and prolonged-Ah! h-h-h! This pronunciation
depresses the base of the tongue and elevates the
soft palate, and a good view of the parts is obtained.
For the better removal of the diphtheritic exudation, or, indeed, in certain surgical operations, it is
necessary that a variety of speculum be used, which
will depress the tongue and keep' the jaws asunder,
thus allowing the surgeon free use of both hands,
and preventing interruption of the operation by
closure of the teeth. One of the best instruments for
this purpose is constructed by Luer, of Paris, and
other cutlers. It is formed of a plate of German
silver, bent into a circle, with eyelet holes on the
one side of its extremity, and a button on the other,
in order that it may be adapted to the capacity of
different mouths, and having at its base, projecting
at right angles, a horizontal tongue piece, permanently attached.
When this instrument is inserted between tne
jaws, their closure is prevented, while the tongue



DIPHTHERIA.                99
is kept down, and out of the way of the operator.
It is made of two sizes, for children and adults;
each, however, can be lessened or increased in
circumference.
The instrument is used frequently by M. Rayer,
at La Charite, Paris, and was by him, I believe,
introduced to the notice of the profession. Charriere has also constructed a mouth speculum on the
principle of his well-known speculum vaginae.
It is, however, considerably more expensive than
the above, but has the advantage of being either
enlarged or diminished in size to suit all ages.
Dr. J. Smith* introduces a speculum to be employed during operations upon the mouth —the
patient being unmder ansesthetic influence.
The journal says, though it is very simple, yet
it must be considered a very important addition
to surgical appliances, for every one experienced
in these operations, knows -how often he has  been
inconvenienced for the want of an instrument
which will keep the: mouth open, and, at the same
time, prevent no imp:ediment to ~the admission of
air, or to the free corurse of the operation. For a
description and a plate of this instrument, the
reader is referred to Rankin's abstract, for 1849,
page 248.
i Edinburgh Monthly Journal, April, 1854.



100             DIPHTHERIA.
SECTION II.
Topical Applications.
When Diphtheria was first noticed, a great many
articles were thrust upon the notice of the profession and the public as certain specifics.  These
have fallen generally into disrepute among the
members of the Homceopathic school, as the true
character of the disease: is better understood. So
far as my own experience goes, I believe topical
applications are not serviceable, and I have tried
many-such as Miuriatic acid, Miuriated tincture of
Iron, Perchloride of Iron, Alum, Tannin, Yeast,
Kali-chlor, and others. I never now employ any
thing, saving perhaps a solution of Muriatic acid
and water, directing all my attention to the proper
selection of the medicine to arrest the constitutional
disease. If there is much swelling and rigidity of
the muscles and glands, the fat of pork or bacon
should be applied, warm, to the outside of the
throat, and, so far as topical applications are
concerned, this is all that I can recommend. I am
convinced, from considerable experience, that since
I have not resorted to any chemical re-agents, that
my patients have gotten along better than when
they were applied.
We believe the disease to be one of the blood;
to be a constitutional affection, and, therefore, so
far as curative agencies are concerned, topical applications are of no value; there may be, however,



DIPHITHERIA.              101
instances in which, from the symptoms, we believe
the larynx not involved, and suffocation, from the
presence of the. exudation within the fauces, may
be imminent; in such cases, as a means of palliation, or to gain time for the action of medicines
internally exhibited, a topical application may be
recommended.
Some Allceopathic authorities do not sanction the
use of escharotics in malignant Diphtheria-and
wisely so —the cause remaining unabated, the effect,
or the production of the false membrane will continue, additional inflammatory action will certainly
supervene, and the patient's sufferings will be
increased; while the nervous system may also be
seriously affected by the excitement produced by
operations.
However, as many practitioners are in favor of
these adjuvants, and in deference to the position
occupied in our school by those who recommend
them, it is proper that such should be herein
enumerated.
Dr. Madden at first employed the muriate of
Iron and Glycerine. He directs, once every twelve
hours, the fauces to be painted with the pure tincture
of the muriate of Iron, and four times, daily, with
Glycerine; but from the preface to Dr. Morgan's
Essay on Diphtheria, it. appears that he (Dr. Madden) has rather preferred of late the M]luriatic acid.'i
Dr. Suss Hahnemann reports a case in which he
used the preparation of iron and glycerine with
* British Journal of Homoeopathy, Vol. XVII, p. 232.



104              DIPHTHERIA.
bility of a disease than the recommendation of a
hundred "sure cures.":Every body knows a certain
remedy for intermittent fever and rheumatism, and,
notwithstanding, these disorders still trouble the
most scientific and well-read physicians, in the
application of their remedies.
The best of all the extraneous means is a solution
composed of two parts of Muriatic acid to one of
water, applied with a soft sponge over the fauces
and those parts which appear covered with the
exudation, and this repeated twice or thrice in the
twenty-four hours: such application may be necessary in cases wherein the false membrane, by its
quantity, appears to be pressing down the epiglottis
and threatening suffocation. The great difficulty,
however, is the act of applying the solution to the
patient, particularly in children. Every one who
has attempted this, will agree with me on this point.
There is, however, one other topical appSlication,
which has lately been recommended, which deserves
some attention, and that is a solution of chlorinated
Soda. The preparation known as Beaufoy's is said
to be the best; and, according to Dr. Wm. Budd,
senior physician to the Bristol Royal Infirmary,*
who has tried all the preparations in vogue, it is
superior to all others. He thus writes:
"In all the cases in which I have hitherto tried
it-amounting now to fifteen-the local disease has
begun to decline from the moment of its first application. An immediate subsidence of swelling of; Vide British Medical Journal, June, 1861, p. 575; or, Braithwaite's Retrospect, Part XLIV, p. 56.



DIPHTHERIA.              105
the lymphatics, in the neighborhood of the disease,
has, in particular, always followed its use-a
fact from which the inference seems pretty clear,
that this agent may do much to prevent that
secondary poisoning of the system by the absorption of putrescent matters from the throat, which,
in many cases, has the chief hand in giving a
malignant turn to the malady.
"On the other hand, its employment is attended
by little or no pain: it causes no inflammation, and
it leads to none of those breaches of surface. which
are inseparable from the repeated use of powerful
escharotics, and which, when once produced, often
make convalescence so painful and protracted.
"Lastly-and this alone is a consideration of the
highest importance-by exercising a local disinfection in the very focus of the diphtheritie virus,
there is reason to suppose that this preparation
greatly lessens the contagious power of the malady."
The solution is applied with a full-bodied camel's
hair pencil, and is directed to be used three or four
times daily.
SECTION III.
Internal Miedicines.
Before alluding to those remedial agents, which
have been used in the treatment of Diphtheria, it
is well to remark, that, as yet we are without a trite
specific for the disease, after it has invaded tlhe
larynx and trachea-such complication being evinced



DIPHTHERIA.                 107
other medicinal substance. The symptoms there
recorded, were salivation, intense soreness of the
mouth and throat, suffocating breathing, &c. Since
then, I have employed the medicine successfully
in various cases of stomatitis.
Bretonneau, in his treatise upon Diphtheria, has
experimented with the drug, and has found no
substance capable of producing similar effects.
He says,* "The action of the oil of cantharides,
when applied to the surface of the tongue and lips,
is almost instantaneous.  In  less than  thirty
minutes, the epidermis shrivels, and becomes raised
and detached. It is soon re-placed by a concrete
pellicle, at first thin and semi-transparent, which
speedily becomes more opaque and thicker.  Like
the diphtheritic exudation, this membrane, which
is at first slightly adherent, is detached and reproduced with great readiness. Within a period of
six or seven days, it may be several times renewed."
Dr. Slade remarks, that from these facts M.
Bretonneau concludes, that the membrane of Cantharides is identical with that of Diphtheria.
Dr. Sandersont has tried the effect of injecting a
solution of Cantlharides, in olive oil, into the airpassages of dogs, and found that, two hours after
the application, the mucous surface of the larynx
was scattered over with patches scarce perceptibly
redder than the surrounding membrane; and that
the structure was covered co-extensively with
K Vide Fiske Fund Prize Essay, p. 51; also, Greenhow, p. 117.
t British and Foreign Med. Chirg. Review, January, 1860, pp. 181-9.



DIPHTHERIA.               111
his father had given him the Antom. caust. as
directed; this was followed shortly afterwards by
his'vomiting some tough stringy phlegm,' since
which he had been gradually improving."
This case recovered rapidly and steadily. In
describing a second case, the same author writes:
"The tonsils were enlarged-one more especially,
but which I do not remember -with numerous
aphthous looking ulcerations upon them. I gave
her a powder of Arsen., 3, to be umixed in water,
and a spoonful to be taken at first every two hours,
afterwards every four hours. She had previously
been taking some Belladonna pilules. The next
morning, her son came to say she was much worse,
and could scarcely swallow. I sent her Mere. iod.,
1, to be taken every two hours, and one drachm
of chlorate of Potash, to be dissolved in a pint
of water, and drank frequently. The following
morning, I was again visited by the son, with the
information that his mother seemed better for a
few hours, after taking the last medicine, but was
now as bad, or worse, than ever. I now gave him
a mixture of Amm. caust;., six drops, in aqua 3 viij,
a desert-spoonful to be taken every two hours. I
heard nothing more of the case until last evening,
when the woman called with her husband at my
house, whilst I was out, and left word that'she
had never had anything to do her so much good
in her life; that every spoonful seemed to give her
new life, and she felt better then than for a long
period.'
To illustrate the treatment of the disease, I



112              DIPHTHERIA.
would here introduce, as concisely as possible, the
general indications and manner of administration
of those medicines, which an actual experience of a
number of years has taught as being most effective
in the disease, after which the therapeutical
views of others shall receive the attention they deserve.
We have every reason to believe, in the present
state of our knowledge, that the use of our hitherto greatly renowned febrifuge, must give place, in
Diphtheria, at least in this climate, to another agent
which appears to possess much more power over
the disease. In Gelsemiinuzr we find this agent,
and, froml the experience of all those who have administered it in the disorder, its value cannot be
well over-estimated.
In that class of disorders in which the vitaljfbrces
are suddenly and fearfully prostrated; when the
system needs a constant and rapid stimulation,
Gelseninteum will ultimately supersede the use of
Aconite.  There are, however, some indications
for its use, which it is well to remember.
It is especially applicable in those cases, in the
commencement of the disease, where the fever is
excessively high, with throbbing headache, aching
in the bones, difficult cleglutition, and some tendency to sleep. It must then be prescribed as follows, and in sufficient doses to make a rapid
impression on the system:
VI   Gelsenmini, tinct.,    gtt. sv.
(A)        Aquae font,    -   -. iv.
MI.   S a tablespoonful every hour; to be



DIPHTHERIA,                113
continued until more or less perspiration manifests
itself.
I can state here, on positive authority, that
severe, and, to all appearances, malignant cases of
Diphtheria, after large patches of m1embrane had
formed upon the fauces, have been cut short by
the timely exhibition of this most powerful medicine.
Those who desire to administer Aconite in the
earlier stages of Diphtheria, should do so in alternation with A, as follows:
Ut-    Aconiti, 1st dil.,   -   gtt. x
(B)         Aquve font,   -    -     s iv
TWhen the patient begins to complain of sore
throat, with lushed face, give in alternation with A,:    I Bella., 2d,  -    -    gtt. vTj.
(C)         Aque font,    -    -    3 ij.
S, every hour during the day, a tablespoonful.
When the appearance presented in the throat,
is that of the primary formation of membrane, as
exhibited by a somewhat shining appearance,
it    Cantharis, tinct.,     gtt. x
(D)         Aquae,    -                3 j
S six drops, in a teaspoonful of water, every
hour, in alternation with B.
If, during this stage, hemlorrhage from the nostrils should supervene, give,
U    Crocus sat., 1st dil.,    gtt. x
(E)         Aque font,    -    -       i
vel.
I~ I4Hamanmelis virg., tinct., gtt. v
(F)         Aquve font,    -    -    3 ij



DIPHTHERIA.                115
vel.
Particularly for puffiness about the eyes and a
peculiar pallor of the skin1*    Apis mel., tinct.,    gtt. xx
(N)         Aquxa,    -    -    -        vj
vel.
(O)  Ja    China, tinct.,  -    -   fl3ss
S five drops every hour.
vel.
a    Ferri pyro-phosph.,   grs. xv
(P)         Aquwe font,       - -       iv
During all this treatment, the patient is to be
rubbed, at least once in three hours, with whisky
and salt, and brandy and water with beef essence
exhibited as often as possible.
It very frequently happens, in severe cases of
Diphtheria, that for the first hours after the administration of a medicine, an evident beneficial
action results, the case progressing favorably —and
then appearing stationary.  This is particularly
applicable to the chlorate of Potash.  When such
is the case, other medicines must be substituted.
This stage of prostration may also be combatted
witha*    Acidi hydrochlor., 1st dil., gtt. x
(Q)         Aquae font,   -    -    -     i
S a teaspoonful every two hours.
When the disorder does not yield to disease, or
rather when the constitutional disturbance appears
to increase, and the local manifestations (as evinced by the disappearance of the membrane from
the fauces) diminish, the practitioner must be upon



116               DIPHTHERIA.
his guard- collapse, rapid and fatal may terminate
the life of the patient in six or eight hours. At
this critical stage, the  medicines, besides the
Arsenicals, areA    Argent. nit., ij trit.,    grs. x
(R)         Sacch. lac.,        -  -  3 ij
M. et fet in pulv. No. X.  S a powder every hour.
vel.
PIC   Cupri sulph., ij trit.,  (grs. xv
(S)         Sach. lac.,      -    -    3 ij
M et ft. in pulv. No. X.  S a powder every hour.
In alternation with either of the above, in these
severe cases, I have seen excellent results from
the Aonm. cau.st., prescribed as follows:
H,    Amm. caust., purae,      gtt. x
(T)         Aquae distil.,     - -       vj
M ft. sol.  S 10 drops every 30 minutes for six
doses; every hour for six doses, and then every
two hours.
When  the recovery is unusually  slow, and
typhoid symptoms set in, besides the ordinary medicines that are well known to all practitioners, the
following is the most efficacious:
Jt    Baptisae, tinct.,    gtt. sxx
(U)         Aque font,      -    -      iv
S a tablespoonful every two hours..With reference to the preparations of Iron and
Bromine, we would here remark, Auburn says that
he cured thirty-five cases of this disease out of
thirty-nine, with Perchloride of Iron, giving 3ij of
a weak solution every five minutes during the day,
and every fifteen minutes during the night.  The



120               DIPHTHERIA.
Ammoniuirm causticurn, by nasal inhalation, but has
not found benefit from the internal administration
of the drug.
Dr. Walter Williamson, of Philadelphia, uses,
with great success, Croton Nig., Cantliarides and
Rhuzus tox., and thus writes:* "The result of the
adoption in my practice, of Croton, Cantlz. and Rlzhus,
as the principal remedies in the treatment of the
throat symptoms in Diphtheria, has been to diminislh the mortality one-hlalf. A careful study of the
pathogeneses of these drugs, and a full consideration of their well-known spheres of action in the
treatment of other diseases, would lead one to anticipate important results in the treatment of Diphtheria, and after repeated trials I have found the
anticipation to be fully justified."
Dr. Preston-t speaks very highly of the Biniodide
of Mlercury; he says it is the best combination of
iodine for true Diphtheria, and that he has, thus
far, met "with no case that did not promptly and
evidently yield to the binioclide; and, in our hands,
it has proved the specific for the present epidemic
without the use of gargles, or any kind of topical
application, external or internal."
Dr. Colton+, of Chicago, in a well written article,
has given very many medicines and the indications
for their use, but more particularly describes the
general symptoms that may be present in the different forms of the affection.
- North American Journal of IHomoeopathy, Vol. XI. p. 170.
t United States Journal of Homoeopathy, Vol. I, p. 242.
+ Op. Cit., p. 235.



122                DIir}T{2RiA.
experience of Drs. Geo. F. Foster, G. C. Brown,
C. W. Boyce and Stearns, all testifying to the great
applicability of the Poke in this disease.
Dr. Couch,* of Fredonia, New York, at the semiannual meeting of the Homoeopathic Medical Society of that State, read a paper on the importance
of Guaiacum officinale, as a remedy in Diphtheria:
and in a letter from Dr. Kenyon, of Buffalo, I am
informed that Dr. Beers has been very successful
in the treatment of the disease by this medicine
alone.  The directions for its use, are, to mix half
a drachm of the mother tincture with a tumbler half
full of sweet milk, and of this mixture to give a
dessert spoonful every one, two or three hours, in
accordance with the violence of the attack.
Dr. Davies, 1in his article, "What is Diphtheria,"
has found service, in the cases he relates, from
Arsenicum, IKali-chlor., locally.  The iod. Merc.,
Nit. acid and Gelseminum.
Dr. Ozannet recommends Bromine, and the bromide of' Potassium.
Dr. Black,~ the iod. Mere., Mfuriatic and Sulphuric
acids, with Cant7larides.
Dr. Kidd,ll Iodine, particularly, though combined
in some instances with other medicines.
- American Iornoeopathic Observer et N. A. Journal of Homoeopathy, Vol.
XIII, p. 102.
t Op. Cit., No. XLI, p. 100.
t Monthly Homoeopathic Review, May and June, 1857, p. 448.
5 British Journal of Homceopathy, Vol. XVII, p. 619.
II British Journal of Homceopathy, Vol. XVII, p. 218.



DIPHTHERIA.                123
Dr. Smith* has used successfully, Ars., Iod.,
Kali-chlor, Nit. ac., and Am. caust.
Dr. J. V. Hobson, of Richmond, Va., in a paper
entitled, "Observations on Diphtheria,"-~ makes
three varieties of diseases, viz:
1st. Croup, or laryngo-tracheitis diphtherica;
2d. Thrush, including apthae and stoomatitis diphtherica;
3d. Diphtheria, characterized by adynamia, and
which, in reference to the blood change, might be
called hcemitis diphtherica, or toxemia diphtherica
(albuminosa?), speaks as follows, in reference to
the treatment: "Hartmann recommends Baryta carbonica and Cantlharides.  I have never tried them,
feeling assured that the disease, as it exists in this
country, would not yield to them. They will be
found useful, however, for some of the sequelae."
He then remarks that the chief reliance must
be placed on those medicines which have already
been mentioned; and, according to his experience,
Belladonna corresponds to the internal symptoms of
cerebral congestion, sore mouth, &c., while Causticum should be recommended where there is deficient systematic reaction.
He has tried, also, with success, IKali-bich. and
Mere. prot., in alternation.  The first triturations
being most satisfactory in the cases in which the
medicines were exhibited.
* British Journal of Homceopathy, Vol. XVIII, p. 100.
t United States Journal of Homceopathy, Vol. I, p. 248.



126              DIPHTHERIA.
and states that his treatment has been very successful. When Diphtheria is epidemic, all adults,
on feeling the slightest mal de gorge, should immediately gargle with an aqueous solution of tannin
every fifteen minutes, occasionally swallowing some
drops, in order that every part of the throat may
be submitted to the agent's action. If, after twentyfour hours of this simple medication, no amelioration is perceptible, an alcoholic solution of the
same substance may be used. The trouble not yet
receding, add to the above six or eight grammes
of tannin, one or two grammes of chlorforom, and
eight grammes of alcohol. If this fails, have
recourse to the etherial solution of tannin. In
treating a child not old enough to gargle, make it
drink very small quantities of one of the above
solutions, and at the same time blow some powdered tannin into its throat. The strength of the
etherial and alcoholic solutions must, of course be
in keeping with the age and susceptibilities of the
patient.*
SECTION IV.
Diet.
The diet of a patient affected with diphtheritis is
by no means an unimportant point, and one which
is too much overlooked by our particular school.
Diphtheria, we believe, to be essentially an albuV* ide American Medical Times, March 15, 1862.



DIPHTHERIA.                   127
minous condition of the blood, and, therefore, it
is better to select those articles of diet which are
known to contain the least of that substance.
1. Isinglass contains from 8 to 13 per cent. of albumen.
2. Sweet bread contains 14.00    "  "
3. White of egg "    15.5  "      "
4. Yolk   "   "    17.47    "     "
5. Ox liver    "    20.19    "    "
6. Caviare   "    31.00    c      "
It is well known that these articles are frequently
brought to the sick room, and they must be rejected
as decidedly objectionable, while either of the following should be given:
Flesh of beef contains of albumen 2.2 per cent.'  venison  "    "    2.3  "
"  mutton  "    "    2.6   "
veal    "    "    2.6 to 3.2 per cent.
"  chicken "    "'   3.0 per cent.
"  fish    "    "    4.4 to 5.2 per cent.
"  pigeon  "    "    4.5 per cent.
The better method is to make an essence of beef,
mutton, venison, or chicken, and give it in spoonful
doses as frequently as every hour. At the same
time, wine-whey may be allowed frequently, or other
stimulant; in some instances, brandy and water is
necessary. The system is overloaded by a poison in
the blood; the disease is rapid in its course, and as
much nutrition as possible should be allowed to the
patient. By this I do not wish it to be understood
that food and drink should be crammed into the
stomach at all times, but I do mean, that if there
be a slight appetite, or if the patient can be
persuaded to take such nourishment as will assist
nature and the medicine to support the constitution,
and throw off the disease, that it is the duty of every



128             DIPHTHERIA.
conscientious physician to do every thing in his
power to accomplish such an end. I know that by
such remarks I am not expressing the views of very
many homceopathists, but I am guided only by my
own experience in these matters; and I am convinced that life has, perhaps, been saved, and
further development of membrane prevented, by
the proper selection of nutritious and stimulating
diet in Diphtheria.
In some instances, if the disease appear to be
stationary, neither advancing nor receding, injections of beef tea and arrow root may be of signal
service; they do no harm, and may, perhaps, be
productive of much benefit.
CHAPTER VIII.-SURGICAL OPERATIONS.
In the treatment of Diphtheria, surgical interference is, in the majority of instances, of doubtful
utility; the use of instruments causes additional
pain, and, in many cases, is absolutely uncalled for,
and, in other instances, death is hastened by the
blundering surgeon, who, disregarding the true
nature of the disorder, seeks, by mechanical means,
to arrest a local disease, while the patient is
succumbing to a constitutional poison; yet there
have been instances in which life has been prolonged, and death averted by the skillful use of
the knife; and, although favorable terminations,



DIPHTHERIA.               129
after surgical operations, in Diphtheria, are not very
numerous, yet, in so malignant a disease, it becomes
the duty of the physician to render his patient the
benefit of all the known means of relief, and to
exercise the discrimination in every case that would
either justify the attempt to save life by operative
procedure, or to forbid, positively, any such hazardous undertaking.
Let us, therefore, examine the matter carefully,
and view it in varied lights, before either positively
contemning, or extravagantly praising, the efforts
made by the surgeon in his attempts to combat the
disease.
The manner of death, in Diphtheria, is different
in different patients. In the one instance, the
exudation may form rapidly upon the tonsils, uvula
and rima-glottidis, and threaten suffocation by
its presence, while the "vocal box" and the
trachea may not be the least affected: in such a
case as this, the question arises, could not laryngotomy or tracheotomy be performed upon a patient
of good constitution and of previous robust health?
The physician cannot be expected to say positively
that the respiratory organs will be affected; and,
when the fact is remembered, that a majority of
cases of pharyngeal Diphtheria recover, the propriety of operating would certainly become a question of the greatest importance: but, on the other
hand, death frequently results from general zymosis and from perfect anemia; the breathing is easier,
deglutition perfect, and, in such an instance, it
were ruthless brutality to inflict the pain of a sur



132              DIPHTHERIA.
only be had recourse to in a few instances, and
must be regal'ded as a palliative means. The true
secret in the treatment, of course, being the internal
medication.
SECTION II.
Tracheotomy.
The results after the operation for tracheotomy
in croup, are not very satisfactory, and in Diphtheria, they are, as far as my own observation,
reading and experience extends, still less so. I
can call to mind but six cases in which the operation has been performed in Diphtheria, one of
which is said to have proved successful. One of
these cases occurred in my own practice, the operation being performed at the very urgent solicitation
of the friends and relatives of the patient.
Cases, however, have occurred, in which the postmortem examinations revealed no extension of the
membranous deposit within the trachea, wherein
perhaps tracheotomy may have been advisable.
In those autopsies which are published in the
chapter on pathology, the trachea was not found
involved, but the general condition of the patient
forbade any attempt at surgical performance.
In all such cases, however, the judgment of the
physician must be carefully exercised, and the true
character of the disease, and the successes and
failures of the operation stated fully to the patient,
or to his friends, before the knife is resorted to.