LIBRARY OF CONGRESS, "ret ~yvr % P — ®qwrf# !*♦ ---- Shelf .:J0&5.r UNITED STATES OF AMERICA. D rn HERIA, C n i iu D ,tc; OR, THE MEMBRANOUS DISEASES: THEIR NATURE, HISTORY, CAUSES, AND TREATMENT; WITH A REVIEW OF THE PREVAILING THEORIES AND PRACTICE OF THE MEDICAL PROFESSION ; ALSO, A DELINEATION OF THE NEW CHLORAL HYDRATE Method of Treating the Same; Its Superior Success, AND ITS TITLE TO BE CONSIDERED A SPECIFIC. f i 3 C. B. GALENTIN, M. Ail 17 CLEVELAND, O. Printed at the Publishing House of the Evangelical Association, ' -pei 3 6 si* Entered according to Act of Congress, in the year 1884, by G. B. GALENTIN, In the office of the Librarian of Congress, at Washington. All rights reserved. PRE FA C E. Whoever adds a new book to the long catalogue of medical works, should have something to say which has either not been well said before, or that is new. On the subjects- treated in this volume much has been well said and written by men in the profession, eminent as writers and teachers. In history, aetiology and pathology, it can be truthfully said r they have constructed an almost faultless edifice, wanting' only a therapeutic finish to complete the fabric. On this latter only has the writer anything very important or new to contribute. On the therapeutics of diphtheria so indefinite and diverse have been the opinions of the architects, that the laborious student is more dazed than edified, by being conducted into voluble labyrinths that end in the confusion of uncertainty and doubt. " Systematic feeding," and direc- tion to " treat the symptoms as they arise," is nearly the sum of what has been developed in the medical treatment of diphtheria. The writer has been led, or driven, into a new and hitherto' untried field of therapeutics in this destructive disease, and for several years, in the treatment of hundreds of cases, has demonstrated to his entire satisfaction the claims of Chloral Hydrate to specific efficacy in the membranous diseases, diphtheria, croup, &c. It is expected that this announce- ment will be received with reserve and a measure of incredul- ity, even by men of fair minds and culture ; by others pos- sibly with positive contradiction and opposition, and by another too numerous class 6f pompous, opinionated and bigoted men, or doctors, if you please, with derision. These in IT PREFACE. latter are the obstructionists of progress, ever ready to sneer at, and strive to detract from the influence of anj^ discovery in medicine so unfortunate as not to have been developed beneath their own hats. However it may be received hj the profession, it is confidently believed that it will be sustained 'fry experience, and will stand, as have other truths, upon its own merits. Other practitioners of ripe age and large experience, both in this city, and elsewhere, at the suggestion of the writer, have tested the efficacy of chloral in a very large number of cases of diphtheria, and unhesitatingly affirm its efficacy, as superior to any other known treatment. Among these I mention with pleasure my esteemed and scholarly friend, Dr. A. G-. Hart, and my daughter and co- laborer in this work, to whom its merits, if an} T be ac- corded it, are largely due. Finally, to those whose lives and labors are honestly devoted to the true interests of the noble profession of medicine, and the welfare of human- ity, I wish to say, Gentlemen, the writer submits whatever is new and use- ful in this little volume to you, for your careful consideration and use ; in the pleasing hope of rendering both to you, and through you, to the world, a tittle of the good service we owe each other and humanity, with a humilitating sense of its many defects. c. b. a. CONTENTS, Introduction vn Diphtheria. Chapter I. Definition 1 " II. Nomenclature 2 III. History 2 IV. Cause 14 u V. Climatic and Atmospheric Influences ... 31 " VI. Mode of Propagation 33 " VII. Predisposing Causes 39 " VIII. Period of Incubation 42 " IX. Prophylaxis 44 ■" X. Symptoms 45 " XI. Diagnosis , . 64 " XII. Prognosis 66 " XIII. Pathology 69 «» XIV. General Treatment 77 " XV. Therapeutic Treatment. 81 «■ XVI. Local Treatment 84 " XVII. Constitutional Treatment 92 Chloral Treatment . Ill <* XVIII. Nasal Diphtheria 121 " XIX. Laryngeal Diphtheria 123 " XX. Treatment of Diphtheritic Paralysis .... 126 » XXI. Medical Prophylaxis 127 " XXII. Croup , 129 " XXIII. Tracheotomy 151 " XXIV. Plastic Bronchitis 156 Foemul^: 163 v INTRODUCTION. The treatment of different diseases by similar remedies, as advocated in the following pages, to thoughtful practitioners will appear neither strange nor unreasonable. Diseases differing widely in their essential characters, are not infre- quently related by symptoms or phenomena that are common to several. The entire system of the so-called " Rational treatment of disease," indeed, consists in the treatment of the symptoms as they arise, if we except only the few instances in which the treatment is specific. Pain in the chest for example, may be occasioned by a variety of diseases, as pneumonia, pleurisy, and neuralgia, but regardless of its cause, requires anodynes for its cure. Hemorrhage, whether from the lungs, the stomach, the uterus, or the bowels, depending on different organic or general diseases, calls alike for gallic acid, ergot, and the like. An exhausting diarrhoea occurs in quite oppo- site states and may be very properly controlled by opium, etc., regardless of the particular disease ; sleeplessness, occasioned by very diverse causes, calls alike for chloral, morphia, etc. ; debility, regardless of its cause, is treated properly with nutrients and restoratives ; and an exalted temperature of the body, whether inflammatory or typhoid, with antipyretics. Symptoms, and not the names of diseases, are treated by intelligent practitioners, with the exception of those treated by specifics as before stated. In the diseases which we call Membranous, and which only are the subjects of this volume, we observe a common diag- nostic symptom or manifestation. It is not pain, nor diar- VII VIII INTRODUCTION. rhoea, nor hemorrhage, nor hyperpyrexia, nor debility, but a peculiar exudation from the blood, generally upon mucous surfaces, denominated false membranes. These membranes are so nearty identical in structure and materials as to render a distinction nearly or quite impossible. As we shall have occasion hereafter to note, their appear- ance has been attributed to both local and general causes, which are possibly so obscure, remote, or ethereal, as forever to elude discovery. What we wish hereto observe is, simply that these diseases, having a like prominent and diagnostic symptom, may rationally be treated by the same or similar remedies without the violation of any principle entitled to professional respect. It is but reasonable to infer, from the identity of these plastic exudates, that some similar S3 T stemic disturbance exists in each of these diseases ; and yet this is only in- ferential. Many regard croup and plastic bronchitis as purely of local origin from the lack of early constitutional symptoms ; while others, equally honest and intelligent, observe that common acute inflammation in the same local- ities is not ordinarily attended by the membranous exudation, and therefore conclude that in these, as in diphtheria, there probably exists primarily some peculiar toxaemia. Neither of these theories is thought to be entitled to, or should be given, any particular influence by the practitioner in deciding upon his therapeutical measures at the bedside, and hence they are dismissed for the present without discus- sion for matters of a more practical nature. AUTHOR. DIPHTHERIA. CHAPTER I. DEFINITION. Diphtheria is an acute, specific, contagious, febrile disease, which occurs epidemically, endemically and sporadically, in most countries of the world, and is characterized by general or constitutional symptoms like other pj^rexial diseases, with a greater or less degree of inflammation of the mucous mem- brane of the pharynx, larynx, air passages, or other mucous passages ; and by the formation on the surfaces of these parts, particularly upon the mucous membrane of the pharynx and upper air passages, of a lympho-fibrinous membrane, generally in patches of a whitish, yellowish, or grayish color. It is further characterized by more or less inflammatory swelling of the glands of the throat and neck or adenitis. During the prevalence of diphtheria, wounded, abraded, or ulcerated surfaces, upon any part of the body, frequently become covered with a membranous deposit similar to that in the more ordinary situations. The constitutional sj-mp- toms usually denote a depressed state of the vital powers. Often the urine becomes albuminous from renal disturbance. The sequelae most common are lesions of the nervous system causing a greater or less degree of paralysis, impairing in proportion, phonation, deglutition, respiration, sensation, etc. Fatal cases usually terminate by gradual apnea ; less fre- qently by asthenia and cardiac thrombosis. (i) 2 DIPHTHERIA. CHAPTER II. NOMENCLATURE. The term diphtheria is of Greek origin, and maj^ properly be defined b} T the English term membrane. Diphtheria, diph- therite, and diphtheritis are ail used as synonyms, and have the same origin. Diphtherite, as applied to the disease under consideration, was origin all}' emplo3 T ed by M. Bretonnau, a celebrated French physician, in his work entitled " Traite de la Diph- therite," published in Paris in 1826. Trousseau, considering the term objectionable because of the termination ite, used in medical science to imply inflammation, changed the word to diphtherie, in order to get rid of the aetiological doctrine of inflammation expressed b} r the suffix ; and, technically speak- ing, diphtheria is the English synonym of the French diphtherie. Among ancient writers the disease received a varity of apellations, as ; ulcus Egyptianum vel Syriacum — the Eg}*p- tian or S} T riac ulcer; angina gangrenosa — gangrenous sore throat ; morbus suffocans vel strangulatorius — suffocating or strangulating sickness ; garotillo — throat disease ; angina suffocativa — suffocating sore throat ; malum canna — throat sickness ; and many others. CHAPTER III. HISTORY. (compiled from the best authors.) It is not the purpose of the writer, nor within the scope of the present volume to enter exhaustively into the bibliography of diphtheria. This alone would fill a volume, and could not be made profitable to the laborious practitioner of medicine, for whom alone, in the interests of humanity, this treatise is HISTORY. 3 designed. The following epitome of what is known on the subject is derived from a careful study of the best authorities, and may be regarded as authentic. Diphtheria, or throat affections in some respects analagous to it, can be traced to a remote antiquity ; their identity with the modern disease is, however, often, only imaginary, or inferred from the resemblance of a few symptoms. There are no proofs of any epidemic prevalence of the disease as it is seen at the present time, until about the middle of the eigh- teenth century. Among the more ancient medical records quoted by writers in proof that the ancients were acquainted with this affection are the following. Nearly twenty-five hundred years ago, or about the time of Pythagoras, an East Indian physi- cian, named D'hanvantare, gave a description of a disease, thought by some to have been diphtheria, in which "An increase of phlegm and blood causes a swelling in the throat, characterized by panting and pain, destro3-ing the vital organs, and incurable : — a large swelling in the throat impeding food and drink, and marked by violent feverish symptoms, obstructing the passage of the breath, arising from phlegm combined with blood, is called closing of the throat." Galen of Pergamos, about the middle of the second cen- tury, speaks of a membranous formation in the pharynx being ejected by expectoration. Aretseus of Cappadocia, a physician of renown who practiced at Rome about the time of Augustus, has left a history of the Eg}^ptian or SjTiac ulcer, considered to have more points of resemblance to the diphtheria of to-day than any other disease of antiquity. This was charac- terized by ulcers on the tonsils, some mild and harmless, while others were pestilential and fatal. " The former, which are common — are clean, small, and superficial, and are un- accompanied by either pain or inflammation. The latter, which are rare — are extensive, deep, putrid, and covered with white, livid, or blackish concretion. If it extends 4 DIPHTHERIA. rapidly to the chest through the windpipe, the patient dies on the same day by suffocation. Ccelius Aurelianus, writing about the close of the third century, " describes the barking sound of the voice and its occasional complete extinction, the stridulous breathing, and lividity of the face. His reference to the defective articula- tion sometimes present, and to the passage of fluids into the nose in swallowing, probably refer to the paralytic symptoms of the disease. It is supposed by some that the Askara frequently mentioned in the Talmud as a fatal epidemic, was, in fact, diphtheria. Rashi, the learned commentator of the Talmud and Old Testament, remarks with reference to the Askara, that sometimes it breaks out in the mouth of a man and he dies from it. 'Also that sudden death ensues from suffocation.' " (Mackenzie.) " Macrobius speaks of a similar epidemic at Rome, A. D. 380, during which, sacrifices were offered up to a certain Goddess — ut populus Romanus, morbo, qui angina dicitur promisso voto, sit liberatus." (Slade.) "Aetius, of Amida, in the sixth century delineated the disease as presenting white and ash-gray spots in the pharynx, slowly ending in ulceration." (Mackenzie.) Brief and unsatisfactory as are the preceding quotations, they are believed to constitute the bulk and basis of the evidence extant that the ancients were acquainted with this malady. From the sixth to the latter part of the sixteenth century, nothing further in medical history is noted as having any very probable reference, or clear analogy to this disease. Hecker's accounts of the epidemics of the four- teeth, fifteenth, and sixteenth centuries, in Holland, France, and England some of them characterized by violent anginose affections, quoted by Slade to connect the ancient and modern records of the disease, must be considered irrelevant, and wanting in any recorded appearance or symptom charac- teristic of genuine diphtheria. . HISTORY. Of modern writers, Bailou, a distinguished French physi- cian, whose writings bear the date 1576, is believed to be the first who makes distinct mention of a false membrane. In the early part of the 17th century an. epidemic angina, denom- inated garrotillo prevailed in Spain. Its best description is by Villa Real, who states that he has seen "a thousand times, in patients at the first onset of the disease, a white matter in the fauces, gullet, and throat. He adds that the matter is of such nature, that if you stretch it with your hands it appears elastic, and has properties like those of wet leather — facts which he noticed, not only by observing the matter coughed up by the living, but also by the examination of it in the dead." About the same period, accounts of the disease, less satis- factory because of the omission of the post-mortem appearan- ces, were written by Herara and Fontecha. They, however, confirm the prevalence of garrotilla (diphtheria) in Spain between the years 1581 and 1611. The name "garrotillo" was first given the disease because those attacked by it perished as if strangled by a cord. In 1617 diphtheria was prevalent in an epidemic and fatal form at Naples and in other parts of Italy. (Sgambatus.) It was sometimes called "Male-de-canna" — disease of the trachea. It continued its ravages for a period of at least twenty years, and has been described by several other writers of authority, as, Carnevale, Zacutus Lusitanius, and Marcus Aurelius Severinus. " Carne- vale in particular has given us full data of this epidemic in his treatise entitled 'de Epidemico Strangulatione Affectu.' The children were first attacked, the disease afterward spread- ing among the population generally, and proving very fatal, The disease commenced by mild inflammation of the throat ; soon the affected parts presented a whitish exudation ; the breath became fetid ; deglutition impossible ; the respiration embarassed, and the patient died of suffocation. This writer also gives us the different appearances which the pharynx 6 DIPHTHERIA. presented in this epidemic ; he also speaks of the extension of the disease to the trachea, oesophagus, and pituitary mem- brane ; — of the diagnosis, prognosis, and the topical remedies, all of which are quite in accordance with modern views" (Slade). Carnevale also asserts its identity with the disease which had been prevailing in Spain under the name of garrotillo. In 1625 the writings of Cortesius show that the same disease extended, a little later, to Sicily. He speaks of a membrane in the throat, which could readily be torn away, as being one of its characteristics. In 1632 Alaymus pub- lished a treatise upon the Syrian ulcer. He prefers this term, he says, inasmuch as it applies to all forms of the disease, which he describes in a manner similar to Carnevale. " In 1713 Dr. Patrick Blair, of London, in a letter to Dr. Mead, described a disease as ' the croops ' which, he says, was epi- demic and universal at Coupar Angus, and which was no doubt diphtheria." (Mackenzie). From 1743 until 1748 the disease prevailed in Paris, and has been described by Malouin and Chomel. About the same date G-hisi describes an epidemic of the disease in Palermo, and noticed the paralytic sequelae. Also about the same time a similar epidemic appeared both in England and at Cremona, accounts of which were given by Fothergill, Starr, and G-hisi. These epidemics were very destructive, especially in England, where it was regarded by Fothergill as scarlatina. He says, " If the mouth and throat be examined soon after the first attack, the uvula and tonsils are found swelled ; and these parts, together with the velum-palati and' pharynx, appear of a bright red color, which is most marked on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of redness, a broad spot or patch of an irregular form, and of pale white, is sometimes seen surrounded with florid red, which whiteness appears like that of the gums immediately after being pressed HISTORY. 7 with the fingers, or as if matter ready to be discharged was contained beneath. G-enerally on the second day of the disease, the face, neck, hands, and breast, are of a deep erysipelatous color, with a sensible tumefaction. A great number of small pimples, of a color more intense than that which surrounds them, appear on the arms and other parts." (In a note he says, " The eruption and redness have not so regularly accompanied the disease during the latter part of this Winter, 1754, as they did last year. In some cases they did not appear at all, in others not till the third or fourth day.") " The appearances in the fauces continue the same, except that the white places become more ash-colored ; and it is now found that what might have been taken for the superficial covering of a suppurated tumor, is really a slough, concealing an ulcer. Instead of the slough, in mild cases, a superficial ulcer, of an irregular form, appears in one or more parts, scarce to be distinguished from the sound, but by the irregularity of surface which it occasions. Towards night, heat and restlessness increase, and a peculiar kind of delirium comes on, the pulse is generally very quick ; in Some hard and small ; in some soft and full. The tongue is generally moist, and not often found coated. In some it is covered with a thick white fur ; and these generally complain of soreness about the root of the tongue." (Slade.) " In 1749 Marteau de Grandvilliers described an outbreak of the disease in Paris, and the elder Chomel, in detailing the symptoms, accurately described diphtherial paralysis. In 1750 the formation of a membraniform concretion in the throat is distinctly described by Dr. Jno. Starr, as occurring as an epidemic in Cornwall, England." (Mackenzie.) In 1757, Dr. Huxham in a treatise denominated "A Disser- tation on the Malignant Ulcerous Sore Throat," described an epidemic which had been prevalent at Plymouth, in which some of the cases were undoubtedly of the character of secondary diphtheria. "Not only," says-he, ; ' were the nos- 8 DIPHTERIA. trils, fauces, &c, affected, but the windpipe itself was much corroded, and pieces of its internal membrane were spit up." " Dr. Starr, of Liskeard, published a paper in the Philo- sophical transactions, upon the malignant ulcerous sore throat epidemic which appeared in that place in 1749. In this paper, besides other details of the epidemic, he gives the full data of a case in which the false membrane commencing in the fauces, extended to the larynx. He particularly dwells upon the physical properties of the exudation, its adherence to the subjacent surface, its frequent detachment and repro- duction. In fact, he gives a complete picture of Bretonnau's diphtheria." In 1789, Dr. Samuel Bard of Philadelphia, in a work en- titled, "Researches on the Nature, Causes, and Treatment of Suffocative Angina," gave a detailed account of " an uncom- mon and highly dangerous distemper " which had recently proved fatal to many children in New York. He recognized the analogy between this disease and croup, as well as the manner in which it spreads from the throat to the larynx. He observed it sometimes as simple angina ; sometimes as angina complicated with laryngitis, and occasionally as lar- yngitis alone. " In general the disease was limited to children under ten years of age, though some few grown persons, particularly women, had symptoms very similar to it. Most of the per- sons attacked were observed to droop before they were con- fined. Usually the first symptoms were a slightly inflamed eye, a livid countenance, and slight eruptions upon the face. At the same time, or very soon after, those who could speak complained of an uneasy sensation in the throat, but without much soreness or pain. Upon examination, the tonsils appeared swelled and highly inflamed, with a few white specks upon them, which, in some cases, increased so as to cover them all over with one general slough ; this, however, although a frequent symptom, did not invariably attend the HISTORY. 9 disease. The breath was not offensive, and deglutition but very little impeded. " These symptoms continued in some cases for five or six days without creating any alarm; in others, a difficulty of breathing came on within twenty-four hours, especially dur- ing sleep, and was often suddenly increased to such an extent as to threaten immediate suffocation. Generally it y this coagulation within the glands and blood-veseels, as- well as upon the surfaces of the body, greatly impoverishes it, and, with its impairment or decomposition within the bloodvessels, is chiefly the cause of its comparative incoag- ulability when abstracted by phlebotomy. Back of this lies, of course, in a causative relation, the original septicaemia. PATHOLOGY. 75 induced by the subtle contagium generated in the body of some other person previously affected with the disease. This great loss or destruction of fibrin robs the blood of its vital and nutritious properties, and in connection with other effects of the blood poison is doubtless the cause of the ever noted asthenic phenomena of the disease. In 1872 Dr. Johnson, as quoted by Mackenzie, put forward,, as the result of a careful comparison of many accuratel}' re- corded cases, the view that cardiac thrombosis is of very fre- quent occurrence in cases of diphtheria, and is a very fertile cause of their fatal termination. He also described in detail the physical signs by which its occurrence might be diag- nosed during life. These views have been controverted by M. Collandreau Defreese, and the phenomenon attributed to antecedent cardiac disease, rather than to the diseased state of the blood ; but be it observed that it is not in the heart alone the tendency to coagulation exists, but it is manifested also in the lungs, the glandular structures, upon the mucous sur- faces, and upon wounds, and veiy probably throughout the vas- cular system ; showing, in the author's judgment, the antece- dence to belong to the blood and not to the heart. Again, this condition of the blood is shown in the earliest stages of the disease, before the period of cardiac complications or thrombosis is manifested, and is one cf the evidences before noted of pri- mary blood-poisoning in diphtheria, and points significantly to such haematics as remedies as are known to possess the power of preventing such coagulation and of thus limiting the forma- tion of an exudation. The brain manifestations depend largely upon the mode of d}ing. If death be from asphyxia, there are found venous congestion with minute extravasations of blood. Pus and lymph may be found upon its membranes in cases of severe toxaemia, and certain degenerative changes have been ob- served in the peripheral nerves and muscles affected b}~ diph- theritic paratysis. M. Charcot found certain nerve C3iinders > 76 DIPHTHERIA. from a paralyzed palate, nearty or quite destitute of medullary matter, and to contain fatty granules of elliptic form, some of which were nucleated. Neither the liver nor spleen have been shown to present an}' uniform lesions characterizing the disease. The kidneys are more frequently found affected than any other internal organs, as from their anatomical situation and physiological function, as well as from the toxsemic character of the disease, they seem more exposed and overtaxed than any other viscera. The blood in diphtheria, as before remarked, exhibits de- rangements, such as, from the disease phenomena noted, might reasonably be expected. From its necessary poverty of fibrinous elements it forms but an imperfect, soft, ill-de- fmcd coagulum. In cases of death Iry asphyxia from the laryngeal form of the disease, as might be inferred, it is "blackish from excess of carbonic acid. Some observers have noted an undue proportion of white blood corpuscles in diph- theritic blood, as in other forms of asthenia, as anaemia and chlorosis. It has also been observed to show evidences of decomposition from the effects of the diphtheritic poison, by the abnormal accumulation of dark-colored debris. In man}- of the organs are found small exudations of blood, as already observed. These are most constant within the cra- nium, and are common in the lungs, the kidneys, and the spleen, and have been observed in the coats of the stomach. " The most cursoiy study of the general pathology of diph- theria suffices to assure us that it is an acute general disease with certain local manifestations. The primary septicemia is due to the specific poison, but absorption from the decom- posing lymph is, no doubt, a cause of secondary infection. In all cases, the attack is associated with some degree of consti- tutional disturbance, while in the severest forms there is ex- treme disorganization of the blood, and consequent implica- tion of nearly every tissue of the body. The general infec- GENERAL TREATMENT. 7T tion is shown at a very early stage, as well as at a period when the local manifestations have disappeared. Besides the constitutional disturbance, by which the attack is ushered in, there is the frequent derangement of the renal function, the marked prostration of strength, the functional disturbance of the heart, and, at a later period, the extensive implication of the nervo-muscular sj'stem. The local sj'mptoms — the false membrane, with its parasitic growths — must be looked upon as the first (?) evidence of constitutional poisoning ; in fact, as the first of the secondary phenomena." (Mackenzie.) CHAPTER XIV. GENERAL TREATMENT. Having shown diphtheria to be, as defined in chapter I., an acute, infectious, specific, febrile, disease, depending primarily upon infection of the blood, manifested not only by general symptoms, but also by a peculiar and often dangerous specific inflammation ; and having described the type and course of both, and the pathological phenomena they severally exhibit ; and also the complications incident to the several types and stages of the disease, with their significations and tendencies ; there yet remains for. us to consider its treatment. This will be done under the heads of General, ^Therapeutic, and Pro- phylactic treatment. The remarkable mortality hitherto exhibited by diphtheria under all the various modes of treatment hitherto practiced, amounting to from twent3 7 -five to ninety-one per cent of the persons attacked, as estimated by several of the most trust- worthy modern observers and authors (See Chapter XII), gives to this portion of our work peculiar interest and im- portance, and is a sufficient warrant and excuse for putting 78 DIPHTHERIA. forward and defending the peculiar and novel mode of thera- peutic treatment introduced by the author, and herein first given to the profession. Without disavowing the ordinary motives prompting to research and labor, the writer distinctly claims the chief motive in view in giving these pages to the medical profes- sion is a desire to diminish the sum of human suffering and the ravages of death from this fearful malady. As diphtheria is a disease manifested lyy great depression of the bodil}' powers, the general treatment should be sup- porting. The patient should be placed in the best available apartment, which should be large, cheerful, well-lighted, well- ventilated, and well-warmed. As a general rule the tempera- ture should be such as is most comfortable to the patient, and hence should be varied in different stages and cases to gratify his demands. The limits of variation may properly be be- tween G0° and 75° F. When the larynx is invaded, moisture diffused in the atmosphere of the sick room is of signal benefit. Whatever be the means of ventilation, keep the air pure and sweet, and its odor may be rendered agreeable by the use of pleasant perfumes. Keep the patient out of cold draughts. The food must be not merely nutritious, but nicely pre- pared, fresh, and agreeably flavored. It ma} 7 consist of sweet or buttermilk, eggs, tender beefsteak well hashed while raw, and lightly cooked, scraped beef, beef-tea or essence, egg-nog, milk-punch, soft cream-toast, rice thoroughly cooked, rice water, toast water, &c, and given regularly and frequently, day and night, in such quantities as are well borne. A little lime water ( 3 i ad 3 ii to 3 i) renders sweet milk, it is thought, more digestible. Food ma} 7 be disrelished or swallowing very painful, still it should be given in some eligible form, or by enemata if that be the only available way. Most children will drink freely of cold fresh milk or GENERAL TREATMENT. 79 buttermilk ; if, however, it agree better, let it bo warmed. If milk be taken freely, especially if a little raw egg with sugar be added, no fear need be entertained of want of nutrition. A high authority has recently stated, " There are few cases -of diphtheria in which sj^stematic feeding does not constitute the most important part of the medical treatment." In cases of marked anorexia, or of continued nausea and vomiting, to force into the stomach large quantities of food ■only to be ejected, or that can at best be but sparingly assimilated, is dangerous and reprehensible, and hastens rather than retards the rapid emaciation, and lessens the patient's chances of recovery. This is true equally with adults and children. Among the latter are found many who, born to rule, have never been taught proper subjection to authority, and hence are, by most emphatic exhibitions of will, in the habit of controlling all about them b} T the force of unreasoning passion and resistance ; and, also, the timid and over-sensitive class, who, from their loathing of food and medicine, painful deglutition, enfeebled powers, and unwonted surroundings, are bereft of their accustomed docility. Both these classes of children, when crowded by force, often resist .absolutely necessaiy treatment with so great excitement and physical exertion as greatty and dangerously to exhaust their prostrate powers, thus increasing the imminent perils of disease. Here arises a necessity for discrimination and the exercise of tact, often more potent for good than drugs, or even food administered unwisely or forcibly. Yield what is necessary in order to conquer peacefully. A little gratification of some longing desire, a little praise or sympathy well expressed, a little quiet repose, a firm look or word, or expressive gesture, or the exercise of an} r of the nice arts that spring spontane- ously ffom the breast of sympathy or affection, will some- times remove mountains of opposition, and are not to be neglected. 80 DIPHTHERIA. Make the necessary food and medicines as agreeable a$ possible j manage the patients well, and they will submit to- necessary general or therapeutic treatment. Sinapisms to the epigastrium or spine for older patients, or bits of lint or brown paper wet with chloroform or chloroform liniment and held in place with the hand a few moments r and, for children, spice poultices containing half a drachm of chloroform, are well borne and beneficial. A small glass of lemonade, iced or hot, as is thought best, or a litte freshly prepared tea or coffee arc to be commended, as also arc any aromatic mint or ginger teas. Recourse may also be had to the remedies advised in chap. XVI, or the formulae appended to this volume. In every case of marked debility, and such constitute a large proportion, the use of alcohol is indicated, in quantity proportioned to the condition and age of the patient. Three- or four drachms of brandy or pure whiskey in twenty-four hours for a child of three or four 3'ears, given in punch or milk and egg mixture, may suffice in cases of only ordinary depression. In similar conditions an adult may take an equal number of ounces. Attacks of fainting, irregular, very slow, or very rapid pulse, sighing, great pallor or duskiness of countenance, or stupor or delirium, are each among the symptoms calling for a more liberal administration of this class of stimulants, regardless of body heat. If, however, in cases of high temperature with rapid pulse, these be increased, the stimulant is of doubtful propriety, and had better be diminished or suspended. The character of the pulse should be carefully noted as one of the chief criteria in the use of any form of alcoholic stimulus. From the overwhelming effects of the severe toxaemia of diphtheria, manifested by feeble action of the heart, or the occurrence at any period of the disease of great exhaustion, it' should be given liberally ; in great emergencies, unsparingly. THERAPEUTIC TREATMENT. 81 The patient's clothing and that of the bed should be changed daity, and oftener if they become soiled, and ex- crementitious matter immediately removed. Time must be given the patient for sufficient sleep, espeeialty during the night. No persons except necessary attendants and unexcludable relatives should be allowed to visit the sick room. All un- pleasant odors, especially from the kitchen, must be excluded, and the most rigid order and quiet enforced. The patient should have a general tepid sponge bath once or twice a day, following which the skin, if hot and dry, may be rubbed with a little olive oil, to which may be added a few drops of carbolic acid or agreeable perfume. If the skin be too much relaxed, the bathing should be with alum-water and alcohol. Other details of the hygienic treatment are omitted as needless for intelligent doctors into whose hands only, or chiefly, is this volume expected to find its way. CHAPTER XV. THERAPEUTIC TREATMENT. An eminent writer says, " Few diseases more severely tax the therapeutic resources of the physician than diphtheria." "Why ? It is, as stated, because " he has to devise and carry out innumerable little details — hygienic, dietetic, and medi- cinal — which do not admit of description, and yet, upon the minutiae of which, success or failure depend ; because, too, of its various types and degrees of violence ; and mainly, I apprehend, because the records of diphtheria disclose no authoritative, established, generally acknowledged, or even reasonably successful mode of treating the disease. 6 82 DIPHTHERIA. The diversity of the therapeutic measures advocated amounts to little less than confusion, and tends to beset the prevailing distrust of all authorities and all remedies, and to drive each individual member of the profession to trust him- self to "devise" from his own resources, measures of treating the symptoms of each individual case as the}' ma}' occur. It may appear to some to be a reflection upon medical science, to be so barren of acknowledged facts, as to be forced to such an acknowledgment in so vital a matter. Such, however, is not the fact. Medical science is not a revelation, like theolog}' ; nor demonstratively exact, like mathematics ; nor so palpable as physics ; but, like chemistry and electricity, has grown from the minutest germ, into a structure so stately as to rival all its contemporaries. In this stately edifice each stone is a golden fact, worked out from the quarries of eternal truth by patient research and careful observation. From its very nature medical science can never be com- plete, but must be ever progressive, and this state of inhar- mon} T and unrest is only the earnest of progress. It is unreasonable to expect the votaries of this science to rest quietly in the presence of a mortalit} 7 so appalling as is disclosed in the records of diphtheria. Inaction would be disreputable, non-professional, criminal. The search for a better, for a specific therapy in diphtheria will continue despite the taunt of "a hobby," ignoring a blind deference to the dead past, refusing servile submission to the dogmas of the present, until the goal is reached, and the prize shines in the diadem of the victor, embellishes the great temple of. medical science, and becomes a blessing to the human race. All honor, we say, to Bretonneau and his compeers, the heroes of general and local blood-letting, of blisters, of caustics to the pharjmx, and of mercury. Dr. Bard wrote, " But al- though I consider mercury the basis of cure, I do not b} T any. means intend to condemn or omit the use of proper alex-, ipharmics and antiseptics." THERAPEUTIC TREATMENT. .83 These authors of the past belonged, as leaders of medical thought, to their own da}' and generation, and not to ours, and if we judge them by our own standards we judge them unjustly, because the inarch of progress has been forward. Occasionally onl} r , in this age, can be found an irrational advocate of mercurial treatment, whilst, with our better knowledge of the asthenic nature of diphtheria, the blood- letting and blisters, with all other depleting measures, we of the present day treat as madness. A few high names may still be quoted in advocacy of strong caustic applications to the throat, among whom we may mention West, Bouchut, Trousseau, Slade, Qertel, and Aitkin. Fortunately for the interests of humanity, as well as in honor of the medical profession, in obedience to the advancing sentiments of the age, these and all other violent measures of treatment are being abandoned. With regard to the want of harmoiry in modes of treat- ment by different practitioners, J.L.Smith writes: "The •wide discrepancy which exists in reference to the proper therapeutic measures, receives partial explanation from the fact of a wide difference of opinion as to the nature of diph- theria and its mode cf commencement, but is more often due to the fact that statistics of its treatment afford very unrelia- ble and often conflicting data, by which to determine the proper medicinal agents. " For scarcely an}' other disease presents such a diversity in type as diphtheria, from cases so mild that nearly all recover, whatever the measures employed, to those so severe that a large proportion die under the best possible treatment, and this difference in t}-pe may be observed in cases occurring at the same time in a great cit}^ like New York, or even in the cases, which two plrysicians, practicing near each other, may be called upon to treat. Hence, one physician recommends with confidence a medicine or mode of treatment, as eminent- ly successful in his hands, of which another physician of equal 84 DIPHTHERIA. experience speaks disparagingly. The theory relating to diphtheria, which, in my opinion, has of late years done most harm, is that which attributes it to low vegetable organisms, visible under the microscope, which alight upon one of the exposed surfaces, usually the fauces, where they excite a local inflammatory action, and if not promptly destroyed, are apt to penetrate the tissues, enter the blood, and establish a constitutional disease. Acceptance of this theory evidently leads to the employment of parasiticide medicines, the so- called antiseptics, or antiferments, externally and internally, to arrest and destro}^ the vegetable growth, their local use sufficing, according to the theory, in the early stage, when these organisms have passed no further than the surface ; but their internal use being required in addition, if the malady have continued longer, and the disease have become general." Therapeutic treatment is divided into local and general or constitutional. CHAPTER XVI. LOCAL TREATMENT. NUMBERS OCCURRING IN THE TEXT REFER TO THE FORMULAE AT THE END OW THE VOLUME. We have already incidentally alluded to the " savage ener- gy " of the local measures advised by Bretonneau and others. The propriety of local treatment of its local manifestations is not to be questioned in diphtheria, any more than in other constitutional diseases with local manifestations, as in syphilis, scrofula, rheumatism, mumps. We must be careful, however, to put only a cautious and limited trust in our local measures, as some in use only increase the local irritation, and none are curative of the constitutional affection. Dr. Bristowe, in the Medical Times and Gazette, 1859, may be regarded as leading the modern sentiment on this subject. LOCAL TREATMENT. 85 He says, " 1. That the throat affection is merel} 7- a local evi- dence of a constitutional disease, which is unlikely to be arrested in its progress by any treatment directed to the secondarjr manifestations only. 2. That the throat affection rarely kills, except by involving organs, such as the trachea and deeper tissues of the neck, which are beyond the region of the possible influence of such agents. 3. That if the theoretical correctness even of such treatment be admitted, the application of remedies to the surface of a thick false membrane, with the hope that they may affect the adjacent mucous tissue, is not onty clumsy, but, as regards the object intended, practically useless ; and that the prior forcible removal of the membrane from the entire surface, in order to their efficient employment, is unjustifiable in the early stage, even if possible, and is likely only to be followed by in- creased inflammation, and reproduction of false membrane. Of course, if a gangrenous state of the tonsils, or any other local complication, supervenes, such topical applications as are commonly had recourse to in like conditions of the throat should be employed." Mr. Wade, in 1862, expressed the conviction that interfer- ence would neither prevent the reproduction of the false membrane, nor prevent its extension to the larjmx. Green- how's maturer views may be inferred from the following language : " I very soon discontinued this rough local medication to the tender and enfeebled mucous membrane. The propriety of this course became evident at the very first post-mortem examination I had the opportunity of witness- ing, and has been confirmed by my subsequent experience." Dr. Hartshorne recommends the use of hydrochloric acid and hone}^, equal parts, painted over the surfaces, or diluted and used as a gargle, also creosote in glycerine ; lime-water ; ice ; and the inhalation of lime-water steam. Aitkin advises warm fomentations externally, and the in- halation of water vapor with acetic acid : he also thinks a 86 DIPHTHERIA. gargle, composed of a fluid drachm of diacetate of lead in eight ounces of rosewater, may be of service, but saj-s gargles must not be persisted in if pain be caused by their use. " The tincture of the perchloride of iron is now fully recog- nized as having a beneficial local as well as general effect, and may be advantageously combined with quinine." He advises that the throat be S}'ringed with a solution of per- chloride of iron, and that the exudation be painted with a strong solution of the same, and also recommends a single efficient application of nitrate of silver, or equal parts hydro- chloric acid and water, and considers useful a gargle of medicinal carbolic acid, one part in a hundred. Cohen does not think highly of local applications or gargles. Fothergill recommends the free use of nitrate of silver, as also do West and others. Oertel, in Ziemssen's Cj'clopsedia, says, " In diphtheria we have to deal at first with an infection which is localized, and afterward with a general disease resulting from this, out of which maj T ultimately be developed still a later infec- tion of various organs." As disinfectants, to be used with the atomizer, he advises chlorate of potash, salicilic acid, and, in the more advanced septic states, permanganate of potash. (See formulae at end of volume.) Prof. Smith says the object of local treatment is "to* reduce the inflammation of the mucous surfaces, and destroy the diphtheritic poison, and contagious properties in the pseudo-membrane, and to destroy the septic poison, and prevent its absorption, if any forms. Irrigating applica- tions, the use of the sponge or other rough instrument for making the application, should be avoided as likely to do harm." He advises the application to be made with a larga camel's hair brush, or better, for most mixtures, with an atomizer. , v In laryngeal cases; he .considers lime-water spray the most LOOAL TREATMENT. 87 efficient, and reports seven recoveries in twenty-five cases thus treated. He advises the inhalations to be nearly con- tinuous. For cleansing and disinfecting the nasal passages he advises Form. No. 8. A very excellent spray solution may be made by the mixture of lime-water and carbolic acid. Favorable effects are reported from dusting the affected parts freely with washed or sublimed sulphur. Prof. M. Mackenzie writes, "In fact, the profession has given up the use of caustics altogether," and in regard to various astringent applications, as tannic acid, powdered alum, and tincture of the chloride of iron, " The disease is sometimes checked by this class of remedies, but on the other hand they sometimes irritate the throat — especially if there is much hyperemia — and frequently increase the nausea and dislike for food which are so common. I now seldom use these drugs with the exception of iron, which when emploj^ed as a constitutional remecty also acts topically." The objects had in view in the local treatment of diph- theria may be thus briefly summarized : 1st. Cleansing the mouth, throat, and air-passages ; 2d. Disinfecting their secre- tions ; 3d. Alla} T ing inflammation b} T promoting secretion ; 4th. The solution of the membrane or its detachment. Two, three, or even all of these indications may be more or less perfectly fulfilled by a single remedj". Thus washing the mouth and throat thoroughly with warm water or weak solutions of chloral hydrate, borax, or chlorate of potash, purifies the surfaces, measurably disinfects the secretion, and promotes secretion and the detatchment of the false membrane. But it is well known that sick children are very generally refractory, and by reason of perverseness, fear, or nervous irritability, or all combined, refuse to gargle, and resist any efforts to wash thorough^ the mouth, throat, or nasal passages. To force them into submission is to exhaust the strength and vitairty; alread\ r , it may be, alarmingly de- 88 DIPHTHERIA. pressed, and which are so necessary to any satisfactory treatment, and to recovery. Let there be no occasion given the little sufferers to either fear or fight their medical atten- dants or nurses — rather let them be coaxed, cajoled, or hoaxed into the use of the best available measures. Some quietly submit to topical applications with a large soffc camel's hair brush, which should be rinsed in hot water as often as it becomes loaded with the viscid secretions. For use in this manner or for gargling, formulae Nos. 2 and 3 are specially recommended. For cleansing and disinfecting the nasal passages when involved in the diseased action, inject three or. four times a day the weaker solutions Nos. 6 and 7, or Prof. Smith's solution No. 8. Avoid caustic and irritating applications, as they greatly aggravate the local mischief by coming unavoidably in con- tact with and destroying parts of the pharyngeal and laryn- geal surfaces not yet invaded by .the exudation, thus making new foci for the appearance and diffusion of the membrane ; by impairing the ability to take nourishment, and, from the pain they occasion, engender opposition and strife on the part of the patient ; and increase the absorption of septic matter. No other local application has proven of equal value in my practice with chloral hydrate. I have used it constantly and exclusively for the last six j^ears in every form of the disease, and in not less than four hundred cases, and can confidently affirm its great superiority, if not its specific control over membranous exudations, especially when used constitution- al^ at the same time. In cases of but ordinary violence in which the air-passages are not invaded, the contact by gargling and swallowing, or simply swallowing the solution prepared for internal use hourly, prohibiting drink or gargling for five minutes after the administration, proves quite sufficient ; both the local LOCAL TREATMENT. 89 and constitutional s} T mptoms beginning in a few hours to abate. The average duration of such cases has been about four days, exceptionally longer or less, with no other medical treatment. The ordinary sequelae rarely occur to retard the convalescence in these cases, the proportion thus affected not being above two or three percent. When the nasal passages are involved in the diphtheritic process, as evinced by the symptoms detailed, they should be carefully cleansed and disinfected b}^ Sj'ringing with weak solutions of chloral every four hours, (Formulae Nos. 6 and 7). Regarding the topical use of chloral, Prof. Mackenzie says, " It was first recommended b} r Dr. Accetella, and subsequently by Dr. Ferrini, of Tunis, and has since been highly extolled by Dr. Csesare Ciattagli, of Rome, and Dr. Massei, of Naples. In this country (England) it has been employed with great success by Mr. Hughes Hemming, of Kimbolton, to whom I am indebted for its recommendation. Mr. Hemming uses the syrup of chloral (grs. xxv in 3 i) and directs that it should be employed every hour or two. It does not, as a rule, cause any pain, and the nurse can easily be taught to apply it. Mr. Hemming observes that 'whilst it rapidly gets rid of the fetor, it is beautiful to see the membrane loosen and come away, leaving a healthy surface underneath.' This remedy has also been very successfully used by Dr. €harles Hemming, of Bishop's Waltham." The following testimony of the remarkable efficacy of chloral, topically applied, is borne by Dr. Rokitansky in the Medicinisch-Chirurgische Rundschau, Nov. 1878, as quoted by the American Journal of Medical Sciences, April, 1879. "Dr. Rokitansky has used a 50 percent solution of chloral in three cases of diphtheria which had resisted the usual remedies, such as salicilic acid, carbolic acid, &c, and every time with the same results. The solution was applied every half hour with a camel's hair brush, and caused very 90 DIPHTHERIA. little pain, except m one case where the tongue was thickly covered with a layer of diphtheritic matter ; here a very con- siderable secretion of saliva was always observed immediately after the application, and the pain ceased entirety after a few moments. In the other two patients, in whom both tonsils were partly covered with the diphtheritic membrane, the pain was insignificant. ' ; After the solution had been applied three times, i. e., one hour and a half after the first application, large pieces of the membrane could be easily removed with the brush. The underlying portion of the mucous membrane was red and covered with fine granulations. As soon as the normal tis- sue could be seen, weaker solutions of chloral were gradually used during a week, at the end of which the patients had entirety recovered." I have rarely used for the last five or six years an}- other topical treatment within the throat, and therefore feel qual- ified to indorse the preceding testimonials of its remarkable efncac} T , and to a*ecommend chloral for this purpose as more effective than an} T other remedy. According to m}- observa- tions it will not only cause a rapid separation of the false membrane in mass, but so act upon it also as to cause its disintegration, thus depriving it of its structural charac- ter and much of its power for mischief. In this manner the exudate can often be defibrinated as fast as transuded, and its membranous or structural character be prevented. Its local application should be by means of a soft pencil of camel's hair or a feather, and when the constitutional treatment is also by chloral, and timety, will seldom be required and need never to be repeated more than two or three times a day, and in strength of from twenty to fifty per cent. The patient, if it be agreeable to him (but not otherwise),, maybe allowed to take, small pieces of ice frequently into the mouth as a means of allaying thirst and morbid heat and LOCAL TREATMENT. 91 dryness. It is thought by some also to have the effect some- times of reducing the local inflammation and swelling about the fauces. This, however, there is ample ground to doubt, and when we consider the nature of the disease, and the peculiar low grade of the inflammation, there is good reason to fear harm from its effects upon the obstructed capillaries of the parts, b} r causing in them a decrease of the already low vitality ; and also b}^ favoring farther fibrinous coagula- tion within the capillary walls, and in the contiguous cellular and glandular structures. The external use of ice by means of ice-bags applied to the neck, although reputably indorsed, for the preceding and other self-evident reasons, can only be potent for evil, and is unwarrantable. Poultices and fomentations are also advocated by many physicians, but in my observation have not proved highly beneficial except in laryngeal cases, in which they are of great value when carefully applied. The use upon the neck of large slices of fat pork is also recommended, but is re- garded by the author as not only useless and filthy, but mis- chievous. The neck should in all cases be enveloped in sev- eral thicknesses of soft, dry flannel. If there be much adenitis- and cellulitis, the most efficient application is, in the author's estimation, a combination of equal parts of tincture of iodine, glycerine, and a fifty per cent, chloral solution, with which the swollen and inflamed structures are frequentty to be thoroughly painted ; and always to be kept well protected from the air by means of several thicknesses of soft, dry flannel, as before mentioned. 92 DIPHTHERIA. CHAPTER XVIL CONSTITUTIONAL TREATMENT. The experience of the medical profession in the treatment of all general or constitutional diseases warrants the assump- tion that it must be largely addressed to the general system through the medium of the blood. If the blood be not itself the sole seat of disease, it must at least be the bearer of the disease germs, and must be made to carry most remedial agents, whether antidotal or recuperative, to the invaded structures. Diphtheria has been shown to be a general disease of the blood, exhibited only incidentally, although with surprising uniformity, b}^ local manifestations. Prima- ily it is to be regarded as a blood disease only, manifested first, or during the stage of incubation, by very slight de- rangements, or none at all. The system is poisoned by the infection derived from some person previously diseased, and the poison is "working," but is endured without manifesta- tions or complaint up to a certain degree, when it is distinctly declared by symptoms, systemic and local. This period is rather illogically called " the attack." The treatment of diphtheria has been and still is, to most practitioners, exceedingly miscellaneous and unsettled, as well as unsatisfactory. The following quotation expresses truthfully the general sentiment of the profession on this subject. Prof. Lennox Brown, F. R. C. S., writes as follows: " Many general remedies have been suggested, and some have been vaunted as specifics, but the most rational and satisfac- tory method seems to be that of treating symptoms as they arise Those who look on the disease as occurring under circumstances similar to those producing erysipelas or phleg- monous sore throat ; and especially having regard to its re- markable tendenc} r to produce anaemia, as well as its extremely asthenic character, will be disposed to give perchloride or CONSTITUTIONAL TREATMENT. 93 other forms of iron ; others who may consider the poison of diphtheria allied to that of scarlatina, will prefer to rely upon cinchona with acid or ammonia ; other practitioners, again, may be more willing to depend upon the sustaining properties of strong and easily digested nutriment, with the moderate use of diffusible stimulants. Seeing how unsatis- factoty the results of drugs are in this disease, it certainly does not appear desirable to push nauseous, and often not easily assimilated medicines, in a disease so prevalent among young children, who in addition to having a natural dislike for medicines, experience great pain in attempts at deglu- tition." Mackenzie says, "There are few cases of diphtheria in which systematic feeding does not constitute the most im- portant part of the medical treatment." Prof. J. Lewis Smith says, "It is remarkable that there is so little agreement in the profession in regard to the medicinal treatment of diphtheria, since this disease has now been under almost constant observation during the last twenty years in the prin- cipal cities of this country, and many epidemics have been closely observed and reported by intelligent physicians in the rural districts." In the presence of the prevailing professional sentiment regarding the therapeutic treatment of this disease, so elegantly and truthfully expressed in the above quota- tions, which fairly represent the diversity of opinions, or positive antagonisms existing among medical practitoners and writers on this subject ; to dissent to the views or prac- tice of eminent medical authors is neither discourtesy nor professional heterodoxy. On the contrary, this condition invites research, observation, experiment; a struggle for new light to supplant the confusing darkness ; and imposes on physicians an imperative duty to report to their brethren the discovery of any new plan of treatment or new remedy, which, supported by sufficient experience, and success on 94 DIPHTHERIA. trial, furnishes a basis for a true faith, and a consistent uniformity, or at least similarity, in the means employed. The writer comes before the medical world with a new book not merely containing a rehash of what has been said or written before on this subject, (although the writings of others have been searched, freely quoted, contrasted, and weighed ; and in the department of therapeutics mainly re_ jected on account of their want of specific practical value)- but he appears in these pages as the herald of a new depart- ure, which is not new in the sense of being untried or un- proven ; and as the advocate of a specific treatment of the membranous diseases by a remed} 7 which has championed its way to his full confidence by the exhibition of such remark- able power in diphtheria as to have reduced its mortality to a percent not greater than that of malarial fever when treated with its specific, qninia. It is hardly necessa^ to say, after what has been already written, that this remedy is chloral hydrate. It is not used to the exclusion of such other rational remedial measures as are indicated by the symptoms, nor such as are believed to aid its specific action. Before detailing the mode of administration and its supposed modus operandi, it seems best, in order to a full view of the subject in hand, that we should cursorily pass in review the remedies in most general use ; that each ma} 7 be, as near- ly as possible, assigned its appropriate sphere by the prac- titioner ; and also to give to the student a correct but con- densed view of the entire literature of the disease. Cathartics. The operation of an efficient laxative in diph- theria is not open to the objection of Dr. Slade, based upon the idea that it increases the asthenia. Quite the reverse is the fact if the remedy be properly selected and its effects lim- ited within reason. By its operation we not only relieve the plethora and the fever, but by promoting the secretion may reasonabl} T hope to eliminate from the system some portion of the specific virus of the disease. CONSTITUTIONAL; TREATMENT. 95 The weight of authority in this matter is on the side of reason, in favor of the administration of a prompt efficient lax- ative as early as possible in the disease, unless contraindicated by some such conditions as diarrhoea, unusual debility, or ex- treme malignancy, all of which must enter into the account of the attending physician in adjusting his treatment. Sir Wm. Jenner and Dr. Aitkin advise calomel and jalap for this purpose, or a calomel and colocynth pill, followed in the in- flammator3 T forms of the disease by a saline aperient. My practice is to give from five to fifteen grains of calomel, ac- cording to age and conditions, combined with an equal or greater weight of bicarbonate of soda, and followed in three •or four hours, if by that time it have not moved the bowels sufficiently, by a draught of Rochelle salt, a portion of castor oil, or an enema of tepid salt water, or soap suds. Emetics, although of doubtful utility, are often emplo} T ed in diphtheria for the purpose of effecting the detachment and expulsion of the false membrane, and are thought by some to be of especial value when the laiynx is involved in the diseased process. If in such cases they prove beneficial, it must be mainly by causing maceration of the false membrane by the free secretion of mucus about and beneath it, aided by the vomitive effort induced for its expulsion. Mucus is not known to be a solvent of the exudate, nor is it by any means certain that its presence greatly accelerates its separation. It is, however, generally abundant in the throat when it is the seat of the deposit. A loosened membrane or one but par- tially detached by the physiological process, and irritating or obstructing the lar}mx and glottis, is not infrequently ■expelled by the vomiting caused by its presence in such localities, and when such a state of the membrane is known to exist and does not occasion the necessary vomiting, it is reasonable and proper to cause it b} T irritating the fauces with a feather or the finger carried far back into the throat. 96 DIPHTHERIA. The debilitating effect of antimony and ipecac, especially the former, is well known, and their use is therefore not to be thought of in states of prostration such as are usually seen in diphtheria. Even the exertion of vomiting, in cases of great debility, is to be feared, and avoided if possible. If in any emergency, the use of an emetic seems imperative, the patient should be guarded from harm by being previously placed under the influence of an alcoholic stimulant, or a sup- porting dose of morphia (one sixteenth to one sixth of a grain), or both combined ; and even then it will be necessary to select only such emetics as act quickly and briefly. Those least objectionable are, doubtless, powdered mustard seed in doses of one or two teaspoonsful in a wine-glass of tepid water, and the sulphates of zinc and copper. The copper salt may be given in doses of from two to ten grains, mixed with powdered sugar, every ten or twelve min- utes until it acts : the zinc dissolved in tepid water in doses often grains for children, to sixty for adults, and may be re- peated in five minutes. Bretonnau, for reasons given, pre- ferred the copper ; J/R Cormack advises the zinc. Opinions differ, and the practitioner has abundant authority for his choice. About the only valid reason that can be assigned for the administration of an emetic in diphtheria, let it be under- stood, is to get rid of the annoyance and danger of detached or partly loosened membranes irritating or obstructing the larynx. They are not believed to occasion its loosening if given before that process is at least partially effected through the ordinary process of inflammation. The tincture of the perchloride of iron, and quinine are the two remedies more generally employed at the present time than any others, though upon what principle it is not easy to decide. They are variously classed by writers as tonics, re- storatives, specifics, recuperatives, and antiseptics, or as be- longing to two or more of these classes. From the fashion in the medical profession at the present CONSTITUTIONAL TREATMENT. 97 time of prescribing one or both of these valuable remedies in every case of diphtheria and in every stage, it is necessarily inferred that they are regarded as specifics. They are pre- scribed as uniformly in this disease as are any of the known specifics in the diseases they are known to arrest. If judged in this light, in view of the slightly diminished rate of mortal- ity since the times of Bard and Bretonnau, with bleeding, mercury and blisters, they must, with these discarded rem- edies, be regarded as flat failures. Among a respectable minority who regard iron as possess- ing no special utility in this disease, West, in his Diseases of Children, has the following : " Neither have I found it to vindicate in my hands its claims to that special specific virtue for which some practitioners have given it credit." Flint, in his Practice of Medicine, speaks most decidedly on this sub- ject, saying : " The tincture of the chloride of iron does not exert a specific influence as some have supposed." If it is not as a specific that iron is prescribed, it is probably as a restorative tonic. Here, in diphtheria, markedly in its early stages, the acknowledged indications for its administra- tion are usually noticeably lacking. M. Bretonnau wrote in 1826 : "At the onset of diphtheria the organic functions and those which belong to the life of relation, are so little dis- turbed that children who are alread} 7 dangerously affected by malignant angina, generally retain their habitual appetite, and continue their play" — an observation very applicable to numerous cases at the present time. The nutritive fluid is not impoverished, as the appetite and digestion are as yet but slightly impaired ; neither anaemia nor emaciation being manifest, but only such depression of the vital powers as results from the toxaemia. The rational indications in this condition seem rather to call for nutrients and alcoholics, or specifics, to fortify the system against the progressing ravages of the disease, or to counteract and eliminate its virus, than for iron as a restorative. It is not rendered even probable by 7 98 DIPHTHERIA. the state of the patient that the blood is suffering from any want of iron in the composition, but as before intimated, from the effect of a specific poison for which iron is not even claimed to be an antidote. This systemic condition calls for support till the disease is overcome by the recuperative ener- gies and its germs eliminated; or else for specific treatment, and iron quite certainly meets neither of these requirements. I am permitted to make the following quotation from an unpublished thesis of an esteemed medical friend : " The tincture of the chloride of iron is by man}'- regarded almost if not quite in the light of a specific in diphtheria. Its admirers and upholders, aside from considering that it de- stroys or neutralizes the specific poison to which the disease is due, advocate its use on the ground that it is a tonic, an astringent, an appetizer, and an antiseptic. All of these qualities, except that of a specific, the remedy under consid- eration most unquestionably does possess. Its action as a specific is certainly not well supported. As a tonic and re- storative, iron is unquestionably one of the best. It is one of the great triad of restoratives, quinia and cod-liver oil being the other members. But is tonic and restorative action required, as a general thing, thus earl} 7 in diphtheria ? And when required, is iron the best agent to employ ? The patients are generally } T oung and vigorous, often plethoric, and tonics are often strongly contraindicated. And when required, beef-juice, eggs, milk, cream, egg-nog, and nutrients generally, fulfill the indications better than iron. " As an astringent, tincture of iron has the same proper- ties as Monsell's solution, intensified in degree, and is more irritating. In common with astringents as a class, it checks secretion by constringing the mucous surfaces with which it comes in contact. But in diphtheria the indication is to get increased action of the mucous glands, as the restoration of the normal secretion facilitates the separation of the pseudo- membrane • and astringents are contraindicated. CONSTITUTIONAL TREATMENT. 99 " The mucous glands under the membrane are either acting abnormally, or not acting at all. This perversion or suspen- sion of their function must be rectified, and the normal secre- tion restored if we would imitate our great teacher, Nature, and favor the separation of the pseudo-membrane in the natural manner. And in the inflamed condition of the throat the local application of an irritant is anything but beneficial. As an antiseptic it does not rank as high as many others that are far less irritating in action. " Appetizers are hardly needed in the commencement of the malady, and in children, with whom we have most fre- quently to deal in treating this disease, the tincture of iron, by its disgusting taste, begets a loathing rather than a long- ing for food. Its exhibition is pushed in diphtheria ; full doses frequently repeated being the rule. But no less an au- thority than Pareira says that when swallowed even in medi- cinal doses it readily disorders the stomach. Hence it de- feats its own object. " In diphtheria the fever is often very marked, and there is a tendency to fibrinous deposits not only in the throat, but in the cavities of the heart, and embolism is not infrequent. Iron certainty will not abate the fever, and is not known to have any power to arrest membranous, or to prevent or ar- rest fibrinous coagulation in the chambers of the heart and the blood-vessels, and therefore is not indicated. After the high fever has passed away and the vital forces of the patient are very low, seems to be a more reasonable time for the employment of this remedy. And there are arguments against its use even here. In Wood's Materia Medica we find the following : Analogy has suggested its employment in other adynamic affections, such as diphtheria and pyaemia, but its value in these diseases is much more than doubtful. " According to Stille, iron is contraindicated in congestion and inflammation, which would go to exclude it from our list of diphtheritic remedies. 100 DIPHTHERIA. "Iron is generally administered in large and increasing doses, from the first to the last visit of the attending physi- cian, to adults in doses of 3 ss to 3 i every two or three hours diluted with water and glycerine, and to children in propor- tionate doses ; or the following to a child of five years : 3 Tinct. ferri chloridi, Potas. chlorat. aa 3 ij, Syr. simp. 3 iv, misce. A teaspoonful every one or two hours. (Smith.) These doses are often considerably increased. If the case be malarial or malignaut, quinia and whisky are far more rational." Quinia may be sometimes required as indicated, but is neither known nor supposed by the writer to possess any peculiar therapeutical properties that render it any more effi- cacious in diphtheria than in any other febrile disease in similar conditions. Its great value as a remedy has led too many practitioners into its indiscriminate use in the most diverse and contradictory conditions, apparently upon no well settled therapeutical principle ; but as being the first thing to suggest itself as possibly possessing some indefinable property to meet almost every emergency, local or general, acute or chronic, that may occur in practice. The very general administration of quinia in this disease can only be accounted for, first, from its being regarded as a specific. This deduction seems almost a necessity, as it is given, as is iron, early and late in the disease ; when symp- toms, are sthenic or asthenic ; adynamic, malignant, or benign ; laryngeal, nasal, or faucial ; and with the same uniformity with which it is given in intermittents, for which it is an acknowledged specific; or second, for its supposed tonic proper- ties, in view of which it nw at times be beneficial. Be it remarked, however, that no small proportion of the cases of diphtheria are characterized for the first twenty-four or forty- eight hours by high arterial action and a corresponding CONSTITUTIONAL TREATMENT. 101 increase of temperature, and that the effect of quinia in ordi- nary medicinal doses is to increase the heart's action and the body heat. It is consequently more rationally prescribed in states of great exhaustion and debility. Any means which, in these sthenic states, has so direct a stimulating effect, cannot be other than hurtful, as the high action is a chief agent in consuming or exhausting the vital powers, which at this stage should doubtless be conserved by a cau- tious lowering of the temperature and calming the circula- tion by tepid sponging, or a few doses of aconite or veratrum in connection with the chloral treatment. Two to four grains of quinia every two or three hours in such sthenic states, which is common practice, theoretically should be, and doubtless is, pernicious. If given at all in such states it should be in anti-pyretic doses of ten grains to a child of five years, and twenty or thirty grains to an adult, and promptly suspended, if, at most, two or three doses at intervals of three hours do not effect the desired reduction in body heat and pulse rate Quinine may be given, third, as a mere matter of routine, or a blind concession to writers whose recommendations are regarded as sufficient warrant for the practice. Quinia is a most valuable remedy, as are also mercury and atropia, but it does not follow that they should be given to all persons in all diseased conditions. Their power for good, when indicated, is no less potent for evil when contraindicated. What, for example, can be expected from such practice as the following, reported, but not sanctioned, by Prof. J. L. Smith in the immediate connection with the remark " that quinia does not exert any special or peculiar action in diphtheria, and is beneficial in the same way and no further than in other acute infectious diseases, is, I think, generally admitted by the profession ; for large doses do not exert that controlling effect, which we would expect from a specific, as is shown by cases like the following, which are not infrequent during severe epidemics : 102 DIPHTHERIA. "C. aged four years, male, was examined by me m con- sultation, on February 10th, 1876. I learned that he had apparently contracted diphtheria from the escape of sewer gas through a defective trap in the little room where he slept, and that the disease began after middaj^ on February 6th, with fever ; at 10 P. M. of the same day, when visited by the family physician, the temperature was 103°, and the fauces were red, but without an}- pseudo-membrane. Four grains of quinia were ordered to be given every two hours, and ten drops of the tincture of the chloride of iron, with two grains of the chlorate of potassa, to be given three times hourly. On the 7th the exudation covered both tonsils and the half arches j temperature 102^-° ; evening, temperature 100° ; pulse 128. 8th, is playful ; pulse 100 ; has slight swelling of the cervi- cal glands; evening, some extension upward of the pseudo- membrane ; has vomiting. 9th, Pulse 144 ; vomits often. 10th, at 3 P. M. began to grow worse ; phanynx and nostrils covered with exudation." Forty-eight grains of quinia and one and one half ounces of the tincture of the chloride of iron a day for four con- secutive days to a child of four years, or a total of 198 grains of the former and six ounces of the latter ! ! What physician will wonder that, with the recuperative powers so weighed down and embarassed with such an amount of nauseous drugs, the little one should grow worse day b} 7- day, should vomit on the third da}', and die on the fourth of "toxsemia ?" "Drugs are medicines when they cure, But poisons when to death they lure." Prof. Smith in commenting upon this case sa}'s: "It was impossible, at the time of my visit to obtain any of the patient's urine for examination, and death occured a few hours afterward from the toxaemia. Forty-eight grains of quinia administered dail}-, from the first day, had no appreci- able effect in sta} T ing the fatal progress of the malady, had CONSTITUTIONAL TREATMENT. 103 no such effect as would be likely to follow, were its action specific or antidotal. But there are two advantages from the quinia treatment, which explain the confidence reposed in it by the profession : 1st. It has an antipyretic effect in doses of from three to five, or more, grains. 2d. In moderate doses it is one of the most reliable tonics. But high febrile move- ment, requiring an antipyretic, I have seldom observed in diphtheria, except in the first forty-eight hours ; and if, during this time, the febrile movement be such that an antip} T retic Is required, quinia in the large doses is preferable, in my opinion, to any other rerned}\ In its subsequent use, namely, us a tonic, two grains may be administered every two to four hours. But other bitter mixtures, which have been found to be the most useful tonics in general practice, perhaps would meet the indication nearly or quite as well." In the history of medicine no remedy has been so much abused, or brought into such undeserved discredit by its advocates, as quinia ; if only we except mercur} 7 and blood- letting, the panaceas of the age just past. "It will certainly cure malarial intermittents, and hence, as they are febrile diseases, it is probably remedial in all other fevers," is a process of reasoning that answered well enough for the facile quack who, after failing to cure his ague by lobelia et al, was forced by suffering, against what he thought his better judgment, to resort to quinia, and being promptly cured, became so strongly converted that he not only prescribed it for every disease, but adopted it as an article of diet, and daily sprinkled with it his potato and bread-and-butter. Such a philosophy is quite too prevalent, as is easy to see, in the practice of some regular physicians. An army phj-sician once prescribed quinine for a subordinate afflicted only with a sore toe. Such aimless, senseless, routine practice may not often endanger the patient, but is certainly a reproach and disgrace to physicians so afflicted with mental or moral stupidity. 104 DIPHTHERIA. As a general tonic the claims of quinia, although strongly contested, are for the present conceded ; and hence we regard it as remedial in states incident to diphtheria, but know of nothing entitling it to rank here as a specific. "As a rule, however," says Mackenzie, "quinia is more useful after the more serious s}'mptoms have abated, when it may be very suitably combined with iron and a mineral acid. Morphia and chloral are occasional!} 7 necessary to combat continued sleeplessness, and to ward off the exhaustion which is its invariable consequence." Chlorate of Potash. This salt, usually classified among diuretics, has since its introduction by Hunt in 1847 for the treatment of cancrum oris, achieved a cosmopolitan reputa- tion in the treatment of ulcerative diseases of the mouth and throat. Many practitioners hold that it, as well as chloral, possesses aplastic powers, or the property of checking the formation of an exudation, and it is doubtless more generally prescribed in croup and diphtheria than almost any other remedy. West is said to have been the first to formulate its use in membranous stomatitis, which occasionally exhibits pseudo-membranous patches on the gums and buccal surfaces. We do not, however, class ulcerative stomatitis among the membranous diseases. Subsequent observers have not only confirmed the favorable reports of Dr. West, but have con- ferred upon this remedy the character of a specific in the treatment of this hitherto refractory affection. Its mode of action is not understood, but its almost universal efficacy in ulcerative stomatitis is one of the few established facts in clinical medicine. Having achieved such a reputation, how naturally comes the suggestion to test its utility in other diseases more uniformly attended with membranous exudation. Bluche is supposed to have been the first to try its efficacy in diph- theria. The results were not as emphatic as in ulcerative stomatitis, but were encouraging. "Since then, cases have CONSTITUTIONAL TREATMENT. 105 multiplied in all quarters, and the facts authorize us to con- sider chlorate of potash, as a remedj^, perhaps not sure, but at least able to render some service in this grave disease. But in this respect we must make an observation. Croupous angina (diphtheria) has ver} T various degrees of gravity, according as it appears sporadically or as an epidemic, and it would be supremely irrational to draw conclusions from thera- peutic experience in cases so unlike. If it is true that in malignant angina, especially when epidemic, chlorate of potassium generally fails, as most treatment does fail, it can- not be denied that the same remedy has procured success in quite different circumstances, that is, when croupous angina presented chances of curability. In this respect the obser- vations made at the children's hospital, or published by a large number of physicians at Paris and in the country, scarcely permit a doubt. We will say, then, with Isambert, that the usefulness of chlorate of potassium, in cases of medium intensity, seems to us proved, not only by a real and -definite success, but by its special and almost elective action upon the pharyngeal mucous membrane, identical with that which is observed in membranous stomatitis. The return of the rose red color, the fall of the false membranes, the low- ered pulse, are often in a space of time which is sensibly the same in both cases. This observer adds that cauterization, employed concurrently, does not seem to him to hasten the action of the chlorate at all, but sometimes to impede it." (Trousseau.) In as much as clinical facts are more to be trusted than the most elaborate theories without such confirmation, and as like testimony to the utility of this medicine in diphtheria is borne by nearly all observers, everywhere, it must be accorded a place among the tried and useful remedies in diphtheria. Its dose is from two to ten grains, in aqueous solution, every hour, and should be given in conjunction with from one to five grains of chloral hydrate. (Form. Nos. 22 & 23 at end of vol.) 106 DIPHTHERIA. The internal treatment of Dr. J. L. Smith, which is very generally followed by American physicians, is the administra- tion in alternation of formulae Nos. 19 & 20, which he de- clares he has found to constitute the most satisfactory inter- nal treatment. He also advises citrate of iron and ammonia, alone, or in combination with carbonate of ammonia, in two grain doses, dissolved in simple syrup, in place of the latter, when the inflammation of the fauces has considerably abated, or is moderate. As a disinfectant to be applied within the nostrils, he advises carbolic acid, gtt. xxiv, glycerine § ij, and water 3 vi ; to be injected every four hours. Also lime- water spray in laryngeal cases. Mercury was considered by Bretonneau and others as the most important of remedies in the constitutional treatment of diphtheria, and Dr. Bard wrote "Although I consider mercury the basis of the cure, especially in the begining di- sease, I do not by any means intend to condemn or omit the use of proper alexipharmics and antiseptics." Very few practitioners of the present time prescribe this agent in any other wa}^ than as a laxative in the early stages of the disease. Its specific effects are now known to increase the asthenia and adenitis, without any compensatory effect to neutralize or to eliminate the specific poison ; hence mercury is practically and deservedly expunged from the list of anti- diphtheritic remedies. Sulphide of potassium, regarded by Swiss physicians as a valuable specific, probably does more harm than good, and is only mentioned to be condemned. Bromine and the bromides hafe also failed to vindicate the expectations of their advocates, and are practically abandoned except in lar3 T ngeal cases. Carbolic and salicylic acids, and the sulphites have been vaunted since the promulgation of the bacterian theory, as constitutional as well as local remedies of great value for the destruction of those minute low organisms of which Eberth CONSTITUTIONAL TREATMENT. 107 has said : " Without micrococci there can be no diphtheria." These remedies, or some of them, doubtless do possess in a high degree, bactericide properties; and, were the theory true, would be genuine specifics for diphtheria, at first locally, and afterward systemically, through the medium of the blood. These remedies I have formerly often used very early in the- disease, both locally by careful application to the entire in- flamed faucial surfaces ; and internally, either at the same time or subsequently, without any apparent modification of the pro- gress of the disease. Other observers have had similar ex- perience of their inutility. J. Lewis Smith expresses himself upon this point as follows : " But experience, if sufficiently extensive, is the safe guide- in therapeutics, and, according to my observations, internal antiseptic measures have not seemed to exert any marked controlling effect on the course of diphtheria." As bearing upon this subject he refers to a case of a four years old child, who took " Almost from the beginning of the sickness, a mixture of potassa and iron on the first hour, two grains of quinine on the second hour, and three grains of salic3'lic acid on the third hour, and this treatment was con- tinued night and day, and yet this child, having from the first taken sixteen grains of quinine, twenty -four of salicylic acid,, beside the potash and iron daily, died after eight days with profound blood poisoning, having had many extravasations of blood." Mackenzie says : " I have not employed carbolic acid my- self as an internal remedy, but the sulphocarbolates as rec- ommended by Dr. Sansom have often proved of service in my hands, in the secondary poisoning of diphtheria. In the primary septicaemia, these remedies have appeared to me quite useless." (Form. No. 26.) Balsam of copaiba and cubebs, so well known for their action on the mucous membranes, have been used both as specifics- and as expectorants in diphtheria, and are well spoken of by 108 DIPHTHERIA. veiy reputable observers. Mackenzie says : he Las found distinct benefit in catarrhal cases from perles of copaiba, but is of the opinion that neither copaiba nor cubebs can lay claim to anything like a certain and specific action. Dr. Be- verry Robinson, one of the physicians of Charity Hospital, New York, following the teachings of Trideau, is an advocate of the treatment by freshly powdered cubebs, {American Jour- nal of Medical Sciences, July, 1876.) Its action he considers to be that of a stimulant to the mucous surfaces, both by con- tact, and by elimination through the respiratory mucous mem- brane and the kidne}-s. To a child of five years he gives gr. x in sweetened water every two hours. Senega alone or in combination with carbonate of ammonia, has also been found useful, probably by promoting secretion by the mucous and salivary glands. B} T increased secretion beneath the false membrane its separation imiy possibly be promoted, and the pharjmgeal congestion in some degree relieved. Of expectorants it has been said no other is equal in effica- 17) is specially recommended. There must be no relaxation in the administration of nu- trients and stimulants, which, if necessary, may be given in enemata. These measures must be reasonably persisted in till the stridor and hoarseness are relieved, and the false membrane destrc^ed or expelled. If this treatment is not successful, there now arises one of the most difficult questions the physician is ever called upon to decide ; namely, the propriety of tracheotomy. . Out of the greatest perils there is no doubt a few have, by this means been rescued ; and from perils apparently equally great, a larger proportion have recovered by the persevering use of means less violent. I know of no satisfactory statistical or other basis for the clear solution of this grave problem. It must therefore be largely a matter of individual judgment, aided, if possible, by the best available counsel. Time, to confer and debate the problem at the bedside, is in every case exceedingly brief, from the very nature of the case. It may be that even a few moments of apparently 126 DIPHTHERIA. unavoidable delay or doubt will prove fatal ; — instantaneous decision and corresponding action are all that remain. In the writer's judgment the propriety of the operation in any case of general infection is exceedingly doubtful, and un- fortunately, such systemic infection exists in ever}' case of undoubted diphtheritic pseudo-membranous laryngitis. CHAPTER XX. TREATMENT OP DIPHTHERITIC PARALYSIS. Diphtheritic paralysis, the only frequent sequel of this disease, is not ordinarily attended with great danger to life. Its mode and period of development, and its attending phe- nomena are described in chapter X, which see. Although rarely fatal, and tending to spontaneous recovery, it by no means follows that medical treatment is unimportant in these cases. When the paralysis is slight, and limited to the pharynx and soft palate, as is most frequently the case, little is needed to be done, save careful nursing, with the tonics appropriate to this stage of convalescence ; and here, if at all, in diph- theria, is an appropriate sphere for iron. Quinine and cod- liver oil are also needed. In the graver cases of muscular paralysis, there is in addition, a need to call to their aid other therapeutical agents, If there be marked loss of power of the pharynx and oesoph- agus or epiglottis, rendering swallowing difficult or impossible in the former, and dangerous in the latter ; the administration of nourishment per rectum may become a necessity. For this purpose milk with raw egg beaten in it, or strong beef-tea, with milk and brandy, are to be used, with the addition of a few drops of tincture of opium to prevent immediate MEDICAL PROPHYLAXIS. 127 expulsion. These may also be made the vehicles for the administration of remedies, as strychnia, iron, and quinine, which are now needed. The feeding and administration of medicines may also be effected by means of the stomach tube. One or both of these modes may be a necessity to prevent death from starvation. If the paratysis prove severe or obstinate, we should, regardless of its seat, resort, in addition, to electricity, friction with the flesh brush or the naked hands, and local stimulants, as tincture of capsicum, or ammonia. The Writer has been well pleased with the effects of the magneto-electric current, though the other electric currents in a mild form are recommended. CHAPTER XXI. MEDICAL PROPHYLAXIS. If the views entertained by me of the chloral treatment of ■diphtheria are well founded, as I believe them to be, and if, as I also believe, its effects are produced primarily on the blood, and through its medium only, the following sequence is, to say the least, logical. The effects of chloral being antagonistic to the S3'stemic poison, or in other words, antidotal thereto in the more advanced stages, it is likely to be equally so during the stage of incubation, and therefore an efficient theurapeutical proph}iactic. That it is such I have often demonstrated in practice, to my perfect satisfaction. It manifests a remarkable power over the diphtheritic poison in every stage of its develop- ment. When given to persons exposed, in the doses heretofore advised, three or four times in twenty-four hours, I have 128 DIPHTHERIA. almost uniformly observed that if they contracted the disease at all, its form was mild. In most instances its protective influence has seemed positive, and its use for the purpose, though new to most practitioners, is earnestly recommended. A little experience in its use will dispel incredulity, and prove the value of this new departure. CROUP. CHAPTER I. In its aetiology croup has little in common with diph- theria. Croup generally has its origin in colds, and rarely occurs except in Winter and Spring, during the prevalence of inclement weather, and is neither contagious nor epidemic ; whereas diphtheria originates from a subtile blood poison, prevails at all seasons of the year, and is both contagious and epidemic. Pathologically their relationship consists in the development in both of a similar exudation ; in the former alwa} T s within the larynx, in the latter almost universally upon the pharyngeal surfaces, from which its extension into the nares and larynx, as well as its development upon any abraded surface of the body, is not rare. We regard both as forms of toxaemia, for the reason that common acute inflam- mation never, or very rarely, leads to a membranous exuda- tion. Just what the antecedent or coexistent cause of the blood poison of croup may be, aside from the catarrh by which it is ordinarily introduced and seemingly induced, is not known ; we are only familiar with the course and phenomena of the disease. These differ as widely from diphtheria as they do from fibrinous bronchitis. All three of these diseases are characterized by an identical membranous exudation, but are not therefore even suspected of being one disease. There is no better reason for suspecting the identity of croup and diphtheria than there is for reckoning all three to be one, and simplifying the nomenclature by calling all diphtheria. 9 (129) 130 CROUP. Indeed, Sir J. R Cormack has suggested that plastic bron- chitis may be a variety of diphtheria, and numerous other writers of great distinction treat croup and tracheal diph- theria as identical. Nevertheless the very wide clinical dif- ferences observed by all, are sufficient to distinguish them as separate diseases, having the one characteristic, a lamellated membranous exudation, in common. Their histories are as distinct as their clinical differences, and both alike disprove their identity. . . . The common membrane, it must be admitted, is suggestive of a similar effect being produced upon the blood by the causes which call into existence these separate affections. Although com- mon forms of inflammation never produce such an exudation, it does not follow that the different causes of these diverse maladies may not, to some extent, similarly affect the blood, and be amenable to like treatment. Fibrinous exudations prove either such an affection of the blood as predisposes to coagulation, or a peculiar form of local inflammation, producing topically, in croup and plastic bronchitis, a condition that in diphtheria has been shown to be systemic. Either may be admitted, or both, without ma- terially influencing the treatment, for the reason that, in the presence of so great danger, no topical or general treatment, known to have a favorable influence is likely to be disre- garded, whether it exactly fits our philosophy or not. The disease now under consideration is given a variety of appellations, as pseudo-membranous laryngitis, croupous or plastic laryngitis, cynanche trachealis, membranous croup, true croup, etc., to distinguish it from other varieties of laryngeal inflammation. The term croup, which was first em- ployed by Sir Francis Home, has long been applied to this malad} T , and is expressive of its earliest symptoms, hoarse- ness and stridor. Its derivation is uncertain and unimpor- tant, while its true meaning is expressive and significant. " Croupy 'cough" and " croupy breathing" are popular ex- CROUP. 131 pressions that are never misunderstood nor disregarded by medical men, and very seldom by the laity. They inspire the popular and the professional mind alike with a well-grounded sense of impending suffering and imminent peril. The disease is essentially a plastic laryngitis, dependent largely for its origin upon exposure in inclement weather, and in some degree perhaps upon specific causes, and also upon peculiar personal or family susceptibility ; and not upon any peculiar contagium. Croup is essentially a disease of childhood, between the ages of two and seven years, but occasionally occurs outside of these limits. It prevails mostly during Winter and Spring and is only exceptionally observed during Summer and Au- tumn. Its occurrence as a consequence of or in immediate connection with common acute catarrh, so masks its stealthy invasion that its serious character is often unsuspected : the patient is thought only to have " caught a cold." Early symptoms and diagnosis. First Stage. Pseudo-mem- branous laryngitis in its early stages is with difficulty diag- nosed from simple or ordinary catarrhal inflammation. Its symptoms are such as depend solely upon laryngeal obstruc- tion. This obstruction is at first, as in all the other forms of laryngitis, due to sub-mucous infiltration, or inflammatory swelling. An inflammatory stage, as in diphtheria, precedes the exudation or the period of membranous formation. Then as croup is, unlike diphtheria, neither epidemic nor conta- gious, no reliable diagnosis can be based upon its epidemic prevalence, or upon exposure depending upon the presence of others affected by the disease. The slight roughness or hoarseness of the voice and clanging or barking cough, as before intimated, are no more, often less, marked in the croup- ous than in simple catarrhal or accute forms of laryngeal in- flammation. Auscultation shows that both the inspiratory and expiratory sounds are a little prolonged, and that the vesicular murmur is more or less marked by laryngeal stri- 132 croup. dor. The supraclavicular, intercostal, and precordial spaces are somewhat depressed during inspiration, the depression being in proportion to the obstruction. Neither rigor, pro- dromic symptoms, nor peculiar form of fever, indicates the true nature of the attack, any more than do the character of the voice and cough. No characteristic expectoration or fau- cial inflammation Or adenitis are so manifest as to enable the anxious practitioner to surely solve the problem of diag- nosis. Is its solution then impossible ? It is only just to confess that, in the early stages, it sometimes is impossible. With physicians of experience and culture, and quick percep- tion of cases, a diagnosis is often like an intuition or a super- added sense, and is no more communicable to a novice by words than are the most difficult problems of geometry. This superadded sense or ready interpretation of the physi- ognomy of disease is a large element of medical proficiency, and either is, or underlies, skill. What, then, we inquire, are the best communicable instructions to aid junior members of the profession to fix upon a diagnosis in the early stages or first period of croup, as a basis for the treatment of this most deadly foe of children ? 1st. Remember that the characteristic symptoms are gen- erally (not always, it must be confessed,) more slowly devel- oped than in the simple inflammatory or spasmodic forms of larj-ngeal obstruction. The cough and stridor are less marked and more insidious and prolonged in this early period, than in the usually harmless spasm of the glottis, whether accompanied or not by some degree of inflammation. 2d. Fever is induced alike in the simple and the croupous forms of laryngitis, and hence is not pathognomonic. It may be said often to appear earlier, and at first with greater vio- lence, in the simple form of laryngitis than the croup. 3d. The differential diagnosis, to be reliable, must depend upon the discovery of the pseudo-membrane. If we are able to make visible the interior of the larynx by means of the CROUP. 1% laryngoscope, the presence or absence of this formation will remove all doubt. This method is not alwa3 r s practicable, and with timid children, sufferino; often as much from friffht as from dyspnoea, is very generally impossible. " If," sa}~s Prof. Flint, " the demonstration by this method fails, the pros • ence of a false membrane is to be inferred, first, from the de- gree of obstruction being greater than in simple acute laryn- gitis, provided the patient be a child; and second, from the pres- ence of an exudation in the pharynx, which is determinable by inspection of the throat. The latter is by far the more reliable. Clinical observations go to show that, in the great majorit}- of cases, an exudation visible in the pharynx accompanies pseudo-membranous laryngitis exclusive of the occurrence of the latter as a complication of diphtheria. There are, how- ever, some cases in which this evidence is wanting. In these cases a positive diagnosis cannot be made independently of the laryngoscope, until portions of the false membrane have been expelled by coughing. In all cases the expectoration should be carefully examined with reference to this, point. The por- tions of false membrane expectorated are sometimes rolled together with the mucus into a mass which must be carefully unrolled in water, in order to determine its membranous char- acter. This evidence of the affection is rarely obtained if the patient be under five jeavs of age on account of the expec- toration beino- swallowed." These remarks by this great teacher serve more to show the difficult character of the problem under consideration than to aid in its solution ; although it must be acknowledged thej' are as truthful as they are characteristically frank and instructive. Let us call to our aid a clinical example. E. S., aged five years, contracted a cold from exposure Nov. 12th, 1880. Family are constitutionally predisposed to croup, two children having previously died of the disease. Parents and living children constitutionally sound except the predisposition 134 croup. above mentioned, which has also been manifested by several violent attacks of diphtheria. Sanitary surroundings and other circumstances reasonably good. When called on the 15th the patient appeared but slightly ill; for three days had had a cold and been moderately but increasingly hoarse, with croupy cough keeping pace with the hoarseness, appetite im- paired, fever so slight that of itself it would not attract at- tention ; had a rather restless night, respiration slightly stridu- lus and distinctly audible. No view of the interior of the larynx could be obtained ; epiglottis and adjacent parts con- gested and coated parti}' with what appeared to be condensed mucus, no djsphagia nor glandular swelling. Diagnosis membranous laiyngitis. If in this stage any doubt may have existed, the subsequent history showed unequivocally the correctness of the diagnosis. At this early period of the disease, the symptoms as epito- mized by Bartholow, are as follows. The attack of the croup usually but not invariably begins as an acute catarrh of. the lar}-nx ; there is a feeling of heat and irritation in the organ, and the voice is a little husk} T ; there is cough with something of stridor about it ; and fever, restlessness, thirst, anorexia, and disturbed sleep accompan3 r the evidences of laryngeal mischief. When the fauces are inspected, more or less red- ness, sometimes dusky redness, will be observed, and also small patches of a thin pellicular exudation of a grayish-yel- low color, studded over the palate, tonsils and pharynx. These patches presently coalesce and then form a dense mem- brane several lines in thickness (?), of a yellowish gray or ash color. As huskiness of voice was one of the initial symp- toms, the same patches of pellicular exudation are forming in the larynx. Evening exacerbations, followed, as morning approaches, by remissions, are, during this period, extremely common, but are at most only suggestive, and not to be considered diagnostic. Says Prof. Mackenzie : " In children it is sometimes very croup. 135 difficult to distinguish catarrhal laryngitis of a severe form from croup. Indeed, in the early stages it is often impossible to differentiate the two maladies." On the other hand J. Lewis Smith (Diseases of Children) writes : " The diagnosis of true croup is ordinarily easy. It might be mistaken for spasmodic laryngitis, but more frequent- ly spasmodic laryngitis is mistaken for it. The differences which will aid in the differential diagnosis are the following : Commencement abrupt and at night in the one, gradual in the other ; presence in one and absence in the other of pseudo- membrane upon the surface of the fauces ; fragments of mem- brane in the sputum in one ; character of the cough, course of the disease growing gradually in one, in the other, with few exceptions, rapidly improving." Trousseau speaks of the lia- bility to eiTor of diagnosis in these cases in which spasmodic laryngitis is associated with pseudo-membranous pharyngitis. " Few phj^sicians hesitate to designate as true croup these cases in which there is a croupal cough in connection with false mem- brane upon the surface of the fauces, and yet the laryngitis, under such circumstances, may be merely spasmodic. This coexistence of pseudo-membranous pharyngeal and of spasmo- dic laryngeal inflammation is, however, probably rare, but its occasional occurrence should be borne in mind." Just how Prof. Smith has rendered the " diagnosis of true croup easy " in the preceding quotation is not easy to see, as he has failed entirely to notice the difficulty of differentiating the disease from catarrhal laryngitis, which Mackenzie truth- fully declares " is often impossible." Much of the apparent clearing up of the diagnosis of true croup comes from its be- ing considered by Trousseau, Mackenzie, Bartholow, and others as identical with diphtheria ; hence the frequent reference to the discovery of membranous deposits on the pharynx as diagnostic of croup : it is, however, more commonly pathogno- monic of diphtheritic infection, and its appearance is excep- tional and rare in uncomplicated true croup. A certain diag- 136 croup. nosis at an early period of the disease is frequently simply impossible. Later Symptoms. As the disease advances the skin becomes hot and drj T , the face flushed, e3 T es suffused, breathing more hurried and stridulous, cough more hoarse and frequent until it becomes toneless, a mere spasmodic expiration ; the labored and hoarse phonation is nearly, and finally entirety extin- guished. The patient, already suffering from asphyxia, be- comes alternately dull, and fretful and passionate. Then occurs a lull, respiration somehow is a little easier, probably in consequence of relaxtion of the lanmgeal structures, the effect of the increasing carbonic acid toxaemia, and the patient not only breathes better, but from better ox} T genation of the blood becomes temporality less stupid, and for a yery brief period seems quite himself again. Yery soon, however, as the irritability of the laiyngeal structures is revived, spasmodic stricture is again added to the organic obstructions, the dys- pnoea returns with increasing violence; the lips and nails be- come blue, every respiratory muscle seems to exert its utmost power to obtain the required air, inspiration is prolonged and stridulous, the intercostal spaces are depressed; the veins of the face and neck become prominent, and a profuse perspira- tion bursts from eve^ pore. Expiration, though obstructed and often prolonged in proportion to the amount of air exhaled, is less painful, because not accomplished in so great a measure by the direct labor of the exhausted respiratory muscles. The effects of the intense labor, and the accumulated car- bon in the blood, soon again produce exhaustion and insensi- bility, and the patient again falls asleep. A brief period of restless repose and labored breathing is soon succeeded by another paroxysm even more violent than the preceding. The cough does not increase in violence as the disease progresses on account of the muscular debility, and is rarely of sufficient force to raise the mucus from the air passages, or to detach and expel the loosening portions of false membrane. The croup. 137 paroxysms of coughing not only do not afford relief, but on the contrary, by lifting the thick mucus or detached portions of membrane to the rim of the glottis, add to the existing obstruction, occasioning increased spasm, and may thus pre- cipitate a fatal termination of the case. The voice during this period is usually extinguished, or so great is the effort necessary to speak, or so painful, that onby a feeble whisper or sign can be elicited. The appetite for food is entirely lost, the thirst incessant, and deglutition not generally difficult. The tongue is heavily coated with a thick white fur except the tip and edges, which are often intensely red. The fauces are red, or ash colored, and occasionally show traces of membranous exudation, but af- ford no index to the violence of the disease. During the third staje, which now supervenes, the exacerba- tions grow less violent as the natural forces decline, and the intermissions fail to recur, while the respiratory effort is con- stantby taxing to the utmost the waning vital and muscular force. The cough grows more feeble or ceases entirely ; the breathing apparently less laborious is feeble and sibilant. The head is forced backward as in opisthotonos, the larynx depressed and alternately moving up and down in aid of the respiratory efforts, which with the co-operation of the abdomi- nal muscles causes the chest to heave violently to increase its capacity, and force the entrance of air. The countenance grows livid and anxious, the eyes dull and pale, the skin dry or clammy and the extremities cold. The pulse becomes very feeble and rapid, the respirations irregular or intermittent : the patient throws himself about upon the couch, often clutching the throat in frantic fruitless efforts to remove the obstacle to breathing. The agony increases, the countenance gradually relaxes, and eitb^r increasing dyspnoea, coma, or convulsions, hasten the tragic scene to a close in death. Death may occur at almost any period of the disease. Fatal cases rarely run a longer period than two weeks, or a 138 croup. shorter than two days. In the earlier periods sudden death is often, no doubt, the result of spasmodic closure of the glottis. Later it may result from the great extent and thick- ness of the membrane, or from detached portions lodging in the chink of the glottis. Still another cause of death may be found in the bronchial obstruction, caused by mucus and pus, which the feeble patient has been unable to expectorate ; and yet another cause of death may be the imperfect aeration of the blood from imperfect respiration, and the consequent gradual accumulation therein of carbonic acid. Pathology. The post-mortem appearances are in accord with the disease phenomena heretofore delineated. As death rarely occurs during the first period, few opportunities are af- forded of determining the anatomical characters which then exist, but as the hoarseness and croupy cough are primarily due to inflammatory congestion and tumefaction, during the first period, only the evidences of such action are known to exist. These consist of intense injection of the larynx, either uniform or in patches, swelling, and a scanty secretion of tenacious mucus, or elementary pseudo-membrane. In its later stages, after the lrypersemia has attained its maximum intensity, the disease is characterized b}^ the appearance upon the inflamed surface of a grayish-white semi-transparent pel- licle or rudimentary false membrane, which rapidly increases in thickness, and which presents much the same physical and chemical properties as the pseudo-membrane formed in well marked cases of diphtheria. It is not of uniform density, and is found more firmly adherent at some points than at. others ; often it is found loose, or being only partially de- tached hangs in shreds or fringes. Its thickness varies from a mere pellicle to several lines. Its location is chiefly in the interior of the larynx, coating the vocal cords, the ventricles, and lower surface of the epiglottis. It is occasionally visible upon the pharyngeal surfaces, but probably less frequently than is often estimated. croup. 139' The formation of the pseudo-membrane in the trachea is also common, and may extend downward to the minutest bronchi, so completely obstructing the passage of air as to have induced emphysema or atelectasis. According to Guer- sent, in 120 cases, the false membrane was limited to the- larynx and trachea in 78, and in 42 extended also into the bronchial tubes. It is seldom so abundant in the larynx as to completely close it against the entrance of air, but on the contrary, necropsy often reveals there merely a transparent pellicle. The dyspnoea which during the first period was due solely to inflammatory tumefaction, was subsequently, in such cases, probably due to spasm of the glottis, excited by the presence of the pseudo-membrane, just as any foreign particle causes such spasm in health ; for it should be borne continu- ally in mind that the most violent paroxysms of dyspnoea, are in nearly all cases, largely due to spasm. The pseudo-membrane, then, surrounded generally with epi- thelial debris and mucus and pus, is the peculiar characteris- tic of croup, as seen by the anatomist, and in the absence of this, no pathologist could venture to pronounce a case pseudo- membranous laryngitis. Treatment. When we consider the great danger from the rapidly increasing obstruction to respiration in this disease, by the increasing congestion of the larynx and the deposit of plastic matter upon its walls, in connection with the natural narrowness and sensitiveness of the chink of the glottis in young children, in whom slight turgessence of its mucous membrane is often sufficient to cause stridulous breathing and alarming spasmodic closure, the importance of early treatment can hardly be exaggerated. Indications. The arrest of inflammatory congestion, limit- ing or preventing the adventitious deposit, or if already formed effecting its disintegration or expulsion and the prevention of spasm are the chief therapeutical indications. While pursuing these objects, the necessity for properly 140 CROUP. supporting the patient's strength so that he may be able to withstand the progress of the disease, must of course be borne in mind, and is to be effected by suitable nutrition, and avoidance of such measures of treatment as tend to induce undue depression. Of remedial measures having the sanction of most authors we first notice emetics. Their effects are, 1st: To diminish the local congestion by occasioning copious secretion and ex- pulsion of mucus. 2nd: To detach the pseudo-membrane by increasing the secretion beneath it, and softening it, and by the expulsive efforts occasioned, to effect if possi- ble its dislodgment and ejection with the matter vom- ited. Emetics are, therefore, generally considered the proper initial of rational treatment. As it is manifestly important to consider the strength of the patient, that he may be able to bear up against the ravages of the disease, and be able in the succeeding periods thereof, by vigorous cough and repeated administrations of the remedy if needful, to effect the object in view ; it is essential to select such emetics as occasion the last prostration. Their repetition, to vigorous patients, as often as three to five times in twenty-four hours, it is thought, is often beneficial. Antimonials, which were formerty much in vogue, are therefore manifestly improper, and must be rejected. Ipecacuanha in substance, or in the form of sirup or wine, although less depressing, is yet ob- jectionable unless with robust subjects, because of the con- tinued nausea and resulting debility. Sulphate of aluminum in doses of a teaspoonful suspended in sirup or honey, given every ten or fifteen minutes till free emesis is produced, is highly commended b}' Prof. Meigs of Philadelphia and others, and is one of the best of this class of remedies ; the large- ness of the dose is the only objection to its use. Sulphate of copper is another of the most prompt and least objection- able of emetics in croup. It is conveniently administered powdered with an equal weight of ipecac, and suspended in CROUP. 141 sirup so that each drachm may contain four or five grains of the mixture, and is given in teaspoonful doses every five- minutes till it operates. It has been administered as often as every two to four hours with apparently good results. So frequent administration is not generally to be advised. The yellow sulphate of mercury in two or three grain doses, to a child of two 3 T ears, is highly praised by Dr. Hubbard, Prof. Fordyce Barker, Prof. J. L. Smith, and others. Dr. Barker gives the remedy without delay, and claims not to have lost a patient thus treated for several years. The dose should be repeated in ten or fifteen minutes if the first dose does not produce emesis. Its employment is sanctioned by the very best authors, and is commended by the writer, although par- tial to sulphate of copper. If there be any degree of constipation, mild cathartics should be early administered. After emesis, resort must be had to those remedies known to prevent or diminish plastic exudations, acting through the blood ; also to the topical use of such as tend to remove such exudate by effecting its separation or solution. The chief remedies of this class are mercury, chlorate of potassa, chloride of ammonium, quinia, bromide of ammonium and chloral hydrate. Mercury. This remedy, which is usually administered iir the form of calomel, has been highly recommended b}^ nearly all reputable authors of the past century. " Dr. Samuel Bard states that Dr. Douglas of Boston, who published in the year 1736 an account of the angina suffocativa, was the first to recommend the employment of mercuiy in croup. Bard says that he was induced to tr} r mercurials after read- ing Dr. Douglas's little essay, and adds, 'The more freely I have used them, the better effects I have seen from them/ To patients three or four } T ears old he gave thirty or forty grains in five or six days, 'not only without any ill effects, but to the manifest advantage of my patient j relieving the 142 croup. difficulty of breathing, and promoting the casting off of the slough beyond any other medicine.' He advises the first dose or two combined with opium, and considers mercury the basis of cure in croup." (Meigs.*) We certainly know that calomel has the effect of increasing and attenuating the expectoration, but whether it also in- creases the secretion within the larynx and beneath the pseudo-membrane and thus assists in its detachment, is not so easily demonstrated nor generally conceded. But this remed} 7 has also an ancient and honorable reputation as an anti-phlogistic and alterative. On account of the former propeily it has been, and still is to a considerable extent, reputed to be the great antagonist to inflammation ; hence it has generally been advised to continue its administration till the inflammation subsides, or the mouth becomes con- siderably affected. As an alterative its effects are produced through the medium of the circulation. By its effects upon the blood or the dis- ease elements, it is well known in some maladies, as syphilis, to have the power so to modify it as to effect a cure. This power of producing an alterative effect upon the blood has been invoked in the treatment of croup. Its reputed efficacy in so modifying the blood as to diminish or prevent membranous exudation, has been sustained by the ablest writers. Prof. West, of St. Bartholomew's Hospital, London, wrote, "Calomel seems to have a twofold utility; it counteracts the tendency to the formation of false membrane in the air passages, and prevents or subdues that inflammation of the lungs which is so frequent and so fatal a complication of this disease." Says Coley, of London, " One or two grains of chloride of mercury must be given immediately, and repeated every hour, until the inflammation has subsided, or the mouth has become sensibly affected." Prof. Meigs says, "It (calomel) ought to be given early in order to produce upon the blood its defibrinizing effect, and thus prevent, or at least limit, the ex- croup. 143 tension of the deposit." Such evidence of the utility of mer- cury in croup, from eminent authors, might be made to em- brace almost the entire list of medical writers up to a very recent date. If to the mass of writers, we add the oral testi- mony of a great multitude of living eminent practitioners, a strong case is certainly made in favor of the use of mercury in this disease, and it is not too much to concede the proprie- ty of its employment. The approved mode of administering this potent remedy may be thus epitomized. To a child one or two years of age give from gr. ss to gr. i, either alone or combined with enough pulv.Dov. to prevent its cathartic effect. At the age of five or six years the usual dose is gr. i to gr. ij. These doses are usually repeated at intervals of two hours, and in violent cases are given hourly. Prof. Meigs affirms that of nine cases so treated by himself, six recovered ; while of seven cases treated without mercury, five died ; showing a balance in favor of mercurial treatment of 50 per cent, in the proportion of re- coveries. It should be borne in mind that with mercury the other approved adjuncts, as emetics, moist air, &c, were con- joined. Notwithstanding the affirmed utility and high repute so long enjoyed, of mercurial medication in croup, the title to its venerable reputation is at the present time greatly questioned. Prof. Mackenzie omits even its mention among the reputable remedies, whilst by some other recent writers it is noticed only to distrust, or to condemn. Neither the theory upon which the practice is based nor the practice itself is any longer re- garded as invulnerable. It must be confessed that the finest theories of medical scientists are at the mercy of clinical facts. Let it be proven as stated loy Meigs and others that fifty per cent, more cures are obtained by this treatment than by any other, and we shall soon see that an improved version of science will furnish an improved theory. If on the contrary, careful observation shall prove the superiority of more recent modes 144 croup. and remedies, no reverence for antiquity, nor list of worship- ing admirers, can save this venerable giant from humiliation. Chlorate of potash is very generally prescribed in some way in pseudo-membranous laryngitis, although both its modus operandi and the benefits resulting from its use, are questions still far from being satisfactorily settled. It was first pro- posed as a remedy in croup by Chaussier in 1819, but soon fell into complete disuse. It was revived again by Blache, and has ever since been used, in connection with other reme- dies, with more or less belief in its beneficial effects. It is re- garded by Trousseau as "having a general influence over the system opposing the reproduction of plastic exudations," and he adds, "Nothing forbids the use of this remedy in so dread- ful a disease as croup, without, however, placing exagge- rated confidence in its virtues, and especially without using it to the exclusion of other treatment of proved (though per- haps limited) efficac}'." Its excessive use is thought to induce inflammation of the kidnej'S with albuminaria. Its possible dangers, therefore, and equivocal benefits in croup, should guard against its too liberal administration. Ammonium Chloride^ administered internally, has long en- joyed the reputation of having a specific tendency to the mu- cous membrane of the air passages, improving its tone and favorably modifying its secretion. "The idea which has ap- peared chiefly to direct its use in medicine is, -that it tends to render all the secretions freer and more abundant, while it at the same time lessens the plasticity of the blood, in other words, that its operation is, in some respects, identical with that of mercur}'," for which it has been b}^ many physicians extensively substituted in practice. Notwithstanding the sug- gestiveness of its reputed physiological action, it has but recently assumed an important rank in the therapeutics of croup,, and in this disease is now used to a considerable ex- tent both in private and hospital practice. Prof. J. Lewis CROUP. 14& Smith writes of its use in Bellevue Hospital, as follows (Diseases of Children, p. 511) : " Calomel has been much used in times gone by for its supposed antiplastic action, and more recently muriate of ammonia and chlorate of potassa as in the- following formula. 3 Potas. chlorat. 3 i. Ammon. muriat. 3ss. Syr. simplic. 3 ss. Aquse 3 ij. Misce. Give one teaspoonful every half hour or hourly. " Since the discontinuance of the calomel treatment, this mixture has been largely used in New York, but is now being superseded by the atomizer, or it is being employed along with the atomizer." Quinia and bromide of ammonium are accounted most valu- able remedies in croup, especially by Bartholow. Quinia in full doses of gr. iii to gr. v with children, inducing and main- taining cinchonism as fully as possible, is thought to effect the arrest of plastic exudation. Bromides, by their elimina- tion by the bronchial and faucial surfaces, no doubt exert a beneficent local effect in addition to their efficacy as anti- spasmodics in controlling the larjmgeal spasms. The bromide of ammonium is given the preference, and is recommended in full doses in alternation with quinia. Chloral hydrate is believed by the author to have proven itself more efficacious in the treatment of croup than any other individual remedy. For seven years it has been freely used in every case treated by him, with much better results than had hitherto been obtained without its use. In eight cases since 1876, of such gravhry as is usually thought to demand tracheotomy, six, by its persistent use, terminated in recovery \ and in no single instance since its introduction has resort to this formidable operation been thought advisable. The spasmodic affection of the larynx, which constitutes so dangerous a complication in this disease, is so perfectly con- 10 146 croup. trolled bj r chloral as to be almost eliminated from its danger- ous symptoms. This effect might reasonably be expected from its well established efficacy in other spasmodic affections. It will be observed that chlorine is an element in all the reputed anaplastic remedies employed in croup, and from the immense amount of this element emplo3 T ed in the manufact- ure of chloral, it might on this ground reasonably be sup- posed to be superior to them all. Having already, when pre- senting its claims to specific action in diphtheria, shown its effects upon the blood to preserve its fluidity and to prevent or arrest the tendency to fibrinous coagulation or exudation, it is sufficient in the present case to refer the reader to that part of this volume, with the remark that its therapeutic efficacy in croup is believed to be as rational and as well established as in that disease. It is believed its use in the treatment of croup originated with the writer about the time of its introduction by him in the treatment of diphtheria, and so far as known, Prof. Bar- tholow alone among standard authors, has arrived at similar views, or commended its use in this disease. He says (Prac- tice of Medicine, p. 437), " Besides the agents above advised, quinia and the bromides — for the laryngeal spasms chloral is to be commended. The author has preferred to give chloral :and bromide of ammonium together, and the quinia separate- ly. Besides its power to allay spasms, chloral is one of the few remedies which possess the property to check the forma- tion of an exudation." To assure its greatest efficiency, it should not only be given earry in the disease, but should be given freely and persist- ently. To a patient two or three years old either of the formulae, 23 or 24, may be employed in appropriate doses every hour or offcener when awake. For older patients the dose should be proportionately large, and in any case increased or diminished according to circumstances, special reference being had to the soporific effects of the chloral. If the tendency to croup. 147 sleep is strong, a less dose is indicated. Its employment does not in any way interfere with the administration of emetics when indicated, nor with any other measures deemed necessary. Moist air being more easily respired in this disease than dry, it is advised that the atmosphere inhaled by the patient be impregnated with steam, either alone or medicated. Chlo- ral and lime in the form of vapor or spra} T is. regarded the most important. An eligible and economical mode of sup- plying the vapor consists in slaking lumps of fresh lime in an open-mouthed bottle, or in a coffee-pot closely covered and rendered tight by placing wet cambric beneath the lid, and so held as to compel the patient to inhale the vapor as it arises or is discharged from the spout, or rubber tube attached. A coffee-pot, or any similar vessel, with the spout placed near the top, is to be preferred, as it furnishes a more dense vapor, which can be easily directed to the nostrils of the patient. The water used for slaking the lime should contain from ten to twenty grains of chloral hydrate dis- solved in each pint. The vapor may be made aromatic by adding to the water a small quantity of some agreeable perfume. The inhalations should be commenced as soon as the disease is recognized, and continued as long as the hoarseness persists. Each inhalation should continue ten to fifteen minutes, and should be repeated every hour or oftener in the early stages, and less frequently as the disease subsides. No case of croup can be efficiently treated so as to afford the patient the best chance of recovery, without resort being had to inhalations of either the above or similar vapors, or of atomized fluids possessing like qualities. The old method of slaking lime in open vessels, thus filling the sick-room with the vapor, is both awkward and wasteful, as well as disagree- able and dangerous to the attendants, rendering them exceed- ingly liable to take cold upon going into the open air. Spray inhalations, though believed to be less efficacious, may be used instead of the above. Those of lime-water and 148 croup. chloral, separate or combined, the author considers most efficacious. (Nos. 10, 11, et seq.) For use in this way Mackenzie recommends lactic acid (16). J. Lewis Smith recommends the nearly constant use of lime-water four parts, and glycerine one part, only intermit- ting its use every second hour long enough to inhale one ounce of No. 14. When portions of false membranes are thought to be loose, or the passages are greatly obstructed by mucus, prompt emet- ics are indicated, and if not successful in dislodging and expelling the obstructing matter, recourse may be had to the use of a small soft probang or brush for the purpose. The local application of cold water and of ice have been advised, but are uncomfortable to the patient, and hence re» sisted by him, and opposed by the attendant friends as "being a harsh and hurtful expedient. Emollients rendered antiseptic, as glycerine with chloral h} T drate (grs. v to x in 3 i), or camphorated oil, or light warm linseed poultices, are preferred by the writer, and are recommended. The patient should be well nourished, and allowed agreeable beverages. Milk and beef juice or essence, with soft farina- ceous preparations, as panada, arrowroot, cornstarch, &c, with custards and syrups, may be given according to the judgment of the practitioner and the taste of the patient. Finally, the grave question of tracheotomy may be forced upon the attendant physician from the apparent failure of the timely and persistent use of the best remedies at his com- mand ; for it is certain that this grave issue must occasionally be faced, despite the important addition of chloral to the therapeutics of this dangerous disease. The indications that call for the performance of this operation are solely such as relate to the respiration. In brief, it is necessary and justifi- able after all other remedies have failed, and impending suffocation can only be averted by making an artificial aper- croup. 149 ture into the windpipe in order to render respiration possible. This procedure, surely to be followed hy the death of a large majority of its subjects, can never be justified upon the plea of conservation, in order to forestall and anticipate dan- gers which either may or may not occur, but only, as it were, in the presence of death itself, with all it implies. Since using the chloral treatment I have witnessed a larger proportion of recoveries from conditions usually thought to demand the operation, bat in which it was not performed, than is shown by the most favorable statistics to have resulted from its per- formance. Six out of eight such cases I have seen recover from the use of therapeutical measures alone, while the best results obtained in the best institutions, D3 7 the most experi- enced and skillful surgeons, in this country and Europe, scarcely average a single recovery in less than five cases operated upon. Between the years 1849 and 1858, according to Trousseau, 466 cases operated on in the Children's Hospital in Paris, 126 recovered, and 340 died. In 1863, so far as ascertained by careful research, the proportion of recoveries at the Hospital des Enfants Malades, was one in four ; at the Hospital Sainte Eugenie, one in six. In the latter, from 1854 to 1875 inclusive, one in four and fifty-four hundredths, and in the former, from 1851 to 1875 inclusive, one in three and eighty-two hundredths. The statistics of Paris probably repre- sent the best results attainable by this operation in croup by the most skillful and experienced operators. In England and America the results are not known to be more encouraging ; practically they are identical and hence need not be repeated. We repeat then, only the gravest conditions can justify so equivocal a procedure. The conditions demanding and justify- ing such an operation are those relating to the degree of laryn- geal obstruction. It is manifest that occlusion of the trachea below the point of operation, or of the bronchi, not only could not be remedied by tracheotomy, but contraindicate its 150 CROUP. performance. The degree of laryngeal obstruction is indi- cated by the greater or less respiratory stridor, and is still further evinced by being accompanied by evidences of insuf- ficient aeration of the blood, as blueness or lividity of the lips and finger tips. When such evidences of asphyxia exist and can in no other way be relieved, then it is clearly time to have recourse to tracheotomy. To delay in the presence of these portentous symptoms is even more dangerous than the opera- tion. Therefore it is now clearly a duty to open a passage for respiration, or it must cease. It is advisable that this extremity, which may occur sud- denly and unexpectedly, should be anticipated by careful pre- paration for prompt action. Have in readiness one or more double canulae, in addition to the instruments for making the incision, which are usually found in every surgeon's pocket case. Every plrysician liable to be called upon to perform the operation is supposed to have familiarized himself with its details, its dangers, and subsequent management, by a knowl- edge of the teachings of the best surgical authors. For succinct advice and directions regarding this proced- ure (tracheotomy), attention is likewise called to chapter XXIII, which has been kindly furnished for this volume by an able, skillful, and experienced operator, R. A. Vance, A. M., M. D., late Professor of Operative Surgery and Clinical Surgery in the Medical Department of the University of Wooster. TRACHEOTOMY. 151 CHAPTER XXIII. TRACHEOTOMY. ' BY R. A. VANCE, A. M., M. D. Systematic writers describe three operations for the relief of obstructive disease of the air-passages — laryngotomy, laryn- go-tracheotorny and tracheotomy. In laryngotomy the open- ing is made through the crico-tlryroid membrane. Laryngo- tracheotomy involves an incision into the crico-thyroid, membrane primarily, followed by section of the cricoid cartilage and adjacent rings of the trachea. In tracheotomy the surgeon opens the trachea by a vertical incision in the middle line of the neck. There is no department of surgery in which more erroneous notions prevail than in that which pertains to operations upon the windpipe. These errors- relate not only to the supposed facility with which the air- passages can be opened, but extend even to the regions in which the operation should be performed. Thus, laryngotomy and laryngo-tracheotomy have been extolled as measures- adapted for the relief of suffocative angina, whether catar- rhal, croupous or diphtheritic. Anyone versed in anatomy knows that laryngotomy and laryngo-tracheotomy can be; readily performed in the adult. The experienced surgeon shrinks from their execution under any circumstances owing to the dangers that attend and follow them. Any interfer- ence with the structures of the larynx may develop distress- ing spasm of the glottis, or initiate fatal inflammation : in patients fortunate enough to escape the immediate dangers of these procedures, necrosis of the laryngeal cartilages frequently ensues, while permanent impairment of the voice is an almost inevitable consequence in those who recover. The readiness, with which laryngotomy and laryngo-tracheot- omy can be performed upon the adult has originated an idea 3 52 TRACHEOTOMY. that these measures can be effected with equal facility upon the child. That the}- can be performed, even upon an infant, no one denies — that they can be easily executed in a child, no one who has attempted either procedure, even upon the cadaver, will maintain. The small size and rigid walls of the ,air-passage at the points where it must be opened, as well as the difficulties attendant upon the performance of these operations and the dangers associated with them, should prevent laryngotomy, or laiyngo-tracheotomy being resorted to for the relief of suffocative angina. Tracheotom}' is the operation that, as a rule, should be resorted to in such cases. But even this procedure has not escaped misrepresentation. Some years since a distinguished physician, the Professor of Practice in the Universit}- of Louisville, spoke of traeheotom}- as the most simple thing in the world, which anyone might perform easily with a razor ! "Well might Dr. S. D. Gross say, that, had this gentleman ■ever opened the trachea he would never have made such an -erroneous statement ; and add — "the amputation of a limb, the extirpation of a glandular tumor, lithotom}' and even the perineal section are trifling matters in comparison with tracheotomy in a short, thick-necked and restive child." To ;such statements as the one reprobated hy Dr. Gross, the sacrifice of man}' lives and the humiliation of many operators lire due. The erroneous impression that tracheotomy 7 is not ■difficult, that little anatomical knowledge, and no surgical experience is demanded for its performance, has led many an inexperienced practitioner to attempt the opening of the -wind-pipe — attempts that but too frequently have cut short the patient's life and injured the reputation of the ph} T sician. Various complicated appliances have at different times ibeen recommended as mechanical devices that would rid this ■operation of danger and render its execution eas}\ It is need- less to spend time in their enumeration, for, to the inex- perienced operator they would be a snare : to the experienced TRACHEOTOMY. 153 surgeon they would be useless. A knowledge ot anatomy and a reasonable degree of surgical skill are all that are demanded for tracheotomy : the experienced surgeon can open the trachea successfully with no other implements than .a sharp knife, and such other aids as can be improvised at a moment's notice in anj T house. Retractors, tenacula, artery forceps, scalpel, sharp and blunt-pointed bistouries, and tracheotom}^ tubes, comprise an outfit that supplies the surgeon with all the instruments he will be likely to need in the vast majority of cases. The use of anaesthetics in the operation is a question to be decided by no hard and fast rule, but a problem to be solved independently for each individual case. The duration of the disease, the condition of the respiration and circulation, the general state of the patient, and the wishes of the individual to be operated upon, are all elements to be taken into con- sideration in arriving at a decision. It can be stated emphatically, however, that the pain of the operation is slight, and that by employing local anaesthesia, or simply benumbing the skin over the trachea with ice, even this -suffering can be materially reduced. The objections to ether •or chloroform in suffocative angina are very great. In order to open the wind-pipe satisfactorily, the light must be good, and the patient properly placed with reference to it, in the supine posture, and should have his shoulders supported by one pillow, his head by another, and his neck made prominent by a hard roll of cloth between the two. In adults it is occasionally desirable to operate with the patient in a sitting position — the patient should then support his head on the back of the chair. The assistant who is sub- sequently to have charge of the sponges now uses the ether spray, or ice, and benumbs the integument over the point where the trachea is to be opened. This done, the surgeon, who stands behind the patient, if sitting, or at his right side, if in the recumbent position, steadies th'e integument with 154 TRACHEOTOMY. the fingers of the left hand, and makes an incision through the skin an inch and a half, or two inches long, the center of the cut resting over the third tracheal ring. This incision is carried down until the fibrous bands uniting the muscles on either side of the mesial line are exposed. Any blood-vessels exposed in the procedure are either drawn to one side, or ligated at two points and cut between. A few strokes of the* knife loosen the central attachments of the muscles, and permit them to be drawn aside. The handle of the scalpel may now clear the anterior surface of the trachea of all over- ling structures save the layer of firm fascia in immediate- contact with it. If the thymus gland projects upward, it can be drawn down ; if the thyroid isthmus projects down- ward, it can be drawn up ; vessels can be pulled to one- side — in a word any structure the surgeon does not wish to cut can be loosened and removed out of the way. The fascia covering the trachea should now be incised, the latter is thus- exposed, and if the subsequent incisions have all been made the length of the original opening in the skin, and the hemorrhage has ceased, the surgeon is ready to open the wind-pipe. In order to do this, the trachea is steadied with a tenaculum, and one ring cut through with a sharp-pointed curved bistoury ; a blunt-pointed bistoury is passed through the opening, and the incision enlarged to a degree sufficient to admit the tracheotomy tube — if no tube be at hand an elliptical piece is cut from the anterior portion of the trachea, and pains taken to keep the edges of the wound widely separated by some kind of improvised retractors as wire bent to suitable shape. If a tube is to be inserted, so soon as- the opening in the trachea has been enlarged to a sufficient, extent, the surgeon passes his finger into the trachea, and at once follows it with the tracheotomy tube, the finger serving- as a guide to pilot the tube into the air-passage. Should the patient be able to breathe through the tube, all that remains to be done in ordinary cases is to fasten the flanges of the TRACHEOTOMY. 155 outer tube around the neck by means of tapes, and give directions for the after treatment. The incision into the trachea should be of such a size as- to fit snugly the tube when the latter is in place. Inasmuch as the opening in the skin is much longer than that in the wind-pipe, it may be necessary to draw the edges of the latter together with sutures after the tube is introduced. Yet I have not always found this good practice : on the contrary, if the parts between the trachea and flange of the canula be filled with absorbent cotton, it will serve a three- fold purpose — hemorrhage will be guarded against ; the wound will be protected from the irritating influence of the tracheal discharge ; and the opening into the wind-pipe will be the sooner consolidated to such an extent as to permit the removal of the tracheotomy tube. It generally takes three days for the wound to assume such a state that it remains patent when the tube is withdrawn. During this time the outer tube should not be disturbed ; if accidentally displaced,, the surgeon himself should return it. The inner tube can be removed for cleansing at any time it may seem necessary, and this duty can be performed by the nurse. When the trachea is opened the patient generally struggles for air — the insertion of the tube and change of the patient's position afford relief. In a short time tracheal mucus of an adhesive stringy character begins to be voided. After a while it may accumulate to such a degree that even frequent removals of the inner tube no longer suffice to keep the passage-way clear : in these cases, in addition to washing the inner tube in hot water every fifteen minutes or so, the nurse will have to use feathers to extract the mucus that accumulates below the canula. In all cases where tracheotomy has been per- formed, surgical aid should be close at hand for the first two- d&ys after the operation. Immediately after the tube is- introduced and it is seen that the patient breathes well, blankets may be hung about the bed in such manner as to» 156 PLASTIC BRONCHITIS. isolate the patient and permit his being subjected to the action of steam without filling the whole room with aqueous vapor. The tube may have to be taken away before the wound has had time to consolidate ; under such circum- stances retractors must be used to keep the edges asunder until the opening is rendered patent by plastic material. For the first few da}~s the patient's diet should consist of fluids : there is no objection, however, to the administration of such drugs as the physician may deem necessary for the proper medicinal treatment of the case. CHAPTER XXIV. PLASTIC BRONCHITIS. Plastic Bronchitis, denominated also fibrinous bronchitis, croupous bronchitis, &c, is a distinct disease which is believed to have its seat primarily in the bronchi of the third and fourth order. Its remarkable and diagnostic feature is the formation, or, rather, exudation, upon the interior of the air passages, below the trachea, of a membrane in character identical with that described in pseudo - membranous laryn- gitis as located upon the walls of the larynx ; and in diph- theria, in the pharj-nx and elsewhere. These diseases, although very diverse in their other characteristics, exhibit by this sim- ilarity, a relationship which is at least ver} T suggestive in re- gard to their classification and therapeutic management. On account of the identity of the membranes, Sir John Rose Cor- mack " suggested that plastic bronchitis may be a variety of diphtheria "; and numerous writers of great distinction, Mack- enzie with others, for the same reason, teach that croup is truly and only laryngeal diphtheria ; while Niemeyer has called it bronchial croup. Such doctrines indicate the recognized rela- tionship, based on the plastic phenomenon, common to each of PLASTIC BRONCHITIS. 157 these diseases ; which, however, is quite insufficient, as shown in the previous pages of this work, to establish their identity; their distinctive features are too numerous, uniform, and em- phatic to be reconcilable with such an idea. In systems of nosology, however, classes are formed upon analogies less apparent, and no good reason exists why these three distinct diseases, thus related, should not be grouped as a separate class, to be denominated Membranous diseases. The class thus formed, though small, is second to none in importance, and this last of the series, although much less common, is hardly less grave than its predecessors. It is observed both as an acute and chronic affection ; most frequently in young adults, although no period of life is known to be entirely exempt. Niemeyer mentions the case of a girl fifteen years old who had almost daily, for years, coughed up almost a complete cast of the left bronchial tree. Causes. Of the causes of plastic bronchitis we know as little or less than is known of those of laryngeal croup. The type of the inflammation is thought to be similar in the two as their products are identical, and also from the tendency of both to extend downward from their original sites, and the general absence of symptoms, except such as depend upon the local disease. The more rapid progress of croup is thought to depend upon its location at the fountain head of the respiratory current, and upon the exquisite sensibility of the larynx, which can- not be made tolerant of the foreign body (the membrane) as are the lower air passages. Inhalation of cold air, and bodily exposure we know aggravate the sjmiptoms of this disease, but their influence in its causation can only be inferred. It is proper here to remark that the disease is neither contagious nor epidemic ; and so rare as to afford little opportunity to investigate its nature or causes. 158 PLASTIC BRONCHITIS. An idiosyncraey, or peculiar state of the blood, as causative agencies are suggested by the membranous deposits and its analogies to croup noted above. Anatomical appearances. " In primaiy independent croup- ous bronchitis (i. e. plastic bronchitis) the same condition of the bronchial mucous membrane is found, and with the same coagulated exudation upon it, which we have described as existing upon the mucous membrane of the larynx in laryngeal croup. In the larger bronchi the caliber of the canal is not usually completely occluded ; and the coagula are tubu- lar ; but in the smaller bronchi they form cylindrical plugs. Croupous bronchitis is seldom spread over the whole lung ; generally it is partial, and confined to a small number of bronchi ; but to this rule there are exceptions." (Nieme} T er.) The larynx and trachea, it is believed, are never involved as in croup and diphtheria. Symptoms and diagnosis. — These, as before stated, depend largely upon the local disease ; the constitutional perturbation whatever it may be, is not declared by known phenomena except the exudation, the existence of which is only determin- able by portions expectorated. If suspicious coagula appear in the sputa, they should be carefully rinsed in water and soaked in dilute acetic acid ; if only condensed mucus they will shrink and be rendered firmer, and the case is ordinarj r bronchitis ; if fibroid, they will swell and soften and indicate the plastic type. S} T mptoms of acute inflammation, fever and pain, are gen- erally slight or entirely absent. When, however, these exist continuously, with extreme dyspnoea, they indicate an exten- sive, acute, and very dangerous form of the disease that may terminate in fatal asphyxia. More or less febrile action, however, is excited, even in chronic cases, by the violent and prolonged cough and labored breathing attendant upon the separation of masses of the exudation ; which, with the cough, quickly subsides when the PLASTIC BRONCHITIS. 159 mass is expectorated. Blood}* sputa, more or less abundant, often precedes and generally follows, for a few days, these occasions ; during which the cough and dyspnoea increase to fearful violence, and the patient appears in the greatest danger of suffocation. When the affection is acute, the casts are quickly renewed, and the course of the disease is limited to a few weeks at most, and is said to prove fatal in about fifty per cent, of the entire number of cases. In the chronic form the casts are also often reproduced and the affection may continue for years with but little clanger to life. The membranous casts when expectorated, may be in convo- luted masses or in the form of branching tubes with clean cut edges, or as solid branching rods if formed in the bronchi of finer caliber. When expectorated in masses, if placed in water and unfolded, they exhibit most interesting models of portions of the bronchial tree ; the trunk being sometimes from a tube of the third or fourth degree, with branches diminishing in size with the successive divisions, to mere capillaries. The patients generally suffer from dyspnoea in proportion to the extent of the obstruction. The respirations are quick- ened from the same cause and in the same ratio. Cyanosis is apparent at times, due to the imperfect aeration. The cough, except about the periods of expulsion of mem- branes, is dry and harassing. Auscultation and percussion furnish almost no aid in the diagnoses of fibroid bronchitis and are of as little service in its treatment. So long as the bronchial obstruction is com- plete the respirator}* murmur is destroyed over the pulmonary area deprived of respiration ; and enfeebled if the obstruction be only partial. Partial bronchial obstruction, according to its degree, also occasions correspondingly varying sibilant sounds. A coarse 160 PLASTIC BRONCHITIS. flapping rale is observed sometimes, and attributed to partially detached membranes fluttered by the respiratory currents. The resonance on percussion and the vocal fremitus are not noticeably changed, except from collapse of the lung sub- stance ; or from solidification from localized pneumonia, which sometimes happens, and in either case more or less dullness is occasioned. In diagnosis none of these sounds are at all distinctive until after their significance has been shown by the expectoration of fibrinous clots or casts. The respiratory movements of the chest are perceptibly diminished if the obstruction cuts off a due supply of air from any considerable portion of the lungs. This is only percept- ible upon one side, when the disease, as is common, is limited to one lung. The most frequent complications of plastic bronchitis are phthisis and pneumonia, which reveal themselves by the superaddition of their appropriate well known symptoms. Treatment. The recognized analogy of fibrinous bronchitis to croup, has led, as might be expected, to a corresponding similarity of medical treatment. " The treatment is to be conducted upon the principles laid down for the management of laryngeal croup." (Niemeyer.) To effect the speedy sepa- ration and expectoration of the casts, the inhalation of warm steam is regarded as of undoubted utilit3 T , as are also vapors or sprays containing chloral lrydrate (JJ. 9, 10, 11), lactic acid (3 .16), or lime (1^ .18). The vapor of lime and chloral (1^ .17), is recommended. Emetics are also used when the obstruction has become con- siderable, to promote the dislodgment and expulsion of the casts. Those advised for croup are especially appropriate. (See croup.) "Kugel and other German authors recommend especially the muriate of apomorphia as an especially appropriate emetic in consequence of the promptness of its operation with but little nausea, and the absence of unpleasant after effects." PLASTIC BRONCHITIS. 161 (Flint, see also Ziemsen's Cyclopedia, vol. 4, p. 467.) In this- country it is rarely employed, and, on account of the danger- ous depression sometimes following its exhibition and the- difficulty of preserving it, it is not to be recommended. The mechanical emetics, t. e. the sulphates of copper and zinc, yellow sulphate of mercury, alum and mustard are equally prompt and more safe, and therefore preferable. " Aside from the treatment having immediate reference to* the removal of the casts, measures for the relief of the bron- chitis are indicated. For this object the iodide of potassium has been found especially useful." (Flint.) " I have never observed any benefit resulting from its action in this disorder." (Niemeyer.) " This remedy is said to have been employed with success." (Prof. A. T. H. Waters, Liverpool.) I have used iodide of potash faithfully in a chronic case of this anomalous affection, without being able to discover any beneficial effect. The same case, when later put upon arsenic,, iron and cod-liver oil, convalesced and complete recovery resulted, though not speedily. Admitting the importance of those measures of treatment to effect the separation and expulsion of the casts, and all such also as are employed " for the relief of the bronchitis," and these embrace all measures of acknowledged efficacy in other forms of bronchitis, it is observed that writers on thi& affection are quite as conspicuous by the omission of all ref- erence to a possible primary constitutional implication, as b} r the constant suggestion, if not positive affirmation that the disease is of local origin ; a partial or limited, specific form of bronchial inflammation. The question, Is the disease a specific form of inflammation,, or, the result of constitutional causes ? although apparently overlooked, cannot be ignored by the thoughtful clinician. This much can be positively affirmed : — the ordinary causes- of bronchial inflammation do not induce fibroid exudation - r else this phenomenon would be as common as other types of 11 162 PLASTIC BRONCHITIS. bronchitis. If the affection be then a specific form of local bronchitis, not from ordinary causes, } T et as it probably does not exist without cause, that cause must be special ; and from its infrequency, is most likely personal and S3~stemic. Such •exceptional manifestations are no doubt connected with, or caused bj T , a constitutional vice, or, what amounts to the same thing, a disordered state of the blood. This view is further confirmed by the almost uniformly pale and cachectic appear- ance of the patients (at times cyanotic from imperfect breath- ing); and, its acceptance by writers may also be argued from the use of such constitutional remedies as iodide of potash, arsenic, iron and cod-liver oil. None of the remedies emplo} T ed for the cure of this disease are known to possess aplastic properties, or efficacy in antago nizing in the blood, the tendency to part with its fibrine, so clearly exhibited in this and the other membranous diseases. Certainly one of the clear indications of treatment, is to cor- rect the constitutional affection by such remedies as "are known to possess the power to limit or prevent an exuda- tion." At the head of this class of remedies we place chloral hyd- rate, either alone or conjoined with bromide of ammonium or chlorate of potassium, substantially as shown in 1^ . 22, 23. These remedies are advised, in plastic bronchitis, mostly on theoretical grounds ; no sufficient opportunities having occur- red to the writer, since the introduction of the chloral treat- ment, to fulty test their efficacy in typical cases of this disease, as has been done in diphtheria and croup. In chronic forms of disease, there is manifestly no occasion to push these rem- edies as advised in acute forms, in which the progress is rapid and the perils immediate. Ample nutrition is a part of the treatment of every case of plastic bronchitis, not to be overlooked, nor considered of secondary importance. FORMULAE. The formulae here given may be variously altered to adapt them to various ages, degrees of violence, and stages of disease, and to the tastes, susceptibilities and tolerance of patients, and the judgment of the practitioner. It is believed, however, that in the main they will, as written, meet the indications for their use. They are not all original, but have been gleaned from various authentic sources, and are not presumed to represent all the remedies needed in the treatment of the membranous diseases. Local Remedies. l. 3, . Pot.Permanganat. gr. x a xx. Aquae § i. M. Useful in gangrene, &c. Apply to fauces with large camel's hair brush. For atomizer reduce ^. 2. 1^, . Chloral Hyd. 3 ss a 3 iss. Sir. Cort. Aurant. | ss. . Aquae J i. M. Or, 3. fy . Sol.Chlor. Hyd.(gr. 40 to ? i) 5 ss. Tr. Iodin. C. 3 iii. Glycerin. 5 ss. Aq. Menth. Pip. ad \ ij. M.' For use as No. 1 in fauces, for effect upon false membrane and disinfection. 4. # . Chlor. Hyd. Tr. Iodin. C. Glycerin. Aquae Or, 5. 31- aa I ss. M. 3i. aa ss. M. 3 . Chloral Hyd. Tr. Iodin. C. Glycerin. Tr. Gaulth. Aquae For external use in glandular and other swellings. — Apply 4 times a day, and keep the parts well covered with dry, soft flannel. 163 164 FORMULAE. 6. ^ . Chloral Hyd. Spt. Gaulth. gr. x a xxx. 3i. M. Or, 7. }£ . Chloral Hyd. gr. x a xxx. Sol. Sod. Borac.(gr. xa 3 i) Aq. Menth. Pip. aa J ij. M. For injecting into nasal pas- sages to cleanse and disinfect. Or, 8. ^,. Acid.Carbol. Glycerin. Aquae gtt. xxiv. Svi. M. For Atomizing. 1^ . Pot. Permang. gr. v. Aquae § i. M. To be used in atomizer for disinfecting. Instead of the Pot. Permang. in 9, use, if preferred, 5 grains each of Chloral Hyd. and Pot. Chlor. 10. # . Chlor. Hyd. Spt. Gaulth. Aq. Pur. Aq. Calc. Or, ^ . Chlor, Hyd. Acid. Carbol. Aq. Calc. Aq. Gaulth. gr.x. 3*. aa § iss. M. gr. x. gr. xv. aa 5 iii. M Or, 11. 5, . Amnion. Brom. Potas. Brom. cagr.vax, Aquae 3 iss. M. The last three useful in laryn- geal diphtheria and croup, every 1, 2, 3 or 4 hours for 15 min- utes. 12. 1£ . Acid. Salicyl. Sod. Borac. 00 gr. v. Aquae ? i. M. Or, 13. ^,. Acid. Salicyl. Glycerin. Aq. Calc. Or, 14. "fy . Acid. Carbol. Glycerin. Aquae Or, 15. I^.Acid. Carbol. Pot. Chlorat. Glycerin. Aquae Or, 16. 3ss. I iii. M. gtt. xxii. \ vi. M. gtt. xxii. 3 iii. 1 iii. J v. 7rf. gr. xx. ?i. itf. I£ . Acid. Lactic. Aquae Recommended also in laryn geal diphtheria and croup. FORMULAE. 165 The following are appropriate quantities of the medicines named for each ounce of water for spray inhalations. Many other medicines and various combinations are also employed in this manner, as the judgment of the practitioner or accredited authorities may in- dicate. If a hand ball atomizer, which, when well constructed, answers every purpose, is emp^ed, let the fluid be warmed to 100° F. or upwards. Acid. Tannic. gr. iii a v *' Lactic. gr. xx. *' Carbol. gr. iii. Ammonium Brom. gr. v a x. Aq. Calc. (undiluted) Chloral Hyd. gr. v. Fer. Perchlor. gr. iii. " Sulph. gr. iii. Potas. Permanganas. gr. v. " Chloras. gr. xx. " Bromidum gr. xv. Vapor Inhalations. 17. fy . Fresh Lime lb i- Water containing Chlo- ral Hyd. 3 i 0. i. Or, 18. J$, . Fresh Lime ft i. Water 0. i. Put the lime in lumps into a coffee-pot, open mouthed bottle or fruit jar, pour upon it the fluid (to the spout of the coffee- pot or similarly constructed ves- sel may be attached a piece of rubber tubing of convenient length when desired), and when the vapor begins to rise direct it into the patient's face so it must be freely inspired ; use every hour in laryngeal" cases and croup. Of inestimable value. General Remedies, 19. r> , Pot. Chlorat. Amnion. Mur. Glycerin. Aquae 3 ij- I vi. M. (riven in cases of croup, &c, in one or two drachm doses every hour, according to age. 20. J£ . Quin. Sulphat. 3 ss. Elix. Tarax. C. 3 ij. M. Dose, teaspoonful every two hours for a child of 5 years, and alternated with 21. 1} . Tr. Fer. Chlor. 3 ij. Pot. Chlorat. 3 ij. Sir. Simp. | iv. M, Dose, same as 20. Prof. Smith declares this in his hands "the most satisfactory treatment " in diphtheria. 22. ^ . Chloral Hyd. Pot. Chlorat. aa gr. xcvi. Spt. G-aulth. vel. Spt. Menth. Pip. 3 i. Aquae Sir. Simp. aa^\]. M, 1G6 FORMULAE. Of great value in diphtheria. Dose for an adult two teaspoon- fuls every hour when awake. No drink to follow the ad- ministration for 8 or 10 minutes. The degree of somnolence is somewhat a measure of the effect of chloral, and should influence accordingly. The pungency of this and the followino; Chloral mixtures should, by varying their strength, be adapted to the different fau- cial sensibility of patients, which can be judged by the complaint, if any, of pain following the administration. 23. ^ . Chloral Hyd. Pot. Chlorat. aa gr. xlviii. Spt. Gaulth. vel. Spt. Menth. Pip. 3 i. Sir. Simp. Aquae aa 3 ij. M. Give a teaspoonful or tea- spoonful and a half every hour when awake to a child from 5 to 10 years of age. See also remarks under ]$, . 22. 24. 5. Chloral Hyd. Ammon. Brom. aagr. lxxx. Spts. Chloroform. 3 i a ij. Sir. Simp. Aquae aa 3 ij. M. Give to adults two teaspoon- fuls every hour, and to children above 10 yrs. one, in laryngeal diphtheria and croup. For younger children use the following : 25. fy . Chloral Hyd. Ammon. Brom. aa gr. 1. Spts. Chloroform. 3 i a ij. Sir. Simp. Aquae aa 3 ij . M. Give a teaspoonful every hour when awake. These are cases of the gravest danger, and demand the utmost vigilance in the use of both local and general treatment. 26. Ijt * Sod. Sulphocarb. Simp. eir. Aquae 3y. aa \ i. M. For a child of five years, tea- spoonful every 3 hours. g r - ■i? a r. 1 a i J. 27. ]^ . Pilocarpin. Pepsin. Acid. Hydrochlor. gtt. ij Aquae § ijss. M. Give a teaspoonful hourly to children. 28. k fy . Pilocarpin* Pepsin. Acid. Hydrochlor. Aquae gr. iss. gr. xxx. gtt. viii. I ijss. M. Give a teaspoonful hourly to adults. INDEX. Abscesses of lymphatic glands in diphtheria, 59. Aitkin, 85. Alcohol, use of, in diphtheria, 80, 109, 121. Albuminuria in diphtheria, 7, 32, 34, 35. Aluminum, sulphate of, in croup, 140. Ammonium bromide in croup, 145. chloride in croup, 144. Antimonials in diphtheritic laryngitis, 140. Antiquity of diphtheria, 9. Antiseptics in diphtheria, 53.- Atmosphere, influence of, 37. Atomizer, use of, in laryngeal diphtheria, 124. Bacteria, 21, 72. germs, 27. in diphtheria, 29. in non-diphtheritic states, 29, 30, 72. Bacterian theory untenable, 25, 26, 37. Ballard, 41. Balsam of Copaiba in diphtheria, 107. Bard, 14. Baths in diphtheria, 81. Blood, the, in diphtheria, 75, 76. Blood-poisoning in diphtheria, 30, 32, 35, 58, 60. symptoms of, 68. secondary, 58. Brain, the, in diphtheria, <5. Bretonneau, 18, 39. Bristowe, 84. Bromides in diphtheria, 106. Bromine in diphtheria, 106. Bronchitis, plastic, or fibrinous, 129. (167) 168 INDEX. Catarrh a predisposing cause of diphtheria, 42, 55. Cathartics, use of, in croup, 141. in diphtheria, 94. Causes of death in croup, 138. in diphtheria, 68. Causes of croup, 129. of diphtheria, 20. predisposing, of diphtheria, 39. Caustics, use of, 87, 88. Chapman, 109. Chloral in croup, 145 et seq. in diphtheria, 87 et seq., Ill et seq. exists in the blood as chloral, 115. not depressant, 117. prevents coagulation of the blood, 113. used in all cases, 119. Chlorate of potassium in the treatment of croup, 144. of diphtheria, 104 et seq. Olimatic and atmospheric influences, 37. Coagulation of the blood prevented by chloral, 113. •Constitutional nature of diphtheria, 7, 30. treatment of diphtheria, 92. Contagium of diphtheria, 26. Convalescence, 59. Copaiba in diphtheria, 107. Copper, sulphate of, in croup, 140. Creasote, use of, 85. ■Croup, 129. and diphtheria, symptoms compared, 123. and laryngeal diphtheria, identity or non-identity of, 129. aetiology of, 129. aphonia in, 136. asphyxia in, 136. causes of death in, 138. cough in, 131, 136. examination of sputa in, 133. exudate in, 134, 138, 139. membrane in, 130. nature of, 131. nomenclature of, 130. INDEX. 169 Croup, pathology of, 138. respiratory sounds in, 131. symptoms and diagnosis, 131 et seq. treatment of, 139. use of chloral in, 145 et seq. use of laryngoscope in, 133. voice in, 136, 137. Croupous diphtheria, 51. Cubebs in diphtheria, 107. Deglutition, difficulty of, caused by paralysis, 62. Diagnosis between diphtheria and membranous laryngitis, 65. and quinsy, 66. and scarlatina, 65. and thrush, 65. Diagnosis of diphtheria, 64. Diphtheria a constitutional disease, 7, 30. age when it occurs, 39. albuminuria in, 49. causes, 20. predisposing, 39. constitutional nature of, 7, 30. predisposition to, 40. treatment of, 92. definition of, 7. diagnosis of, 64. feeding in, 78. gangrene in, 54, 70. hemorrhages in, 54. history of, 8. incubation of, 42. laryngeal, 51. malignant, 46. mortality in, 67, 115. nasal, 52, 121. of Eustachian tubes, 52. of lachrymal duct, 52. of rectum, 53. of vagina, 53. of wounds, 7, 53. 170 INDEX. Diphtheria, predisposing causes of, 39 et seq. prognosis in, 69. prophylaxis and prophylactics in, 44. sequelae of, 60, 63. sewers and, 41. sex in, 40. skin eruption in, 55. symptoms of, 45 et seq. synonj^ms of, 8, 11. temperature in, 56. treatment of, 77 et seq. unfavorable symptoms in, 69. uraemia in, 68. Diphtheritic croup, 51. exudate, 50. laryngitis and membranous croup, 15, 66, 1231 membrane, 50, 70. mode of production of, 71. membranes, separation of, 57. paralysis, 60, 126. causes of, 63. electrical applications in, 127. frequency of, 63. statistics of, 61. treatment of, 126. Duration of incubation of diphtheria, 42. Eberth, 24, 72. Emetics in croup, 140. in diphtheria, 95. Epistaxis in diphtheria, 123. Eustachian tubes, diphtheria of, 52. Feeding in diphtheria, 78. Fibrinous or plastic bronchitis, 129, 130, 156. exudations, 130. Fomentations, use of, 91. Formulae, 163. Gangrene in diphtheria, 54. INDEX. 171 General treatment of diphtheria, 77. Glands, swelling of the, in diphtheria, 36, 74 Guttmann, Dr., 108. Heart affections in diphtheria, 74. Hemorrhage in diphtheria, 54. History of diphtheria, 8. Hydrargyrum in the treatment of diphtheria, 106. Hydrochloric acid, use of, 85. Ice in diphtheria, 90, 91. Incubation of diphtheria, duration of, 42. Infection of diphtheria, manner of, 40. 41. Inhalations of steam in croup, 147. Inoculability of diphtheria, 40. Ipecac in diphtheritic laryngitis, 140. Iron in the treatment of diphtheria, 96 et seq., 116. Kidneys, symptoms connected with, 32, 76. Labadie Lagrave, 56. Lachrymal duct, diphtheria of, 52. Lactic acid, use of, in diphtheria, 125, Laryngeal diphtheria, 123. treatment of, 124. Laryngoscopic examination in croup, 133. Laryngotomy, 151. Laryngo-tracheotomy, 151. Lime water in diphtheria, 86, 122, 125. Local treatment in diphtheria, 84. Lung affections in diphtheria, 74. Mackenzie, 32, 36, 37. Measles and scarlatina predisposing causes, 42. Medical prophylaxis, 127. Membrane, diphtheritic, 35. in croup, 134, 138, 139. seat of, in diphtheria, 35. 172 INDEX. Membrane, decay of, 53. Membranous croup, 129. diagnosis of, I31~et seq. treatment of, 139. Membranous deposits in larynx, 134, 138, 139. Mercury in treatment of croup, 141 et seq. of diphtheria, 106. Micrococci, 22 et seq., 29. Microzymes, 28. Mode of propagation in diphtheria, 39. Moist air in croup, 147= Mortality in diphtheria, 67, 77. Muguet and diphtheria, 65. Nasal diphtheria, 52, 121 epistaxis in, 123. treatment of, 122. Nitrate of silver in the treatment of diphtheria, 86. Nomenclature, 2. Nourishment in diphtheria, 78. Oertel, 23, 86. Paralysis diphtheritic, 126. affecting vision, 61. frequency of, 63. of extremities, 62. of heart, 62. of muscles of neck, 62. of muscles of trunk, 62. of pharynx, 61. of sphincters. 62. Pilocarpin, use of. in diphtheria, 107. Potassium chlorate, in diphtheria, 104 et seq. sulphide, use of, 106. Plastic bronchitis, 156. Poultices, use of, 80, 91. Prognosis in diphtheria, 6Q. Prophylaxis, medical, 127. INDEX. 173 Propagation, mode of, in diphtheria, 39. Pyasmia, 53. Quinia in croup, 145. in diphtheria, 96, 100. Rectum, diphtheria of, 53. Rokitansky, 89. Salicylic acid in diphtheria, 106. Secondary blood-poisoning, 58. Senega in diphtheria, 108. Septicaemia, 73. Sex in diphtheria, 40. Silver nitrate in diphtheria, 86. Sinapisms, 80. Skin eruption in diphtheria, 55. Spray inhalations in croup, 147. Sputa, examination of, in croup, 133. Sulphide of potassium, 106. Sulphites, use of, 106. Sulphur, 87. Symptoms of diphtheria, 36. unfavorable, in diphtheria, 68. Synonyms of diphtheria, 8, 11. Thrombi in diphtheria, 68, 75. Tonsils, ulceration of, 59. Tracheotomy, 148, 150. anaesthetics in, 153. in diphtheritic laryngitis, 125. mode of operation, 153. statistics of, 149. Treatment of diphtheria by chloral, 111 et seg. constitutional, 92. general, 77. local, 84. therapeutic, 81. Trousseau, 41, 60, 105. Tympanum, perforation of, 52. 174 INDEX. Ulcers of tonsils and fauces, 59. Urea increased in diphtheria, 33. Urine, casts in, 23. albuminous, 32. Vaginal diphtheria, 53. Vance, 151. "Wounds, diphtheria of, 7, 53.