Volume 1 — GENERAL DISEASES. (continued 16)

Diphtheria of the mouth, as a primary affection, is not of very frequent occurrence; not rarely, however, is it associated with diphtheria of the fauces and nose, mainly when they have assumed a septic or gangrenous character; it appears on cheeks, tongue, angles of the mouth and gums, and, after the fetid discharges have excoriated the skin, on the lips also. In all of these localities it appears less in the form of an extensive, thick membrane than an infiltration of the tissues. It is most apt to occur where, from the start, the mucous membrane of the mouth was eroded or ulcerated. The ulcerated base of a follicular stomatitis is very frequently the starting-point of a general diphtheria of the mouth. It is always a disagreeable symptom, points to a long duration of the whole process, and threatens septic absorption.

The oesophagus and the cardiac portion of the stomach are the seat sometimes of very massive and extensive, mostly fibrinous exudations, in typhoid fever, dysentery, cholera, measles, and scarlatina, or after injuries following contact with mineral acids, alkalies, corrosive sublimate, or antimony. When the normal tissue was not injured I never saw any that were not superjacent and could not easily be peeled off (croupous). In cases of extensive pharyngeal and laryngeal diphtheria the upper part of the oesophagus is often covered to a distance of half an inch or an inch with membrane, the lower part of which is thinning out into a mere film. A case of local diphtheritic deposit near the cardiac portions of the oesophagus, upon the seat of a stricture, I have described in my Treatise, p. 83. Actual diphtheria of the stomach is rare. So is that of the intestine, which is much more liable to be affected in animals than in man. In the cow intestinal diphtheria is frequent (Bollinger). In the gall-bladder, resulting from the irritation produced by calculus, it was seen by Weisserfels. The diphtheritic form of inflammation of the human colon and rectum—dysentery—is frequent enough, but will be the subject of discussion in another place. But, besides this, in the lower portion of the small intestines and in the colon long, tough, coherent membranes are sometimes found in the male and female (not in the hysterical female only). As a rule they are not diphtheritic, but consist mostly of nothing but mucus hardened and flattened down by protracted compression. The few cases of intestinal diphtheria I have met with gave rise to the usual symptoms of enteritis, and were diagnosticated as such.

Wounds of all kinds are easily and rapidly infected by diphtheria; for instance, vaginal abrasions and erosions of the external ear, tongue, and corners of the mouth. Scarification or removal of part of the tonsils is followed in half a day or a day by a deposit of diphtheritic membrane on the wound. The wound caused by tracheotomy becomes liable to be infected with diphtheria within twenty-four hours. Leech-bites, skin denuded by vesicatories, removal of the cuticle by scratching during cutaneous eruptions, all furnish a resting-place for diphtheria in a short time. What Billroth has described under the name of muco-salivary diphtheritis, as it occurs after the extirpation of a large portion of the tongue and resection of the lower jaw, belongs to this class.

At times immediately at the beginning of an invasion of diphtheria, at other times only on the second or third day, an erythematous eruption, more or less general, appears on the skin. Now and then it appears on the chest, shoulders, and back; at other times it covers the body, and has not infrequently led to its being confounded with scarlatina. It is not always accompanied by much fever, and cannot therefore be mistaken for that form of erythema which frequently appears in children with delicate skins during high fever from any source. I cannot say that I have found this complication to give a more malignant character to the disease, but true erysipelas does. I am not prepared to prove that the two processes, erysipelas and diphtheria, are identical under some circumstances, but the complication of the two, and the ferocity with which they combine, renders a close relationship probable. I have seen an infant dying from an erysipelas added to a post-auricular diphtheria, this being due to a slight abrasion of the surface. Erysipelas originating in the tracheotomy wound, though ever so carefully disinfected and secured, is frequently observed after two or three days, and is a very ominous symptom. Erysipelatous surfaces, denuded of their epidermis by spontaneous vesication or injured by ever so slight a trauma, are very liable to be covered with diphtheritic membranes.

An eruption resembling urticaria in the beginning is as innocent as erythema, but purpura in the latter stage is a symptom of mostly ominous nature.

On the vulva and vagina of little girls diphtheria is sometimes met with; probably in every case it is due, under the epidemic influence, to a local catarrh or erosion. In but few cases, comparatively, the inguinal glands are swollen. There are not many cases of vaginal diphtheria which are followed by the pharyngeal affection. Diphtheria of the vagina in puerperal women is liable to become the cause of general sepsis, and is a dangerous disease; it is seldom complicated, but uterus, Fallopian tubes, and peritoneum may become the seat of inflammatory and septic disturbances. In the bladder it may occur when the urine is alkaline, in chronic cystitis, after lithotomy, urethotomy, the operation for vesico-vaginal fistula, and in ectopia vesicæ. This form has a marked tendency toward localization, but by extension of the phlegmon, when of putrid character, to the retro-peritoneal cellular tissue, peritonitis may ensue and terminate fatally. Sepsis from absorption is also frequent. Vesical diphtheria is sometimes quite unsuspected. A man of sixty had urinary trouble a long time; his urine was frequently very offensive, containing blood and pus. About five days before his death he suddenly collapsed. I found the bladder well filled, and introduced a catheter, but succeeded in removing but a few drops of fetid liquid. Assuming the presence of a malignant tumor at the neck of the bladder, I attempted to draw off the urine by puncturing above the symphisis pubis; again without success. At the post-mortem examination a thick membranous lining of the bladder was found detached in the form of a sac containing about a quart of urine. During life the beak of the catheter evidently passed into the space between the bladder and the membranous sac, which accounts for the unsuccessful attempts at catheterization.

Diphtheria of the placenta was observed by Schüller. The membrane was between uterus and placenta, and attached to the latter. It resulted from puerperal sepsis. Balano-posthitis is liable to result in local and general diphtheria; so are circumcision wounds. They are apt to become affected either primarily, without apparent cause, or when other members of the family are suffering from the disease.

The kidneys may become affected in various ways. Albuminuria is not always of significance, as it occurs in severe and mild cases alike, both before and after tracheotomy, and therefore is not connected always either with the height of the fever or the degree of dyspnoea; at times it disappears in a few days, in other cases it is of longer duration. It is not invariably complicated with changes in the kidney, neither do we always discover casts or degenerated epithelial cells in the urine. In other respects also it does not behave like albuminuria in scarlatina. In the latter it appears seldom before the second week of the process, and frequently later, while in diphtheria it is often seen early. It sometimes lasts but a few days, particularly in many cases which set in with a high fever, which rapidly diminishes, and terminates in speedy recovery. In these occurrences the presence of albumen appears to attend the rapid elimination of the poison.

Albuminuria seldom lasts longer than a week, and is not often complicated with oedema, but sometimes it is but a symptom of a local or general nephritis, and then hyaline, epithelial, and fibrin casts and granular cells are found in the urine. Nephritis then assumes as serious a character as it possesses in scarlatina. Cases of nephritis, fortunately rare in a very early period of diphtheria, are liable to run a rapid and often fatal course.

The heart and blood are affected in various ways by the diphtheritic process. Where the disease runs a slow course, accompanied by high fever, a granular degeneration occurs, similar to that appearing in other acute infectious disorders—typhoid, for example. In diphtheria, however, it would seem that this condition may arise even without marked elevation of temperature. The pathological changes in the heart produced by diphtheria are not always the same. Ecchymoses, cellular hypertrophy, and granular degeneration have frequently been noticed after death where the symptoms had been severe. The result, of course, is considerable weakness of its muscular tissue, evidenced by the formation of local (Beverly Robinson) thrombi, general sluggishness of the circulation, dyspnoea, muffled heart-sounds, a cool and pale skin, and sudden death, preceded by a very feeble and frequent, sometimes, however, by a very slow, pulse. Aside from this, there is actual endocarditis during the course of diphtheria or convalescence therefrom. It affects especially the valves, and among them particularly the mitral. It is characterized by high fever, precordial pain, attacks of syncope, and a systolic murmur.

The rapid decrease of red blood-cells and a moderate increase of leucocytes were demonstrated by Bouchut and Dubrisay, but the disproportion was not such as to necessitate the diagnosis of leucocythæmia. Wunderlich reports two cases of Hodgkin's disease, the pseudo-leukæmia developing during diphtheria. And the slowness of final recovery in many cases, even of but short duration and not complicated with nervous disorders, appears to point to a serious disintegration of the elements of the blood. The dark color and defective coagulation of the blood in autopsies of diphtheria cases have often been remarked.

The direct and rapid introduction into the blood of a foreign substance has amongst its earliest symptoms fever. This reaction of a nervous system depends both on the quantity and quality of the substance or poison introduced, and on the susceptibility of the patient. High temperatures are, however, not the only, nor are they the most dangerous, nervous symptoms. To the latter belong the different shades of paralysis met with during or subsequent to diphtheria.

Sudden and unexpected collapse is sometimes observed, not infrequently in the earlier part of the disease. The changes found in autopsies, such as a dark color of the blood, deficient coagulability, extravasations into and friability and granular degenerations of the tissues, accumulations of degenerated cells, and granules between the fibres, degeneration mainly of the heart-muscle, the presence of heart-clots, thrombi in remote veins,—they all show to what extent the disease can destroy life in the shortest time possible. In the heart either the pneumogastric or the ganglionic nerves may be affected, and the symptoms will vary accordingly. Paralysis of the former will accelerate the pulse, degeneration of the sympathetic will diminish its frequency, yet death may ensue in either.

The usual form of diphtheritic paralysis makes its appearance during the period of convalescence, at a time when all danger seems to have passed by. As a rule, the soft palate and the muscles of deglutition are the first to be attacked, while the condition of these organs is apparently normal (and no longer oedematous, and thereby inactive, as in the first period of the disease). While they are recovering, or before, the accommodation muscles of the eyes become paralyzed. Sometimes, however, these are the first to be affected. This paralysis does not, as a rule, follow severe cases; on the contrary, it is not uncommon to observe it after apparently mild attacks of the disease. In consequence of the former paralysis, deglutition becomes difficult; fluids are expelled through the nose or enter the larynx and bronchi, thereby giving rise to pneumonia; in the latter there is strabismus. The upper and lower extremities become paralyzed afterward. As a rule, a number of muscles are affected at the same time, and improvement will take place in about the same order in which the individual muscles became affected. After paralysis has become affected, circulation begins to suffer. The extremities now and then become bluish, cool, emaciated; rarely atrophy and fatty degeneration have been observed. The muscles of the neck also become paralyzed; the head cannot be carried, or with difficulty only. The fingers are but seldom affected. The same holds good of the bladder and intestines. The respiratory muscles are not frequently attacked. Their paralysis is very ominous, and may prove fatal in a short time from apnoea.

Not only motory but sensory paralyses may occur. Anaesthesia, amaurosis, deafness have been observed; a number of cases of locomotor ataxia are on record, and but lately Hadthagen¹² publishes a case which he claims as disseminated sclerosis.

¹² Arch. f. Kinderheilk., vol. v., 1883.

Sometimes the nervous affection in diphtheria is localized in a peculiar manner; it seems as if there is a predisposition on the part of a certain nerve to become diseased. The case of a boy, active and healthy, in the practice of H. Guleke, is very interesting. In the course of three years he had three attacks of diphtheria. In the very beginning of the disease he always became soporous with an almost normal temperature and a slow but regular pulse. Probably the heart's ganglia are the first to submit to the influence of the poison and exhibit symptoms of flagging function. In most of the cases of diphtheritic paralysis the prognosis is good; the large majority will run a favorable course in from six to ten weeks.

INVASION.—Is diphtheria, primarily, a local or a constitutional disease? Mercado's well-known case of diphtheria, engendered by the biting of a finger, has been alluded to. I know of one case in which the vagina became first affected, and later the pharynx. Bayles saw denuded portions of skin assume a membranous character, and general diphtheria develop afterward. Fresh wounds become diphtheritic, and the general disease arises from this source. Even paralysis will follow. I had a death from diphtheria when a long incision into a phlegmon of the thigh had become diphtheritic. A little girl, who had a considerable amount of discharge from a catarrhal vagina, and sore thighs in consequence, exhibited first, during the epidemic of 1877, membranes on the denuded cutis, and afterward general diphtheria. Brehm reports the case of a woman on whom he performed colotomy. The wound became thoroughly diphtheritic and gangrenous, but the pharynx and respiratory organs remained intact. A few days after, her daughter, who attended her in her sickness, was infected. In her the pharynx was the seat of disorder. Besides, the tonsils are very frequently coated with a membrane without any general symptoms in the beginning, fever and general illness occurring only later on. Now, all of these facts tend to show that there are cases in which the origin of the disease is purely local.

It must, however, not be forgotten that during the prevalence of an epidemic every one is more or less under its influence, and but little is wanting to call forth the disease. Some years ago a well-known physician, with whom I was intimately acquainted, died from facial erysipelas and meningitis which had originated in a slight abrasion of the upper lip. During an epidemic of typhoid we daily see persons with fever, headache, and lassitude. Diarrhoeas are frequent during an epidemic of cholera. An epidemic of diphtheria is accompanied by a great number of cases of pharyngitis. When, in the year 1860,¹³ I reported two hundred cases of bonâ fide diphtheria, I at the same time observed one hundred and eighty-five cases of non-membranous inflammations of the throat. Such occurrences may be considered as possible or incipient cases of pharyngeal diphtheria. Therefore, contrary to the view of a local origin of diphtheria, it may be claimed that the individual taking the disease was already saturated with the poison, and the local membrane represented perhaps nothing but a symptom, or at the utmost the causa proxima. Accordingly, then, there are undoubtedly cases in which the pharyngeal membrane is the first cause and symptom of the final affection, and others in which the poisoning of the blood through inhalation is the first step in the development of the disease, amongst the symptoms of which the pharyngeal or nasal membrane counts as one.

¹³ Amer. Med. Times., Aug.

In these cases the first complaints of the patients relate to their general condition. Sometimes they are ignorant of any local trouble when they consult a physician. When it is perceptible, however, it is usually found on the visible pharyngeal and respiratory mucous membranes. This would seem to indicate that the infectious elements while being inhaled are there deposited. Thus there is a possibility of simultaneous affections of both the throat and the blood in the lungs, in either equal or variable proportions. We are easily led to defend at least a partial admission of the poison by the respiratory act, when we reflect that the membranes which are swallowed are rendered innocuous by the action of the gastric fluids, and, therefore, the alimentary canal, from the oesophagus downward, cannot be made responsible for the admission of the poison into the system. Thus it is that the general symptoms—as fever, lassitude, etc.—precede the local phenomena in very many cases, while there are exceptional cases in which the membrane appears first and the fever later. This is especially the case when the tonsils are very large and occupy a prominent position in the throat.

Those cases which begin with high fever and moderate or no local symptoms must be looked upon as constitutional diseases. If a person, in the course of several hours or a day, be taken with high fever and a moderate membrane-formation, these symptoms subsiding in one or two days, leaving the patient weak and exhausted, but fully restored to health at the end of a week, we would be justified in assuming (cæteris paribus) that there was a rapid absorption of a large amount of poison, and an equally rapid elimination thereof. They are, moreover, the same cases in which the second or third day of the disease furnishes albuminuria, with rapid elimination and speedy recovery. When, however, the process is slow in developing, accompanied by moderate fever, and the course is indolent, we have reason to infer that moderate amounts of the poison are being continually taken into the system and making their influence felt to a moderate degree, but for a longer period. Such are the cases which, without any violent symptoms, are accompanied by frequent local relapses, or run, when the absorption is constant as well as copious, a septic course, or terminate in paralysis.

Thus there are cases in which a local infection of the skin or of a wound may be one of the causes, or the only cause, of the disease, and there are cases in which the poison, in passing through and caught in the pharynx, gives rise to local phenomena before the system at large gives evidence of infection. But, as a general thing, diphtheria must be looked upon as a constitutional disease, giving rise to local phenomena, in the same way as scarlatina does on the skin, on the mucous membrane of the alimentary canal, and in the uriniferous tubules; measles on the skin and respiratory mucous membrane; or typhoid in the lymph-follicles and on the mucous membrane of the intestine; or, in other words, the diphtheritic poison may enter the system locally through a defective, or sore, or wounded integument or through the lungs.

Is diphtheria contagious? Undoubtedly it is. The contagious element is liable to be directly communicated by the patient; it also clings to solid and semi-solid bodies, and in this way is transmitted even after a long time. There is hardly any disease which can cling so tenaciously to dwellings and furniture; it can be transported by the air, though probably not to a great distance, and hence in houses artificially heated, while the windows and doors are mostly closed, rises from the lower to the upper stories; and it is for this reason advisable to keep the sick on the top floor. It is certainly transmitted by spoons, glasses, handkerchiefs, and towels used by the patient. The contagious character increases directly in proportion to the neglect of proper ventilation. That it is spread by the feces is not clearly established in my mind. I can give personally no examples of its being carried by visitors or by the attending physician; this is said to have occurred, however. The character of the disease communicated, and the local manifestation, do not depend on that of the original sufferer; thus mild cases may produce severe ones, and vice versâ, and convalescents can convey the disease in its full force. Naturally, the softer character of the tissues in children renders them more susceptible to infection, and the activity of their lymphatic system more liable to severe forms of the disease.

Many tragic cases are recorded in literature of infection by direct contact from pharynx to pharynx, or from the opening in the trachea to the mouth of the surgeon; and one of the saddest cases, perhaps, is that of the much-lamented Carl Otto Weber. Myself and others have contracted diphtheria from sucking tracheotomy wounds.

In regard to the length of the incubation periods, there can be no better authenticated facts than those contained in a report of Elisha Harris to the National Board of Health, an abstract of which is found in No. 1, National Board of Health Bulletin, June 28, 1879. The report says that in the fourth school district of the township of Newark (Northern Vermont), amidst the steep hills where reside a quiet people in comfortable dwellings, the summer term of school opened on the 12th of May. Among the twenty-two little children who assembled in the school-room in the glen were two who had suffered from a mild attack of diphtheria in April, and one of them was, at the time school opened, suffering badly from what appeared to have been a relapse in the form of diphtheritic ophthalmia. Besides, it is proved that these recently sick pupils had not been well cleansed, one of them having on an unwashed garment that she had worn in all her sickness three weeks previously. At the end of the third day of school several of the children were complaining of sore throat, headache, and dizziness, and on the fourth day and evening so many were sick in the same way that the teacher and officers announced the school temporarily closed. By the end of the sixth day from school opening, sixteen of the twenty-two previously healthy children became seriously sick with symptoms of malignant diphtheria, and some were already dying. The teacher and six of the pupils were not attacked, nor have they since suffered from the disease.

A case¹⁴ is reported of a surgeon who, while attending a diphtheritic child, had some secretion thrown into his face. Twelve hours after his right eye was inflamed and painful. The affection proved diphtheritic, and recovery was completed after several weeks only. In a case seen by me, with Dr. L. Bopp, a child removed from a house infected with diphtheria was attacked after fourteen days and eight hours.

¹⁴ Würt. Med. Corresp. Bl., 1878, No. 2.

It would then appear that, in the direct communication of the disease to healthy or nearly healthy mucous membranes—as healthy as the prevailing epidemic will allow—the period of incubation is from one or two to fourteen days. In only a small number of cases the disease has an even shorter period of incubation than this, as when tonsillotomy or a similar operation is undertaken during the prevalence of an epidemic. One may rest assured that any operation on the tonsils while an epidemic of diphtheria is at its height will be followed within twenty-four hours by diphtheritic deposits on the wounded part. To what extent we are justified in considering this a bonâ-fide incubation of the disease in a previously healthy body is, of course, another question. It seems to me that these cases positively prove that the operation is only the causâ proxima of a diphtheritic affection, and that we may take it for granted that during an epidemic every individual is more or less under its influence and affected by it, so that it needs but a wound or an accidental abrasion of the surface of the mucous membrane to call the disease into action. In a similar way, fresh wounds or morbid conditions of the mouth may call forth the disease. The ruptured vesicles of a follicular stomatitis are liable to serve as resting-places for diphtheritic membranes, and thus I have seen the complication of a follicular stomatitis with oral diphtheria; and any lacerations of the vagina during labor may become diphtheritic within twenty-four hours. If now, on the one hand, incubation depends on the condition of the affected surface, it is probable, on the other hand, that the intensity of the poison at the time plays an important part in determining the period that is to elapse between infection and the invasion of the disease.

ETIOLOGY.—Diphtheria is pre-eminently a disease of early life; in this respect it is said to differ from the genuine fibrinous bronchitis, which by some is held an absolutely different disease, and stated to occur but rarely in children. But even this statement is probably incorrect. In the spring of 1879 I met with four cases of fibrinous bronchitis in children under three years of age. The number of cases of diphtheria in adult life is not very large, while in old age it is very small. Of 501 deaths in Vienna in 1868, only 1 had reached the age of sixty-two; of more than 300 cases in which I performed tracheotomy but 2 were over thirteen years old.

I do not know that sex exerts any predisposing influence over diphtheria, yet of the six hundred cases or thereabouts of laryngeal diphtheria in which I either personally performed tracheotomy or observed the progress of the disease in the practice of others, I found the majority in males, and the recoveries in inverse proportion to the number thereof, the mortality being greater among boys. As far as age is concerned, nearly all the zymotic diseases are seen most frequently in children. They exhibit a greater disposition to submit to diphtheria than adults, if we except those under ten months. Where, however, the disease has occurred previous to the seventh or eighth month, the greater number of cases has been found under three months. Tigri reports the disease in a child of fourteen days. A child of fifteen days was seen with diphtheritic laryngitis and oesophagitis by Bretonneau, one of seventeen days by Bednar, one of eight by Bouchut, one of seven days by Weikert; Parrot mentions several cases, and Sirédey¹⁵ reports eighteen cases of diphtheria in the newly-born. They occurred in the Hospital Lariboisière in the spring of 1877, and were probably infected by the nurses of a neighboring children's asylum. Membranes were found on the soft palate, tonsils, or larynx, and also on both pharynx and larynx. One case occurred where the posterior nares alone were affected. I have met with four cases of diphtheria of the pharynx and larynx in the newly-born myself. One of these became sick on the ninth day after birth, and died on the thirteenth day; the other died on the sixteenth day after birth; the third was taken when seven days old, and died on the ninth day. The predisposition to diphtheria during childhood¹⁶ seems to be explainable by several circumstances. The mucous membrane of the mouth and pharynx in the child is more succulent and softer, and frequently the seat of a congestive and inflammatory process. The nasal cavities are small and frequently affected by catarrhs, the buccal cavity often the seat of catarrh and of stomatitis, and insufficient cleanliness leads here to irritation of the mucous membrane. Any abnormal state of the mucous membrane, with the exception of an atrophic condition and cicatricial changes, affords an excellent abode for diphtheria. The tonsils are proportionally large; in fact, we rarely see the tonsils in children completely sheltered by the arches of the palate. On the other hand, the pharynx is anything but spacious, and while the protuberant condition of the tonsils affords a resting-place for the invading disease, the remaining space is so small that it becomes a source of uneasiness to the well in many instances, and very much more than that to the child during diphtheritic tumefaction. Furthermore, we must take into consideration the large number and size of the lymphatics, which can be more easily injected in the child than in the adult, according to Sappey, and the fact of greater intercommunication amongst the lymphatics and between them and the system; for S. L. Schenck has found that the network of lymphatics in the skin of the newly-born, at least, are endowed with stomata, loopholes through which the lymph-ducts can communicate with the neighborhood, and vice versâ.¹⁷ These circumstances, although they may have no influence in calling the disease into existence, yet assist in its development and in adding to the severity of the symptoms.

¹⁵ Thèse, Paris, 1877.

¹⁶ W. N. Thursfield (London Lancet, Aug. 3d, 10th, 17th, 1878) collects 10,000 cases of diphtheria in England between the years 1855 and 1877. Of these 90 per 1000 were under a year, 450 per 1000 from 1-5 years, 260 from 6-10, 90 from 11-15, 50 from 16-25, 35 from 26-45; 25 per 1000 were 45 years and over.

¹⁷ Mittheil. aus d. Embryol. Instit., i., 1877.

On the other hand, while the above reasons go to prove that diphtheria attacks children by preference, there is again an anatomical and physiological condition—to wit, the free slightly acid secretion of the mouth, beginning with the third month—that acts as a hindrance to the frequent occurrence of diphtheria after the third month. A poison or poisonous product of whatever nature can less readily find a hiding-place so long as it can be readily—we might always say must surely be—washed away. During these months of eruptive secretion from the mouth diphtheria, therefore, is not very frequent; thus teething, in the case of diphtheria, cannot be held responsible by mothers fond of diagnosticating dental diseases. In this connection the remark of Krieger ought not to be overlooked, who explains the relative scarcity of the disease in the first year of life by the fact that cumulative influences will produce a great number of cases, and cumulation requires time. Undoubtedly, however, an important etiological consideration is the fact of having had the disease previously. We can cite a host of zymotic diseases the occurrence of which once serves as a protection against future attacks. Not only can no such security be expected after one attack of diphtheria, but, cæteris paribus, the disease shows a preference for those who have survived a previous attack. The statement that only the mild cases, with but slight elevation of temperature and freedom from severe constitutional symptoms, are likely to suffer a relapse is founded on error. True, I have more frequently seen relapses after mild cases—which, fortunately, are in the majority—but the disease has also recurred where originally high fever and an extensive lymphadenitis proved it to be a severe case. Besides, second attacks of membranous croup are also recorded (Guersant, N. F. Gill, Quincke).

As there are individuals, so there are families, which have a predisposition to diseases, as there are others in whom, notwithstanding ample exposure, infection does not easily take place. Yet in the families in which diphtheria is of frequent occurrence it cannot always be attributed to enlarged tonsils and a tendency to pharyngeal or nasal catarrh.

Still, catarrh and the vulnerability of mucous membranes must be considered as a frequent source of diphtheria; children will get numerous relapses often after a nasal or pharyngeal catarrh. Sudden changes in the temperature of the atmosphere or of the surface of the body are therefore dangerous in predisposed persons. And thus it is that while severe epidemics have spared no climate or land known to us, the majority of cases have occurred in winter and spring; in other words, at a time when catarrhal disorders are of most frequent occurrence. In my experience at New York, the first quarter of the year yielded more cases than any other. Still, they are frequent enough in warm seasons. Krieger insists upon the injurious influence of hot summers and dry hot rooms. I do not doubt the correctness of his views, which cannot but be strengthened by the damaging results of our furnace-heating. But the influence of season on the invasion and course of diphtheria is but indirect and conditional, and may be, perhaps, after all, compared with that exerted by filth—a term which is lately used to express all sorts and forms of nastiness, from filthy bodies of men to their clothes, their habits, their food, and the air they breathe, whether polluted by carbonic acid, by excrementitious gases, or by exhalations of sewers.

Cases of diphtheria which are traced to exhalations from sewers (or even to filthy habits of life) are very frequent. Yet typhoid is attributed to the same causes. So is dysentery. Can, then, foul exhalations produce alike diphtheria, typhoid, and dysentery? Do these diseases arise from a common poison? Or is the poison of a treble character, so that a part may give origin to diphtheria, another part to typhoid, a third to dysentery?¹⁸ Have we to deal, in such occurrences, with specific influences, or only with a lowering of the standard of health, thereby affording other morbid influences an opportunity to exercise their power? These questions are still involved in darkness, and constitute problems the solution of which still engages the minds of both individual writers and authorities. A report of the Board of Health of Massachusetts, closely adhering to the results of exact observations,¹⁹ leaves them doubtful, and the affirmative reports of some modern writers do not bear scrutiny.²⁰

¹⁸ In regard to the causal connection of the two latter diseases with sewer exhalations we can be more positive than in regard to the former.

¹⁹ Author's Treatise on Diphth., p. 35.

²⁰ M. A. Avery, Med. Jour. and Obst. Rev., Feb., 1882.

Air polluted by bad drainage or leaky sewers has been considered responsible for diphtheria as well as for typhoid fever and dysentery. Not only the impairment of general health, but the direct and unmistakable disease, has been attributed to it. Thus Bayley refers, in the endemic of Bromley,²¹ the first cases to unventilated sewers and cesspools. School-children multiplied the disease. Thursfield attributes the diphtheria at Ellesmere²² to the accumulation of excrements under the school-room, and to deficient supply of water, which, moreover, was of bad quality. Tripe (like Railton, Bailey, Russell, Bell) accuses sewer gas;²³ others polluted waters or bad drainage.²⁴ I have not been convinced, however, that diphtheria can be considered a sewer-gas disease, in the same way as typhoid fever. The deterioration of the general health resulting from the inhalation of foul air is sufficient to explain the outbreak of the individual attack during a prevailing epidemic.

²¹ Sanit. Record, Aug. 10, 1877.

²² San. Rec., 158, 1877.

²³ Ibid., June 14, 1878.

²⁴ Ibid., April 18, May 2, 1879.

In regard to polluted water, I do not think that pathologists who attribute infectious diseases to bacteria only are justified in condemning it. It may not be so guilty, after all, for the admixtures, inorganic and organic, minerals, admixtures of wood and plants, also lower fungi and their products—algæ, infusoria—would render water rather disagreeable, but not exactly unhealthy. The latter effect can be accomplished—always assuming the bacteria theory correct, for the sake of argument—by bacteria only. But when they arrive in the stomach, their doom is sealed; they are decomposed. The only places where, possibly, they could take root would be diseased or ulcerated places in either the oral cavity or the upper portion of the oesophagus.

Not only water, but the milk of animals also, has been accused of being the direct cause of diphtheria. Powers concludes, though a connection between diphtheria and the consumption of milk have not been proven as yet, that it is very probable indeed. His careful investigations into the causes of some local epidemics in North London exclude any other source from which the people could have been affected. Perhaps one of the forms of garget, cow mammitis, is of an infectious character. His reasoning, however, is not accepted by A. Dowrus,²⁵ who still believes that the milk which gave rise to diphtheria at a distance may have been soiled and infected. For though the connection between milk and scarlatina and typhoid fever had been known for years and variously studied, no observation of the kind had yet been made in regard to diphtheria. Besides, where the young, in England, drink much milk—viz. in the cities—diphtheria was very much less frequent than where little or no milk was taken—viz. in the country. Even in the country the well-to-do classes, who drink milk, had but little diphtheria, while the children of the poor, who obtained none, suffered a great deal from it.

²⁵ "Diphtheria and Milk-Supply," Brit. Med. Journ., Feb. 1, 1879.

In regard to this transmission of diphtheria by means of milk O. Bollinger²⁶ hesitates to express any opinion, except that the matter is very doubtful indeed. Probably the possibility of contracting diphtheria directly from animals is very much greater than the danger from water or milk. On a Pomeranian farm, during the winter 1875-76, every newly-born calf died of diphtheria. The superintendent of the farm and the woman who attended to the calves were taken with diphtheritic angina.²⁷ Similar occurrences have been recorded. Bollinger reports a mycotic disease of the trachea and lungs in birds.

²⁶ D. Z. f. Thiermed. u. vergleich. Pathol., vi., 1879, p. 7.

²⁷ Damman, in D. Zeitsch. f. Thiermed., 1876, p. 1.

Friedberger's report,²⁸ presented to the Veterinary Society of Munich, on croup and diphtheria of domestic fowls, leaves no doubt as to its frequency, particularly amongst the nobler varieties.

²⁸ D. Zeitsch. f. Thiermed., v., 1879, p. 16.

Nicati²⁹ studied an epidemic diphtheria amongst hens which had similar symptoms and a course very much like that in man; it could be inoculated into other animals, and was contemporaneous with the outbreak of the epidemic amongst the human population of Marseilles. Trasbot³⁰ succeeded in inoculating a healthy hen from a diphtheritic one, but the attempts at transmission to dog, pig, and man were unsuccessful. The Med. and Surg. Journal³¹ contains the following: In a house at Ogdensburg, N. Y., five children were ill with diphtheria. Three kittens who had been playing with them from time to time took the disease and died. Post-mortem examination showed diphtheritic membranes in their throats.³²

²⁹ Revue d'Hygiène et de Police sanitaire, 1879, p. 3.

³⁰ "De la transmission de la Diphth. des Animaux à l'Homme," Gaz. hebdom., 1879 Avril 25.

³¹ Med. Rec., Nov. 8, 1879.

³² An elaborate description of the croupo-diphtheritic inflammations of mucous membranes in hens, turkeys, pheasants, and pigeons may be found in Zürn. Krankh. d. Hausgeflügels, 1882, p. 104.

Gerhardt³³ reports the following: 2600 hens were imported from Verona, Italy, into a village, Messelhausen, in Baden. Some of these hens were affected with diphtheria when they arrived. Within six weeks 600 of their number died of diphtheria, and 800 more soon after. In the following summer 1000 chickens were raised by artificial breeding, all of which died of diphtheria within six weeks. Five cats kept in the place also died of diphtheria; a parrot fell sick with it, but recovered. An Italian cook, suffering from diphtheria, in the month of November, 1881, while being subjected to local treatment with carbolic acid, bit the head-nurse's left foot and hand. Both these wounds became diphtheritic, the man falling sick with high fever, and requiring three weeks for his gradual recovery. Besides, four of the six workingmen employed in taking care of the hens of the establishment were taken with diphtheria. Not a single case, however, occurred in the neighboring village. Thus, it is safe to assume that the diphtheritic disease of hens can be transmitted to man.

³³ Verhandlungen des (ii.) Congresses für Innere Medicin, Wiesbaden, 1883, p. 129.

Diphtheria may be also produced by outside influences. In this regard the attempts at generating pseudo-membranes by artificial means are very interesting indeed. As early as 1826, Bretonneau, by the introduction of tincture of cantharides and olive oil into the trachea, succeeded in producing a "dense, elastic, reed-like membranous concretion." Delafond called croup into existence by the use of ammonia, oxygen, chlorine, corrosive sublimate, arsenic, and sulphuric acid. On the other hand, H. Mayer asserts that it is impossible, by means of ammonia, to produce a croup in the windpipes of animals which in the slightest degree resembles that occurring in human beings. Trendelenburg, however, after producing membranes in the trachea by the use of a solution of corrosive sublimate (1:120), succeeded in hardening the entire mass with bichromate of potassium, which it was impossible to do with the most tenacious mucus.

Rey observed croup in horses that inhaled smoke in a burning stable.³⁴ In the collection of the veterinary school of Zurich there is a croup membrane from a heifer which had been exposed to a fire; at Munich, one from the trachea of a horse, produced by forcibly injecting medicines into the nose. Hahn made an observation on cows, W. Ammon on horses, of long croup membranes after the animals had been exposed to smoke and fire; and Oertel constantly insists on there being "no actual difference between croup as it ordinarily occurs and that excited in the windpipe of a rabbit by means of ammonia. The color and texture, the physical, chemical, and histological characteristics, are identical."

³⁴ Journ. de méd. vét. de Lyon, 1850, p. 249.

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

³⁵ Man. prat. des mal. de l'enfance, 1877, p. 81.

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

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

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

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

³⁶ Med. Times and Gaz., ii. p. 204.

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

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

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

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

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

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

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

³⁷ Treatise on Diphtheria, p. 126.

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

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

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

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

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

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

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

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

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

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

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

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

³⁸ Gerhardt, Handb. d. Kinderkr., iii., 2, p. 20, 1878.

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

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

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

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

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

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

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

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

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

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

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

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

⁴⁰ Weigert, in Virch. Arch., vol. lxxvii., p. 294, 1879.

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

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

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

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

⁴¹ Wernich, in F. Cohn's Beitr., iii., 1859, p. 115.

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

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

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

"I. Disinfectants to be employed:

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

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

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

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

"II. How to use disinfectants:

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

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

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

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

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

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

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

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

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

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

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

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

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

⁴² Amer. Med. Times, Aug. 11th and 18th.

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

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

The effect of the chlorate of potassium is partly a general and partly a local one. The general effect may be obtained by the use of occasional larger doses, but it is better not to strain the eliminating powers of the system. The local effect, however, cannot be obtained with occasional doses, but only by doses so frequently repeated that the remedy is in almost constant contact with the diseased surface. Thus, the doses, to produce the local effect, should be very small, but frequently administered. It is better that the daily quantity of twenty grains should be given in fifty or sixty doses than in eight or ten; that is, the solution should be weak, and a drachm or half a drachm of such solution can be given every hour or every half hour or every fifteen or twenty minutes, care being taken that no water or other drink is given soon after the remedy has been administered, for obvious reasons.