Part 113

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

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

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

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

"II. How to use disinfectants:

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

"All discharges should either be received in vessels containing copperas {699} solution, or, when this is impracticable, should be immediately covered with copperas solution. All vessels used about the patient should be cleansed with the same solution.

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

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

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

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

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

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

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

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

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

There are very few cases of diphtheria which do not exhibit larger surfaces of either pharyngitis or stomatitis than of diphtheritic membrane. There are also a number of cases of stomatitis and pharyngitis, {700} during every epidemic of diphtheria, which must be referred to the epidemic, sometimes as kindred diseases, and sometimes as introductory stages only, which, however, do not, or do not in the beginning, show the characteristic symptoms of the disease.

When, in 1860, 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.

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

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

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

I have referred to these facts with so much emphasis because of late an attempt has been made to introduce chlorate of potassium as the main remedy in bad cases of diphtheria, and, what is worse, in large doses (Seeligmüller, Sachse, L. Weigert, C. Küster, Edlefsen.)

{701} Large doses of chlorate of potassium (2 drachms daily to an adult I claim to be a large dose, particularly when its use is persisted in for many days in succession) are dangerous. In several of my writings I have given instances of its fatal effects. I have seen fatal cases since, and scores have been published in different journals. The first effects of a moderately large dose are gastric and, more especially, renal irritation; the latter it was which I experienced when I took half an ounce twenty-five years ago. Fountain of Davenport, Iowa, experienced the same before more serious symptoms developed, of which he died. The symptoms are those of acute diffuse nephritis, with suppression of urine, or scanty secretion of a little black blood, and uræmia deepening toward death in fatal cases. My earlier cases I considered as primary diffuse nephritis, and I have even been inclined to attribute the frequent appearance of chronic nephritis, amongst all classes and ages, in part to the influence of the chlorates, which have become a popular domestic remedy and are found in every household. But the experimental researches of Marchand and others prove that, at least in many instances, the extensive destruction of blood-cells is the first and immediate result of the introduction into the circulation of the chlorate, and that the visceral changes are due to embolic processes.

Special Treatment.--The first axiom in the treatment of diphtheria is that there is no specific; the second, that in no other disease the individualizing powers of the physician are tested more severely.

The treatment is both internal and external. The local remedies are either such as dissolve the mucous membrane, or such as thoroughly modify the mucous membrane from which the pseudo-membrane has been removed, or real antiseptics, with the power of destroying either chemical or parasitic poisons.

The number of remedies recommended in diphtheria is immense. No other proof of its dangerous nature is needed. In the following I shall review those which I consider it worth while either to reject or to recommend.

Steam is used partly to soften the membranes, but principally to increase the secretion from the mucous membrane, and thereby throw off the superjacent membrane. This can be done to advantage only where there is a natural tendency to it; that is, where there are a great many muciparous follicles under a cylindrical or fimbriated epithelium. This is the condition on part of the pharynx, but not on the tonsils; and in a small portion of the larynx, in the trachea and bronchi, but not on the vocal cords. Wherever there is pavement epithelium on the normal surface, and where the membrane is imbedded into the tissue, steam can hardly be expected to do good. In the other cases it will. Thus, the locality of the diphtheritic process determines to a great extent whether steam is indicated or not. If it be used, the necessity of a full supply of atmospheric air must not be disregarded. Steam, with an overheated room and without pure air, is liable to be as injurious as steam in pure air is beneficial in a number of cases.

{702} There can be no better proof for the necessity of individualizing, and the impossibility of treating all cases alike, than the fact that many will do well under steam treatment, and others are certainly injured by it. I have repeatedly had the joy of seeing children with croup become less cyanotic after their removal from an atmosphere of vapor, and I can readily see that pure atmospheric air would be more agreeable and wholesome to a child with stenosis of the larynx than an atmosphere laden with steam. Of course this remark does not apply to cases of pseudo-croup and bronchitis, which are generally benefited by a warm, moist atmosphere. Those, however, who deem it judicious to employ steam as a vehicle for carbolic acid, salicylic acid, chloride of sodium, chlorate of potassium, or lime, had best resort to the atomizer for applying these remedies. It can be used without trouble; most children are sufficiently intelligent to allow the spray to be directed upon the fauces and larynx every ten or fifteen minutes in case of necessity. When it is deemed advisable to administer steam, I warn against the use of gas stoves. They require a great deal more oxygen than an alcohol lamp, which ought to be preferred when a stove or slaking lime or hot iron or bricks immersed in water are not available.