Part 114

Water may be made serviceable in different ways. Its effect on the skin, when taken in large quantities, under normal or abnormal circumstances, is a matter of daily experience. Copious perspiration is its immediate result. The very same effect is produced on the mucous membranes. In diphtheria, besides professional hydropathists, I know of but one who favors the plentiful use of water, 100-200 grammes (3-6 ounces) every hour or oftener, either by itself or mixed with an alcoholic beverage.

Severe inflammatory symptoms, such as redness of the throat, great pain, swelling of the glands, require cold applications, either an ice-bag or ice-cold cloths well pressed out and frequently changed. They must, however, be placed where they can do most good--in laryngeal diphtheria around the neck, in pharyngeal diphtheria with glandular swelling over the affected part. In the latter, therefore, the flannel cloth which covers the whole of the application must be tied over the head, and not behind. When ice-bags are used, care is to be taken lest they should be too large; if so, they will not affect the desired spot at all. Small pieces of ice frequently swallowed are greatly relished by the patient; water-ices in small quantities will render the same service; ice-cream, in half-teaspoon or teaspoon doses every five or ten minutes, adds to the necessary nutriment. When the fever is high and the surface hot, sponging with tepid or cold water, or water and alcohol, will mitigate both. For the cold bath or the cold partial pack (trunk and upper part of the thighs) the general indications hold good. As a rule, I favor the latter, for many cases have such a tendency to debility and collapse that sometimes the circulation of the surface of the body is badly interfered with by cold bathing. Therefore, a contraindication to cold bathing must be found at once in cold feet, either before or after a bath. When, unfortunately, the feet do not recover their normal temperature in a very short time, they ought to be warmed artificially, and the cold bath not repeated. In such cases the cold pack, however, is still indicated. A linen or cotton cloth, {703} large enough to cover the trunk and half of the thighs, is dipped in cold water, well pressed out, and the body of the patient wrapped tightly in it. The arms remain outside; the whole body is then wrapped up in a blanket; the feet may be warmed meanwhile when necessary, and the cold pack repeated as often as required to reduce the temperature--viz. once every five minutes, every half hour, every hour.

The contraindications to the use of cold have in part been alluded to. Very young infants bear it but to a limited extent. The beginning of recovery contraindicates it, unless for some local cause; for instance, an inflamed gland. The extensive use of cold water or ice is also forbidden when there is no fever, where there is perhaps an abnormally low temperature, where we have to deal with the septic or gangrenous form of diphtheria, where the vitality is low and the mucous membranes pale or even cyanotic. In such cases, on the contrary, while unlimited internal stimulation is required, the hot bath, or hot pack and hot injections into the bowel, will be found beneficial.

Lime-water, glycerine, lactic acid, pepsin, neurin, papayotin, chinolin, and pilocarpine are all solvents of pseudo-membrane, but whether there is sufficient time and opportunity to produce a curative effect by every one of them is a question open for discussion. Of lime-water and glycerine I have employed a mixture of equal parts in considerably more than a hundred cases after the completion of tracheotomy, directing the remedy through an atomizer into and below the canula, but cannot say that the descent of the membrane into the trachea or bronchi was prevented by it. Lime-water may be used in the nose and throat as an injection, spray, or gargle, but its solvent effect is greatly diminished by the action of the carbonic acid of the breath on the lime. I have no doubt that if water alone was used with the same persistence as lime-water, its effects would be nearly the same. Still, what little effect the minute dose of lime (1:800) in the lime-water may have may just as well be utilized. What I object to is the omission of more powerful agents. If lime is to be used, slaking lime frequently in the presence of the patient is attended with vastly more benefit, inasmuch as by that proceeding a large amount of powdered lime is projected into the air of the room and the mouth and respiratory organs.

Lactic acid also, in from ten to twenty-five parts of water, has yielded no better results in my hands. Those cases of tracheotomy which I afterward treated with lactic acid spray terminated no better than such as were treated with lime-water and glycerine. Of the solvent effect of pepsin I have not been able to convince myself so as to recommend it. The accounts of neurin have not encouraged me to try it at all. Chinolin (tartrate) has been used locally by O. Seifert, Müller, and others. It is said to remove the membranes and relieve the fever. For a gargle it is dissolved in five hundred parts of water, or it is mixed with ten parts of water and alcohol each, and applied by means of a sponge. To relieve the burning sensation ice is swallowed afterward. The local applications of alcohol have the same drawback. There are but few patients who do not suffer intensely from its local contact.

Papayotin has been recommended by Rossbach for the purpose of dissolving membranes in a one-half per cent. solution. It peptonizes {704} albuminoids, and macerates meat, intestinal worms, and croup membranes in both neutral and feebly alkaline solution. In concentrated solutions it has a caustic effect. It is recommended, not as an anti-diphtheritic, but merely as a solvent remedy. Whatever reliance may have been placed upon it has, however, been jeopardized by Rossbach's remarks on the variability of the preparations in the market. Not only are the specimens very unequal, but each of them is variable, easily spoiled, and particularly affected by moisture.

Muriate of pilocarpine was recommended for this purpose three years ago. It was praised by Juttmann as a specific, and has failed. The quackish recommendations of the drug have, indeed, earned for it a certain amount of distrust which it does not deserve in all cases. It is expected to increase the secretion of the mucous membranes to such an extent as to float the pseudo-membranes. It sometimes succeeds in so doing, but only in those cases in which the membrane is deposited upon the mucous membranes. When the tissue is impregnated the drug fails. It also fails in septic cases, and mostly for the reason that it diminishes and paralyzes the heart's action. It ought, therefore, never to be given unaccompanied with large amounts of stimulants. Where the patient is strong, and the heart healthy, it may be tried; I know that a few cases of moderate laryngeal diphtheria improved with pilocarpine, steam, and turpentine inhalations. The dose is 1/30 grain, dissolved in water, every hour.

Turpentine inhalations were recommended by C. Edel. Fifteen drops of oil of turpentine are inhaled from a common inhalation apparatus, which is placed at a distance of three inches from the mouth of the patient, for a period of ten minutes every hour. He claims recoveries in from twelve to forty-eight hours. I allow the patient to remain in his bed, and keep water boiling constantly on an alcohol lamp, on the stove, or over the gas. A tablespoonful of turpentine, more or less, is poured on the water, care being taken that nothing is spilled in the fire. Thus the room is constantly filled with a penetrating odor of turpentine, which is not at all disagreeable, even when in great concentration. The effects are very satisfactory indeed. Where circumstances allowed or required it I have raised a tent over the bed, large enough not to give inconvenience to the patient and to admit either the whole apparatus or the tube containing the mixed vapor of water and turpentine.

Ammonium chloride may sometimes be used to advantage for its softening and liquefying effects. Its internal administration in bronchial and tracheo-laryngeal catarrh is so old that it has several times been obsolete. Of late, more stimulant effects have been attributed to it than it actually possesses. But its liquefying action, in cases where the secretion of mucus is defective and expectoration scanty and viscid, is undoubted. Thus it proves valuable in many cases of simple catarrh, both when administered internally and inhaled. The latter mode I have often resorted to, and believe that its macerating influence has been of service to me in cases of laryngeal diphtheria. Half a teaspoonful of the pure salt is spread on the stove or burned over alcohol {705} or gas. It evaporates immediately, and fills the room or the tent with a white cloud, which, when dense, excites coughing. But it does not irritate to any uncomfortable degree, and the process may be repeated in an interval of an hour or more.

Not all cases of diphtheria are septic or gangrenous, nor are all the cases occurring during an epidemic of the same type. Some have the well-pronounced character of a local disease, either on the tonsils or in the larynx. The cases of sporadic croup met with in the intervals between epidemics present few constitutional symptoms, and assume more the nature of an active inflammatory disease--very much like the sporadic cases of fibrinous tracheo-bronchitis. These are the cases in which mercury deserves to have friends, apologists, and even eulogists. Calomel, 0.5-0.75 gramme (gr. viij-xij), divided into thirty or forty doses, of which one is taken every half hour, is apt to produce a constitutional effect very soon. Such doses, with minute doses, a milligramme or more (gr. 1/60), of tartar emetic, or ten or twenty times that amount of oxysulphuret of antimony, have served me well in fibrinous tracheo-bronchitis. But the mucous membrane of the trachea and bronchi is more apt to submit to such liquefying and macerating treatment than the vocal cords. The latter have no muciparous glands like the former, in which they are very copious. And while the tracheal membrane, even though recent, is apt to be thrown out of a tracheal incision at once, the pseudo-membrane of the vocal cords takes from six days to sixteen or more for complete removal. Still, a certain effect may even here be accomplished, for maceration does not depend only on the local secretion of the muciparous glands, but on the total secretion of the surface, which will be in constant contact with the whole respiratory tract. Thus, either on theoretical principles or on the ground of actual experience, men of learning and judgment have used mercury in such cases as I detailed above, with a certain confidence.

If ever mercury is expected to do any good in cases of suffocation by membrane, it must be made to act promptly. That is what the blue ointment does not. In its place I recommend the oleate, of which ten or twelve drops may be rubbed into the skin along the inside of the forearms or thighs (or anywhere when their surface becomes irritated) every hour or two hours. Or broken doses will be useful, such as given above, or hypodermic injections of corrosive sublimate in 1/2 or 1 per cent. solution in distilled water, four or five drops from four to six times a day, or more, either by itself or in combination with the extensive use of the oleate, or with calomel internally. Lately, the cyanide of mercury has been recommended very strongly. I hardly believe that it will work more wonders than any other equally soluble preparation. Within the past few years the internal administration of bichloride of mercury has been resorted to more frequently and with greater success than ever before. My own recent experience with it has been encouraging, and so has that of some of my friends. Wm. Pepper gave 1/32 grain of corrosive sublimate every two hours in a bad form of diphtheritic croup, with favorable result. But in this very bad case, desperate though it was--child of five years, resp. 70, pulse 160--large membranes, "evidently from the larynx," had been expelled before the treatment was commenced on the {706} seventh day of the disease. The remedy ought to be given in solution of 1:5000, and in good doses. A baby a year old may take one-half grain every day for many days in succession, with very little if any intestinal disorder and with no stomatitis. A solution of the corrosive chloride of mercury in water is frequently employed of late as a disinfectant. It acts as such in a dilution of 1:20,000. As healthy mucous membranes bear quite well a proportion of 1:2000-3000, any strength between these extremes maybe utilized. A grain of the sublimate in a pint or more of water, with a drachm of table-salt, will be found both mild and efficient. As a gargle or nasal injection it will be found equally good. But it has appeared to me that frequent applications give rise to a copious mucous discharge; hourly injections into a diphtheritic vagina became quite obnoxious by such over-secretion, which ceased at once when the injections were discontinued. Thus, when it is desirable not only to disinfect but also to cleanse the diseased surface, the injections with corrosive sublimate appear to yield a result inferior to less irritating applications.

Chloride of iron is undoubtedly a valuable remedy in diphtheria, but in its administration it must by no means be forgotten that small doses at long intervals are out of the question. I have not the least doubt but that the failure of the remedy may be attributed in most cases to the fact that the doses were too small and administered too seldom. A dose of from five to fifteen drops, properly diluted, every fifteen minutes, half hour, or hour is indispensable for a proper estimation of its effects. Gargles are not of much service, for the simple reason that they do not come into sufficient contact with the affected parts, and reach at the utmost to the anterior pillars of the soft palate. A direct application of the remedy to the mucous membrane of the pharynx may also be desisted from, thereby avoiding any irritation, the internal administration at short intervals causing the pharynx to be sufficiently influenced by local contact with the remedy. It must, of course, not be expected that the chloride will remove the membrane, but it can frequently be seen to reduce the hyperæmia and swelling and prevent the reproduction of exuded material. The chloride of iron exerts a decided influence on the vital contractility of the blood-vessels. This increased contractility certainly assists in diminishing the rapidity of absorption of putrid fluids through the blood-vessels, which constitutes the principal source of danger from the disease.

It cannot yet be positively asserted that the chloride of iron exerts a direct effect on the lymphatic vessels. Naturally, this was claimed when the remedy was recommended, in the treatment of diphtheria, on account of its therapeutic effects in erysipelas, with the accompanying inflammation of the lymphatic vessels of the skin. Although we know of no direct compression of the lymphatic vessels due to the action of the chloride, yet it may be assumed that perhaps the compression of the blood-vessels exerts a similar influence upon the neighboring lymphatics. In consequence of this there would be an impediment to the absorption and further development of poisonous substances in the lymph. The chloride, like the sulphate of iron, is a tolerably powerful disinfecting agent. If this observation be correct, it may go very far toward explaining the action {707} of the chloride of iron in septic diseases, which are accompanied by an exalted activity of the lymphatic vessels and an increase of the white blood-corpuscles. Furthermore, Saase has endeavored to show that the ferrous salts possess the power of converting oxygen into ozone. They share this power with the blood-globules exclusively, and could hence, to a certain degree, supply a deficiency of the latter. Pokrowsky, too, has shown that iron increases the process of oxidation in the body by demonstrating that in health there is an elevation of temperature and an increase of the percentage of urea in the urine during its administration. In anæmic persons, to whom iron has been given for the purpose of increasing the amount of blood, the above phenomena may be observed before this object is accomplished. Thus iron appears to replace the blood-corpuscles to a certain extent. Now, in infectious disorders of the blood, where the red globules are perpetually menaced with destruction, it seems plausible that the preparations of iron should exert an antiseptic action.

Finally, it has been found that of all the preparations of iron the chloride possesses the greatest power of stimulating the nervous system. Possibly this effect may be traced to an increase of the arterial pressure in the nerve-centres. It has been said that this effect has been vividly illustrated in certain forms of chlorosis. If this be true, iron would be all the more indicated in diphtheria, since it would act as a prophylactic against a series of nervous phenomena that so frequently present themselves, both during and subsequently to the diphtheritic process. Thus it is that for many years the muriate of iron has constituted the main element, with me, of internal medication in most cases of diphtheria, both of the mild and the most dangerous septic type. A common formula is, for a child of two years,

Rx. Tinct. Ferri Chloridi fl. drachm ij; Potass. Chlorat. gr. xx; Aquæ fl. oz. v; Glycerin. Pur. fl. oz. j. M.

S. A teaspoonful every fifteen, twenty, or thirty minutes.

Carbolic acid exerts a powerful influence on the vitality of all living elements, and hence also on rapidly proliferating epithelium, which constitutes a part of the diphtheritic membrane. It is of great advantage for local use. Its local effect, undiluted or diluted with equal or larger parts of glycerine or alcohol, in shrinking and removing membranes, is sometimes very useful; in mild solutions in water (1/2, 1, or 2 per cent.) it is very efficient in nasal injections or for external applications or mouth-washes. Rothe's prescription for external use is carbolic acid and alcohol each 2 parts, water 10, tincture of iodine 1. Its internal administration to the extent of five to twenty grains daily, given largely diluted, in small and frequent doses, is of less positive value.

Salicylic acid, in a solution of 1:30-50, is caustic. A milder solution, 1:200-300 relieves or removes foul odor from the nose or throat, but it does not detach membranes or shorten the duration of the disease, apparently. Internally, it acts no longer as a disinfectant, but is changed into a salicylate and is an antipyretic. It is then better to replace it by the sodium salicylate. With its administration (for a child of 2 years 3 grains every hour until 20 or 25 grains are taken) it ought not to be {708} forgotten that serious brain troubles, collapse, and irregular and paralytic breathing, as well as gastric and intestinal disturbances, may follow its use. It ought not to be given without careful watching and the simultaneous free use of alcoholic stimulants.

Binz found, as the result of experiments with solutions of pure quinia varying from one part in a hundred to one in a thousand, that the latter sufficed to prevent the development of bacteria in fluids capable of undergoing putrefaction; but even estimated thus, a patient with eighteen pounds of blood would require one hundred and thirty-eight grains of quinia circulating therein in order to satisfy the conditions of Binz's experiment. If Binz considers two grammes (half a drachm) of quinia per day sufficient for an individual weighing one hundred and twenty pounds, his calculation is founded on experiments with dogs, in which septicæmia was avoided by the injection of quinia. It is also necessary to bear in mind that Binz makes a distinction with regard to the preparations of quinia employed. He warns against the use of the bisulphate as being the most inactive. No matter which preparations are used--I prefer the muriate--I have come to look upon quinia as of no great service in reducing the temperature in infectious fevers. The main indication for its use can only be found in inflammatory fevers. When it is given, however, salicylate of sodium may be added for a short time to obtain a speedier effect.

On the part of bromine Wm. H. Thompson claims the following advantages: 1. When applied locally, it promptly arrests fetor by arresting directly the gangrenous process, and thus lessens risk from absorption. 2. It acts as an anti-putrefactive likewise in the fluids of the body generally--i.e. blood, interstitial circulation, and secretions--owing to its high rate of diffusibility, equal to that of sodium chloride itself. 3. It locally destroys the communicable property of the discharges, shown by the immunity of attendants from any sore throat when it is used, and from its checking the spread of the disease in the locality. He orders two solutions to be used: the first of equal parts of Lawrence Smith's solutio bromini and of glycerine, applied with a hair pencil to the membrane, as gently as possible. Sometimes he uses the solution full strength. The brush should be washed at once in water, and does not last more than one day, owing to the action of the bromine on the hair. If, however, the membrane be very extensive and the parts much swollen or difficult to reach, he resorts instead to douching with a Davidson syringe, using half a drachm to one drachm of the solution to a pint of warm water. By beginning gently with the stream directed against the buccal mucous membrane, the child soon becomes accustomed to the current and allows it then to play against the deeper parts.

Internally he orders from six to twelve drops of the solution in a half ounce of sweetened water, every hour, two, or three hours, according to the urgency of the case, and continuously.

The most convenient way of making Smith's solution is: Take two ounces of a saturated solution of potassium bromide in water; add to this, very slowly, in a bottle and with constant shaking, one ounce of bromine. It is better to add a part, and then let it stand a while before adding the rest; then fill up gradually, and with constant shaking with water, until it measures four ounces.

{709} Ozone has been used as an anti-fermentative in inhalation during three or five minutes every hour or two, by Jochheim.

Boric (boracic) acid, in saturated (1:25) or milder solutions, has some antiseptic effect. It is mild, and not very injurious when swallowed by necessity or mistake. In diphtheritic conjunctivitis it is valued highly, and in nasal injections I have found it very useful. It is less repugnant than most other substances administered in that way.

Sodium benzoate cannot be relied on either as an anti-diphtheritic nor as an anti-febrile. The doses which were recommended were two scruples or a drachm daily for a child a year old.

Sulphur has been used locally. It gives rise to coughing and vomiting.

Cubebs have been given in incredible doses, two drachms of the powder to a child a year old. The drug disorders the stomach and kidneys.

Local Treatment.--The mechanical removal of the membranes is not permissible unless they are almost detached. It is best to avoid their being cast off, unless partly loosened membranes in the larynx or trachea afford an indication for an emetic. Scratching and eroding the mucous membrane of the neighborhood give rise to new deposits. Even after spontaneous elimination of a membrane a new one may be formed within a few hours.