A treatise on diphtheria

Front matter

By .Dr. H. Bourges,

UNITED STATES OF AMERICA.

SPECIAL NOTE.

Table Of Contents

Page

Translator's Preface i-xxii

Author's Preface i- 2

II

At the meeting of the Soci^te de Medecine Pratique, January 3, 1889, when the paper of Dubousquet was read, commending the method of cauterizations advocated by Gaucher, Guelpa (who made considerable stir in the Society discussions of diphtheria) demanded if the good results which had been claimed for this method might not have been due largely, if not altogether, to the frequent irrigations which formed a part of the treatment. The majority present at this and subsequent meetings were understood to deprecate all use of strong caustics, as well as the forcible removal of the false membranes.

At another meeting, held April 4th, and at a subsequent meeting of the Therapeutical Society, Guelpa read a long paper in answer to the question, " Why, in the treatment of diphtheria, do the same medicaments give satisfactory results to some practitioners and negative results to others ? "

He criticised the numerous remedies which have been advised in this disease. Some, as resorcin, have been extolled as almost specific. This medicament, so successful in the hands of Callias, saving nearly all his patients, has not proved efficacious in the practice of Cadet de Gassicourt, who has used it in all degrees of saturation.

Phenic acid has been highly commended by excellent authorities, notably Kempster, Jacobi, Oertel, Billington, Smith, and Mackenzie, but others have not found its effects especially favorable. The same judgment may be passed upon caustic soda and glycerin, lime-water, lemon-juice, boric acid, tannin, iodoform, and even perchloride of iron.

While recognizing the fact that there is a difference in the malignancy of epidemics, and that remedies act differently at different periods of the same epidemic, the writer, nevertheless, felt compelled to conclude that the same medicament in the hands of certain practitioners had given favorable results, while it had failed completely with others. The cause, he believed, he had found. We quote his words:

" M. Callias, repeating the trials with resorcin made by Andeer, Leblond, and Joja, is careful to tell us that he mops out the throat every hour, night and day, with a 5-per-cent. solution. To this he adds spraying the buccal and nasal cavities with a 2 per-cent, solution every two or three hours, and fumigations, twice or three times a day, with resorcin in

substance, sublimated by a moderate heat

Note the fact that the throat is swabbed out every

hour tiight and day With regard to phenic

acid, M. Roulin tells us that he employs his carbolic irrigations every hour in the twenty-four, and claims extraordinary success. Kempster and Rothe paint the throat every hour with a strong carbolic mixture, and use every half-hour a weaker preparation for a gargle. Giovanni Calligari applies every quarter of an hour to the diseased places a i-per-cent. carbolic solution. Jacobi sprays and irrigates very frequently with carbolic solutions. Oertel declares that phenic acid constitutes the best and surest means at our disposal for combating diphtheria. But this medicament should be employed with energy. The practitioner should spray every two hours, every hour, or oftener, according to the age of the patient, with a 5- per-cent. solution. The atomizing tube should be made to enter the patient's mouth. All practitioners have obtained excellent results from this frequent use of the carbolic preparations. Oertel, in fifty-one cases, did not lose a patient.

"If we come to the employment of perchloride of iron in diphtheria, we have still less difficulty in establishing the fact that the disease is the more surely and rapidly overcome the more frequently and thoroughly the part which is the seat of the disease is medicated with the solution employed. Thus, we see the Aubruns, father and son, administer to their diphtheritic patients a spoonful of a 4-per-cent. solution every five minutes during the day, and every quarter of an hour at night. Jacobi advises to give the solution of perchloride ot iron every quarter of an hour, or every hour, according to the gravity of the disease. Colson, Clar, Noury also administered this medicament about every half- hour, day and nighty

It will be seen from the above extract that, in the estimation of the writer, it is the frequency and thoroughness with which the applications are made that are the principal elements of success. Firmly believing in the local origin of diphtheria, and that if the seat of the disease can be kept antiseptically clean the microbes will be impeded or thwarted in their development, and blood-poisoning and further extension by contiguity of the disease prevented, he advocates irrigations every hour of the nasal cavities (in the event of nasal diphtheria existing) and of the throat with a 5-per-cent. chloride-of-iron solution. For this purpose, a common hand rubber-ball syringe will answer the purpose; the capacity of the rubber ball should be about four ounces. The nozzle, which should be of hard rubber, is inserted successively into each nostril, and the solution injected with sufficient force to penetrate the pharynx. When the irrigation is to be made by mouth, the nozzle can be inserted behind the last molar tooth. Generally there is no great difficulty. The child is held in the lap of the nurse or medical attendant, with the head pressed against the chest of the latter; and the cannula of the syringe is slipped in behind the last molar. Generally at this moment the mouth is opened wide in the struggle, and it is very easy to inject with full stream quite a quantity of the liquid. Part of the liquid is swallowed, but the most of it flows back. For the nasal douches a weaker solution is recommended (3 per 1000).

Guelpa regards these irrigations as of great use " in fortifying the surrounding mucous membrane and in wa-hing away the septic products, whose absorption constitutes the true danger of the disease, and whose accumulation serves to irritate the contiguous mucosa and render it a fit soil for the development of the diphtheritic bacillus." As for parasiticides, there are probably at least a dozen agents, any one of which, if used with sufficient frequency, will almost equally well fulfill the leading indication; phenic acid and perchloride of iron are among the safest; resorcin demands further trials; corrosive sublimate (1 to 5000) would probably be the best if the free use of this bactericide were not attended with some danger. The intent of the irrigations is not to clear the throat or other diseased surface of false membranes; the false membrane, says Guelpa, need give no trouble as long as it remains within certain fixed limits. The true end of treatment is to prevent the pseudo-membrane spreading over too large a surface. If the false membrane is not allowed to extend, if the subjacent tissues are not irritated by the treatment, the diphtheritic patches will become loosened, and fall off in the course of a week; if other patches form in their places, these are always more limited, are thinner, and sooner mature and fall off.

Cousot, of Brussels, in the Journal de Me'decifie et de Chirurgie Pratique, April, 1889, also insists that the treatment of diphtheria at its commencement should be chiefly local; that it should destroy the germs of diphtheria wherever they appear; should entirely prevent putrefaction, and, at a later stage, when systemic infection occurs, local remedies should still be vigorously applied, and additional measures employed to relieve the general symptoms. The medicine for local use which Cousot believes best fulfills these indications is a mixture of acacia, spirits of peppermint, and tannin, employed in the following formula:

Mucilage of acacia, 100 parts.

Tannin, 10 parts.

Spirits of peppermint, 2 to 20 parts.

The syringe is employed for its application, for this alone permits sufficient irrigation and impregnation of the inflamed surfaces. If the false membrane occupies the pharynx, tonsils, or nasal fossae, whatever may be the degree of its development, it is necessary to inject the mucilage and tannin into the mouth and nares every tivo hours. Whatever may be the degree of decomposition of the diphtheritic patch, its putrid odor ceases on the first application, and it contracts and becomes detached. The efficacy of this method seems to be established by abundant statistics.*

Whatever may be said of the efhcacy of irrigations, they are not always easily administered, and the pursuance of this treatment every hour or two day and night is certainly fatiguing to the patient, and must more or less interfere with sleep. To be sure, according to the French authorities most zealous in advocating these injections, in a disease fraught with so much danger as diphtheria, that treatment which will save the most lives should be adopted, no matter how difficult of execution. The question, then, for solution is this: Is the method of frequent irrigation the best method of meeting the indication ? Good authorities have claimed most excellent results from milder measures. Thus a child may be made to frequently swallow a solution of chloride of iron without great difficulty, and this would appear to accomplish the same end as the forcible injection of the same fluid. Sprays containing carbolic acid can be used alternately with the mixture, and port wine (which contains tannin and alcohol) can be administered freely in the interval. An occasional irrigation, or even mopping out the throat, may be practiced, the swabbing being done with due gentleness, so as not to cause lesions or excoriations, to be new centres of infection.

These are the principles of treatment advocated by numerous American authorities, as J. Lewis Smith, Abram Jacobi, C. E. Billington. Smith and Billington make much account of the frequent administration of tincture of chloride of iron. The following is a favorite prescription of the latter:

B Tinct. ferri chloridi, 3 iss.

Glycerin, ) f - .

Water, f aat 3J-

M. Sig. : A teaspoonful every hour.

Smith gives about the same quantity of iron hourly, combined with four grains of potassium chlorate; the vehicle is simple syrup. Both deprecate forcible removal of the pseudo-membranes and all energetic topical applications by sponge or probang. Besides the hourly dose of chloride of iron, Billington gives every hour a teaspoonful of a mixture of lime-water and glycerin, in which a little chlorate of potassium is dissolved. Both make much account of spraying with the hand atomizer, and prescribe solutions of carbolic acid and lime-water for that purpose. A favorite combination of Billington's is the following:

~R, Acid, carbolic, TT[xv.

M. Sig: To be applied to the throat very frequently in the form of spray.

In nasal diphtheria, the nares should be syringed out two or three times a day with salt and water, then with a mixture of salicylic acid, ten grains, with thirty of sulphate of sodium, to glycerin half a fluidounce, and water two and a half fluidounces. For this injection, a hard rubber ear-syringe may be employed.

In adult patients, with particularly unyielding diphtheritic patches, once or twice a day a mixture of tincture of chloride of iron two parts, glycerin one part, may be carefully applied to the surface of the membrane with the tip of a camel-hair pencil. It seems, says Billington, to shrivel up the membrane and hasten its disintegration. But strong applications should never be "mopped" over the inflamed throat, and it is not thought safe, as a rule, ever to apply a brush to a child's throat.

III

Fresh evidence has been steadily accumulating to prove the invariable causal connection between Loeffler's bacillus and ordinary diphtheria, and Prudden has recently made an important communication in which he concedes to this microbe the primary role in the etiology of this disease {Medical Record, No. 1067). Dr. Welch, of the Johns Hopkins University, has published the results of his and Dr. Abbot's studies at the Johns Hopkins Hospital, and these add striking confirmation to the data on which has been founded the doctrine of the primarily local origin and development of the infection — a doctrine which, we observe, has been lately conceded by Cadet de Gassicourt, though opposed in the first edition of his masterly work, " Lecons Cliniques sur les Maladies des Enfants" (t. iii, 1884).

"Of capital importance," says Professor Welch, "is the establishment of the fact that the diphtheritic bacillus develops only locally at the site of infection, and does not invade the tissues or the circulation. It is found only in the diphtheritic pseudo-membrane, and not even in the subjacent mucous membrane. Indeed, it is only the superficial parts of the false membranes which contain the bacilli. The determination of this fact gives at once a clear and decisive answer to the long-mooted question as to the primarily local or constitutional nature of diphtheria. The germ which causes this disease not only makes its first appearance and multiplies where the pseudo-membrane is formed, but it does not even subsequently invade the blood and organs. As we shall see later, the constitutional symptoms are due to the reception of a chemical substance or substances of remarkable toxic properties produced by the local development of the diphtheritic bacillus."*

We are, then, again brought around to the primary indication of treatment, made more and more certain and imperative as researches accumulate: to destroy the contagium in situ before the microbes have had time to elaborate their poisons and infect the organism.

It would seem that diphtheria primarily occurring on any accessible cutaneous surface might always be readily arrested by deep, thorough cauterization. Such cases are, however, very rare, and, when they occur, generally follow inoculation of a wound. The primary lesion is too often on mucous surfaces, which, like the posterior nares and the larynx, are not easily amenable to thorough topical treatment.

What shall be the treatment of the toxaemia resulting from absorption of the poisonous principles produced by the bacilli ? Every physician is familiar with the change which often takes place at a variable time — two, three, or four days — after the first appearance of the patches; the sthenic symptoms, on which hope was based, give way to symptoms of prostration, and the system seems overwhelmed by a paralyzing poison.

Ignorant of the proper antidotes of this poison, if such exist, we can only combat it on general principles, by stimulants and tonics. The internal employment of corrosive sublimate in frequent doses of jfar to \ g ra ^ n » or °f calomel (^ to i grain every hour), is no longer justified on the ground of a microbicidal

* 'Medical Xctvs, May 16, 1S91, p. 559.

action exercised by these drugs, for the constitutional symptoms are not due to microbes, but to their soluble products, and there is no evidence that mercurials destroy these products in the blood.

The same judgment must be passed upon the sulphites and hyposulphites, counseled by Giacchi and Polli, in Italy, phenic and salicylic acids, vaunted by Besnier in France and Foutheim in Germany, and benzoate of sodium, recommended by Helferich, Sanne, Love, and others.

If the internal use of corrosive sublimate has been attended with good results, these might very properly be attributed to the topical action of the mercurial while passing over the mucous membranes in the act of deglutition, and not to any effect on the blood. Per contra, there is reason to believe that the tinctura ferri chloridi, one of the best topical remedies, may exercise beneficial constitutional effects. Recent investigations (as those of Ferguson) have shown that the diphtheritic poison rapidly spoils the blood-corpuscles; there are still lacking observations which directly show that tincture of iron retards this disintegration, although good authorities, basing themselves on large clinical experience, believe that this preparation, freely and continually administered, does have this power. Dr. Whittier believes that this medicine, given so as to saturate the system, is the best that can be employed. Baruch prescribes hourly doses, in quantity varying from eight to twenty-five drops, mixed with glycerin and water. Food and stimulants are administered before the iron, but not immediately afterwards, so that the iron may first have a local effect on the fauces.

" That now, after thirty years' constant use of the tincture of chloride of iron in both hemispheres, there is an almost unanimous verdict in its favor, renders it probable that the few who have not observed good effects have treated unusually bad cases, or have given the medicine in small and inadequate doses." (Dr. J. Lewis Smith.)

The employment of pilocarpine (either by potion or by subcutaneous injection), first recommended by Guttman, has gone out of use. Archambault, Schmidt, Alfoldi, Jacobi, and J. Lewis Smith have pointed out the dangers of this treatment. Sudden filling up of the bronchial tubes with secretion, and heart-failure, have not unfrequently followed its use.

Quinine has been much prescribed in diphtheria, and when given in sufficient doses doubtless does have some tonic effect; it is, however, depressing in large doses, and, on account of its bitterness, is always repugnant to children. " It does not," says Smith, "seem to exert any decided action upon the local affections or blood-poisoning in diphtheria."

The same judgment may be passed on the internal administration of chlorate of potassium, a remedy, doubtless, too much administered, being of no specific value, and being toxic in large doses.

Alcoholic stimulants have an important place in the therapy of diphtheria, and many authorities, as Jacobi, recommend quantities that in health would be toxic. J. Lewis Smith does not hesitate to give a teaspoonful of good brandy or whiskey hourly to a child of five years, and Jacobi states that he has often seen children get well with ten ounces a day who were doing badly with three or four. Cadet de Gassicourt (" Traite" Clinique," etc., t. iii) would give to a young infant from half an ounce to two ounces of old rum or brandy per day.

Caffeine, camphor, strychnine, and Siberian musk have been recommended to counteract depression and heart-failure. Jacobi believes musk to be the best stimulant in urgent cases of heart-failure. '• If," he says, " ten to fifteen grains, given [in thin mucilage] within three or four hours to a child of one or two years, do not restore a healthy heart action, the prognosis is bad."

Zannelis {Bull, et M/m. de la Soc. de Me'd. Pratique, 1889) speaks favorably of strong infusions of tea or coffee in adynamic stages. Nourishment should be for the most part liquid, for obvious reasons; the digestive functions are depressed, and the frequent ingestion of medicine and alcoholic stimulants more or less interferes with the secretion of gastric juice and the formation of peptones; the mechanical obstacles to deglutition are frequently considerable, and anorexia is generally a marked symptom in the toxic stage. Hence milk, beef-juice, liquid peptones, raw eggs beaten up in milk, given in such quantities as can be tolerated and not too often to interfere with the administration of antiseptic medicines and of alcoholic stimulants, are especially ind cated.

In concluding this rather long therapeutic re'sumi, I would repeat that physicians are likely to profit more and more from the exact knowledge which we are acquiring of the nature of diphtheria. h\\ pathies must sink into insignificance before scientific medicine, and the Bacterial Pathology is giving us a scientific basis for therapeutics.

The importance of the new etiology has justified a restatement of the whole subject, and therefore the present treatise by a well known French pathologist and master of bacteriology will be welcome in an American dress.

E. P. HURD, M.D.