Diphtheria.

One of the most frequent and important affections, next to
the essential fevers, is diphtheria. This disease prevails often as
an epidemic, and in the intervals between these epidemics is always
more or less prevalent. Unlike many of the infectious diseases, it
seems to be independent of ordinary hygienic regulations—attacks
all classes of the community, and at all times of the year. It is
supposed that Washington and the Empress Josephine were among
its victims during epidemics.

While the disease thus may occur quite unexpectedly, yet it is
equally certain that a large number, if not the majority, of cases des­
ignated diphtheria by some physicians, as well as the non-profes­
sional, have no right whatsoever to that name. For diphtheria is a
general, a constitutional affection, usually manifesting itself, it is
true, by inflammation in the throat, among other symptoms, but by
no means comprised in a local inflammation, whether in the throat
or elsewhere. The numerous cases in which the throat is red and
sore, and perhaps a few whitish points are visible on the tonsils-
such cases are not necessarily diphtheria, and in fact have rarely any
of the characteristic signs of diphtheria. There may be, it is true,
mild cases of the disease, in which the constitutional symptoms are
not sufficiently severe to invalid the patient completely ; yet in most
instances, even when the local disturbances in the throat are not
severe, the patient is nevertheless unquestionably ill.

’ Symptoms.—The symptoms of diphtheria, while agreeing in
most essentials, present wide diversities in the degree of those feat­
ures. One of these differences occurs in the development of the
disease. Sometimes the onset is very rapid and acute ; the patient
suffers a severe chill, followed at once by a high fever. In other
cases, again, the commencement is gradual and insidious ; the pa­
tient complains for some days or a week of vague and indefinite
illness, perhaps even without alluding to any unusual soreness in the
throat. It may even happen that the discovery of the throat affec­
tion is made accidentally, especially in the case of children. The
consideration of the symptoms may be, for convenience, divided into
those which affect the system generally, and those which are asso
ciated immediately with the inflammation in the throat.

The sensibility of the throat would seem to be somewhat dim­
inished in this disease, since there is rarely so much pain and sore­
ness as would seem inseparable from the extreme swelling and
inflammation that are seen actually to exist. A point which should
never be forgotten in household practice is to inspect the throat
whenever an individual is suffering from any indefinite ailment; if
this were a more general practice, mothers would often be spared
the surprise and chagrin which occurs when, upon the first visit of
the physician, he discovers in the throat of the child, who may
have been ill several days, a thick, white coating of diphtheritic
membrane. The act of swallowing is sometimes accompanied with
considerable pain, but not necessarily so, even though the throat
be considerably inflamed. Another symptom which may be pres­
ent early in the disease is a paralysis of certain muscles concerned
in swallowing, so that this act is but imperfectly performed ; as a
result fluids return through the nostrils. In these cases there may
also be an acrid discharge from the nose, causing soreness of the
adjacent parts of the skin. Then, again, the simple mechanical
effect of the swelling in the throat may interfere seriously with
swallowing, and even breathing.

Although the local affection is usually manifested first, and
chiefly in the throat, yet it is not necessarily limited to this part of
the body, but may extend also into the larynx. Under these cir­
cumstances, the symptoms of true croup are added to those of
diphtheria. Weakness of the voice, a peculiar character of the
tone, difficult, labored and audible respiration, with the character­
istic “ croupy “ cough, mark the spread of the disease to the larynx.
This, however, is not an extremely common complication; many
symptoms indicating difficult respiration may be caused by the
swelling in the throat, without any interference with the larynx.
For diphtheria proper is entirely distinct from croup in the location
of the throat inflammation, as well as in its essential nature.
As has been said, there are mild cases in which the patient is
scarcely compelled to take his bed ; yet the gravity of the case is
not always indicated by its severity at the outset. There is not
usually so high a grade of fever as characterizes scarlet fever ; at
times, indeed, the skin seems only naturally warm to the hand.
An occasional symptom is the rupture of small blood vessels, caus­
ing reddish spots on the skin ; a similar rupture in the vessels of
the nose accounts for the bleeding from the nostrils which is some­
times observed. There is no skin eruption characteristic of diph­
theria, although various forms of rash not infrequently occur during
the course of the disease.

The digestion is quite deranged, even before the swelling of the
throat makes swallowing difficult. This derangement of digestion
is indicated, as in other constitutional diseases, by loss of appetite,
coating of the tongue, often vomiting. This is a symptom of con­
siderable practical importance and gravity, for it interferes seriously
with the success of efforts for sustaining the patient’s strength, and
in probably no other disease is his strength so soon exhausted as in
diphtheria. The mind is not usually affected unless the case termi­
nate fatally. In children, it is true, convulsions occur, as they may
from other causes, even when slight. Dropsy, so frequent in scar­
latina, is an unusual symptom of diphtheria.

The disease may last one to two weeks, before the patient
begins to convalesce. Fatal cases may, of course, terminate much
sooner. There is a malignant form of diphtheria which, like
malignant scarlet fever, may destroy the patient’s life before the
characteristic symptoms of the disease are manifested. Yet diph­
theria is by no means over when the patient begins to convalesce,
since some of the numerous complications may seriously impair his
health for months subsequently.

Perhaps no other of the infectious diseases brings in its train
such a number and variety of complications as diphtheria. First
of all is the paralysis of the muscles concerned in swallowing and
in articulation. These muscles may not be affected until the severer
symptoms of the disease have subsided; and they may recover their
power within a few weeks; so long as the difficulty endures, there
will be difficulty in swallowing; and fatal accidents have been known
to occur from this very cause—the food passing into the windpipe
and causing strangulation. Sometimes it is even necessary to feed
the patient through a stomach-tube. The paralysis may also affect
other muscles than those engaged in swallowing; the muscles of the
eye are occasionally affected, the iris being paralyzed so as to keep
the pupils dilated. The result is that the patient is unable to read
ordinary print, becomes, in fact, far-sighted; then again the arms or
legs—often the latter—may exhibit partial or complete paralysis.
There may be impairment of sensation also, as well as of motion;
that is the power of feeling may be partly or completely lost. This
loss is usually limited to a portion of the face; or there may be loss
of power to perceive light; there may be also a change in direction
of one or both eyes—the individual is, in other words, cross-eyed.
So, too, the muscles concerned in breathing may become paralyzed,
giving rise to difficulty in the performance of this act, and even
causing danger from the failure to breathe. There may be also
impairment of the muscles concerned in the evacuation of the
bowels and bladder; also impairment of sexual power and instinct.
The characteristic feature of diphtheria, by which alone we are
enabled to express a positive opinion as to its nature, is the pe­
culiarity of the local inflammation; this, it is true, is usually found in
the throat, but not necessarily so, since we recognize as diphtheria
cases in which the same local inflammation is found on other mucous
membranes, those of the intestine and of the female genital organs
especially. As seen in the throat, the first appearance is usually
redness accompanied by swelling of the tonsils; the surface of
these is soon covered with a thin grayish substance, which, in the
course of a day or two, is much increased in thickness and becomes
white or ash-colored. This substance—the diphtheritic membrane
—varies much in its extent and location. In bad cases it forms an
almost unbroken sheet over the tonsils and perhaps on the back of
the throat as well; but in most instances it appears merely in small
patches scattered over the tonsils and back part of the mouth and
pharynx. The gray membrane is surrounded by an intensely red
area. When these gray patches are detached there appears to be a
bright red surface with numerous bleeding points. Furthermore,
the detachment of one layer may be followed by the formation of a
second and even of a third membrane on the same spot. In this
characteristic—the bleeding surface upon gentle removal of the
membrane—is found one of the characteristics of the diphtheritic
as distinguished from other gray patches in the throat. It is no
uncommon thing to find, even in healthy throats, and especially in
those subject to a little catarrh, grayish white spots, particularly on
the surface of the tonsils. These should not be mistaken for diph­
theritic membrane; they are not surrounded by the intensely red
area, they do not cling to the surface with the same tenacity, nor
do they leave when detached a bleeding surface. These are the
cases which are so often miscalled diphtheria.

The true diphtheria is usually accompanied by swelling of the
glands at the angle of the jaw; this swelling may subside with the
affection in the throat, or may result in the formation of abscesses.

Cause.—Like the other infectious diseases, diphtheria is due to
a specific virus or poison; that it is eminently communicable, admits
of no doubt, though it seems, with our present knowledge, that it
may also originate without previous exposure of the individual to a
patient suffering from the disease. The malignant form of diphtheria
occurs especially as an epidemic. It is an interesting fact, that these
epidemics were unknown in America between 1771 and 1856, while
since this latter date they have frequently visited all parts of our land.
Such an epidemic is often restricted to a particular section of country;
it may even prevail on one bank of a stream, while the other side
escapes unvisited. The greatest susceptibility to the disease appears
to be childhood, between three and twelve years especially; yet
people of all ages are susceptible to a greater or less extent.
The chances for recovery from diphtheria vary extremely with
many circumstances. The scattered, so-called sporadic, cases are
attended with far less mortality than the average epidemic. One of
the dangers is from an extension of the inflammation to the larynx;
such cases usually terminate fatally. A second peril is from exhaus­
tion ; in some instances, as has been already narrated, death occurs
within a day or two, before the local effects of the disease have been
manifested in the throat. Such cases evidently die overwhelmed
with the violence of the poison; and many other instances occur in
which the patient, though resisting for days the onset of the disease,
finally succumbs before the condition of his throat is such as to im­
peril life. A third danger is one which cannot be foreseen, and
scarcely explained, that is sudden fainting, from which the patient
cannot be aroused ; this has repeatedly occurred in individuals who
were apparently convalescent, but who, upon some unusual effort,
even getting out of bed, have swooned and died. In view of this
fact, it is important to use especial care during the convalescence
from diphtheria, particularly in those who have suffered from severe
attacks. If death occurs from simple exhaustion, it is apt to happen
during the second week of the disease.

Treatment.—The treatment of diphtheria resolves itself into
two chief aims: general treatment, that is the support of the
patient’s strength; and local measures, to subdue and restrain the
inflammation in the throat. For this latter purpose, measures vary
according to the severity of the inflammation and to the effect upon
the throat. It will rarely be advisable to use strong caustics; in
most cases a gargle of some antiseptic properties will best answer
the purpose.

 One of the best of them is the following :
Hyposulphite of soda,         -        -         Three ounces.
Glycerine,           -                                     Two ounces.
Water, -                                              Six ounces.

Half an ounce of this solution may be placed in a glass of water
and used as a gargle at short intervals. If the patient be a child
too young to gargle, this solution may be applied directly to the
throat by means of a camel’s hair brush. Much comfort and benefit
will also be derived from permitting the patient to hold pieces of
ice in the mouth until dissolved. Instead of the above solution,
the familiar mixture of muriatic acid and honey in equal parts;
lime water; carbolic acid (one part to twenty of water), may all
be employed. If there be much difficulty in breathing, relief will
be obtained by saturating the atmosphere of the room with steam;
or a tent may be made out of a sheet and placed around the bed;
a kettle of boiling water may be made to discharge its steam into
this tent, and thus accomplish the desired object. Cloths wrung
out in hot water may also be applied to the neck.

Yet the greater reliance must be placed upon the constitutional
treatment, for which alcohol in some form is absolutely indispens­
able. There is but little danger of intoxicating the patient. Half
an ounce of brandy may be given every hour to a patient twelve or
thirteen years old, with the best results, if the case be one of
extreme exhaustion. Another important agent is quinine, a grain
of which may be administered in the whisky or brandy every hour
or two during the day. If the patient be very young, say three
or four years old, half a teaspoonful of brandy and a quarter of a
grain of quinine would be a sufficient dose. Sometimes consider­
able difficulty is experienced in persuading the patient to take
nourishment. The danger from this must be recognized and neces­
sary measures employed to meet the requirements of the case.

In cases where the larynx is obstructed by the formation of
false membrane, the outlook is extremely serious; yet, even in
these, it is sometimes possible to save the life apparently lost, by
making an opening into the windpipe-—an operation technically
called tracheotomy—whereby the imminent danger, suffocation, is
averted.        This fact is mentioned here, not because the operation
should ever be undertaken by other than a skillful surgeon, but
simply to emphasize the value of tracheotomy in proper cases. There
are, it is true, instances in which the patient must eventually die of
exhaustion, and the result could not be averted by the simple ad­
mission of air to the lungs. Yet it is equally true that there are
many instances where death occurs from suffocation, and in which
a timely performance of tracheotomy would undoubtedly have
saved life, as it has done in numerous other instances. The diffi­
culty lies in the fact that parents obstinately refuse to listen to any
suggestion for the use of the knife until it becomes evident that the
child must die, and then the operation is, of course, too late; and
there is no doubt that the responsibility for many a child’s death
rests upon the unreasoning dread and prejudice of the parent against
an operation.

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