DIPHTHERIA.
By Robert S. Cross, Esq., Petersfield.
Throughout these last eighteen months, this town and neighbourhood have been visited by throat-disease in various forms; considerably above a hundred cases, of a diphtheritic character, having occurred under my observation, varying in character from the mild form, in which small spots of white easily detached lymph or exudation membrane, on more or less enlarged and inflamed tonsils, was the type; little or no constitutional disturbance being present; to the most severe kind, suddenly ushered in by severe symptoms of exhaustive febrile action; the tonsils, uvula, and whole of the parts at the back of the mouth as low down as could be seen, were coated with a dirty white or brown grey, firmly adhering membrane; life being destroyed in a few days, sometimes by extension to parts necessary for respiration, but as often by apparently a state of exhaustion of the system being induced, in which death occurred sometimes very unexpectedly.
Two cases (in one family, of six children, the oldest 11 years, and all of whom, with the exception of the infant, had the disease) were sufficiently remarkable to deserve a separate notice. In two boys, aged respectively 8 and 9, the throat symptoms were very severe from the first. About the fifth day, healing set in; so rapidly, that, by the end of the seventh, a sloughing ulcer which had embraced the whole of the parts at the back of the mouth within the reach of observation, were quite well. One day only of apparently perfect convalescence intervened; and vomiting set in, with pain and tenderness over the epigastrium, extending particularly to the hepatic region. There were constipation; total loss of appetite; prostration; rapid emaciation; thirst; and, in one case, there was intense pain in the head for the last forty-eight hours. One boy died at the end of three weeks of such condition; the other, at the end of ten days.
A very careful post-mortem examination of the last case was made. The tonsils appeared gone— i.e., their site was occupied by some loose irregular granulations, which had the character of remaining, the interstitial structure being absent. There was no extension of the disease into either œsophagus, or larynx and trachea. The lungs were healthy. The liver was enlarged and pale. The stomach contained about half a pint of greenish viscid fluid. The mucous membrane, particularly at the edges of the rugæ, which were very prominent, was of a deep chocolate, almost mahogany colour; the colour was not distributed in patches, although there were degrees of depth of shading, varying from this to deep rose colour and red, but pervading the whole, and extending a long way—l should say, throughout the whole of the small intestines, most intensely in the duodenum. The mucous membrane was softened and thickened, and presented at the two orifices appearance of separation, as though it might readily be detached.
The disease in question has occurred in all situations and among all classes. The mortality has been about ten per cent. of the whole. This ratio, I should remark, includes as well those cases in which application has been made too late to offer any reasonable chance of doing good, as it does those in which everything has been done from the very first moment of attack. As to contagion, I have been unable clearly to trace this cause in more than one case; as in those families where two, three, or more children were the subjects of the disease, the cases have occurred at such intervals as to preclude the idea of such being the exciting cause; and, moreover, often only one has had it, even where the discovery was made too late for any attempt at isolation. One adult has died; and one who had it, had been nursing a child with angina, she herself having been the subject of scarlet fever since adolescence. Albumen has been sometimes present in the urine; sometimes not. I should say, that on the average the subjects of the malady had not been remarkable for their apparent vigour of constitution, but rather the least robust and healthy of the community.
The treatment has consisted of sulphate of zinc or ipecacuanha emetics, with mild calomel purge, followed by mineral acids, with bark or quinine; sometimes citric acid, chlorate of potass, tincture of sesquichlorate of iron, &c.; with applications of nitrate of silver, solid and in solution (five grains to one drachm); solution of chlorinated soda, hydrochloric acid, &c., diligently applied by sponges, and gargles of like character; externally, an embrocation of compound camphor liniment, soap liniment, and laudanum. Leeches were applied in one case, followed by a blister, which caused a most unhealthy sloughing sore, which undoubtedly accelerated the end. And here I may mention one unfavourable symptom always attendant on the severer forms— i.e., filling up from ear to ear under the chin, with a hard, tense, brawny kind of shining swelling, corresponding to a similar infiltration of all the internal parts. The diet has consisted of beef-tea and nutritious bland nutriment, with wine, according to its apparent necessity. On the first and second day, if given, wine appeared to aggravate the constitutional irritation already severe; and in like manner, about the third day, when the exudation membrane was beginning to separate, allowing the escape of a highly offensive discharge. Caustic or any pungent application to the throat seemed to do harm from the same cause.— Brit. Med. Jour.