Treating Diphtheria With Copper (Cuprum)

In the ordinary form of diphtheria the sulphate of copper has also been found useful by some observers. Dr. W. Squire speaks of it as one of the most effectual emetics, and recommends a solution of 5 gr. to the ounce to be given in divided doses - a teaspoonful only to young children, so as to induce moderate vomiting ("Reynolds' System," i., p. 147, second edition). In cases of formation of diphtheritic membrane on the cutaneous, or nasal, or vulvar surface, lotions of the sulphate are found to destroy it, and to prevent its re-formation.

Treating Diphtheria With Iron (Ferrum)

This malady is clearly allied to erysipelas, and has been successfully treated by the same preparations of iron, both locally and internally. Some of the earliest observers recommended the application of perchloride to the seat of exudation, on the ground of the effused membrane being parasitic (Jodin, Laycock), but fungus elements are not essential to diphtheria, and other physicians, regarding exudation as only one sign of constitutional infection, discouraged the use of such local means as might irritate: Trousseau, for instance, was disappointed in a strong tincture of perchloride used "as a caustic," and such application is not to be recommended; his remarks, however, do not apply to the use of a more dilute form, for blood-poisoning may occur from the affected surfaces, and I entirely agree with Dr. Heslop, Sir William Jenner, Dr. George Johnson, and others, that judicious local disinfection is very important and advantageous; various remedies may serve, but the gentle application of diluted ferric solutions has given very good results in competent hands. Dr. Nelson (New York), after ample experience of several methods of treatment, expresses the strongest conviction in favor of local applications of Monsel's solution (liq. ferri subsulphatis) diluted with glycerin and water; among forty cases thus treated he had only three deaths (New York Medical Journal, January, 1874). Dr. Billington, in an excellent practical essay, maintains that diphtheria is at first a local affection, and to be treated most successfully by early local disinfection; he has used lime-water, carbolic acid, etc., but gives a decided preference to the tinct. ferri perchlor., 2 parts, to 1 of glycerin; this he paints especially over the tough adherent membranes, and all adjacent parts. Three hundred cases treated upon this principle show a large percentage of recoveries, and other physicians corroborate Dr. Billington's results (New York Medical Record, March 25, 1876).

Bertheau describes, in a recent thesis, a severe epidemic of "diphthe-rite" affecting two hundred and twenty people (Indre), and in which the most useful of all the means employed was the local application of tinct. ferri perchlor. (30° Beaume); when the membrane was unusually thick, this was painted on three or four times daily ("Du Traitement de Diph-therite,"etc, Paris, 1876). Dr. Fera applies the finely powdered sulphate of iron freely to the affected part, and attributes to this the successful termination of eighty cases, while De Sabbata speaks in equally favorable terms of the use of an acid solution of the same salt (London Medical Review, November, 1876).

Referring now to my own experience, I find detailed notes of twenty-seven consecutive cases of diphtheria, in which the perchloride was used locally or internally; for the local application I employed an atomizer with equal parts of the solution and water, and continued its use for five to ten minutes every hour or two. In six cases no internal medication was ordered, but, besides using the spray, the throat was swabbed out with solution of perchloride mixed with an equal part of glycerin, two or three times in twenty-four hours. The age in these six cases varied from five to nine years, and five of them recovered; but the attack lingered longer, and its course was more unsatisfactory, and convalescence more tedious than in other instances when internal treatment was conjoined: one child, aged four years, had nasal diphtheria, and sank on the third day. In another series of six cases, including children of from two to seven years, I gave minute doses of iodide of mercury (1/40 to 1/30 gr.) and also liquor arsenicalis, and used freely a spray of perchloride of iron locally, and these six cases did well. The remaining fifteen, varying in age from two to ten years, were also treated by the spray, and in addition they received from 10 to 20 min. of the liquor ferri perchlor. every one or two hours, and of these cases twelve recovered. Nine of the total number had albumen in the urine on being first seen by me, and three, haematuria; another had severe epistaxis, and all showed much exhaustion, with more or less dyspnoea and delirium. The iron given internally seemed to exert a sedative effect on the circulation, lowering the frequency of the pulse, and rendering it more full and forcible. I have never seen hemorrhage, or albuminuria, or congestive symptoms of any kind which could fairly be traced to its action, and am indeed satisfied that its effect on the course of the disease is beneficial, though we cannot, any more than in erysipelas, consider it a "specific."

Admitting, however, that twenty-seven cases do not furnish sufficient basis for a positive conclusion, it will be desirable to review briefly the experience of previous observers. This we shall find to be strongly in favor of the iron treatment. Dr. Godfrey, of Enfield, reported three cases of "diphtherite" treated by the perchloride at the very commencement of the epidemic, and speaks of it as the best remedy (Lancet, ii., 1857). It was strongly recommended to the profession at about the same time by Aubrun, in France, and soon after by Dr. Heslop in this country (1858-59). The mortality before that date was most severe- thus, of twenty-six cases related by Aubrun, and treated without iron, twenty-two died. In the next series of cases, in which he used the remedy both internally and locally, out of twenty-seven three only died, and in another series of twelve cases there were no deaths at all (Gazette des Hopitaux, 1859); nor does it seem that any natural lessening of virulence in the epidemic accounted for this striking and suggestive difference.

Aubrun was most particular in his method of administration, ordering one or two teaspoonfuls of a solution every five to fifteen minutes through the day and night, for the first three days of the attack, "because usually membranes would be detached, or would cease to form after that time" -then the medicine could be taken less frequently (Comptes Rendus, 1860, t. li.). Da Silva, commencing with only the local application of perchloride, soon found improved results from using it internally, and recorded many successful cases (Gazette des Hopitaux, Fev., 1859). Is-nard was a still more earnest advocate for this treatment. Following Aubrun in the principle that "iron strengthened the vital power" he reasoned also that it might prevent exudation just as it might hemorrhage, rendering the blood more plastic and also less liable to contamination (blood-poisoning): and, acting as an alterative on the mucous membrane of the respiratory tract it was better than alkalies, for they were too slow in action and too lowering; it should be given early and repeatedly so as to influence the blood-condition as soon as possible; in support of his reasoning he adduced thirty-nine cases, of which thirty-five got well in a natural manner, and two after tracheotomy. Dr. Heslop, after referring to the then excessive mortality of diphtheria, and the failure of all accepted modes of treatment, records several striking cases of recovery from almost hopeless conditions under the internal use of tinct. ferri perchlor: he conjoined with it local applications of dilute hydrochloric acid: at the same time that he praises the remedy, he cautions against regarding it as "a specific" (Medical Times, i., 1858). Mr. Pound relates equally favorable results (British Medical Journal, i., 1858), and Mr. Houghton (Dudley) contributes four striking cases of recovery under very unfavorable conditions (Dublin Journal, February, 1859). A very severe epidemic in the fen country was controlled, according to Mr. Stiles, by the same treatment (British Medical Journal, ii., 1858), and, of fifty-six cases, reported by Mr. Prangley, two only died after commencing the remedies: he used iodine locally and perchloride with potash chlorate internally. Mr. Salter contributed additional testimony to the same effect, and altogether the change of tone, and of the amount of mortality recorded in writings of this period, abundantly testify to the benefit derived from iron tincture, allowing even for accidental circumstances. Mr. Fisher attaches much importance to the use of a preliminary emetic or purge (Lancet, ii., 1862), and Dr. George Johnson, agreeing that treatment with perchloride internally is the most successful of all, conjoins with it local chlorine applications (Lancet, i., 1875). Sir W. Jenner, careful to place mere medical treatment in a subordinate position, states that in his experience benefit has accrued from the perchloride, as from other medicines, only in certain cases suited for it ("Clinical Lectures"), while Dr. Wade expresses some distrust of the remedy, fearing it may increase the renal congestion, for he has found, in fatal cases, more pronounced alteration in the kidneys of patients treated by iron than in others (Lancet, ii., 1862): he would prefer iodide and chlorate of potash. Certainly there are arguments in favor of Dr. Wade's view, but it is not supported by my own experience, and I think it will be conceded, that the illustrations and authorities already given, furnish ample evidence of the value of perchloride of iron in diphtheria. The appearance of albumen, blood, or tube-casts in the urine does not contra-indicate the use of iron in this disease, but, on the contrary, calls for its administration; and when blood or tube-casts are present the iron should be given in conjunction with nitric or hydrochloric acid: under the same conditions stimulants should be judiciously regulated, but seldom withdrawn. Ordinary diuretics are injurious, but as a rule demulcents should be freely taken. Patients should be well nourished with beef-tea, soups, eggs, milk in any form, chicken panada, etc., and ice sucked or swallowed is very agreeable and relieves the painful condition of the fauces: the skin should be kept clean and warm, and the house and room well ventilated; aperients, as a rule, weaken the patient and cause an extension of the exudation in the throat; all these and other matters as they arise should be carefully attended to during the administration of any iron preparation in diphtheria.

Treating Diphtheria With Kalium (Potassium)

Chlorate of potash in full doses, either alone or combined with iodide, has seemed very useful to many observers (Squire, Hillier, Perrin, Henoch, Vogel). I quite agree with them; I have for twenty years used it more or less with advantage. In America, it is commonly given with chloride of ammonium. Recently Dr. Ciattaglia (Rome) has recorded his very successful results with doses of 10 to 15 grammes daily; but in addition he thoroughly applied to the affected part a wash of chloral - 1 dr. in 5 of glycerin (Lancet, i., 1876).

The permanganate of potash has also proved useful in diphtheria, as well internally as locally (Copland: Lancet, i., 1863, p. 151, and Ranking, i., 1865, p. 55). I can add my testimony to its value, though it is right to recognize the statements of Dr. H. C. Wood, that he "has never seen the chlorate do a particle of good in such maladies as scarlet fever, diphtheria, etc.," and with regard to the permanganate, "as immediate decomposition of it must occur in the stomach, the absurdity of its internal use needs only to be pointed out" ("Elements of Therapeutics," 473-586).