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course of the disease, to prevent its fatal issue or its epidemic spread, to mitigate the subjective sufferings of the patient, to ward off consequent morbid processes, in a word, to cure diphtheria, daily observation must give a negative reply.
The endeavour of physicians to deduce a plan of treatment from a knowledge of the thing to be cured, whilst they contented themselves with a very defective knowledge of the effects of the medicines employed for the cure, has always stood in the way of any fruitful progress of therapeutics. As often as the prevalent pathological view respecting the disease underwent a change owing to further researches, the plan of treatment founded upon it had to be given up, in order to make way for another which could not have a better foundation than its predecessor. Moreover the treatment based upon pathological knowledge, the chemical qualities of the medicines used being in many cases the sole qualities considered, after long-continued observation and comparison showed itself to be not much less injurious than the morbid process it was designed to cut short and render harmless. Thus we have recently seen in the medical periodical literature judgments pronounced by thoughtful and philanthropic physicians, which reject treatment directed to the local destruction of the micrococcus diphthericus as not only unsatisfactory, but as absolutely injurious.* Even in the case where the drug employed, to whose chemical qualities was credited the destruction of those microbes, in other words, the disinfection of the diseased organism, such as Carbolic acid, Salicylic acid, Chlorate of Potash, &c, was able to accomplish this object perfectly, still it could not be regarded as a perfect remedy, for its chemical action is not exhausted on the destruction of the morbific agent, but extends to the seat of the morbid process in the mucous membrane, and, contrary to the intention of the practitioner, by means of the bloodvessels and nerves inevitably sets up from this point abnormal reaction-phenomena, which, be they slight or
• Vide Grvndrits der Disinfectionslehre u. I. to., von Dr. Med. A. Wernich, 1880, p. 161.
severe, the patient must perforce take into the bargain. But still more injurious than the chemical and specificdynamic qualities of the fungus-killing substances, is the loss of sleep caused by the frequent repetitions of inhalation, swabbing and gargling, whereby the resisting power of the affected organism is broken, the occurrence of spontaneous cure rendered difficult and in many cases impossible, and so the fatality of the diphtheric morbid process is increased; for restorative sleep is the conditio sine qud non for spontaneous cure. If we form an accurate idea of its evils, the advantage of the disinfecting treatment, i.e. the destruction of all the microbes at the seat of the disease, is questionable, even were it possible, which it is not. It is impossible to prove that the fluid employed in swabbing and gargling comes in contact with each individual fungus; and should it fail to reach even one single individual, in twenty-four hours this would have multiplied a billionfold by fission. But even granting that the microbes present at the seat of the disease are capable of being utterly destroyed, the spores would be unmolested in those media whence the diphtheritically diseased organism received them, and it may continue to receive them afresh as long as the pathological condition of the tissues involved, and of their secretions affords them the conditions necessary for their existence and propagation.
We cannot deny the existence of such a predisposition or liability to specific disease in human beings suffering from diphtheria, in discussing the factors to which the disease in question owes its origin in every single case. If we are to regard the micrococcus diphthericus as the only factor, we must admit the necessity of a simultaneous sickening of all the individuals in a limited population equally exposed to the morbific agencies in the atmosphere, the food, the clothing, &c, whereas the fact is that in ever so wide-spread an epidemic of diphtheria, only a minority of the population is, as a rule, affected. Now, as it is scarcely possible to get at the one factor within the organism affected with diphtheria, and utterly impossible to reach it in the media common to all individuals, it must be the aim of therapeutics to combat the other factor, i.e. the liability to specific disease in the human organism, in other words, to aid the diseased organism to attain immunity from the morbific agent.
Is this practicable?
Are there any facts which allow us to recognise the possibility of carrying out such a radical treatment?
Have any experimental investigations been made which have led by way of induction to the knowledge of something of supreme efficiency applicable in practice to each individual case?
Does our present knowledge extend to forces and laws of nature which help us to the physical explanation of natural cure in general, and to the cure (and prevention) of diphtheria in particular?
These questions are suggested by the point of view stated above. In the following pages their answer shall be attempted; but I shall not, as might be expected, reply to each question in a separate chapter, as that would lead to much repetition and make this essay intolerably long.
I shall premise by a historical account of my first acquaintance with epidemic diphtheria.
In February, 1864, my son, aged seven, a stout lad, physically and intellectually, after rising from his bed one morning, showed a want of liveliness and freshness. After school he gave a long recitation to his school-fellows in the court-yard of the school, the temperature of the air being a long way below freezing-point and the wind blowing strongly from the north-east. He evidently inspired more cold air than his young organism could warm by its own heat. So when he came home in the afternoon I heard the first complaints about painful feelings in the palate and throat. His throat presented the ordinary signs of angina catarrhalis: redness and swelling of the mucous membrane of the palate, fauces, and tonsils, with constrictive aching pain on swallowing, combined with dryness in the throat. At the next meal the patient ate little and made grimaces whenever he swallowed. All this only in moderate degree. The most striking thing about him was the most unusual want of interest and depression. As after dinner he complained of headache, his temperature was increased and his pulse quick and small, I sent him to bed early. Believing I had an ordinary case of angina catarrhalis before me, I gave him Belladonna every four hours, as for years I have done in similar cases with success. For the first time this remedy failed completely, which was obvious after thirty-six hours, as the intensity of the symptoms appeared to be considerably greater and new ones were added, among which was a considerable swelling of the submaxillary glands on the left side. Sleep was disturbed at night, the patient tossing from side to side. There was complete anorexia, he could with difficulty be persuaded to take a few spoonfuls of beef tea. The usual stool was not passed, the urinary secretion was diminished. The pulse became quicker and smaller. Slight sweat occurred only in the upper part of the body, especially the front of the chest. There was considerable prostration. The swelling was larger, the mucous membrane bluish red, the tonsils, especially the left, studded with small yellowish points. There was remarkable fcetor dris and slight salivation.
I now substituted for the Belladonna Mercuring solubilis Hahnemanni which had previously always proved efficacious in such cases, especially when there were present fcetor oris and salivation. But this prescription was also useless. The next night was more disturbed than the previous one. The following day hoarseness came on, whilst the dirty colour of the confluent points of exudation had spread over the left arch of the velum palati and a portion of the uvula. I had never seen anything like this before. On the fourth night the respiration was much altered, the several acts of inspiration no longer occurred at equal intervals; they were at one time short at another longer, until at length there suddenly occurred an attack of coughing with distinct croup sounds. In the course of the next hours the cough came on in ever shorter intervals, during which the patient always anxiously*raised himself up and clutched convulsively at the counterpane. I thought I had to do- with a complication with croup, which I tried to combat with Iodine, being of opinion that the laryngeal affection was the most important thing to attend to. I lost sight of the affection of the palate and fauces as I had to give up the inspection, because every attempt at it caused convulsive spasms of coughing and the patient resisted inspection with all his might. During the next two days the paroxysms of coughing diminished in frequency and severity, but this I ascribed less to the influence of the Iodine than to extreme weakness, for the respiration which was accompanied by a sawing noise was performed with ever greater difficulty, and was accompanied by increase of the opening of the fauces and visible movements of the normal muscles. After little more than three days employment of the Iodine, being myself physically exhausted, I knew not what to do, and anticipated the collapse of my poor child. Just as I was preparing with a sad heart to go on my morning round, one of my colleagues, Dr. A. Beck, came to see me, having heard that there was a case of serious illness in my house. I gave him a circumstantial report of the case, and with his assistance I made an inspection of the primary seat of the disease, which was now done more easily as the paroxysms of coughing had much diminished in intensity. The soft palate was throughout its whole extent changed into a greenish-grey, greasy, foetid mass, in which all the contours were lost. I returned to my study with Dr. Beck to consult over this state of things. He said he remembered in his studies having read in a book on medical jurisprudence of five cases of poisoning by Cyanuret of Mercury in which all had died in a short time. In all five cases there was found a necrotic destruction of the soft parts of the palate and fauces. He recommended a trial by way of experiment of this remedy, though it had not yet been proved; I begged him to undertake the case, as I felt myself quite unequal to it. I rushed with the prescription to the nearest chemist and got him to make me a sixth cent, dilution of Cyanuret of Mercury. In two hours I returned home, put five drops in a tumblerful of water and at once