CONTRIBUTIONS 
TO THE 
PATHOLOGY AND THERAPEUTICS 
of diphtheria. 
/by 
A. JACOBI, M.rx, 
CLIN. PROF. DTS. CHILDREN IN TITE COLLEGE OF PHYSICIANS AND SURGEONS, 
NEW YORK, ETC. 
(A Paper read before the Medical Society of the County of -New York, December 28, 1874J 
Reprinted from “Journal of Obstetrics” for February, 1875. 
NEW YORK: 
WILLIAM WOOD & CO., No. 27 GREAT JONES STREET. 
1875. CONTRIBUTIONS 
TO THE 
PATHOLOGY AND THERAPEUTICS 
OF DIPHTHERIA.*' 
A. JACOBI, M.D., 
CLIN. PROF. DIS. CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 
NEW YORK, ETC. 
(A Paper read before the Medical Society of the County of New York, December 28, 1874.) 
Twice before this evening have I had the privilege to appear 
in extenso before the medical profession of New York with 
remarks on the subject of diphtheria. The first time with a 
paper published in the American Medical Times, August 11th 
and 18th, 1860, to which Dr. Harris, in his recent remarks be- 
fore the Public Health Association, kindly alluded as the first 
elaborate essay written since the times of Barth ; the second time 
in a memoir on croup, read before ‘this Society in 1868, aiid 
published in the first number of the Journal of Obstetrics and 
Diseases of Women and Children. At this late day I cannot 
but look upon those two papers as fair exponents of what, if 
not generally adopted as final, was believed to be based on the 
numerous facts then known and attested. 
In the first paper I described the pseudo-membranes as “ dif- 
fering in size, thickness, color, and consistency; their shape as 
various. Some are round, some angular, some regular, some 
irregular; their thickness varies from a film to a quarter of 
an inch and more. Their color is white, glassy, greenish, gray, 
yellowish, reddish, brown, according to their thickness, expo- 
sure to air, and admixture of blood ; unaltered blood adheres, 
sometimes, to their lower surface. They are either merely ad- 
herent to a mucous membrane, without any alteration of its 
* From Journal op Obstetrics, Feb. 1875. 2 
Jacobi : Contributions to the 
tissue; such is usually the case on the mucous membrane of 
the bronchi and trachea,and mostly on the soft palate; or they 
are imbedded in its substance, as mostly on the tonsils, and the 
posterior wall of the pharynx, and frequently in the larynx. It 
is a very remarkable fact that the same continuous membrane 
will now be readily removed from the surface of the mu- 
cous membrane, and again at a very short distance tear the 
substance of the mucous membrane at every attempt to separ- 
ate it. The surrounding parts are hvpersemic, and swelled by 
oedema during life. At post-mortem examinations the oedem- 
atous swelling is sometimes found, but the hyperaunia is no 
longer met with after the refrigerating and contracting in- 
fluence of the atmosphere has had time to operate. Pseudo- 
membranes are found in the pharynx, on tonsils, uvula, and 
velum, on the gums, lips, and tongue, on the mucous mem- 
branes of the month and nose, in the larynx, trachea, and 
bronchi, in the superior part of the oesophagus, in the lower 
part of the intestinal canal, round the anus, in the vagina, the 
external ear, the naso-lachrymal duct, on the conjunctiva, and 
on the cutis, wherever and by whatever cause it has been 
deprived of its surface; thus on sore nipples, etc. In all of 
these places the chemical as well as microscopical constitution 
of the membranous exudation is entirely the same.” 
With these observations before me I could not but believe 
in the identity of the croupous and diphtheritic process. Both 
clinical experience and the study of the histological elements 
of the membranes, or deposits, as far as then understood, ap- 
peared conclusive. Is or did further experience, necessarily large 
in this great city, chaiige my views in that respect, when, eight 
years afterwards, I returned to the subject, in this very place. 
In the paper then read {Jour. Obst., May, 1868, p. 30 seq.) 
after some remarks upon pharyngeal and laryngeal catarrh, I 
continued : “ Another form is the follicular process on the tonsils 
with its subsequent changes, the formerly so-called herpetic 
angina, which I have characterized already in a paper on diph- 
theria, published in August, 1S60, in the Am. Med. Timea. 
It is exudative, membranous in character, feverless, but will 
not infrequently be followed by large croupous or diphtheritic de- 
posits. Another form is the membranous deposit proper, a fibrin- 
ous exudation, amorphous in character, mixed with mucus and [ Pathology and Therapeutics of Diphtheria. 
3 
blood-corpuscles and normal epithelium. It is either deposited 
upon the mucous membrane, and then can be easily lifted up 
from it, or into it, and into its subjacent tissue. The first form 
has frequently been called croupous, the latter diphtheritic. 
But whatever clinical difference there may be between a 
simple membranous inflammation and constitutional diphtheria, 
there is no anatomical difference between the membranes wher- 
ever they make their appearance. Another form, and not an 
infrequent one, is originally confined to the epithelium, which 
rapidly undergoes fatty degeneration, which may or may not 
be complicated with fibrinous exudation. The soft, pultaceous, 
easily macerating diphtheritic masses are of this character; 
and the fearful cases of diphtheria with rapid necrosis of the 
tissue are usually of the same nature. The neighborhood may 
be in various conditions, oedematous or dry, hypersemic or 
anaemic. An oedematous and hypersemic condition is most 
frequently found ; a dry condition is a frequent occurrence in 
the necrobiotic process of fatty degeneration; anaemia of the 
surrounding parts, or interspersed portions, depends on com- 
pression of capillaries by infiltration, which means: newly 
formed cells and connective tissue. Anaemia would once have 
been considered impossible as a lesion of inflammation, but we 
have fortunately passed by the time when this nutritive dis- 
order was supposed to depend necessarily on previous congestion 
of the parts. 
All those forms of change of tissue are not found uncompli- 
cated in every given case. When large surfaces are attacked 
at once, you may see in the mouth a catarrhal proliferation 
or croupous condensation of the epithelium, on the tonsils a 
diphtheritic deposit imbedded into the tissue, in the larynx and 
trachea a plain croupous deposit, and in the bronchi a muco- 
purulent secretion. And again, under the same endemic and 
epidemic influences you will find a case of catarrh, a case of 
croup, a case of diphtheria, a case of follicular exudative 
amygdalitis in the same family, in, the same week.. Thus it 
appears, that in the long list of morbid, conditions, met with, ca- 
tarrh on one side, the diphtheria on the other, are but the starting 
and terminating points between which all the different shapes 
and forms may be registered according to their dignity—their 
modification depending on individual, local, endemic and epi- 4 
Jacobi: Contributions to the 
demic influences. The only form which is perhaps, but per- 
haps only, to be excluded, is the necrotizing diphtheria. And 
when we compare the clinical characters of the affection, we 
find similar differences. The affection may be local without 
fever, or simply febrile, or local and obstructing, or septic, or 
obstructing and septic. In some cases the process will not even 
be confined to the respiratory organs, but similar to the Rinder- 
pest of animals, the digestive organs will participate in the 
process, and skin, kidneys, spleen may follow.” 
Row, Mr. President, a careful observation of this year’s epi- 
demic, as of those of former years, in which the nature of the 
cases was the same, only their number less, exhibits the follow- 
ing forms of local change in the complex of symptoms called 
diphtheria. 
1st. Inspection of the pharynx yields catarrhal conditions of 
its whole surface, or part of it. Soft palate, or pillars, or pos- 
terior wall, or tonsils, or some or all of them are of a deep-red 
color, soft, swelled. This catarrh is a precursor of further de- 
velopment of diphtheria, or its complication. It need not 
necessarily result in diphtheria, for the number of independent 
cases of pharyngeal catarrh is very great in every epidemic. 
The Journal of the Dispensary, from which I took the cases on 
which was based my paper of 1860, exhibited 185 cases of in- 
dependent pharyngitis to 200 of diphtheria. Rot always is the 
catarrh very extensive. It is useful to know, and in individual 
cases very important to notice, that not infrequently small 
territories of blood-vessels and mucous membranes are in the 
morbid condition mentioned. This change would be an abso- 
lutely indifferent matter in normal times ; during an epidemic 
of diphtheria it may usher in or be the first symptom of a regu- 
lar attack. Sometimes, however, the differential diagnosis is not 
easy at all. For in many cases where a slight film of what ap- 
pears to be mucus is seen to cover a portion of a tonsil on a 
hypersemic base., we have in reality to deal with diphtheritic 
changes in the epithelium, and not infrequently are these the 
cases in which fever is unusually high, and general symptoms 
prevalent. 
2d. In many cases we have to deal with small deposits as de- 
scribed above. They .are not inflammatory, for there is no 
nuclear proliferation and subdivision, no intimate admixture of Pathology and Therapeutics of Diphtheria. 
5 
leucocytes, a few of which, may, however, be found adhering to 
the lower surface. The superficial epithelia are the principal 
sufferers ; the lower strata are less changed. Their outlines 
are but feebly marked, sometimes not perceptible, with the ex- 
ception of a very indistinct network containing an amorphous 
granular, dark, contoured material. Such granular material is 
also found outside the netwoik. Part of it is described as con- 
sisting of round, oval grains with sharp outlines, of one-tenth or 
one-twentieth of the size of a blood corpuscle, conglomerated, 
and is sometimes found in large masses. It is said to be fre- 
quently not distinguishable from detritus, fine particles of al- 
bumen, and fat globules. Because it has been observed to spread 
and increase rapidly, and because of its similarity to the botani- 
cal parasites in putrefying material, it has been taken as botani- 
cal, parasitical; and called either splisero-bacteria, micrococci, 
or monades. These elements have been presumed to be the es- 
sential matter in diphtheria, and the source and means of conta- 
gion. The fungous vegetations develop either in the mucous 
membrane without previous exudation, or in superjacent emula- 
tion, and are believed to infect the system by entering the 
lymphatics and finally the general circulation. Nutritive dis- 
orders are said to result from embolism of such parasitic masses, 
which increase rapidly. Thus not only results a destruction of the 
tissue and epithelial cells of kidneys, liver, spleen, and heart, 
but also large pneumonic infiltrations. Besides, in the opinion 
of some, new and unexpected changes result from the products 
of poisonous decomposition lit up by the presence of the immi- 
grant parasites (Orth). The tendency of natural philosophy 
and its daughter, medicine, to realistic appreciation of natural 
phenomena, and the apparent facility of explaining some facts 
which are difficult to understand, have been the cause of the 
almost general acceptation of this theory, which appears to 
subvert well-nigh all our experience on the slowness with 
which, as a rule, all scientific progress is developed. The theory 
is so enticing, I might say bewitching, that we can hardly help 
burying everything we knew of pathology, and diving headlong 
into the new fountain of apparently “exact” knowledge. To 
what extent the best intellects can be captivated by a brilliant 
theory, especially when they had something to do with the 
establishment of the new edifice, we can learn from the following 6 
Jacobi : Contributions to the 
quotation from Prof. C. Ilueter’s General Surgery, 1873, p. 
269 : “ The insufficient penetration of the monades ”—this is 
the name proposed and preferred by him—“ into the tissue in 
cases of croup is an obstacle to their entrance into the lymph- 
ducts and blood-vessels, and therefore no serious general symp- 
toms are found in croup. The progress of diphtheria cannot de- 
pend upon the effects of the movements of vibrating epithelia, 
because of their rapid destruction by the monades of diphtheria. 
When diphtheria getsdown to the smallest bronchi the monades 
emigrate into the pulmonary tissue, and establish a pneumonia. 
But if it first establish itself on the tonsils and the mucous 
membrane of the pharynx, it cannot but descend into the 
larynx, because its access to the cheek and tongue is retarded 
by the heavy layers of pavement epithelium, and the immigra- 
tion into the oesophagus is rendered impossible by the same 
cause. The nasal cavity appears to be better protected than 
the larynx; perhaps the secretion of muciparous follicles has 
something to do with that.” I have quoted this passage to 
show to what extent the very best intellect can err when 
obnubilated by the influence of a pet theory. Not only shall 
we hear of better reasons for the absence of general symptoms 
in membranous croup of the larynx, but the whole theory, 
founded on the rapid destruction of vibrating epithelium, is also 
defective, for the reason that this very epithelium resists better 
than any other a speedy destruction by the diphtheritic pro- 
cess. Finally, not only is laryngeal diphtheria not an absolute 
necessity, as Prof. Ilueter appears to believe, and nasal diph- 
theria the exception, but, on the contrary, the former is fortu- 
nately rare, and nasal diphtheria a common occurrence in pro- 
tracted epidemics. 
Nor is this all. We ought not to forget that histologists do 
not at all agree about the nature of the corpuscles claimed as 
bacteria in almost all infectious diseases. The number of in- 
vestigators is very large, and good names are counted amongst 
them. But I, who am not a histologist laden with new dis- 
coveries, am aware of the fact that the world-wide reputation 
of some of these names is based almost absolutely and solely on 
bacteria, and that is too narrow a basis. I cannot but warn to be 
careful in accepting not facts, but their explanations. The read- 
ing with the microscope is relied upon as unimpeachable least by Pathology and Therapeutics of Diphtheria. 
7 
those who are the acknowledged masters in that field. Panum 
is positive as to the chemical nature of putrid poison, so is 
Bergman, and so Verneuil. Billroth has published a series of 
investigations extending over many years in his great work on 
Coccobacteria. His conclusions are not identical with the bac- 
teria theory as defined before. lie is more inclined to believe 
that a. chemical poison is the source of infectious disease, but 
that this may result from the presence and influence of cocco- 
bacteria in the blood. In the No. of Nov. 30th, 1874, of the 
Berliner Medicinisehe Wochemchrift, Arnold Hiller contends 
against the alleged characters of the bacteria as pathognomo- 
nic. I described, according to the general acceptation, bac- 
teria as possessing well-marked outlines, great brilliancy, and 
a strong power of reflection. Hiller contends that it requires 
unacquaintance with botany and bacteria to believe that. Ac- 
cording to him, both direct observation and comparison with 
fat molecules prove that bacteria excel by an opaque dulness 
rather than by brilliancy and distinct outlines, and for this 
reason are so remarkably difficult to discover, and that the re- 
flecting power of a micrococcus stands in the same proportion 
to that of a fat molecule, as the appearance of an yeast-cell to 
that of a fat globule of equal size. Thus those very alleged 
characteristics of presumed bacteria would speak for their being 
products rather of fatty degeneration. Beale, than whom few 
investigators of bacteria have been more industrious or suc- 
cessful, insists emphatically upon the immense magnifying 
powers required to properly study these organisms. lie also, 
as is well known, repudiates the idea that bacteria must be 
causes of the lesions of tissues in which they are found, when 
bodies precisely similar in appearance are equally abundant in 
health, “ millions of bacteria are normally present in the 
mouth.” However, it cannot be my aim to go beyond my sub- 
ject; but in connection with our theme, I meant to protest 
against the dangerous consequences of ail exclusive scientific 
enthusiasm. 
3d. The small deposits spoken of under 2d, go on increasing, 
not only on the surface, but into the substance of the tissue. 
They have the same appearance, with a tendency to grayish 
discoloration. Removal of the surface detritus reveals an ulcera- 
tion of the membrane with a moderate admixture, among the 8 
Jacobi : Contributions to the 
epithelial remnants, of pus and blood corpuscles.1 This is the 
form in which the detritus, bacteria, or whatever either the 
morbific or nosogenic elements may be, are principally met 
with. From what has been said of the elementary structure of 
the two last forms, we may draw inferences which will be found 
to exist in reality. We may infer that there may be removable 
and deeply imbedded deposits in close juxtaposition, and that 
after the removal of a surface deposit, the same process will 
take possession of the deeper tissues; and such is just the 
observation which is frequently made. 
4th. The last form of diplitherite, as found sometimes on the 
conjunctiva, and in all cases of diplitherite of the oesophagus, 
vagina, trachea, and lower portion of the larynx, has been taken 
to consist of fibrine as principal constituent. The deposit con- 
sists of large flaps deposited upon the mucous membrane, lined 
underneath with mucus corpuscles, and a very few blood, cor- 
puscles and epitlielia. Even that, according to E. Wagner, is 
the result of a metamorphosis of the epithelium. But it has 
been urged that this is impossible. Only lately Senator has in- 
sisted upon the fact that, at the most, the epithelium is found in 
three or four layers, and that these are insufficient for the for- 
mation of thick and coherent membranes. The objection is 
not well taken, for in cases where the pseudo-membrane cover- 
ing, for instance, the uvula, or soft palate and tonsils in general 
attains a thickness of several lines, it must be remembered that 
epithelium is known to reappear rapidly when thrown off or 
removed. A cast of the trachea and bifurcation thrown up by 
vomiting was replaced by another one within six or seven hours, 
and found at the post-mortem examination. The same happens 
in the nares, where the same author, not having seen cases, 
denies the occurrence of croup membranes altogether. In 
many of these deposits the epithelial structure has been noticed 
to be still apparent. It is not, however, necessary to deny that 
genuine exudation may be complicated with the original pro- 
cess of epithelial proliferation and transformation. For in 
the chamadeon like changes of a diphtheritic process, irritation 
i Fair specimens of this form are found on the tonsils and the upper half of 
the larynx, rarely the soft palate. Still, I have met with complete perfora- 
tions of the soft palate in two instances. Pathology and Therapeutics of Diphtheria. 
9 
of the neighboring tissues, and nutritive disorders of an inflam- 
matory character may be expected to take place. 
The several forms of diphtheritic disease, the description of 
which I have given, have a peculiar tendency to develop in 
certain localities. Where the whole lining membranes of the 
air-passages from nares to trachea and the month are covered 
with diphtheritic degeneration, the third form, viz., impregna- 
tion of the mucous membrane, with its epithelium, and some- 
times submucous tissues, is found all over the tongue, edges of 
the lips, and frequently over mucous membrane of lips and 
cheeks ; also on the tonsils, at the lower portion of nares, and the 
upper part, particularly anteriorly, of the larynx. The fosssie 
Morgagni are also, in most cases, in the same condition; seldom 
the soft palate, on its posterior aspect, more frequently on its oval 
surface. The first form, deposits in specks of small size, in the 
tonsils, and isolated portions of the posterior wall of fauces. The 
last, the so-called croupous form, viz., deposits upon the mucous 
membrane, easily removed in large flaps, or readily macerating 
in the copious secretion of the subjacent muciparous glands, in 
portions of the nares, in the posterior aspect of the soft palate, 
on trachea and bronchi. 
Certain peculiarities of the tissues in general, the mucous 
membranes in particular, have frequently been assumed to 
exert a considerable influence on the nature of the diphtheritic 
process. Eberth, whose histological knowledge is remarkable, 
though his clinical observation appears to be but limited, refers 1 
to the fact that a violent diphtlierite of the larynx need not de- 
scend to the trachea, though he exaggerates the frequency of 
such an exclusive occurrence. Trendelenburg infected the 
trachea of a rabbit with diphtheritic deposits removed from 
the pharynx and tonsils, where they had been firmly and deeply 
imbedded into the tissue, and the results of his experiments were 
deposits loosely attached to the surface of the mucous membrane 
of the trachea, where he transplanted them. In general the 
condition of the mucous membrane varies in different organs 
and locations. Uniformly we find in successive layers: 1st, 
epithelium; 2d, the so-called basement membrane, thin and 
deprived of structure; 3d, connective tissue largely mixed with 
1 P. 6 of C. J. Eberth, “Zur Kenntniss der Bakteritischen Mykosen.” 
Leipzig, 1872. 10 
Jacobi : Contributions to the 
elastic fibres, with blood-vessels, nerves from both the cerebro- 
spinal and the sympathetic nervous systems, and frequently 
spindle-shaped nuclei. On the free surface of the mucous 
membrane we distinguish in addition papillae, fiocci, villi, 
and the apertures of a number of various glands. As all of 
these constituents influence pathological processes in the mucous 
membranes, they require a special consideration. I shall first, 
however, briefly review the parts which are the principal loca- 
tion of the diphtheritic process. 
The mucous membrane of the mouth contains a large num- 
ber of elastic fibres mixed with its connective tissue, and is 
covered with a thick pavement epithelium in three layers, the 
upper one flat, the second more polyedrie, the lowest oval and 
perpendicular upon the mucous membrane. Many small 
papillae extend from the mucous membrane into the epithelium, 
thereby resembling the papillae of the cutis. Acinous mucipa- 
rous glands are frequent, most numerous on the anterior sur- 
face' of the soft palate. The lymphatic ducts are very numer- 
ous on lips, tongue, uvula, soft palate, anterior and posterior 
pillars, and cheeks. The uvula contains so many that their 
injection doubles or triples its size. They discharge their con- 
tents into, and in case of morbid irritation infect the deep 
facial glands. Those of the tongue are more intimately con- 
nected with the upper layer of the deep cervical; those of 
the floor of the mouth, and many of the tongue, with the sub- 
maxillary glands. The vasa efferentia of all of them discharge 
their contents into the superior jugular glands in the trigonum 
cervicale superius, and finally into the numerous (15-20) infe- 
rior jugular (or supra clavicular) glands which through numer- 
ous connections form the jugular lymphatic plexus. 
The tonsils are conglomerates of an uncertain number of 
glandular bodies, each of which has a thick capsule with irreg- 
ular outlines, consisting of connective tissue, and is lined inside 
with mucous membrane and pavement epithelium. In the 
connective tissue there are a large number of closed follicles 
containing numerous lymphoid corpuscles. These follicles 
have been taken for identical with, or analogous to lymphatic 
glands. This assumption is problematic, as neither in-going 
nor out-going lymphatic ducts have been conclusively proven 
to exist. It would result, as a practical conclusion, that there Pathology and Therapeutics of Diphtheria. 
11 
was no connection of the tonsils with the lymphatic system, nor 
is the supply of blood-vessels a large one ; it is decidedly small 
in chronic inflammation and enlargement, with hypertrophy of 
connective tissue. 
The mucous membrane of the nares is of various thickness, 
consists of connective tissue fibres with numerous nuclei, and 
has no admixture of elastic fibres, but many nerves and an 
unusual number of blood-vessels. In fact the Schneiderian 
belongs to those mucous membranes which are uncommonly 
supplied with blood. Its submucous tissue is, therefore, very 
apt to swell, or to bleed, as well in diseases of distant organs 
resulting in venous stagnation as in slight local provocation. 
The inner aspect of the cartilages is covered with pavement 
epithelium. The lower portion of the nasal cavity, the so-called 
respiratory part, as far as supplied by the fifth pair of cere- 
bral nerves, has cylindrical epithelium, and a large supply of 
acinous muciparous glands. The upper portion, the so-called 
olfactory part, lias vibrating epithelium, and, according to 
Todd and Bowman, long and straight tubular glands. Some 
of the epithelial cells have been found, by M. Schultze, to 
connect with the terminal ends of the olfactory nerves, partic- 
ularly a layer of those which are more spherical, branching 
out in two directions, and have been denominated as olfactory 
cells. In this portion the lymphatics are but slightly devel- 
oped, but they are very abundant in the lower part, also in the 
aim. They terminate directly into the deep facial, and the 
posterior submaxillary glands, with all their connections. 
Thus the mildest provocation, a nasal catarrh in a child, is apt 
to produce glandular swelling either temporary or permanent. 
The epiglottis has on its anterior or upper surface a piave- 
ment epithelium of 0.2 mm. in thickness. On its posterior or 
lower aspect it is but 0.1 or 0.06 mm. The upper stratum is 
spherical or polygonal, the deeper more cylindrical and joined 
palisade-like together. Hearer the insertion of the epiglottis 
the polygonal cells disappear, the cylindrical then rise to the 
surface and are supplied with cilia of 0.005 mm. in size. Below 
them round and oval cells are found to such an extent that the 
whole epithelial covering measures about 0.15 mm. The same 
form—ciliated epithelia—are found below on false vocal cords 
and in the ventricles of Morgagni. But along the posterior 12 
Jacobi : Contributions to the 
aspect of the pharynx, over the ary-epiglottic folds, where more- 
over the mucous membrane is lined underneath with a very 
thick and loose submucous tissue, and along the true vocal chords 
—the covering is formed of polygonal pavement epithelium / 
in the direction of both the ventricles of Morgagni and the 
trachea it is replaced by ciliated epithelium in a thin layer. 
The mucous membrane itself is most loosely attached in the 
neighborhood of the ventricles of Morgagni, and is very thin, 
loosely adhering, and often folded upon the true vocal cords. 
Acinous glands are numerous, from fifteen to twenty on a square 
centimetre, and longitudinally arranged. They are very fre- 
quent about the ventricles, with cylindrical epithelium (rarely 
ciliated) in the ducts. There are, however, no acinous glands, 
no glands of any hind, in spite of the looseness of the submucous 
tissue, in the true vocal cords. 
These acinous glands carry no lymphatic vessels. In other 
parts of the laryngeal mucous membrane and submucous tissue 
these are, however, met with. They are, in fact, both numerous 
and large, with the general character of the lymphatics, viz., 
endothelium, dilatations, constrictions. In the epiglottis of the 
newly-born they form but a single layer, in the larynx itself 
and in the trachea two, in some portions provided with a large 
amount of submucous tissue, even three. The inner and smaller 
layer takes a perpendicular, the outer and larger a horizontal 
course. The posterior aspect of the epiglottis and the true 
vocal cords (not only during the first year of life) exhibit by 
far the smallest number and calibre of lymph-vessels. 
Agminated glandular substance, that is, lymphatic glands 
(extensively found in the cat, according to Yerson, and always 
in Morgagni’s ventricles in the dog) are rarely found in man. 
The exceptions found by Luschka, referring to the vestibule of 
the larynx and the margin of the plica ary-epiglottica, and also 
upon the posterior aspect of the epiglottis, confirm rather than 
weaken the rule. 
The mucous membrane of the trachea and bronchi contain 
more elastic than connective-tissue fibres ; a fair number of 
lymphatic vessels, no lymphatic glands ; very many acinous 
glands; and is thickly lined with ciliated epithelium. 
The accompanying table will condense some of the above 
statements. Pathology and Therapeutics of Diphtheria. 
13 
NOSE. 
MOUTH. 
TONSILS. 
EPIGLOTTIS. 
LARYNX. 
TRACHEA. 
Elastic fibres. 
None. 
Many. 
Very many. 
Many. 
Many. 
Very many. 
Epithelium. 
Pavement near cartilage. 
Pavement thick 
Vibrating anteriorly, foss. 
Vibrating. 
Cylindrical in resp. part. 
Pavement. 
Pavement. 
ant., thin post. 
Morg. and false vocal cords. 
Vibrating in olfact. part. 
Vibrating at inner 
Pavement posteriorly, and 
insertion. 
true vocal cords. 
Lymph ducts 
Very numerous in resp. 
part. 
Many. 
Few, if any. 
Moderate ant., 
Numerous, usually no lymph 
Numerous. 
Moderate in olf. part. 
Uvula very 
few post. 
glands. 
numerous. 
None on vocal cords. 
Blood-vessels. 
Very numerous. 
Few. 
Nerves. 
Very numerous. 
Numerous in respir. 
Scarce. 
Acinous glands. 
part. 
Tubular glands in olf. 
Numerous. 
Very numerous in vent .Morg., 
some, however, have no 
Very numerous. 
part. 
lymph ducts. 
Submucous tissue 
None on vocal cords. Very 
copious in plica ary-epiglot- 
tica. 14 
Jacobi : Contributions to the 
Of all the tissues and organs mentioned, the elastic tissue, 
which enters so largely into the fabric of the connective tissue, 
is least affected by chemical or organic influences. On being 
boiled it yields no glue; like connective tissue, it is not 
changed by water, acetic acid, alcohol, gastric juice, or moderate 
heat. It is firm, dense, has a degree of elasticity never at- 
tained, normally, by any other tissue. It has but few blood- 
vessels, no nerves; few lymphatics, and a slow metamorphosis. 
In consequence, upon injuries received, it is not reproduced, 
but the healing process results in the formation of a fibrous 
cicatrix. 
There is no elastic tissue in the mucous membrane of the 
nose, a large amount in the oral cavity, and particularly in the 
walls of the lymph follicles of the tonsils; and such an amount 
in the trachea that the connective tissue fibres are in the 
minority. The influence of this anatomical condition on the 
diphtheritic process must be considerable. It will be easily de- 
monstrable, that where elastic tissue abounds it resists the deep 
diphtheritic impregnation of the tissue for a long time, but 
when it has taken place resists recovery as well. 
The epithelial changes which form the diphtheritic deposit 
belong principally to pavement epithelium. Where this 
abounds, the diphtheritic poison is most apt to find a place to 
rest and develop ; thus the tonsils, not only for their prominent 
location, but also for the structure of their surface, form a fit 
receptacle and breeding-place. Vibrating epithelium is not so 
apt to be destroyed. It is higher in the animal scale, and lias 
a more complicated structure function. 
Where muciparous follicles abound, their normal secretion, 
as a rule, prevents deep-seated degeneration of the tissue. 
Epithelial conglomerations are lifted up from the surface, no 
tissue takes part in the morbid process to any great extent, 
the serum of the mucus penetrates the deposit, and disposes 
it to macerate. Thus the deposits formed in the respiratory 
part of the Schneiderian membrane are apt to be constantly 
discharged from the nostrils unless their production is too 
massive, and the membranes of the trachea are frequently 
gushing out of the newly-made tracheotomy opening in semi- 
solid consistency. The frequency of muciparous follicles in 
the larynx and trachea is also the reason why the numerous Pathology and Therapeutics of Diphtheria. 
15 
lymph-ducts of the mucous membrane cannot act much on the 
superjacent, but loosened masses, thus offering a better reason 
for the merely local character of laryngeal and tracheal diph- 
theria, and the absence of constitutional symptoms, than that 
which Ilueter offered as an explanation. 
The vocal cords are deserving of a special mention. They 
form the borders of the narrowest entrance into the lungs. 
Foreign substances, no matter whether of benign or malignant 
character, will be retained by them. They are supplied with 
pavement epithelium, which is the principal seat of diphtheri- 
tic degeneration. They*have no muciparous glands, nor have 
they lymph-vessels. Thus, if there is any organ predestined for 
diphtheria, it is the vocal cords. Where there is not poison 
enough for a thorough infection, there is still enough for a 
local deposit. Where diphtheria has died out as an epidemic, 
the stray cases with limited infecting power will be known for 
years or decennia as so-called sporadic membranous croup, as 
you would speak for a generation of an occasional case of spo- 
radic cholera, or a stray case of variola. There is not infection 
enough to poison the throat and larynx and blood, but just suf- 
ficient for the most favorable place, the vocal cord. No 
speedy removal of the diphtheritic mass can be obtained, for 
there are no acinous glands underneath. No general infection 
can spread from them, for there are no lymph-ducts to commu- 
nicate it. Besides, suffocation sets in too soon for the neigh- 
boring lymph-vessels to become agents and bearers of infection, 
in case the deposit would macerate. 
Thus, if anatomy and physiology mean anything, I hope the 
vexed question of “ croup,” or “ diphtheria ” in the larynx will 
be considered as settled. 
The distribution of blood-vessels, and more still, of lymph- 
ducts, is of the greatest importance as far as general symptoms 
are concerned. Their absence from the tonsils explains the 
benign character of tonsillar diphtherite; their number and 
size, and the direct connection with lymphatic glands in the 
Schneiderian membranes, explain the danger of nasal diph- 
theria. Sometimes the lymphatics have hardly time or oppor- 
tunity to act. In the many cases of slight hemorrhage to 
which I allude at some other place, from the nostrils, absorp- 
tion appears to take place through blood-vessels directly; in 16 
Jacobi : Contributions to the 
those cases the usual immense swelling of the glands of the 
neck is missed, but the effect on the general system is never- 
theless developed rapidly. 
To the lymphatic ducts and glands I have alluded very fre- 
quently. In fact, they are of prominent dignity in a large 
number of Serious or fatal cases. Thus they deserve a few 
moments’ special attention. 
The number of lymph-vessels, distributed as they are over 
bones and fasciae, blood-vessels and nerves, connective tissue and 
fat, is almost incredible. The larger ones form a closed system 
of canals. Their walls consist, like those of blood-vessels, of 
three layers—an intima, a media, and an adventitia; the first 
is made up of elastic fibres, with pavement epithelium; the 
second is muscular and contractile, only thinner than that in the 
blood-vessels; and the third has a looser connective tissue than the 
corresponding layer in arteries and veins. The smallest lymph- 
vessels, like the capillaries of the blood-vessels, claim no con- 
stituent to their walls except a pavement endothelium. Whatever 
connective tissue is lining this simple layer of endothelium, be- 
longs to the surrounding organs, and not the lymph-ducts. Thus 
they can hardly be thought of, except in the most intimate con- 
nection with the fibres and cells of all connective tissue. Thus 
far, all histologists at the present time agree. The modus of 
this connection, however, has been explained in the most dif- 
ferent manners. Ivolliker, for instance, looked for the last dis- 
tributions of the lympli-ducts in the pointed outgrowths of the 
connective-tissue cells. Recklinghausen denies the existence of 
membranes in the finest distributions; according to him the 
open interstices between the connective tissue or epithelium 
cells are the first origins of lymph capillaries. Neumann 
claims the system of lymph capillaries as a closed system of 
canals, at least as far as concerns the skin, which he has made 
the subject of a recent monographical study. Its walls, accord- 
ing to him, are lined with pavement epithelium, not interrupted 
by any stomata, in no way directly connected with open spaces 
between the connective-tissue cells; their superficial layer con- 
sists of the most minute forms. They are just interior to the 
superficial blood-vessels ; their inner layer is larger and some- 
times endowed with valves, and they are found in innumerable 
quantities all through the connective tissue, fat, perspiration Pathology and Therapeutics of Diphtheria. 
17 
glands, sebaceous follicles, hair follicles—in all of which Teich- 
mann and Sappey were not able to find them—besides the papil- 
he and the whole tissue of the cutis. Thus it appears, from the 
discrepancies of observations and opinions alluded to as speci- 
mens, that the origins of lymph capillaries may vary in different 
organs. Recklinghausen is positive in his statement (so different 
from Sappev’s) that the most minute terminations in the peritoneal 
epithelium and on the pleural covering of the diaphragm are 
open stomata, thus exhibiting the large thoracic and abdominal 
cavities, as it were, in their character of immense lymph-sacs. 
Through these stomata the lymph, viz., nutrient fluid minus what 
is being used for tissue building, plus what has been excreted 
from the tissues, would be admitted to the smaller and gradu- 
ally the larger lvinph-ducts (the valves of which are diverted 
towards the heart) under the influence of three motors, one of 
which is muscular contraction, the other arterial pressure, un- 
broken by the slow current of terminal plasmatic circulation, 
the third, central aspiration. 
The liquid contents of the tissues, or such particles or in- 
gredients as can be suspended in them, of a gaseous or 
chemical, or parasitic character, are swept off to the lymph- 
glands, the peripheric fascia propria of which forms a first rest- 
ing-place. For here the lymph-vessels are divided in branches, 
before perforating it and discharging into the lymph-spaces of 
the alveoli of the cortical layer, which are filled with lymphoid 
corpuscles composed of coarsely granulated protoplasm. From 
it the lymph, in thin canals, is swept into the medullary part of 
the glands, the nature of which is the same as the cortical, with 
the exception that it is less compact, inasmuch as the connective- 
tissue trabeculm are less developed, and the lymph-spaces 
more numerous and larger. The lymphoid corpuscles origi- 
nally formed in them are swept away with the incoming current, 
thus increasing the amount getting into the outgoing ducts, 
which are smaller in number, but larger in size than the in- 
going ones. Whatever infectious material enters through the 
vasa efferentia, and is small enough to be swept out with the 
lymph and the newly-suspended lymphoid corpuscles, will then 
be introduced into the unimpeded current of the lymph and 
blood-circulation, those cases excepted in which another ob- 
stacle to an uninterrupted flow is found in a second tier of 18 
Jacobi: Contributions to ike 
lymphatic glands. Whatever is of the unirritating character of 
the lymph, and not larger in its microscopical measurements 
than it, is swept through the fascia propria and into the reser- 
voirs of the cortical and medullary substances of the gland in 
an uninterrupted current. But two accidents may happen. 
The foreign admixture may be too large to pass easily. Then 
there will be stagnation, irritation, either in the fascia or the 
trabecles of the substance. The circulation of the blood capil- 
laries will be stopped by pressure, swelling will ensue, pro- 
liferation take place, the circulating lymph mix with white 
corpuscles from the lympli-spaces and the stagnating blood- 
capillaries, and an abscess, either intra- or peri-glandular, result. 
Where this is not the end, the foreign material will be retained 
inside the fascia, in the connective tissue, or the dilated lymph- 
ducts of the cortical substance. Thus the coloring matter of 
injected liquids has been found safely stowed away in this ex- 
ternal part of the gland, without entering the circulation. Thus 
the gland, with or without being much disturbed in its own in- 
tegrity, may form a receptacle for noxae swimming with the 
lymph current. Thus syphilitic or other poisons deposited in 
the gland may be suspended in their injurious consequences, 
or when their presence results in irritation and speedy sup- 
puration. Thus they may be eliminated by the timely opening 
of an abscess. 
The glands may be engorged even when the foreign material 
is not excessive in quantity, but only highly irritating in charac- 
ter, by being of a heterogeneous nature; no matter whether 
chemical or parasitic. In cadaveric infection the axillary glands 
will swell to fifty times their original size, they and not the 
cubital glands, forming the first depot for the majority of the 
lymph-ducts of the fingers. Thus the glands of the neck swell 
in diphtheria in a few hours to an unseemly extent. To a certain 
degree this swelling must be expected to take place whenever 
anything irritating enters the lymph circulation ; the irritation 
of a simple nasal or oral catarrh results in gradual swelling of 
the neighboring lymph glands, and many a case of presumed 
scrofula diagnosticated from glandular enlargement finds its 
ready explanation in the existence of a chronic catarrh of the 
nose, or protracted uncleanliness of the mouth. But when 
irritaments are very small, and very numerous, large numbers Pathology and Therapeutics of Diphtheria. 
19 
may be swept into the general circulation before resulting in 
local swelling. When they are very small, and not very numer- 
ous, they may pass the lymph ducts and glands for days, and 
perhaps weeks, resulting in general poisoning rather than in local 
disturbance. Thus the poisonous detritus, whose elements are 
ten or twenty times smaller (if at all measurable) than lymphoid 
corpuscles, may fluctuate to and fro through the blood, interfere 
with general nutrition, stagnate in the slow side circulation of 
the white corpuscles in the smallest blood-vessels, increase ra- 
pidly, emigrate, form deposits, purulent, septic, and gangrenous, 
and disintegrate tissue to any extent, before local symptoms are 
diagnosticated. Not infrequently do we find, that the very 
mildest cases—apparently—result in the most severe attacks. 
Sudden collapse and death in diphtheria is generally observed 
in alleged mild cases, such as I have mentioned fourteen years 
ago, and it has been my experience and that of many observers, 
that paralysis will occur in the convalescence in the same class. 
Thus the question of mildness and severity of local or gene- 
ral affection appears still shrouded in mystery. 
Is diphtheria principally a local, or principally a general 
disease ? Or which form of the two is the more dangerous one ? 
In 1860 {Am. Med. Times, Yol. I. p. 95) I used the following 
wrords, which express the opinion, I believe, of many of my 
professional brethren : “ Diphtheria is a general disease; it 
has local deposits, it is true, but in the same manner that scarla- 
tina will localize itself on the skin, mucous membrane of the 
Bellinian canals, etc.—measles on the skin and the mucous mem- 
brane of the respiratory organs, or typhoid fever on the mucous 
membrane of the intestinal tract.” In most of its bearings the 
question is, in my opinion, an idle one. Any injury to the 
system has to pass in through a specified locality. The difficulty 
to decide through which, is perhaps best illustrated by the dis- 
pute concerning the typhoid noxa entering the organism 
through either the lungs or stomach. In some cases there is 
no dispute; whooping-cough is admitted to prove contagious 
by entering the lungs. Nor is there much dispute on the 
admission of diphtheria into the system. With the rare excep- 
tion of those cases in which the vaginal mucous membrane, 
or denuded cutis or the intestinal mucous membrane proved the 
first seat of infection, we meet it first on the respiratory mucous 20 
Jacobi : Contributions to the 
membranes or where respiratory and digestive mucous mem- 
branes cross. In the large majority of cases we iind local 
changes as soon as called to see a new (rase, together with, or 
in preference to, general symptoms. Seldom are there the 
latter, particularly fever, without some of the former, viz., that 
class, which more than fourteen years ago, I described as “ diph- 
theritic fever.” Taken for granted that the latter cases exist, how 
do they originate? The morbid matter, chemical or parasitic, 
unless retained before descending so far, enters with respiration 
into the pulmonary alveoli. Their surface, if spread out, would 
cover 2,000 square feet, under which the immense lake of blood, 
amounting to one-fifth of the whole weight of the body, is 
brought into contact with five thousand quarts of air every 
twenty-four hours. Gaseous, or chemical, admixtures of a 
poisonous character find no difficulty in entering the circulation 
as easily, or nearly so, as air. The only separating line between 
the atmosphere and its contents on one side, and the blood lake 
on the other, is a single layer of epithelium (sometimes absent), 
of the alveoli, of 0.003 to .004 lines in thickness, spread over 
an elastic basement membrane, behind which capillaries of 
0.003 to 0.005 lines in thickness are found. All the epithelia 
of the respiratory organs are cylindrical and vibrating, and 
as such not apt to permit of an easy entrance of foreign sub- 
stances into the smallest ramifications of the bronchi. Their 
function of and success in removing large masses of mucus 
from the bronchi, in an upward direction, would alone make us 
infer that the admission of specific solid poisons into the blood 
through the respiratory organs was not an easy matter or fre- 
quent occurrence. At all events, such elements cannot be swept 
through epithelia lining alveoli and capillaries with the same 
facility as through air, and the relative slowness with which 
changes in the epithelium of visible mucous membranes are apt 
to take place, renders the rapid absorption of poisons through 
lung epithelium somewhat doubtful on the hypothesis that these 
poisonous germs were really bacteria. 
Thus we should say that in all cases in which a patient is 
taken ill suddenly, or pretty suddenly, in the course of a few 
hours, or a day, after having enjoyed entire health, with a high 
fever and some diphtheritic deposit ; remains , sick for half a 
day or a day, or even two, with the same fever, which then Pathology and Therapeutics of Diphther ia. 
21 
rapidly diminishes and leaves him fatigued and feeble for a few 
more days, until in the course of five or seven days he feels 
perfectly well again, we should say that such a case of sudden 
attack and sudden elimination of the noxa must positively bo 
the result of a gaseous substance or of one soluble in the fluids of 
the human organism, and not of a solid body. And these are no 
hypothetical cases, they are to be found every day. It is true 
they are not all of the same kind; nor is, for comparison’s sake, 
scarlatina. There are rapid cases, slow cases, high fever, 
low temperatures, large deposits, minute plaques. There is no 
case which would exclude the possibility of a sufficient expla- 
nation on the theory that we have to deal with a gaseous or 
liquid substance, whether complicated with or attached to 
bacteria or not, is indifferent, but there are at all events some 
—just such as I have mentioned—which cannot be explained 
by the bacteria theory as well. 
Other facts might be explained by it, as by the gaseous poison 
theory. The facility of deposits on prominent elevations, such 
as the tonsils, would occur in both. The resistance of the 
vibrating epithelium of the nose to diphtheria is explainable by 
both. Inhalation takes place through the nares principally, and 
still while we have a great many cases of nasal diphtheria in the 
epidemic of this year, Ave can almost always prove the case to 
have originated in the pharynx, and ascended. Primary nasal 
diphtheria is but rare, for the pavement epithelium of the lower 
portion of the nose is so near the surface, and so frequently in 
contact with mucus, etc., that the first deposit will not take place 
there. Facts like the following will admit either theory. 
Two boys in a family were taken Avitli symptoms of diphtheria 
at the same time. One evening the one had slight fever, and 
severe headache, the other without fever, a deposit on the left 
tonsil, which Avas by far the larger of the two. In him both 
tonsils had been known to be large, in his brother they Avere 
small, hardly visible. Next morning the one had a deposit on 
his tonsils in addition to his fever and headache, the other 
and headache in addition to his diphtheritic membrane. 
Fever is not the only symptom resulting from the direct rapid 
introduction of an irritating material into the blood. In fact, it 
is safe to assume that high fever—individual peculiarities always 
excepted—results from rapid absorption of large quantities 22 
Jacobi: Contributions to the 
only; provided again, that they are of an irritating character. 
For even septic processes run their entire course without, in 
many instances, a serious elevation of temperature. Not in all 
cases, however, have we to deal with large quantities of poison 
and rapid introduction *into the blood. What, in my mind, 
points to a slow absorption through the blood, of more or less 
of the poison, and to its distribution to certain centres or lo- 
calities, are the cases of gradual or sudden collapse and paraly- 
sis. The first case of collapse 1 ever observed has been pub- 
lished in the first vol. of the American Medical Times, p. 95. 
A healthy and robust boy of four years complained of some 
pain in swallowing, and appeared languid and sleepy. It was 
in the autumn of 1857, and no epidemic of any kind prevailed 
in the city at that time. The child did not appear to be very 
sick; there were very few local symptoms in the throat, a little 
tumefaction of the tonsils, no particular oedematous swelling, no 
unusual degree of local liypersemia, but several small patches 
of membrane on either tonsil. Pulse ninety, feeble. Moderate 
temperature of the skin, extremities not cold, skin rather dry 
and flabby. The child was listless, indifferent, took some food 
as a matter of course without longing or asking for it. No 
local pain anywhere, except a slight uneasiness on pressure ex- 
ercised on the tonsils; bowels rather constipated. Questions 
were answered intelligibly, but indifferently and slowly. Pu- 
pils reacted to the light. No cerebral symptoms whatever, ex- 
cept the slowness of mental function alluded to. No diagnosis 
except that of pharyngeal diphtherite, as I had not seen a case 
of general diphtherite at that time. No particular change next 
day, nor on the third, with this exception, that the child grew 
more and more indifferent, listless, and melancholy, cared little 
for anything that was done to rouse and ease him, and ap- 
peared to have no desire for or objection to anything. The 
pharyngeal membranes extended somewhat, but not over a sur- 
face of more than two-thirds of an inch in diameter. No pro- 
gress downwards, no affection of the respiratory organs, no dys- 
pnma. No appreciable change had taken place on the morning 
of the fourth day, except that the general adynamic condition 
of the child was increasing. Thus it kept on, although the 
child took some food, uttered a few words now and then, an- 
swered questions, and retained apparently the full amount of Pathology and Therapeutics of Diphtheria. 
his intellectual faculties. The temperature decreased, the pa- 
tient sank more rapidly, and died in the afternoon; no dys- 
pnoea, no perceptible cause of death. Extinction of life like a 
tire slowly extinguished from want of fuel. Post-mortem exam- 
ination yielded but negative results. Iso organ abnormal; 
general anaemia. Little blood in the vessels, thin, and of a dark 
color. No diphtheritic membrane in any part of the body ex- 
cept in the pharynx. 
I look upon the result of that post-mortem examination as 
very incomplete. Changes in the tissue were not examined or 
noticed. It was seventeen years ago, long before Zenker and 
his successors had discovered and described the granular de- 
generation and parenchymatous inflammation taking place in 
most tissues in all kinds of feverish, and particularly infectious 
diseases. The only important symptom mentioned is the dark 
color and thin consistency of the blood. The same condition 
has since been found by other observers in cases of sepsis and 
sudden death; also extravasations, fragility and granular de- 
generation of tissues, sometimes accumulation of cells and 
nuclei between the fibres. Hiller and Mosler emphasize in 
such cases the degeneration of the heart muscle ; others, coagu- 
lations in the heart, resulting either from insufficient contraction 
of the heart itself, or from floating thrombi which were formed 
in distant veins suffering from the general circulatory weakness, 
sometimes from thrombi formed in the small veins of the neck 
during the efforts of croupous respiration. Others look for the 
explanation of the sudden death in the interrupted innervation 
of the heart. Either the pneumogastric or the sympathetic 
nerve may be affected,’and the symptoms may vary accordingly. 
A paralyzing influence working in the tissue of the former will 
accelerate the pulse; a degeneration of the sympathetic heart 
ganglia renders it slower, and death may finally occur in either 
condition. It is the same apparent incongruity of symptoms, 
easily explained, however, which we notice is the common form 
of fatty degeneration of adults. 
We must look upon the changes leading to death, in the 
majority of such cases, as of the same character, although of 
different degree, as those belonging to diphtheritic paralysis. 
It is frequently accepted that the poisonous material, parasitic 
or chemical, exerts a local influence upon a nerve, or a set of Jacobi : Contributions to the 
24 
nerves. Oertel, whose article on diphtheria in Ziemssen’s Cyclo- 
paedia has suddenly obtained amongst us a notoriety which in 
my eyes it but partially deserves, takes for granted that diph- 
theritic paralysis is a progressive peripheric paralysis. lie 
claims that every case begins in the pharynx, admits, however, 
that diphtheritic paralysis exhibits a very unsteady character, 
can return to a nerve territory which had recovered, and attack 
distant territories at once, or gradually. I do not believe that 
every case of diphtheritic paralysis, many of them appearing 
when convalescence is fully established, can be explained in 
the same routine manner. Many of them may be, as they ap- 
pear to be, identical with the cases of paralysis after typhoid 
fever, variola, dysentery. In some the paralysis has certainly 
crept away, as it were, from the first attacked mucous mem- 
brane, in others it results from fatty or granular degeneration 
of muscular fibres (Buhl), or from capillary hemorrhage and 
waxy disintegration. In some the affection is decidedly cen- 
tral. Thus nuclear proliferation and hemorrhage have been 
found in the spinal ganglia by Buhl, in the gray substance of 
the spinal chord, even disseminated myelitis by Oertel. In 
many it may be due to the facility with which nutritive disor- 
ders, local effusions and extravasations occur in conditions of 
general hydrsemia, and insufficient restoration of the blood- 
vessels, when the progressing convalescence ‘invites to undue 
over-exertions of the heart. In former years I inclined to ex- 
plain every case of diphtheritic paralysis upon view. But in a 
large percentage of cases of diphtheritic paralysis I attribute 
it to the presence of the morbid substances in the blood and 
nerve, into which they were received through the lungs, slowly, 
without much feverish excitement, without many local symptoms 
about the pharynx or nose. The more fever, the more rapid 
elimination of the poison. This hypothesis is more than merely 
plausible for several reasons. It is a frequent experience that 
paralysis will follow a case of diphtheria with pharyngeal or 
nasal symptoms, when but little developed. Where they are 
well marked the temporary paralysis of the soft palate, which 
Oertel takes as the regular starting-point of the affection, is 
frequently observed. It results partly from oedematous suffu- 
sion of the tissue, partly from diphtheritic affection of the motory 
branches of nerves distributed in them. But serious paralysis of Pathology and Therapeutics of Diphtheria. 
25 
distant nerves will rarely follow. On the contrary, the paraly- 
sis of the superior and inferior laryngeal, the ciliary, facial, 
the optic, the spinal nerves of both trunk and extremities, are 
usually met with after cases of diphtheria, which ran their 
course in a short time and with but few local symptoms. The 
very fact that the paralyzed nerves need not necessarily belong 
to the same neighborhood or territory appears also to prove 
that the circulation is the highroad on which the poison enters 
nerve-centres, or peripheries, without regard to tonsils or pal- 
ate. While Oertel, then, assumes that bacteria mine their way 
through the tissue, I find it easier to believe, and more in ac- 
cordance with clinical experience, to assume that a slow admit- 
tance of the poisonous elements to the blood, in constant suc- 
cession but relatively small numbers, yields a readier explana- 
tion of that much dreaded symptoms.1 
The questions regarding prognosis are twofold. 
1. Which class of persons are apt to be infected with diph- 
theria ? 
2. Which class of cases are apt to prove serious or fatal ? 
1st. Most infectious and contagious diseases are observed 
amongst infants and children. Scarlatina, measles, hooping-cough, 
diphtheria, are mostly seen at that period of life. Typhoid 
fever is not a rare disease; but it is as frequent in adults as in 
children, and more serious. In the new-born it is exceedingly 
rare; there are but four doubtless cases on record. The fifth 
1 Let me here illustrate my opinion of Oertel’s article, which is by no 
means his best work, nor even an addition to our knowledge of diphtheria— 
after his own previous and other elaborate researches—but has done more 
than anything else to make his name known amongst the profession, and the 
public who are never satisfied with anything less than a surprise, or a panic. 
I allude, as an instance of his methods of reasoning and teaching, to his re- 
marks on the treatment of diphtheritic paralysis. He recommends the in- 
terrupted and the galvanic current, warm salt-water, sea and sulphur bathing. 
Of internal remedies he rejects nux vomica, declares it to be positively inju- 
rious, and in its subcutaneous administration abominable. And why ? Nux 
vomica acts through the nervous centres only,therefore, “ at the best,” it injures 
the patient. May we ask : What does nux at its worst when “ at its best” 
it injures the patient ? Besides, the theory of the efficacy of nux is not so 
safely established that it can subvert general experience. And general expe- 
rience is in all countries unanimous in the praise of nux in cases of diphthe- 
ritic paralysis. This is one of the remarks in which our author’s clinical ex- 
perience is insufficient, and, at all events, inferior to his powers as a histo- 
logical observer and describer. 26 
Jacobi: Contributions to the 
was reported by me, and specimen of intestine shown—baby 
died when sixteen days old—two years ago in the Obstetrical 
Society. Throughout childhood the cases are mild, getting 
more severe with advancing age. I believe this is so, because in 
very early infancy part of the lymph system, particularly Peyer’s 
plaques, are very undeveloped, and because of the superficiality 
of inhalation, probably also because of the rapid metamorphosis 
which enables infants to rid themselves, while slow infection is 
going on, of a large portion of the noxa. Measles, scarlatina, 
hooping-cough, are rarely met with beyond the age of twelve 
or fourteen, because of their having occurred before, and their 
return being but exceptional. Diphtheria is rare under eight 
or ten months of age. more frequently before the third, than 
between the third and sixth or seventh month. Childhood is 
more liable because of their greater softness and moisture of 
tissue, their larger number and size of lymph-vessels (Sappey 
emphasizes the fact that in the young the lymph-ducts of the 
pharynx are easier to inject than in the adult), their greater 
tendency to nasal, and especially to mouth catarrh—from want 
of cleanliness, as far as removal of nasal mucus and remnants of 
food is concerned, and principally because of the excessive rel- 
ative size of the tonsils. There are few infants and children 
where the tonsils do not overlap the pillars of the palate ; the 
roominess of the fauces is relatively little; these large tonsils 
cease to be annoying only when toward puberty, the fauces 
enlarge without contemporaneous enlargement of the tonsils. 
Infants from two to eight months are almost exempt from 
diphtheria because of the large amount of secretion, slightly 
acid, in their mouths. Even thrush, with its oidium albicans, 
is rare at that age; transmigration, or rather attachment of 
immigrating poisoning substances being prevented by this 
acid.1 The majority of cases below seven or eight months, 
which have come under my notice—two cases of pharyngeal 
and laryngeal diphtherite in the newly-born included—were 
under two or three months. Liable to be infected are further 
1 It is probable that the diphtheritic poison attacks the conjunctiva so rarely 
for the same reason, viz., because of the copious lachrymal secretion. It may, 
however, be merely accidental that I have seen more cases of conjunctival 
diphtherite twelve or fifteen years ago than at present. It is probable that 
such patients avail themselves at once of the increased facilities for the treat- 
ment of eye diseases. Pathology and Therapeutics of Diphtheria. 
all those whose mucous membranes, respiratory and digestive, 
that have been in a condition of chronic catarrh. Catarrh of 
the mouth, with caries of the teeth, pharyngeal and nasal 
catarrh, congenital and acquired enlargement of the tonsils, ex- 
posure to cold air, to inhalation of dust, excessive screaming, 
cauterization, are just as many invitations extended to the diph- 
theritic poison. 
Which locality yields the better or worse prognosis ? Affec- 
tion of the tonsils is decidedly favorable ; of the larynx, for 
reasons amply set forth, decidedly grave, almost always fatal ; 
of the nares grave. The narrowness of the infants and child’s 
larynx induces suffocation ; the adult larynx is large enough to 
permit the diphtheritic deposit to assume a septic character. 
But once in my life have I been called upon to perform 
tracheotomy in an adult for membranous croup. The nares 
have been spoken of as dangerous ground. The large number 
of lymph-ducts, and neighborhood of lymph glands, the large 
number of superficial blood-vessels, and the facility of absorp- 
tion, the liability to putrefaction through exposure to moisture 
and air of all the contents of the nasal cavity, and the inhalation 
and of the fetid smells, explain the fact of nasal diphtherite be- 
ing so grave. But it shows unacquaintance with the facts, as in 
Oertel’s essay alluded to before, when lie assumes that it is al- 
most always fatal, and unacquaintance with the proper treat- 
ment on the part of a celebrated Paris authority, when he was 
heard to say in his wards, but a few years ago, that nasal diph- 
theria was always a fatal malady. It is apt to be so when 
not properly treated ; its mortality is not grave, when timely 
and regularly attended to; but this attention must be timely 
and punctual. 
Which form of the disease is the most grave? Next to the 
attacks involving laryngeal obstruction, ranks the septic and 
gangrenous form of diphtheria, whose dangers are in propor- 
tion to the rapidity of absorption and inhalation. But the mild 
form may change into the sevei-e, and therefore the prognosis 
is never a safe one, until the process is fairly near the end of 
its full course; and then even relapses may take place. 
The condition of the general system is of great importance. 
Large wounds are liable to become diphtheritic. I have lost 
two patients of wound diphtheria after exsection of the hip- Jacobi : Contributions to the 
joint; one was taken while in fair recovery, in the third week 
after the operation ; one was attacked, a day after the opera- 
tion, with scarlatina and diphtheria. General an semi a is a bad 
complication, as is also starvation during the course of the 
disease. In a condition of hunger or abstinence the absorbing 
lympli-vessels are found full and active, and the chyle-vessels 
empty. During digestion the latter are full, the former empty. 
Low or high temperatures, when observed but once, give no 
special prognosis. Of low temperatures in dangerous cases I 
have spoken before. High temperatures and other grave reflex 
actions, vomiting, convulsions, may occur without meaning 
much harm unless they last long. A few days ago the first 
temperature taken by Dr. Conrad in the axilla of an adult and 
robust patient, who had complained since the previous evening 
only, was 107°. The local deposit was but small. In eighteen 
hours the temperature was 102°, in a few days normal ; evi- 
dently elimination was as prompt as the absorption of the poison. 
In such cases a vigorous action of the heart is surely as positive 
a safeguard as is a feeble circulation a danger. 
Liability to glandular swelling, or the presence of enlarged 
glands, with a tendency to press on the jugular vein, tends to 
increase cerebral symptoms. Complication with measles or 
scarlatina is frequent, especially with the latter. The course 
generally taken by diphtheria complicating these diseases illus- 
trates beautifully the tendency arising from previous conditions 
of the mucous membranes. Diphtheria in measles, with its 
catarrh of the respiratory organs, is apt to terminate in mem- 
branous croup of the larynx; putrid bronchitis, however, is rare 
because of the very antiseptic character, to a certain extent, of 
carbonic acid. Scarlet fever, however, with its localization on 
the digestive mucous membranes, is but rarely followed by 
laryngeal diphtheria, while the malignant forms of throat 
diphtheria are numerous. 
Hemorrhages from the throat prognosticate badly. They 
prove destruction to a certain depth, and prophesy a rapid 
progress of the process, perhaps with absorption. Fortunately 
the number of such cases is but small, and a goodly number of 
them even, as long as no general purpura sets in, are not fatal. 
Pneumonia is a serious complication. Of its presumed 
origin from immigrating bacteria I have spoken. Broncho- Pathology and Therapeutics of Diphtheria. 
29 
pneumonia may result from atelectasis (as oedema from swelled 
blood-vessels) in the impeded respiration of laryngeal croup. 
Pneumonia may result from the aspiration downwards of 
decomposed materials. Embolism results from thrombi in 
small veins, either near the larynx in croup,or in other parts from 
debilitated circulation, or by portions of a heart clot torn away. 
Nephritis is not an unfrequent complication, although albu- 
minuria is more so. The presence of albumen is frequent 
enough. It may result from high temperature only, and then 
contains but few or no tissue elements, or from swelling and 
fatty degeneration of the kidney epithelium, as in other acute 
infectious diseases, or from venous stagnation during the course 
of membranous croup. 
If, at the conclusion of this paper, I venture to speak of the 
therapeutics of diphtheria, I may be permitted to say a few 
wrords in my excuse for appearing commonplace and trite. For 
in truth, the remedies which I use are so simple in character and 
so few in number, that I should hardly risk to speak before you 
were it not that I feel that I have always tried to stand on the 
safe ground of a sound pathology. Many a case of diphtheria 
I have not attended, because I believe I have prevented it. I 
do not speak of those members of a family who if exposed 
would have fallen sick, but who were protected by isolation 
of a patient under the same roof. I speak principally of 
the preventive apparatus in the hands of every family practi- 
tioner. I look after the mouth and pharynx of the children in 
my acquaintance as a regular thing. Eruptions on the head 
must be removed, and glandular swellings around the neck 
thereby cured or prevented. The same is done for nasal catarrh 
and catarrh of the pharynx in the good season, where the prog- 
nosis of your treatment is more propitious. Hypertrophied ton 
sils must be exsected at a time when no diphtheria prevails. 
For at such times every wound is apt to become diphtheritic ; 
and hardly any operation inside of the mouth will heal without 
turning diphtheritic. For the same reason I postpone any sort 
of bloody operations during the epidemic of diphtheria, if barely 
possible. But lately I have seen the wound of an operation for 
cystocele, performed by one of our most prominent operators, 
in a house where there was no diphtheria before, to turn diph- 
theritic and jeopardize the success of the operation. Jacobi : Contributions to the 
As a further means of preventing disease I may at this junc- 
ture speak of a remedy. I allude to chlorate of potassa and chlo- 
rate of soda. I cannot say that I place much reliance on it as 
a remedy in diphtheria, and still I give it in almost every case. 
The chlorate is the remedy eminently fit for most sorts of 
stomatitis. The large number of cases of stomatitis and pharyn- 
gitis during a period of diphtheria, and their usual complica- 
tion with and initiation of the diphtheritic process justify and 
require its use. I give it, then, for its effect on the inflamed 
mouth and pharynx, hut not for diphtheria. It acts as a preven- 
tive by returning the mucous membrane to a normal condi- 
tion. Nor do I administer much more in cases of mild tonsillar 
diphtheria. As this is a benign affection, it is of greater im- 
portance to prevent it from spreading than to remove it from 
the tonsils, where its communication with the systems of blood 
and lymph vessels is so very limited. In order to have the full 
effect I insist upon frequent administration. Doses ought to 
follow each other in rapid succession. At least every hour, 
every half-hour, every quarter of an hour sometimes, ought 
a small dose to be given to keep up a constant contact of the 
endangered mucous membrane with the remedy. From half a 
drachm to a drachm may be given during the twenty-four 
hours. As many families are acquainted with the remedy, and 
use it without being bidden, see to it that the dose is not too 
large. The death of Dr. Fountain, of Davenport, Iowa, and 
many others from overdoses of chlorate of potassa ought to be 
heeded. 
My views on the treatment of diphtheria have been framed 
in strict accordance with the opinions I have expressed in re- 
gard to its pathology. Although finally a constitutional dis- 
ease, it is at the beginning nearly always local, or, in other 
words, infection enters the blood at a limited portal, which is 
the same in the great majority of cases. From this point of 
view constitutional diphtheria is analogous to the septicaemia of 
wounded men and of puerperal women, and the local disinfection, 
which has been accepted as the sheet anchor in the treatment 
of these affections, must be also the main reliance in that under 
consideration. We may congratulate ourselves upon this fact, 
since we do possess some positive knowledge in regard to the 
disinfection of accessible putrid fluids, while it is safe to say Pathology and Therapeutics of Diphtheria. 
31 
that as yet we have no proof of our ability to disinfect the 
blood of the living body. We seem indeed to be able to some 
extent to increase its power of resistance to the action of poi- 
sons that have been absorbed into it, but we cannot affirm that 
our remedies act by destroying the poisons themselves. I shall 
refer to this again in speaking of quinine. 
Local remedies may be divided into three classes. 1st, those 
which dissolve the false membranes, and thus facilitate their 
removal. 2d, substances modifying the surface from which 
the membrane has been removed. 3d, disinfectants, equally 
capable of arresting chemical changes, and of destroying ani- 
malcular life," and applicable therefor, whichever theory be 
finally adopted to explain the infectious properties of the diph- 
theritic exudation. 
1st Class.—The rapid solubility of the false membranes is 
chiefly important when they occupy the larynx, and thus in my 
paper on croup I have dwelt especially upon this class of 
agents. Those which still hold the first place are lime-water, 
glycerine and moist heat. The latter is claimed to be particu- 
larly effective. I admit it softens pseudo-membranes like any- 
thing else, furthermore it may increase the secretion of acinous 
glands, and thereby raise and expel membranous deposits. 
But the fact that it softens healthy tissue as well as morbid ex- 
udations appears to facilitate the penetration of the poison into 
deeper layers. Both of these theoretical views ought to be re- 
membered to guide the practitioner in an individual case. In 
the majority of cases the application of ice will be found more 
in accordance with the requirements of the secondary inflamma- 
tions and enlargements. 
The remedies in the 2d class that have been most largely 
employed are, with the exception of chlorate of potassa, all 
more or less astringent. It is a noteworthy fact, however, that 
the pure astringents, alum, tannin, nitrate of silver, formerly 
employed in diphtheria, and still retained in the treatment 
of simple catarrhal pharyngitis, have been generally abandoned 
as remedies for the exudative disease. Oertel objects to astrin- 
gent parades on the theoretical ground that, instead of facili- 
tating the separation of false membranes and the destruction 
of micrococci, they tend to arrest the formation of pus, and 
even favor the wandering of the infectious elements into the Jacobi : Contributions to the 
submucous tissues. From what has already been said, it is 
plain that I do not commit myself to this, or to any other 
theory of Oertel’s, but I am willing to admit that experience 
has pronounced against the efficacy of the pure astringents, and 
for my own part I never employ them. 
But the substance which to day is ranked among the most 
powerful of all astringents, the perchloride of iron, is, on the 
contrary, a remedy which, when suitably handled, most decidedly 
merits confidence. Muriate of iron was first employed in 
diphtheria from an alleged analogy between this disease and 
erysipelas, in which this drug had been found to render real 
service. It was used in France by Velpeau, and in England 
in 1851 by Hamilton Bell, in the treatment of erysipelas, being 
applied locally, and also administered internally. In 1858 
diphtheria was treated by the perchloride in France by Gigot, 
and the following year by Dr. Crichton in Scotland. In 1865 
a report was made in Melbourne, Australia, by Bi chard son, of 
220 cases of diphtheria, observed during a period of seven 
years, and treated since 1861 exclusively by full doses of the 
muriate of iron, together with chlorate of potassa in powder. 
The number of deaths was 18, or 8.2 per cent., very little in 
excess of that of measles. Since these first experiments 
British and American Journals have abounded with reports of 
success obtained bv the perchloride of iron, and in a recent 
monograph Schaller has asserted that “the dilute muriate of 
iron is to be preferred to all other remedies in diphtheria.” 1 I 
have extensively used that remedy myself, have, in fact, men- 
tioned it amongst those employed by me, in the first paper of mine 
alluded to before, after some considerable experience with it 
extending over the years 1858, 1859 and 1860. 
The mode of administration of the muriate is of the utmost 
importance. To insufficient doses, or careless applications, 
may be traced many of the cases of failure. Thus Steiner of 
Prague is believed to have refuted Schaller’s assertions by 
experiments on four children, to whom was administered hourly 
a teaspoonful of a mixture containing five to eight drops of 
the tincture to three ounces of water. Local applications were 
made three and four times a day of a mixture containing thirty 
drops to two ounces. The two youngest children, one and three 
1 Reviewed in Schmidt’s Jahrb. 149, p. 339, 1871. Pathology and Therapeutics of Diphtheria. 
33 
years old, died by extension of the disease to the larynx, the 
two others recovered. 
To be of any efficacy muriate of iron must be given in large 
doses frequently repeated. From five to fifteen drops every 
quarter, half, or every hour, is a dose that alone fairly tests 
the effective powers of the medicine. Gargles and direct 
applications to the pharynx may be dispensed with, and their 
irritating effect avoided, since the throat is sufficiently washed 
by swallowing. According to the testimony of all observers, 
and with which my own observations concur, the muriate does 
not facilitate the separation of membranes, but seems to act 
upon the surface from which they have been removed, lessen- 
ing the hypersemia, reducing the swelling, and seeming to limit 
the reproduction of the exudation. But how does the action of the 
perchloride differ from that of any other astringent ? Although 
all astringents coagulate albumen, there is no question but what 
the albuminate formed differs notably in different cases. In 
some comparative experiments, made before the class of the 
Woman’s Medical College of the Infirmary of New York by 
Dr. Mary Putnam Jacobi upon the white of egg, with alum, 
tannin, creasote, acetate of lead, carbolic acid, and per- 
chloride of iron, marked differences were observed in the 
density of the coagulums formed. The tannin produced a 
cloudy, diffused coagulum; carbolic acid also a diffused 
coagulum, but only after one-lialf a minute; alum a tenacious 
clot that sank to the bottom of the test-tube without increasing 
in size ; three drops of creasote instantaneously formed three 
dense curds, each of which sank separately, increasing in size 
like a rolling snowball; perchloride of iron gave a layer of 
coagulum a few lines in thickness that sank very slowly, leav- 
ing the fluid clear above it. When subcutaneous veins were 
exposed on a living rabbit, and touched with a drop of per- 
chloride, no visible effect was produced for over a minute ; 
then they were seen to markedly diminish in calibre; while a 
drop of creasote formed a coagulum that instantly obliterated 
the vein by compression. This second effect was mechanical; 
the first implied that the perchloride acted by exciting the vital 
contractility of the blood-vessel. 
Nitrate of silver, which when applied to a mucous or a serous 
membrane is reduced and deposited in the albuminous cement 34 
Jacobi : Contributions to the 
between the epithelial or endothelial cells, cannot be compared 
in its action to the perchloride of iron, or rather this latter 
cannot be compared to it. It seems probable that one of the 
first ways in which the muriate modifies the diseased mucous 
membrane is by reawakening the contractility of the paralyzed 
blood-vessels. The restoration of their tonus would itself di- 
minish the rapidity of putrid absorption by the lymphatics, 
which we have seen to constitute the great danger of the dis- 
ease. 
Has the perchloride of iron any more direct effect upon the 
lymphatics % 
Such an effect, which was clearly or vaguely assumed when 
the muriate was transported from the therapeutics of erysipelas, 
with its predominant inflammation of the cutaneous lympha- 
tics, would indeed be a grand desideratum. It must be con- 
fessed, however, that we know little about the matter at 
present, although from analogy we may believe that a local 
astringent to blood-vessels would not leave the dilated lympha- 
tics uncompressed. Such compression would oppose a power- 
ful obstacle to the free course of the poisonous particles that are 
streaming onward towards the torrent of the circulation. 
The perchloride of iron, like the sulphate, is a tolerably 
powerful disinfectant. It is well known that all astringents in 
sufficiently large doses are disinfectants, and some of the best dis- 
infectants, as creasote, are powerfully astringent. It was used in 
the treatment of wounds by Nunnely, and is strongly recom- 
mended by Beale, especially when associated with glycerine, as 
a most powerful antiseptic. According to this author, it acts by 
arresting the growth of bioplasm, which constitutes the soft, 
pulpy, unhealthy masses that cover ulcerated surfaces. It is 
equally capable of arresting the movements of bacteria and 
micrococci, or of coagulating albuminous ferments, so that its 
action is conceivable according to either of the three great 
reigning theories of local putrefaction. 
In experiments on the disinfection of London sewers, 2.27 
litres of chloride of iron were found sufficient to deodorize 30,- 
000 litres of foul water; while for the same purpose 1.36 
kilograms of chloride of lime and 36.35 pounds of lime were 
required.1 The chloride of iron was included long ago in 
1 Schmidt, Yol. 133, p. 122. Pathology and Therapeutics of Diphtheria. 
35 
Chevallier’s list of disinfectants, and is ranked, with other 
metallic salts, by Herbert Barker, among those substances which 
chemically destroy the noxious body.1 
It is unquestionable, however, that the internal administra- 
tion of the perchloride is of at least equal importance with its 
local application. The absorption of the muriate of iron into the 
blood, and its action after absorption involves many problems 
that are as yet imperfectly solved. Several interesting sugges- 
tions have been made, however, that are worth considering in 
the bearing on our subject. 
1st. It has been said that the perchloride was decomposed 
immediately after injection, and that the hydrochloric acid 
alone entered the circulation. But the free acid has not been 
detected in the urine any more than the entire salt. There is 
reason, on the contrary, to believe that the perchloride is ab- 
sorbed, and with unusual rapidity, directly from the stomach, 
the subsequent appearance of iron in the faeces being due to 
the re-elimination of the metal by the intestines. 
2d. Quincke2 found that, by injection of the perchloride of 
iron directly into the veins of animals, emboli wTere rapidly 
formed in the pulmonary vessels by coagulation of the blood.3 
But if the injection was made very gradually, so that the con- 
ditions more nearly corresponded to those of absorption from 
the stomach, only very minute precipitates were formed and 
taken up by the white blood corpuscles, existing in great 
abundance in them. This observation, if accurate, may be of 
importance in explaining the effect of the muriate in septic 
diseases, accompanied by increased activity of the lymphatics, 
and an excess of white blood corpuscles. 
3d. Saase4 has modified the common opinion in regard to 
the influence of iron and the oxydation of the blood, by as- 
cribing to iron salts the property of converting oxygen into 
ozone. In the circulation they share this property exclusively 
with the blood corpuscles, and hence are able to supply their 
1 On Deodorization and Disinfection, Hastings Prize Essay. 
2 Arch, fiir Anat., 1868, Schmidt, Bd. 143. 
3 Dr. M. Putnam Jacobi has observed the same thing in fifteen minutes 
after ingestion of large doses of solution of tannin. Experiments not pub- 
lished. 
4 Schmidt, Bd. 126, 1865. 36 
Jacobi : Contributions to the 
place to a certain extent. “ Until oxygen lias been ozonized,” 
observes Saase, “ it is as useless for the purposes of respira- 
tion as pure nitrogen.” 1 
That iron increases the oxydations in the body has been 
shown by Pokrowsky, who proves that even in health the heat 
of the body is raised and the amount of urea in the urine in- 
creased by its administration.2 In anaemic subjects these 
effects precede an}7 increase in the number of blood corpuscles, 
and hence cannot depend on their renewal. The iron does in- 
deed seem to partly supply their place. 
That such substitution, if effected, could not fail to be emi- 
nently useful in those poisoned conditions of the blood where 
the red blood corpuscles are incessantly menaced with destruc- 
tion is evident. 
4th. It has finally been affirmed that, among all the prepara- 
tions of iron, the perchloride is especially distinguished by a 
capacity for stimulating the nervous system; probably by in- 
creasing the arterial tension in the nerve centres. It is said 
that its remarkable efficacy in nervous chlorosis, as distinguished 
from true anaemia, is an illustration of this.3 If this be true, we 
may perceive another mode of action in diphtheria in assisting 
to sustain a nervous system incessantly threatened with local 
paralysis or general collapse. 
I pass to the 3rd class of local remedies, the disinfectants 
proper, especially carbolic acid. 
It would be quite superfluous in this place to relate or to 
criticize the vast mass of experiments that have been made to 
test the disinfecting properties of carbolic acid. Probably noth- 
ing is better proved in therapeutics to-day than the fact, that 
suitable solutions of carbolic acid will arrest putrefaction, kill 
bacteria and microzyma, and immobilize white blood corpuscles. 
The great value of carbolic acid as a local disinfectant in diph- 
theria, as in puerperal septicaemia, cannot be adduced as a proof 
that the local process depends on the presence of animal germs. 
These indeed abound in the mouth in the absence of any dis- 
ease whatever.4 But carbolic acid exercises a powerful action 
1 I have not had opportunities which would be sufficiently conclusive to 
test inhalation of pure ozone. 
3 Arch. Virch., Bd. xxii. 
3 See Anstie on Neuralgia. 
* Beale, Disease Germs, p. 290. Pathology and iherapeutics of Diphtheria. 
37 
on the life of all vital elements, and therefore upon that of the 
rapidly proliferating epithelium which constitutes the diphtheri- 
tic exudation. It has been experimentally proved to destroy the 
power of vaccine lymph. It is therefore probable that carbolic 
acid may also destroy the unknown poison of diphtheria. 
In regard to the antiseptic effect of quinine I think that, if 
exerted, it can only be by immediate contact with the false 
membrane, and not after absorption into the blood. In Binz’s 
experiments a solution of pure quinine was used, containing 
from 1 per cent, to 1 pt. in 1,000 of the alkaloid, and this suf- 
ficed to prevent the development of bacteria in putrescible fluids. 
But even in this smallest proportion a patient with 18 lbs. of 
blood would require to carry in his circulation 13S grains of 
quinine to realize the conditions of Binz’s experiment. The 
author himself insists that only 2 grms. = 32 grains a day should 
be necessary for a man of 120 lbs. weight, but this calculation 
is based upon experiments on dogs, where injections of quinine 
have averted septicsemic fever, and not on the experiments with 
putrid fluids. However, it is important to remember Binz’s 
assertion that, as an antiseptic and antipyretic, the acid sulphate 
is the worst preparation of quinine that can be used. 
In mild cases of tonsillar diphtheria I sometimes try to remove 
or to destroy the membrane where it is easily accessible. I 
insist upon this latter clause, because probang and solid stick 
and mineral acids have, in my opinion, done much more harm 
than good. Where I cannot reach the diphtheritic deposit and 
touch it thoroughly, usually with concentrated carbolic acid, I 
let it alone altogether. The experience is not new that abrasion 
of the mucous membrane and injury to the epithelia will spread 
the process in a very short time. The remarks I made in the 
course of this paper on the vulnerability of the pharyngeal mu- 
cous membrane, the tendency to spread on the part of the dis- 
ease, and the danger of making new wounds, justify that prac- 
tice. Thus most of my simple cases of tonsillar diphtherite take 
frequent and small doses of a chlorate, combined with lime- 
water, or tinct. ferr. mur. 3 ss.— 3 ii. a day, and generally 
mixed with a little glycerine, principally for the purpose of 
keeping the remedy in longer contact with the diseased surface, 
if not for its own anti-fermentative effect. There is seldom any 
fever which requires attending to, and rarely but little swell- 38 
Jacobi : Contributions to the 
ing of the neighboring glands. Where there is I nse cold 
water or ice applications, for reasons which I need not here ex- 
plain after having spoken of the secondary process in and 
round the lymphatic glands. 
At the other end of the list of diphtheritic affections we 
meet with laryngeal diphtherite, membranous croup. I have 
nothing to add to my remarks made before you more than six 
years ago, if it is not that my success in former years, if not 
with internal treatment, at all events with the ultimum refu- 
gium, tracheotomy, has not continued to the same extent. 
Since 1868 I have saved but a very small percentage of suffo- 
cating children, and still I cannot but stand by my former in- 
dication for the operation. It must not be omitted when ob- 
struction in the larynx threatens to be the cause of death by 
suffocation. ISTo complication of disease or epidemic influence 
ought to be a contra-indication. As in former years, I have used 
ice externally, an occasional emetic when required, lime inha- 
lations, lactic acid spray. 
Every individual case ought to be treated on general princi- 
ples. Thus fever ought to be reduced by washing, bathing, 
and remedies by no means exclusively adapted to diphtheria, in- 
creasing debility obviated, collapse attended to, severe reflex ac- 
tions, as vomiting or convulsions, relieved. Whether ether, wine, 
brandy, champagne, camphor, musk, ammonia, and coffee are 
to he selected, the individual case teaches better than a lecturer. 
All of these means are frequently unsuccessful, because they 
are given too late and in too small doses. Whatever is to be 
done in a severe form of diphtheria must be done early. If I 
have reason to be satisfied with my success it is because I have 
lost no time. More than anything I prize attendance to feed- 
ing. Remembering the greediness of lymph-vessels when the 
chyle-vessels are not supplied, I feed as well as the digestive 
powers of the patient will permit, always, however, recognizing 
the fact that the stomach of a feverish patient must be care- 
fully looked after. In most cases of high fever meat diet will 
neither be relished nor tolerated. 
I turn to another class of diphtheria, in which everything 
depends upon doing the right tiling at the right, that is, the 
early time. I shall, for the pathology of nasal diphtheria, refer 
to my former remarks. I repeat only this one, that most cases Pathology and Therapeutics of Diphtheria. 
39 
originate in the pharynx, and reach the nose by ascending. 
Where an occasional case is first established in the nose it 
shows itself very soon by a peculiar thin flocculent discharge, 
sometimes not at all copious, and by very early swelling of 
glands round the neck. In both of these classes of cases the 
local treatment has to be commenced at once, and in the large 
majority of cases the treatment will be successful. 
What are the dangers of nasal dipththeria % Rapid absorp- 
tion, putrefaction, inhalation of foul smells. The indications 
are clear enough. The surface of the nares must be cleaned 
and disinfected. When you begin early, you reach those layers 
of epithelium which form the original lesion. Then disin- 
fection is successful, and your injection will wash the surface 
clean. No strong disinfectant is required. Two or four grains 
of carbolic acid to the ounce of water is sufficient and mild 
enough not to be abhorred more than lukewarm water would. 
Injections must be made into each nostril until the current 
comes free through the other nostril, or through the mouth, 
every hour, or oftener if necessary. At the same time care 
must be taken that some of the liquid reaches the fauces.1 The 
fear of otitis I have not. Probably the Eustachian tube is closed 
by catarrhal or diphtheritic swelling. The mouth ought to be 
kept open. I have never seen any difficulty arising from my 
injections. A common syringe suffices; but an ear syringe fre- 
quently filled is better adapted to the nursing powers of most 
attendants. A nasal douche, a fountain syringe is much better, 
the current more uniform. I have now and then seen neglected 
cases in which an injection would not open the closed-up nares. 
In such cases I have used probes and pincers to remove the 
coarsest material, in the same manner as I, although averse to 
meddling with the infected mucous membranes, have had to re- 
move large and thick membranes from the uvula, or palate, when 
deglutition was interfered with. Every hour, or every half 
hour, is not too often. The child, frequently with swelled 
glands, head thrown back or sideways, is suffering more, and 
sleeping less, from the obstructed nares and fauces than when 
the injections are regularly made with certain relief. I have 
found many children insisting upon their frequent repetition. 
Often have swelled glands diminished in size within twenty- 
1 For that purpose the nostrils must be momentarily compressed. 40 
Pathology and Therapeutics of Diphtheria. 
four hours after the commencement of the local treatment. If 
it was objectionable, or a discomfort, the objection would not 
count. There is but one way to save a case of nasal diphtheria, 
that is, b}7 disinfection, and washing of the parts. 
What disinfectant is preferable ? I avoid those which stain, 
and those which coagulate. For that reason I avoid the local 
application of the sub-sulphate of iron, and also the per- 
manganate of potassa. I have generally used carbolic acid. 
Where there is no smell, I have often used lime-water, pure or 
somewhat diluted, for its solvent effect. 
Internal disinfectants, antiseptics, are of no effect unless the 
source of the sepsis is stopped, no matter whether hyposulphites, 
or carbolic acid, or quinia. With the local attendance the large 
majority of cases will recover; without it they will die. The 
mortality need not be large. I admit it is difficult to procure just 
that punctual and sometimes apparently cruel attendance which 
is required. It is more cruel, however, to sacrifice than to save. 
The panic, in my opinion, in the city is absolutely unjustified. 
It is the result, not the cause, of sensational newspaper 
articles. Let the public understand that, with the exception of 
a limited class of almost absolutely fatal cases—as far as our 
knowledge now goes—there is no infectious disease that can be 
more readily and more successfully managed than diphtheria, 
and that its mortality ought to be small. Let them understand 
that, and the panic will be over. 
There is one point to which I wish to return. A case of 
diphtheria, mild or severe, ought to be attended to at once with- 
out loss of time. In connection therewith I will admit that a 
good deal of “ stamping out ” has been done amongst us, and I 
understand diphtheria to have been selected as the next victim 
of our Board of Health. I propose one measure which will be 
more successful than the disinfecting of infected houses. Let, 
for the time being, every district be supplied with a physician, 
who shall be well paid by the city, who is a beginner in practice, 
and has ample time, whose residence and business shall be ad- 
vertised in the papers, schools and police-station houses, and 
let it be understood that he will at once, when called upon, look 
after the throat of every pauper or tenement-house child with 
symptoms of either diphtheria or pharyngitis. And we shall 
hear less and less of the ravages of the scourge. 
O O