CASE OF DIPHTHERIA. 
ACUTE LARYNGEAL SYMPTOMS-TRACHEOTOMY- 
RECOVERY. 
BY JOHN BELL, A.M., M.D. 
Physician to the Protestant Infants' Home, Montreal Dispensary, <tc. 
MONTREAL: 
Printed at the " Gazette " Printing House. 
1878. (From Canada Medical and Surgical Journal, February, 1878.J 
CASE OF DIPHTHERIA. 
Acute Laryngeal Symptoms-Tracheotomy-Recovery. 
BY JOHN BELL, A.M., M.D., 
Physician to the Protestant Infants' Home, Montreal Dispensary, &c. 
On Monday the 24th of September last, Mrs. F., Ontario 
street, near St Lawrence street, called at my office with her 
son, two and a half years old, who had a sore throat which she 
feared was diphtheritic. I found he had a white membrane 
covering both tonsils and extending up the pillars of the fauces 
to the uvula. He had not been well, and, having complained 
of some difficulty in swallowing, the mother had that day exam- 
ined his mouth and discovered the diseased condition of the 
back part of it. She had observed that he was feverish from 
the Thursday previous. 
The boy is rather delicate, and last year had the measles, 
which was followed by a prolonged attack of bronchitis and 
debility. In February last, Dr. Osler and I removed from him 
a large cyst, containing yellowish fluid and cholesterine, situated 
over the sternum. 
The treatment I followed consisted in the application of tinc- 
ture of iodine to the diseased surface once a day, in wiping out 
the fauces and pharynx every hour with a mixture in equal 
parts of sulphurous acid and glycerine, with sulphite of soda, 
and in the administration of the citrate of iron and quinine. 2 
The weather being fine, the boy was brought to my office daily 
until the 1st of October. No improvement in his condition 
took place, but rather the reverse. The area of diseased sur- 
face covered with white membrane had increased, extending 
over the sides of the pharynx. On the 1st of October, being 
out of town, Dr. Blackader kindly saw the case for me, and 
made a rather unfavourable prognosis, as dyspnoea had com- 
menced. He ordered poultices to the throat, and water con- 
taining carbolic acid to be constantly boiled near the bed. This 
production of carbolized steam was continued for the following 
three weeks, and the successful result of the subsequent opera- 
tion was probably largely due to its continuance. During the 
2nd of October the dyspnoea increased, and brandy was added 
to the remedies employed. The boy's strength had, of course, 
been kept up by a liberal supply of meat broths and milk. 
On the afternoon of the 3rd of October the dyspnoea had 
become so extreme that the blood was but imperfectly aerated, 
coma was beginning, and death was not far distant. Having 
been instructed to that effect the father brought word of this, 
and Dr. Roddick went with me -tracheotomy to be performed, 
if thought advisable. After finding the urgent dyspnoea, the 
advanced cyanosed condition, the marked diaphragmatic respi- 
ration, that the lungs were in a healthy condition, and that 
death would soon end the child's struggle for life, chloroform 
was administered and I rapidly opened the trachea. But 
before the tube was inserted the patient had ceased to breathe. 
Dr. Roddick, with characteristic promptitude and energy, per- 
formed artificial respiration while, by applying my mouth to the 
tube, I expelled the clotted blood with which it had become 
obstructed, and inflated the lungs each time Dr. Roddick raised 
the arms. A beautiful pink colour of the lips and skin soon 
took the place of the ashy purple, and the patient continued the 
respiration for himself. A Durham's tracheotomy tube was 
used, but the inner one, proving of too narrow calibre to admit 
sufficient air, was not used. The blood and mucus were subse- 
quently removed from the tube by means of feathers, although 
the little fellow kept it pretty clear by energetically blowing 3 
out the obstructions. A warm, moist sponge was placed over 
the tube and against this was constantly directed through a paper 
cone or tube, a current of steam from a tin tea-pot, which con- 
tained half an ounce of pure carbolic acid, in four or six ounces of 
water. This was continued for more than two weeks, and until 
after the tube was permanently removed. I watched him myself 
until the next morning, and am indebted to Messrs. McCorkill 
and Rutherford, medical students, for kind assistance in this way. 
The following are jottings of the progress of the case : - 
Oct. 3rd.-Pulse 120 ; respirations 40 to 50. 
5th.-Pulse 130 ; respirations 36 ; temperature 100°. F. 
6 th.-Pulse 128 ; respirations 36. Removed and washed 
the tube, the patient in the meantime breathing through the 
incision alone, which remained open. 
9th.-Is able to force a small quantity of air through the 
larynx when the incision is closed. The mucus from the trachea, 
which had become clear or white shortly after the operation, has 
been stained with blood for the last two or three days. 
lOtA.-Pulse 140 ; respirations 36 ; temperature 100°.- 
Back and base of right lung dull on percussion ; left side quite 
resonant. Is able to blow more strongly through the larynx 
when the tube is out. 
11th.-Pulse 132 ; respirations 28 ; temperature 99.2°. 
12th,- Pulse 100 ; respirations 38 asleep, 26 awake. 
13tA.-Pulse 128 ; respirations 28 ; temperature 101.2° ; 
midnight, pulse 120 ; respirations 32. 
14t7i.-Pulse 120 ; respirations 40 ; temperature 99.6°. 
15th.-Pulse 120; respirations 32; temperature 99.8°. 
Breathes with comparative comfort through the larynx, but with 
considerable effort and noise, while a piece of plaster keeps the 
edges of the wound together. The voice is formed sometimes 
for an instant in his efforts to speak. 
17t/t.-Pulse, 140 ; respirations 40 ; temperature 100°, while 
asleep. 
19^A.-Tube left out altogether. The dulness of the right 
lung has almost entirely disappeared-poultices, mustard plas- 
ters and an expectorant mixture having been used for it, together 4 
with the brandy, which had been freely continued. It was almost 
as curious to watch this congestion run its course without a cough, 
as it was to see the little fellow cry piteously without a sound, 
and had I not watched the condition of the lungs I could not 
have detected. the congestion from any change in the breathing, 
although, corresponding with it, there is a rise in the respiration 
rate and temperature which might, however, have been caused 
by other agents. 
After the operation the sulphurous acid mixture was applied 
with less frequency to the throat, and half a teaspoonful was 
swallowed four or five times a day. The almost perfect free- 
dom from all sources of irritation of the parts affected, together 
with the action of the antiseptic remedies, locally and through 
the circulation, soon arrested the diphtheritic exudation and 
caused its entire disappearance from the parts in sight several 
days before the removal of the tube. A diphtheritic patch at 
one angle of the mouth had also healed. The surface of the 
incision in the neck was for the first few days covered with a 
thin grayish-white layer, but this was changed to healthy granu- 
lations before the process of contraction began. The quantity 
of mucus emitted from the tube was at no time large, and it 
steadily decreased in amount and became more viscid in quality 
as the bronchial irritations, above referred to, declined, so that 
the carbolic acid inhaled could not have had any local injurious 
effect. The amount of carbolic acid inhaled with the steam 
during more than two weeks must have been great, for more 
than BOoz. were evaporated during that time, and about two 
gallons of alcohol were consumed in its evaporation. His bow- 
els kept regular, requiring laxative medicine only once or twice 
during his illness, and his urine was passed freely in normal 
quantity. 
About the 10th, his little sister, five years of age, who lived 
on the same flat, became ill and feverish, and well-marked diph- 
theritic exudation appeared over the tonsils and fauces, and 
extended into the posterior nares with severe coryza accompany- 
ing it. She had all along got the benefit of the carbolic acid 5 
vapour; and tincture of iodine and citrate of iron and quinine 
were early used. The disease was not intense, and she was not 
confined to bed, but three weeks elapsed before the exudation 
and granular oedema of the superficial membrane had disap- 
peared at the back of the uvula and velum palatinum. 
About the 15th, the mother, who was four months pregnant, 
began to suffer from malaise and chilliness followed by fever and 
weakness. The throat was sore, and from white specks in the 
tonsillar crypts an exudation extended over both tonsils, being 
thickest on the left. She was so weak and exhausted that she 
was confined to bed. Quinine, iron and brandy were exhibited, 
and tincture of iodine was applied to the exudations. The cork 
having been left out of the bottle it had become stronger than 
officinal, and some of it having touched the velum palati and 
roof of the mouth of the left side, it was followed by a free 
exudation over the irritated parts. Subsequently the exudation 
was touched three or four times a day with Tilden's bromo- 
chloralum (a compound of aluminum, bromine and chlorine in 
various states of combination), and she gargled her throat more 
frequently with a solution of the same. The throat was quite 
well in little more than a week, and she had nearly recovered 
her usual health without a mishap by the end of the month. 
The little boy became very thin during his illness, and con- 
tinued weakly for some time after. There was considerable 
tendency to bronchial irritation, especially on exposure to 
slight draughts, and this is not yet quite gone, although his 
voice is almost entirely restored and his form is again well filled 
out, while his lips and cheeks have regained their normal colour. 
If there is anything peculiar in the treatment of the foregoing 
case, it is in the amount of antiseptic agents that were adminis- 
tered to the patient in various ways and for a prolonged period. 
The disease itself was undoubtedly diphtheria. Had the 
medication anything to do with the successful result, and if 
so, in what way ? 
Croup is a local malady, (See Dr. J. L. Smith's article in 
Trans-Inter national Medical Congress, 1876), this was a 6 
constitutional one as shewn by the systemic infection in the 
formation of the peculiar membranes in other parts of the body, 
and also by the blood disease in the malnutrition, anaemia, and 
weakness which continued for a considerable time after. There 
can be no doubt that the sister and mother contracted the 
disease from this case, as neither of them were out of the house 
from the first of October until the disease appeared in the 
sister on the 10th, and in the mother on the 15th of October. 
They were exposed to the infection from the first, and we may 
justly conclude that several days were included in the period 
of incubation. In the mother the actual appearance of the 
diphtheritic condition was preceded for two or three days by 
severe constitutional symptoms which do not appear in simple 
cases of croup. The membranes in this case were not examined 
microscopically, so that it is uncertain whether they contained 
micrococci or not. After reading the elaborate array of facts 
advanced by Oertel in Ziemssen's Cyclopaedia of Medicine, one 
cannot help thinking that bacteria may have something to do in 
the causation of this disease, although it seemed to me that he 
is quite as anxious to prove that micrococci are the actual cause 
of the disease as to find out the true nature of the materies 
morbi. He has not proved that the bacteria of diphtheria differ 
from those found in the tissues in a state of comparative health, 
and because in this disease they appear in immense numbers, 
he seems to assume that they are the cause of the disease. If 
they are, the circumstance is unique, for we know of no other 
constitutional disease that is caused by the introduction into 
the body of a vegetable parasite. In diphtheria, as well as in 
scarlet fever and other constitutional diseases with local lesions, 
there appears to be an unusual activity aroused, by some cause, 
in the bioplastic elements of the blood and solid tissues. In 
diphtheria this happens to be accompanied by the rapid multi- 
plication of the bacteria already existing in the tissues. These 
bacteria may in turn be utilized as the carriers of the infection, 
which, as shewn by Beale in the case of scarlatina, most pro- 
bably consists of minute particles of protoplasm in a pathological 
state of activity, and which, like pus-cells of various kinds may 7 
institute the formation of elements similar to themselves from 
the normal healthy tissues. The particles of morbid bioplasm 
constituting the poison or contagium of diphtheria, whether 
formed by self-division in the blood, or by a degenerating action 
on the reproduction of existing tissues, are probably endowed 
with a high degree of energy in a lowered plane, and with a 
capability of living for varying periods undei* extremely altered 
conditions. There is no limit to be set to the minuteness of 
these particles of materies morbi, until possibly we reach the 
ultimate molecule of the bioplasm, composed of certain atoms 
whose immediate relations to one another, under the influence 
of degraded vitality, may differ from those of a healthy mole- 
cule. The nature of nearly all of the poisons of the infectious 
diseases, including diphtheria, seems to be to lower the vitality 
of the tissues and set up processes tending to septic poisoning, 
necrosis and putrefaction. 
We know that carbolic acid and other antiseptic agents have 
the effect of arresting the formation and multiplication of pus 
cells and bacteria, and probably also of other histological ele- 
ments in a lowered plane of vitality, in which might reasonably 
be included the morbific matter which constitutes the contagium 
of diphtheria and other allied diseases. On the supposition that 
the contagium of diphtheria is of the nature, either of living 
substance, bioplasm in a pathological condition, or of a physico- 
chemical poison tending to the extinction of the vital force 
and disintegration of the component molecules of the tissues, 
the use of carbolic acid, as antagonistic to its life or action, 
seems to be preferable to that of many other antiseptics, inas- 
much as it may. be introduced into and retained in the system 
in an unaltered form, as was done in the case which forms the 
subject of this paper. 1 have since used carbolic acid in steam 
as an adjuvant in the treatment of several cases of typhoid fever, 
one of which was complicated by a diphtheritic condition of the 
nares and pharynx with commencing septicaemia, and in each 
case the practice was satisfactory, as evidenced by the state of 
the mouth and pharynx, together with the general condition 
during treatment, and the ultimate result.