Each case, ity in the action of the bowels. ORIGINAL COMMUNICATIONS. CARBOLIC ACID USED IN FULL BY OSCAR H. ALLIS, M.D., SUR gery attributed their success to carbolic acid. As introduced, it was employed in a dilute aqueous or oleaginous solution. For a time it was the sole antiseptic. To-day it is mainly used in general surgery as a bath for surgical instruments. Few surgeons will de A discharge of mucus by the rectum is a valuable sign in certain cases of obstruction. I have observed this symptom in three instances, and in all of them the obstruction was complete and appeared late. Secondary section was performed upon the first case on the twentieth day after the primary operation. The descending colon was found completely blocked with hard fæces. The second case was operated upon on the twenty-third day. The condition of the patient would not warrant making an exploration, consequently the ascending colon was stitched to an incision in the belly-have not personally experienced its benumbing wall and opened. The resulting fæcal sinus closed spontaneously in four weeks. The third case was operated upon on the twelfth day. A large pelvic hæmatoma was found pressing upon the sigmoid flexure. All of the patients made a good recovery. The mucus discharged by these patients was perfectly clear, and resembled closely the white of an egg. The discharge was always preceded by severe pain and bearing-down efforts. The quantity of mucus varied from 1 drachm to I ounce each time it was passed. Judging from my experience in these cases referred to, I believe a mucous discharge from the rectum indicates not only that the obstruction is complete, but that it is situated below the splenic flexure of the colon. In determining the presence or absence of obstruction in a given case it is important, in addition to the symptoms presented by the patient, for the surgeon to bear in mind the various causes of intestinal blocking, and to take into consideration the likelihood of the operation being followed by such a complication. For example, the general character of the operation and the fact of raw surfaces or apertures being made at the time of section must be considered. Again, it must be remembered that incomplete operations and cases septic at the time of section are liable to develop septicemia. Finally, every point, not only as to the operation itself, but also as to the technique of the operator, must be thought of. 2011 WALNUT STREET. DR. JOHN WELSH CROSKEY has removed to 1802 Chestnut Street, Philadelphia. mand a reason for its abandonment. Few effects, and have thus been able to assign the collapse following its employment to something different than loss of blood, shock of operation, or anæsthetic. its dilute form, I confess that I was quite With such an experience of carbolic acid in astonished to learn from my friend, Dr. B. F. Gardner, of Bloomsburg, that he was in the habit of using the article in its full strength upon extensive cut surfaces, and that, too, with the happiest results. As this article owes its entire value to Dr. Gardner, I will give in detail his method. When Lister introduced his paste Dr. Gardner used it quite extensively. After an application to quite an extensive wound surface he was surprised to find it turn white and that he He therefore had used pure carbolic acid. the wound, keeping it open until oozing had immediately washed the surface and dressed ceased. The case did so well that it inaugurated with him a line of treatment that he has extensively employed. As a typical application, let me take an amputation of the female breast. After its removal and the ligation of the bleeding vessels carbolic-acid crystals, dissolved in sufficient water for solution, are applied with a sponge to all parts of the cut surface. Immediately upon the application of the acid the tissues turn white, which is a guarantee of its thorough action. The wound surface is then washed with water previously sterilized by boiling, and then approximated with provisions for drainage. This is espe cially necessary, as for twenty-four hours the oozing must find ready exit. During the first * Read before the Philadelphia Academy of Surgery. few days there is a slight local hyperæmia | its use in hydrocele a half-drachm or more is along the borders of approximation, but this injected into the tunica vaginalis, and resoludeclines without crisis. tion without suppuration ensues. It is possible Dr. Gardner claims for carbolic acid applied that by its action upon the wound surface an in officinal strength :action similar to that obtained by heat may be 1. That no systemic absorption attends its produced, and thus facilitate repair. use, and hence no danger, no shock. 2. That it is a local anesthetic; hence, there is not as much pain after the operation. 3. That it is, in a measure, a hæmostatic, acting especially upon the capillary vessels. I have taken the removal of the mamma only as an illustrative case. In all operations outside of the pleuritic and abdominal cavities, such as amputations and resections, Dr. Gardner resorts to it. In hydrocele he lays open the sac freely, then applies carbolic acid to the tunica vaginalis, and concludes with packing or drainage. The operation is not followed by excess of any kind, and recovery is prompt. He has used it in gunshot wounds of the knee and ankle. If he get such a case after suppuration has set in he freely opens the joint, applies the carbolic acid to every part, washes out all excess freely, secures ample drainage with fixation, and confidently awaits the result. Ankylosis may follow, but this will depend on the extent of the injury, the delay in treatment, and the conduct of the patient. Dr. Gardner has used bichloride of mercury, hydrogen peroxide, iodoform, etc.; none of them has answered the claims made for them; all have disappointed him, but pure carbolic acid never. I have said that Dr. Gardner does not use this upon serous membranes, i.e., within the abdomen. I must modify this statement. In a case of strangulated hernia in which he found patches of syphacelus-not deep, but threatening-he cautiously applied the pure acid and returned the gut. Fortunately, the strangulation had been arrested by operation in time to save the gut. Nothing eventful in the subsequent history, which was speedy. I do not know Dr. Gardner's theory of the actions of this powerful drug, and shall attempt no explanation. The turning of the wound surface white is due probably to the coagulation of the albumen of the tissues and fluids of the wound surface, and not that the acid has a necrotic effect. That it does not produce a true destruction of tissue may be inferred that after a large breast or thigh amputation he will have primary union and no suppuration. In I will conclude this article by briefly stating my own experience with it. On entering the wards of the Presbyterian Hospital I found that one of my amputations of the thigh had not done well, and looking at the stump found it swollen and of an angry, threatening character. The seam of approximation was perfect. I therefore removed all the sutures, and separating the flaps found them almost in a state of gangrene. Taking carbolic acid pure, I applied it freely, pressing it into the tissues with the sponge applicator, removed the excess, and, packing the space between the flaps, renewed the dressing. This was done without anæsthetic and without apparent pain. The exposed surfaces soon began to granulate, when they were approximated and recovery soon followed. I have also frequently applied it upon a carrier with cotton to sinuses, and after curetting glands. THE TREATMENT OF DIPHTHERIA.* By E. L. B. GODFREY, A.M., M.D., Physician to Cooper Hospital; Lecturer on Medical Nursing in New Jersey Training School for Nurses, Camden, New Jersey. I DESIRE to call your attention, as an nounced in the programme, to the treatment of diphtheria. The subject is full of interest not alone from the past and present prevalence of the disease, but from the startling fact that, despite the great advancement in sanitary science, diphtheria is more continuously present than any of the acute, contagious diseases. Further than this, it can be said that diphtheria, despite sanitary science, has steadily advanced, and, for several years past, has maintained the character of an epidemic in this section of the country. I shall speak from the stand-point that diphtheria is primarily a local disease, the systemic infection is secondary to the local invasion,—and beg to call your attention to the hygienic treatment, the medicinal treatment, the local treatment, the constitutional treatment, and the preventive treatment. * Read before the Camden County (N. J.) Medical Society. It is The Hygienic Treatment.-In the hygienic | for the confinement of a case of ordinary treatment the selection and care of the sick- severity. I make confinement in the bed an room and the care of the patient, as regards imperative rule, so long as there is noticed the toilet, are matters of prime importance. disturbed rhythm in the action of the heart. Neglect in these particulars means danger of Rest in bed tends to ward off renal complicare-infection and the further spread of the tions and paralysis, which are the most imdisease. portant sequelæ. Paralysis takes place, as a rule, during or after the establishment of convalescence, and may follow a mild case. claimed to be due to absorption of the ptomaines or the poisonous products of the specific bacteria, and is regarded as a toxic neuritis with degenerative changes of the nerve-tissue. This accounts for the great exhaustion, the tendency to paralysis, and for the extraordinary slowness of the recuperating process. Even after apparent recovery, paralysis, either local or general, may supervene, so slowly does nerve-tissue regain its power. Its tendency to paralyze the heart, through inflammation of the cardiac nerves, makes the disease one of constant dread. Sudden exertion contributes to heart paralysis, when degenerative changes. have taken place in the cardiac nerves or in the structure of the heart. Rest in bed, therefore, should be insisted upon until health is practically regained. The sick-room should be selected in reference to its air-space, its exposure to sunlight, its ventilation, and the isolation of the patient. The care of the room is equally important. All unnecessary furniture should be removed to obviate the need of keeping it clean and of disinfecting it after the termination of the disease. Dust should be banished from the sickroom, because it irritates the throat and affords a medium in which the poison thrives. Cleanliness during the progress of the disease and the disinfection of the premises after its termination constitute, in the main, the duties of the nurse attendant. However trite this may seem, it is so rarely carried out that it will bear iteration and reiteration until every patient knows its worth. None of the infectious diseases require greater cleanliness or more thorough disinfection for their stamping out than diphtheria. The temperature of the room should be kept at 68° F., and continuously moistened with steam, medicated with turpentine, thymol, or eucalyptol, etc., especially so if laryngeal invasion have taken place, when the temperature should be both warm and moist. Care of the patient's toilet and frequent changes of bed-clothing are needed, on account of the liability of their becoming soiled with sputa and the salivary and pharyngeal secretions, which contain the virus of the disease. This is not extensively diffused in the room, but attaches itself to the clothing, bedding, and the sick-room appliances. All soiled clothing should, therefore, be disinfected with boiling water before being removed from the room. These points are not insignificant; their observance will not only mark the difference (when the disease is treated from its initial stage) between a short or long continued case, but the difference between the limitation of the disease to one in the household or the infection of others. The confinement of the patient to the bed, as well as cleanliness in the toilet, is a matter of moment. This should be done during the progress of the disease, and for a considerable time after convalescence is established. Three weeks are not too great a time The Medicinal Treatment.-The medicinal treatment of diphtheria, though far from satisfactory, as the variety of treatments in vogue indicates, is not so much a matter of speculation as formerly, since the bacterial origin of the disease has been established. The bacillus of KlebsLoeffler is now claimed by our best authorities to be the exciting cause. Experimentation has shown that cultures of these bacilli, inoculated into the larynx of animals, will cause diphtheritic exudation with necrosis of tissue, and that the injection of their ptomaines into the blood will cause paralysis allied to that belonging to diphtheria. From this relationship of cause and effect, and with these premises admitted, the conclusion is irresistible that diphtheria is the result of their activity within the throat. Still the bacilli are not found, it is claimed, in the blood, even during the period of systemic infection, but are found, in connection with other bacteria, in the diphtheritic exudation. These germs, coming in contact with the mucous membrane of the throat, excite inflammation, destroy the cells of the superficial epithelium, which destruction constitutes the false membrane. This, for a time, is so closely adherent to the underlying structures as to pre vent the poisonous products of bacteria from | and listerine and the peroxide of hydrogen, being absorbed, unless the membrane of the throat is in an inflamed or ulcerated state, when systemic infection is frequently first observed. Following the state of inflammation, cell de struction, and the formation of false membrane, there follows a condition of suppuration, tissue necrosis, detachment, and abrasion, during which the toxic products of the bacteria are absorbed by both lymphatics and bloodvessels, and the system consequently contaminated. Believing this, the medicinal treatment of diphtheria will be presented from both a local and constitutional stand-point, but only in so far as the treatment relates to cases under my care at the present time. glycerin, and water has given good results. The swab, made of absorbent cotton, affords the best service. By this method of direct application every part of the throat can be reached, and upon it rests largely the success or failure of the local treatment. A combination of corrosive sublimate, cocaine, Monsel's solution, and glycerin is my chief reliance. Occasionally I employ salicylic acid, glycerin, and alcohol, or the nitrate of silver, or peroxide of hydrogen and glycerin. For insufflating, when this can best be done, calomel is used; after the membrane has become detached, leaving an abraded surface, aristol and boracic acid are employed. For inhalations medicated steam is used, of which I shall speak later. The use of ice is encouraged for the double purpose of allaying thirst and reducing congestion. Its application to the neck has been abandoned for warm or hot applications, especially during the process of sloughing of the membrane. As an application to the enlarged and painful glands, ichthyol and lanolin, or hot, medicated flannels are used. If it is true that diphtheria is due to the activity of specific germs, then the importance of local treatment is admitted. If admitted, then the treatment should be directed to arresting the development of the germ. To accomplish this the antibacterial solution must be placed in direct contact with the germs. The success of the treatment, therefore, de The Local Treatment. The local treatment should be directed to the arrest of the develop. ment of the Klebs-Loeffler bacilli. This can This can best be done by thorough cleanliness and thorough disinfection of the nose, mouth, and throat, since the membrane in the early stage of the disease cannot be removed. Forcible detachment of the membrane is condemned, because it affords both an easy ingress for the veins and makes applications painful to endure. Thorough cleanliness, however, of the nose, mouth, and throat is imperative. Brokendown tissue, mucous accumulations, and sordes must not be allowed to accumulate. Free expectoration should be encouraged, and the sputa-receptacle kept filled with a disinfecting solution. For cleansing the teeth, mouth, and throat, vinegar and water, lemon juice, glyc-pends upon its thoroughness and the accomerin and water, claret wine and water, or pineapple juice and water will be found of advantage, both on account of their being palatable and because of their tendency to arrest, from their acid nature, the development of the germs. Thorough and repeated disinfection of the mouth is required in addition to cleanliness, and under no circumstances should the nose be neglected in either of these particulars. For the treatment of the throat, the gargle, the spray and the swab, insufflation, inhalations, and ice are used. The gargle does not affect the posterior part of the throat, and, if pain is caused by throwing the head backward, is discontinued. The spray is repeatedly used, and corrosive sublimate dissolved in fluid extract of pinus Canadensis, glycerin, and listerine has proven the most satisfactory; although the sulpho-carbolate of zinc dissolved in glycerin plishment of the object sought. This requires patience, skill, and courage. But when applied with this definite object at least every hour of the first day, the disease will be cut short in its death-dealing progress. The disease makes rapid progress. The child should be awakened for local treatment, because local treatment is more important than sleep. It will be observed that the cleaner the throat is kept, the milder will be the disease. The Constitutional Treatment.—The object to be accomplished by the constitutional treatment is to combat the effects upon the system of the toxic absorption from the throat. This, excluding the sequelæ of paralysis, bears a definite proportion to the throat-deposit. consists chiefly, as has been stated, of a toxic neuritis, with impoverished blood, etc. To combat its effects, there is no specific remedy. The object to be attained is to place the patient It The Preventive Treatment.-The importance of this treatment will be admitted when I tell you that 2624 cases of diphtheria were reported to the Board of Health of Philadelphia, from January 1 to October 28, 1893, with 750 deaths, making a death rate of 281⁄2 per cent. During the same period in Camden 220 cases were reported to the Health Board, with 56 deaths, making a death-rate of 25%1⁄2 per cent. These are startling figures, and prove that the principles of preventive medicine are not practiced to any great extent by physicians, or executed by public-health officials. Were cholera or small-pox present in either city to the extent that diphtheria prevails, both cities "would be up in arms." under the best sanitary environments, to regulate the secretions, and to maintain the strength by regular feeding and tonic remedies. For this, a combination of corrosive sublimate and tincture of the chloride of iron is first employed. The corrosive sublimate is pushed almost to its toxic effects, but is withdrawn if symptoms of gastro-enteritis present themselves. It has not given me the satisfaction in diphtheria that has attended its administration in scarlet fever. As soon as the necrotic condition appears within the throat, a combination of the chlorate of potassium and Basham's mixture is given. Basham's mixture is more easily absorbed than the tincture of the chloride of iron, and proves of better service in stimulating the function of the kidneys. The depressing effect of the chloride of potassium upon the heart must not be forgotten. The condition of the heart should always receive The danger of heart-paralysis from neuritis of the cardiac nerves or from endocarditis is always present, especially during convalescence. The least disturbance in its rhythm, or the first appearance of a slow or a rapid pulse, calls for special treatment. Strych-tient, but from the sputa, the salivary and the nia, or the tincture of nux vomica, digitalis, and stimulation are employed according to the condition of the heart's action. Regular feeding, during the day and night, is very important, because diphtheria, more than any of the acute diseases, tends to exhaustion. In difficult deglutition or continued nausea, nutritive enemata are resorted to. The food is given hot and in liquid form. Milk should be the basis, and to vary the taste, which is an important item, it may be given in coffee, tea, cocoa, wine, oyster-juice, clam juice, with vanilla, nutmeg or eggs, or in the form of whey, junket, gruels, custards, etc. If curds are vomited, peptonize the milk; beef-juice and beef-pulp should also be given. For laryngeal invasion, steam-inhalations are given. The steam is medicated with turpentine, eucalyptol, or carbolic acid, introduced into a tent under which the patient is continuously kept. Calomel is given internally with. stimulants; vomiting is early induced, and if dyspnoea is not relieved either intubation or tracheotomy is recommended. For nasal complication, indicated either by the odor or the discharge from the nostrils, the nostrils are syringed every half-hour or hour with a warm solution of corrosive sublimate. To subdue the disease, isolation and disinfection must be insisted upon. These principles, as they relate to the patient, have been considered. Equally important is it that disinfection be applied to the premises. To insure the practice of isolation, cleanliness, and disinfection in diphtheria, the people must be educated to the fact that the virus of diphtheria does not come from the breath of the pa laryngeal secretions; that the virus possesses the powers of life and development; and that it attaches itself to clothing and furniture, and in order to destroy it the disinfectant must come in absolute contact with it, and must be of such a nature as to destroy life. This education is the province of health officials, and if made a part of the policy of boards of health the prevalence of diphtheria will be materially checked. |