Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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at all ; it may last only a few hours, or remain a longer time, or re-
appear after having been absent for several days. It differs entirely



DIPHTHERIA. 117

from scarlet fever in that, it is never followed by desquamation of the
skin.

9. Hemorrliage^ either from the nose, mouth, or fauces. A bad sign ;
and when occurring as a sort of purpura, in the worst forms of the
disease, a fatal one.

10. Urinary symptoms. Presence of albumen is not constant ; in
some cases only at a later period ; in bad cases it probably exists
from first to last. The microscope shows casts of uriniferous tubuli,
by which the so-called BrighUs disease is characterized.

11. Febrile sym,ptom.s vary much in intensity. In a number of
cases the height of the fever seems not at all proportioned to the
severity of the attack, whilst in other cases it is ushered in from the
beginning with violent fever heat, even unto convulsions. Coi^re-
sponding to this, we find in many cases the pulse" frequent, but weak ;
whilst in other cases it is quick, hard, and wiry. Very often the
disease commences with chilly feelings, which are followed by heat.
Mostly this heat abates in the morning, and increases again towards
evening and through the night ; in severe cases the fever is continu-
ous. Its remission is scarcely ever marked by sensible perspiration.

12. Great, characteristic debility. Characteristic, I call it, because
the disease is marked by this symptom, fully developed from the out-
set. Before any loss of vital fluids has occurred in any way, the
patient is at once stricken down by a feeling of great prostration,
showing that the disorder attacks the vital forces themselves.

Complicatio7is are said to be scarlet fever, small-pox, rheumatism,
pleuro-pneumonia, and venous congestion.

Its sequelse are :

1. Ansesthesia of the nerves of sensation. There are observations
which show that it has taken months after the attack was over, before
the patient recovered the normal actions of these nerves. It some-
times leaves all the cutaneous nerves in such a state that external
pressure is little observed ; sometimes this want of sensibility is
limited to one finger. Trousseau mentions the loss of sensibility in
the velum palati, which was characterized by an inability to talk
clearly and to swallow. It is quite remarkable that this anaasthesia
of the nerves of sensation sometinies will be interrupted by spells
of hyperesthesia, so that even the slightest external impressions
become painful and unbearable. Also the nerves of special sense
may thus remain impaired for a long time. Most frequently we
find the nerves of the lower senses aftected ; taste, smell, and touch ;
although the higher senses — sight and hearing — are not excepted.



118 MUCOUS MEMBRANE OF THE MOUTH.

But all these forms of anassthesia are less persistent tban similar
affections after scarlet fever, wliere lesions of the organs of sight or
hearing are of a much graver nature.

2. Akinesia. The motory nerves may also be affected, such as those
of the arms, lower limbs, tongue, or pharynx. There may be either
hemiplegia or paraplegia. In still other cases this paralytic state
may be combined with hyperkinesia, manifesting itself as trembling
of the hands, or as tottering or reeling when wallcing ; as wry neck,
or as a rolling of the head by its own weight, which, when once fixed,
is kept immovable.

3. Abscesses, which may form in different parts of the body. Most
frequently the glands about the neck suppurate. Abscesses in the ears
are not frequent, and in the lungs they have been observed only
occasionally.

•i. Albuminuria may continue a great while after the attack is over.

Differential Diagnosis.

1. Tonsillitis shows no membrane on the affected tonsil ; causes
more acute pain in the throat and difficulty in swallowing, and is
attended by a continuous sthenic fever until the abscess breaks.

2. Ulcerated sore-throat is scarcely ever an acute affection; shows
nothing of the characteristic prostration and nothing of the peculiar
odor.

3. Parotitis has no skinny exudation in the fauces ; neither rat-
tling breathing nor croupy cough.

4. Measles observe a well-marked rhythm in their development.
The rash appears at a certain time ; commences first at the forehead
and spreads thence gradually all over the body ; the eruption forms
in blotches ; when pressed with the finger the resulting white spot
fills from^ the centre towards the periphery; the fever is continuous
until the eruption is all out, and then decreases. There are none of
those throat symptoms in measles, and the discharge from the nose is
not corroding like that in diphtheria.

5. Scarlatiyia shows no remission of fever until the eruption is fully
developed. After that it generally slackens somewhat. The scar-
latina eruption is always followed by desquamation, and scarlatina
never runs into species of croup by a change of locality ; scarlatina
does not protect against diphtheria.

6. Group is always a primary affection, commencing at the larynx
and spreading sometimes downwards into the trachea, but not up-
wards.



DIPHTHERIA. 119

Prognosis.

Often tlie mildest attacks in the commencement have resulted un-
favorably. Bad signs are :

The acrid discharge from the nostrils. The invasion of the larynx
or the development of diphtheritic croup. Hemorrhages from nose
and mouth ; purpura ; petechias. Coldness of the external surface of
the body. Albuminuria; diarrhoea and vomiting. Convulsions.
Complications with scarlet fever, measles and small-pox.

Certain localities and seasons seem to be the occasion of more
dangerous cases than others.

Therapeutic Hints,

Bryon., the patient is quickly prostrated, shuns all motions and
complains, on moving or when being moved, of pain everywhere;
white tongue ; feeling of dryness in the mouth without particular
'thirst, or else desire for large quantities of water.

Beliad., the patient is restless, complains of sore throat; the fauces
look highly inflamed ; the pupils are enlarged ; he feels drowsy, and
yet unable to fall asleep ; starts suddenly out of sleep.

Lachesis, when, after Belladonna, by next evening there is no marked
change for the better ; or when he is even worse in the morning after
some sleep, with a decided development of those skinny patches on
the tonsils, worse on the left side ; or when croupy symptoms appear
and the patient cannot bear any thing touching his neck and throat.

Lycop., when the aspect of the fauces is rather of a brownish red-
ness, worse on right side, and worse from swallowing loarm drinks ;
when the nose is stopped up, and the patient cannot breathe with his
mouth shut ; he keeps his mouth constantly open, slightly projecting
his tongue, which gives him a silly expression ; the nostrils are widely
dilated with every inspiration ; on awakening out of a short nap he
is awfully cross, kicks and behaves naughty, or he jumps up in bed,
stares about and knows nobody, seemingly dreaming with open eyes ;
frequent jerkings of the lower limbs, mostly with a groan, awake or
slumbering ; great fear of being left alone.

Rhus tox., when the child is restless, wants to be carried about,
wakes up every now and then complaining of pain in the throat ; when
a bloody saliva runs out of the mouth during sleep ; when the parotid
glands are a good deal swollen; when there are transparent, jelly-like
discharges from the bowels at stool, or afterwards.

Apis mel., great debility from the beginning ; the membrane assumes
at once a dirty-grayish color ; there is pufl&ness around the eyes ; pain



120 MUCOUS MEMBRANE OF THE MOUTH.

in the ears, when swallowing ; an itchy, stinging eruption on the skin ;
a sensation of weakness in the larynx ; numbness of the feet and
hands and even paralysis. (Never does good either before or after
Ehus t.)

Phytolacca, great headache, violent aching in the back and limbs ;
great prostration ; cannot stand ; when rising up in bed gets faint and
dizzy,

Gelseminum, local tingling of parts during the fever ; incipient paral-
ysis or anesthesia; defective or impaired vision ; objects appear a long
way off, are seen double or inverted.

Cantharides, too copious or dif&cult urination; the urine contains
shreds or coats of uriniferous tubuli ; extreme prostration, sinking,
death-like turns; irritable-looking rash upon the skin or shining
through the epidermis.

Kali bichr., the discharge from the nose is tough and stringy ; pain
in the left ear ; swelling of the parotid glands ; croupy cough ; measle-
like eruption ; red, raw, shining tongue ; deep-eating ulcers in the
fauces.

Arsen., great restlessness, constant desire for cold drink, bu.t takes
only little at a time, or better by drinking hot water ; all symptoms
worse about midnight.

Natr. mur,, swelling of the submaxillary glands and lymphatics ;
map tongue; burning in the throat; after application of caustics,
especially nitrate of silver. (In different regions of Pennsylvania a
weak solution of kitchen-salt was used during the last epidemic as a
gargle with great success.)

Baptisia tinct., oppressed breathing unto suffocation because of pul-
monary congestion. Rising in bed does not relieve ; the patient must
go to the window for fresh air.

Tart, em., difficult breathing, gasping for air; rattling in the chest;
retching, vomiting of tenacious mucus ; small circular patches, like
small-pox pustules, in and upon the mouth and tongue ; oedema of
the lungs.

Ammon. c, obstruction of the nose ; the moment he falls asleep he
is aroused again by want of breath.

Nitr. ac, ulcers in the mouth ; corroding discharge from the nose ;
intermitting pulse.

Bromide of Potassium and Argentum in cases in which there is an
anaesthesia of the roof of the mouth and fauces. The first, because the
old school recommend the use of it previous to surgical operations



DIPHTHERIA. 121

in these parts, because " it numbs tbem," and tbe otber, because I have
succeeded once in curing a numbness of the fauces by it.

It is quite important that I should add to this a new theory of
diphtheria, as advanced by Dr. v. Grauvogl in No. 24, &c., of the
Allgemeine Homoeopathische Zeitung, of 1867. Dr. v. Grauvogl con-
tends that the so-called diphtheritic membranes consist, principally,
of cells of ferment and microscopic fungi, (diplosporium fuscum,) which
grow between the cells. Professor Hallier, of Jena, was the first that
discovered these fungi upon diphtheritic membranes. They live and
grow at first upon the decomposed particles of food, of which more or
less always remain in the fauces. The fungi soon root deeper, grow
into the mucous membrane, compress its minute vessels, and thus
cause mortification of this structure. By the same process they may
develop upon any other accessible mucous membrane, in wounds, &c.
In conformity with this view, all AUoeopathic authorities agree, that
diphtheria originates especially in badly-ventilated localities, where
large masses of decomposed organic matter are allowed to accumulate ;
in damp, cold, dirty, mouldy dwellings, where, consequently, there
exist first-rate conditions for the production of mould. It need not
surprise us that diphtheria should cause not only a local destruction,
but also be attended by various constitutional disturbances, such as
paralysis, &c. ; as the achorion Schonleinii— which, produces favus — is
likewise followed by various general complaints.

The contagious nature of diphtheria seems not to be questioned.
Wherever the spores of the fungi find a congenial soil, there they
grow. The white or sometimes gray or yellowish-white, usually
changing at last to a brownish-looking mass, which we observe in
diphtheria, appears before, or at least simultaneously with, the signs
of inflammation ; it cannot be, therefore, a 'product of this inflamma-
tion ; on the contrary, this so-called diphtheritic exudate, which is a
compact mass from its very first appearance, is the cause of the inflamed
state of the mucous membrane, and its subsequent mortification. The
fungus which Professor Hallier observed in a bottle of water, in wliich
the brush had been cleansed, after it had been used for applying nitrate
of silver upon a so-called diphtheritic membrane, was not at all
destroyed by the nitrate of silver, but grew in the water, and was
found to be the diplosporium fuscum — whose spores assume a brown
color at the time of their maturity ; thus showing exactly all the
changes which we observe the so-called diphtheritic membrane to
undergo during the progress of the disease. For these reasons Dr. v.
Grauvogl thinks that he is justified in considering the diphtheritic



122 MUCOUS MEMBRANE OF THE MOUTH.

plaques as a fungous growth. And this at once settles the differential
diagnosis between diphtheria and croup and scarlatina, or between
angina gangrenosa seu diphtheritica, membranacea et scarlatinosa.
Group is caused by sharp west and northwest winds from October
to April, and is never contagious ; its exudate appears in consequence
of inflammation; first, as a fluid plasma, which gradually coagulates
upon the mucous membrane into a compact membranous mass ; never
destroying or cicatrizing the mucous membrane underneath, from
which it IS exuded. Croup is never accompanied by swelling of the
submaxillary or parotid glands ; has never such a peculiar fetid
breath, nor an increased flow of saliva from the mouth ; neither a
bloody and fetid discharge from the mouth and nose ; and is never
attended with a total inability to swallow, for any length of time.

Angina scarlatina is a symptom of scarlatina and is not contagious,
though the fever to which it belongs is; its exudation cannot be
scraped off — as can be done with the diphtheritic plaques — because it
is a fibrinous infiltration into the tissue of the mucous membrane
itself, not an exudation wpon it ; it never spreads to the larjmx, nor
to other accessible mucous membranes ; nor even upon the external
skin, where there are wounds, &c.

In regard to treatment of diphtheria, Dr. v. Grrauvogl makes the
following observations : The diplosporium fuscum belongs to the
family of penicillium glaucum — common mould — as we observe
growing upon bread when it is exposed to a damp atmosphere. His
next object was to find out by what substance this fungus could be
most easily and effectually destroyed. Accordingly, several pieces of
bread had been placed in the cellar until they were covered all over
with a dense vegetation of penicillium glaucum. Then he poured
upon one a concentrated solution of nitrate of silver ; upon the other
a solution of chlorate of lime ; upon the third a solution of Kali
causticum ; upon a fourth a solution of sulphate of copper ; upon a
fifth chlorate of iron ; upon a sixth mercurius corrosivus ; upon a
seventh spirits of camphor, and upon the last alcohol. The alcohol at
once caused all the fungous growth to be thrown down and totally
destroyed ; so did the spirits of camphor — converting them, at the
same time, info an amorphous mass ; but all the other substances did
not seem to affect the fungous growth in the least ; they ran over it,
and only on deepened places, where they had to remain for a longer
time, they seemed to injure the fungi to some extent. When all these
different pieces were being put back again into the cellar, and were
allowed to remain there for a suflicient length of time, it was observed



SCURVY. 123

that no renewed growth of the penicillium glaucum had taken place
upon those pieces of bread which had been treated with alcohol and
camphor, whilst upon all others there was as luxuriant a growth of the
mould as ever there was before; even on those places where the mould
seemed to have been injured by the application of those fluids. Hav-
ing thus found in alcohol and camphor the means by which the vege-
table parasite can effectually be destroyed, he chooses for this purpose
the alcohol, (for obvious reasons,) and orders a mixture of equal parts
of French brandy and water, or of rectified alcohol and water for a
gargle every hour until all traces of the diphtheritic plaques have
disappeared. To prevent any painful shaking of the sore parts by
gargling, it serves the same purpose to allow the fluid to come in
contact with the fungous growth by taking a mouthful of it and lying
on the back with the head low. A sense of smarting and burning
indicates that the affected parts have been reached, and then it may
be spit out again, or it may be sAvallowed slowly if the parasite
should extend down into the oesophagus. This has to be continued
until all traces of the mould shall have been removed. In those
cases where the parasite has extended into the cavity of the nose and
of the larynx, Dr. v. Grauvogi recommends the inhalation of
alcohol by Dr. E. Siegle's inhalation apparatus. These inhalations
must be continued at intervals until all signs of hoarseness, &c., have
entirely disappeared. So much for the local treatment. For con-
stitutional treatment, to overcome the gangrenous tendency, which
in all cases of diphtheria is produced by the mould. Dr. v. Grauvogi
orders Arsenicum'' to be taken every hour, in four or five drop doses
in a teaspoonful of water during the day. Lower attenuations cause
aggravations and drug-symptoms. He still further observes : The
use of alcohol alone is not sufficient to prevent the gangrenous
destruction ; neither is the sole use of Arsenicum sufficient to destroy
the mould. Both have to be used together.

Scurvy.

The pathological character of scurvy consists in a peculiar alter-
ation of the blood, causing a bloody serous infiltration into the
mucous membrane and the submucous tissue, by which those parts
enlarge, swell, and portions of them not unfrequently burst and
bleed. , Its seat is the mouth — principally the gums. The remaining
mucous membrane is pale and of an anaemic condition, excepting,
perhaps, a few patches here and there of bloody extravasations.

It commences mostly with general prostration, pale and sallow



124 MUCOUS MEMBRANE OF THE MOUTH.

complexion, and febrile motions. Soon the gums commence bleeding
when brushed, when chewing food, or from slight pressure. Ocular
inspection shows them to be swollen, receding from the teeth, and
of a bluish redness. There is fetor from the mouth. The more
the infiltration and swelling increases, the more this bad smell in-
creases ; presently there is a constant oozing of dark-red blood from
the gums of a frothy nature, seldom, if ever, coagulating. If there be
still further progress, the swelling forms an unsightly dark, livid mass,
being covered sometimes with ulcers, the gums receding still more
from the teeth, so that they, the latter, become loose and fall out. The
roof of the mouth looks pale, as well as the remaining mucous mem-
brane. On the tongue and inside of the cheeks, spots of bloody
extravasation appear, and the whole aspect of the patient is that of
anaemia. The progress of the disease is always slow ; and, as it is a
dyscrasia of the blood, the above-given description is only a part of
the morbid affection. Its manifestation in the mouth alone claims
notice in this chapter ; for this reason I shall not add any therapeutic
hints, as the right remedy may be indicated by still other symptoms
than those of the mouth.

Noma, Carbunculus vel Gangraena Oris.

The first symptom of this malignant but rare disease is a small
blister, situated in the middle of the cheek, or toward the corner of
the mouth on. the inside of the cheek. It is filled with a pale-reddish
or turbid grayish or brownish fluid. It bursts so soon that its form-
ation is mostly overlooked, and appears afterwards as a superficial
ulcer with an unclean basis, soon assuming a gangrenous character.
Simultaneously with this blister, underneath it, a small lump is
found, which may be felt even outside on the cheek, which consists
of infiltrated cellular and adipose tissue. Now the gangrenous de-
struction goes on rapidly, and on the outside appears an oedematous
swelling of the diseased cheek, often shining fatty or oily, or appear-
ing livid, pale, or marbled. By -and -by there is also formed outside,
mostly on the middle of the cheek, an inflamed spot or blister upon
a hard basis, which soon covers itself with a dark crust. This crust
being removed, there appears under it gangrenous ulceration, like
that on the inside of the cheek, which spreads Avith the same rapidity,
destroying in a short time the greater part of the affected side, of the
face.

The general and concomitant symptoms seem at first to indicate
nothing alarming. Generally the glands of the neck swell, and the



GENERAL OBSEEVATIONS. 125

face has a pale, cacliectic aspect. Soon, however, there is a general
sinking of strength, diarrhoea sets in, and death may ensue from
exhaustion, before the gangrenous destruction extends over the
whole cheek.

This disease is mostly found in childhood, and always in sickly
children, or after scarlet fever, measles, typhus, and sometimes after
small-pox and mercurial poisoning. Adults are very seldom at-
tacked by it, and then it appears only after typhus or puerperal
fever, and especially after the abuse of mercury.

TJiei'apeiitie Hints, — The disease being of rare occurrence, our
literature contains little about it. The main remedies recommended
are, Arsen., Helleb., Secale, China, Carbo veg.



NECK.

GENERAL OBSERVATIONS.

Ocular inspection of the neck externally, as a whole, presents
various noticeable features.

A short and thick neck, in consequence of hypertrophy of its mus-
cles, is found in emphysema of the lungs ; and

A long, thin neck mostly accompanies tuberculosis.

A spasmodic contraction of the neck hackiuards denotes meningitis,
with exudation on the base of the brain.

The external jugular vein puff's out in the triangular space, which is
called the interstitium intersterno — cleido-mastoideale — in all cases
where the free circulation of the blood through the thoracic cavity
is interfered with, as in diseases of the heart, and in consequence of
continued violent coughing, screaming, singing, and the like.

The carotid artery is seen to pulsate more strongly in feverish con-
ditions ; and its jumping pulsation is a sign of insufficiency of the
valves of the aorta.

The acromial and suptr a- sternal regions sink in when the upper parts
of the lungs shrink ; and

These regions hecome inflated during inspiration or expiration, when
there exist emphysema or caverns in the upper part of the lungs;
also, during bronchitis capillaris of little infants.

Swellings of the neck are of various nature :

They are emphysematous when, in consequence of internal or ex-



i2o NECK.

ternal injuries of the larynx or trachea, air penetrates into the sub-
cutaneous cellular tissue ; or when, in consequence of a rupture or
laceration of the lungs, the air is forced through the mediastinum
into the cellular tissue of the neck.

They are oedematous in case of general dropsy, or when, by tuber-
cular or scirrhous tumefaction of the lymphatic glands, the vena
jugularis or anonyma becomes compressed; this causes at the same
time an oedema of the face, or of the arm.

There is a swelling of the lymphatic glands, either by infiltration
with tubular or scirrhous masses, or by becoming involved, second-
arily, in inflammatory processes of the mouth, throat, face, or scalp,
of which we have spoken.

Parotitis or mumjis appears on the upper part of the neck in front
and below the ear, whilst

Struma or goitre, which is an enlargement of the thyroid gland,
appears lower, sometimes on one, sometimes on both sides of the neck.
Simple enlargement or hypertrophy of this gland is, according to
Porta, found only in children and young persons, whilst in older per-
sons strmna is always a degeneration of this gland, consisting in
formations of cysts, which contain a thick, gummy, jelly-like sub-
stance, of a yellow or brownish color, and which are known under the
name of colloids. According to Schuh these colloids are either inter-
spersed between the substance of the gland or they form separate
round or oval appendages upon the gland, without involving the gland
itself into the morbid process.

The struma of new-horn children consists, as above mentioned, in a
simple enlargement of either the entire gland, or of one of its lobes ;
and interferes, sometimes seriously, by its pressure upon the trachea,
with the child's respiration. In severe cases it may produce death in
a day or two, or even a few hours after birth. This is especially the



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 13 of 65)