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Diphtheria Of The Air Passages

Diphtheria Of The Air Passages
By J. H. McCOLLOM, M. D.,

Definition. The term diphtheria, derived from the Greek word xxxxxx meaning skin or leather, should be applied only to those cases of sore throat in which a membrane is found, and in which a culture taken from this membrane or near it shows the presence of the bacilli of diphtheria, or in those cases in which there is a profuse nasal discharge, a culture from which shows the presence of these organisms. In cases of laryngeal stenosis, although no membrane is visible and the cultures are negative, the existence of this membrane has been proved by autopsies and by the fact that membrane has been coughed up. The term membranous croup is a misnomer and is a relic of past ages. No such disease, as distinguished from diphtheria, exists, and the term should be erased from the nomenclature. Laryngeal stenosis in children in the vast majority of instances is caused by the presence of a membrane which is the result of the growth of the bacilli of diphtheria. Streptococci may cause the appearance of a membrane in the air passages, but this membrane is not sufficiently thick and tough to impede the respiration.

History. It is generally supposed that diphtheria is a disease of modern times, but Aretaeus, a Greek physician of Cappadocia, wrote a description of a disease similar to diphtheria in Ill A. D. In the sixteenth century the disease was prevalent to a greater or less extent, according to written state¬ments of the physicians of that time. In 1821 Bretormeau wrote the first fall and elaborate account of the disease. After that time until 1847 diph¬theria did not seem to attract much attention among the physicians of the Continent. In 1847 an outbreak of diphtheria occurred in England, which was traced to its origin at Boulogne and was known as the "Boulogne sore throat." Since that time diphtheria has been more generally recognized and more carefully studied; and for this reason, although the disease is somewhat more prevalent at the present time than formerly, yet the apparent increase is due in a measure to its better recognition.

Diphtheria was first recognized in Boston, Massachusetts, in 1859, in which year there were 19 deaths from this cause reported. From what is known of the disease to day, it seems reasonable to suppose that if 19 deaths from a so called new disease were reported, there must have been many cases of the same disease that were not recognized. The following year there was only one death from this cause reported in Boston. Since that time the death returns have shown a gradual increase in the number of deaths. In 1863 and 1864, in Boston, with a population of 186,526, there were 353 and 287 deaths, respectively. From 1865 to 1874 there were very few deaths from diphtheria. In 1875 the number of deaths from this disease increased to an alarming extent. In 1881 there was quite a severe epidemic of this disease in this city, the deaths for that period numbering 802, giving a rate per 1000 of the living of 2.178. Since 1881 the number of deaths from diphtheria has varied from 285 to 878 each year. The number of cases reported in 1894 was 3019, with 878 deaths, making the death rate from this disease per 1000 of the living for 1894, 1.803, while that of 1893 was 1.145. The most marked increase in the cases of diphtheria in 1894, as compared with 1893, occurred in the last six months of the year. The ratio of deaths per 1000 for 1895 was 1.173, and that for 1896 was 0.980.

In England the increase of the mortality from diphtheria has been much more marked in the larger towns than in the rural districts. In London this has been more particularly noticeable.

IEMology. The discovery by Klebs of the bacillus of diphtheria in 1883 and the investigations by Loffler a year later, placed the etiology of diphtheria upon a scientific basis. The result of these researches shows conclusively that diphtheria is distinctly a contagious disease; that it never originates spontaneously ; that it is a local disease; and that the constitutional symptoms are due not to the presence of' the organism in the blood, but to the toxin caused by the growth of the bacillus.

It is now generally conceded that imperfect drainage and unsanitary conditions should not be considered important factors in increasing the frequency of this disease. Twenty years ago diphtheria was considered to be a filth disease, but careful investigation of the course of epidemics in various cities and towns has shown conclusively that diphtheria is do more prevalent where unsanitary conditions exist than where the general sanitation is good.

The influence of mild cases of diphtheria in the public schools has a marked effect oil the prevalence of the disease. The accompanying chart, which gives the number of cases of diphtheria reported in Boston, Massachusetts, by months, for five years, shows that when the schools are in session the number of cases is much greater than during vacation time, in the months of July and August.

Cows may have diphtheria, and when suffering from the disease may be a source of infection. Klein, in a report to the Local Government Board of London, traced an epidemic of the disease to milk from cows that gave unmistakable evidence of being ill of diphtheria. Small areas of false membrane were found on the teats of these cows. Cultures made from these lesions contained the diphtheria bacillus. Cats fed on the milk from these cows contracted diphtheria. While there is no positive evidence that the milk in the udder contained the germ of the disease, there is every reason to believe that the milk was contaminated by the bands of the milkers.

One factor in the spread of diphtheria is the existence of this disease in cats and dogs. Diphtheria manifests itself in cats and dogs, Dot by the presence of marked membrane in the throat, but by the condition of the lungs simulating pneumonia. The animal has a peculiar strident cough, has anorexia, and loses flesh rapidly. If children are allowed to play with animals suffering from this disease, they may contract it from them.

The area of infection of diphtheria is not as great as that of scarlet fever, but that it is a distinctly contagious disease must be admitted. The discharge from the nose and the secretions from the mouth may be the carriers of the contagium, hence the importance of burning or disinfecting all articles soiled by these discharges. Kissing frequently conveys the germs of the disease from one person to another.

Morbid Anatomy. Diplitheria must be considered a local disease at the outset; and the symptoms that occur later are the result of the toxin caused by the growth of the bacilli. The growth of these organisms causes the formation of false membrane, which, according to Weigert, as stated by Councilman,' is due to a necrosis of the epithelial surfaces. The exudation from the vessels beneath coming in contact with the necrosed tissue coagulates and forms fibrin. Wagner' says the presence of the membrane is due to hyperemia and inflammation of the tissues beneath, and that there is a fibrinous metamorphosis of the epithelial cells. Heubner' found that in the beginning of the disease membrane was formed in the most superficial layers of the epithelial cells and gradually extended to the deeper ones. The appearance of the membrane during the first twelve hours, as compared with its appearance forty eight hours later, is explained by this view of Heubner. The membrane in diphtheria is generally of a grayish white color, and, as a rule, cannot be easily detached; but this is not universally the case, as frequently it is white, and appears only in small circumscribed patches easily detached. The membrane sometimes early in the disease assumes a gangrenous appearance, which is an omen of very grave import. Nasal diphtheria is characterized by a profuse nasal discharge, and it is the exception that any membrane can be detected without a rhinoscopic examination. Diphtheria of the eye, often caused by the transmission of the germs of the disease from the nose, is of frequent occurrence. There is great swelling of the lids, intense congestion of the conjunctiva , and frequently, but not always, the formation of a false membrane. Frequently the pharyngeal inflammation extends through the Eustachian tube and causes an inflammation of the middle ear. The membrane may extend into the larynx, giving rise to marked dyspnea. Below the vocal cords the membrane is not very firmly attached to the subjacent tissues and is frequently coughed up. Fig. 598 represents membranous casts of the trachea coughed tip by a patient ill with diphtheria. Casts of the right and left bronchi can be clearly seen.

Membrane may extend into the various ramifications of the bronchi. The heart may be of a grayish yellow color, and when death occurs late in the disease, may show evidences of fatty degeneration. The kidneys, as a rule, are enlarged; and on section the cortex is found swollen and the region of the convoluted tubes opaque. When death occurs late in the disease, during apparent convalescence, there are no characteristic macroscopic lesions found, as a rule, at the autopsy. Microscopical examination, however, of the nerves shows in the majority of instances marked degeneration of the nerve tissue.

Prophylaxis. The importance of isolating every case of doubtful sore throat cannot be overestimated, and it is also equally important to isolate' every child who has a profuse nasal discharge, until the diagnosis can be definitely made by means of a bacteriological examination. It is a trite saying, but nevertheless true, that mild cases of contagious disease are much more dangerous to the public health than the severer ones. The writer has investigated quite a Dumber of outbreaks of diphtheria which could be definitely traced to mild cases of the disease, cases so mild that no physician saw them. Too much emphasis cannot be laid upon the danger of permitting children with profuse nasal discharges, loaded with the bacilli of diphtheria, to mingle with others. The careful medical inspection of schools, in order that children suffering from mild attacks of diphtheria may be isolated at their homes, is a very important factor in prophylaxis. When a patient is taken ill with diphtheria, be should be placed in an upper room of the house. All hangings, stuffed furniture, and carpets should be removed from the sick room. If possible, only one person should attend upon the patient, and she should wear cotton gowns, which should be frequently changed and disinfected. All discharges from the patient should be disinfected by corrosive sublimate, 1 part to 500, or by a solution of carbolic acid, 1 part to 20. No handkerchiefs should be used, but in place of them pieces of old cotton cloth should be employed to receive the discharges from the nose and mouth. These pieces of cloth should be burned. All utensils should be sterilized in boiling water or by washing with a solution of corrosive sublimate, care being taken, however, to thoroughly wash them after the immersion in corrosive sublimate. The room should be well ventilated and, if possible, should have a sunny exposure. An abundance of sunlight in the room of a patient is of very great importance. The germicidal properties of sunlight have been very clearly demonstrated by v. Esmarch. In his experiments he proved conclusivelv that the bacilli of diphtheria in culture tubes and on cloth were destroyed in from four to five hours. Pure air and plenty of sunlight are Nature's most effective germicides. Burning sulphur in a room where a patient is ill is a most reprehensible practice. It not only fails to do any good, but is a source of very great annoyance to the patient and nurse. The nurse should always carefully disinfect her hands with corrosive sublimate after any manipulations of the patient, and it is well to frequently wash the mouth with Dobell's solution, I part to 3. The physician, when making his visit, should wear a cotton gown, and should be particularly careful to wash his hands in a solution of corrosive sublimate after his visit. Careful attention to these various details diminishes the chance of spreading the disease.

After the recovery or death of the patient, the mattresses and blankets should be sterilized by superheated steam. The floors and woodwork should be washed with a solution of corrosive sublimate, I part to 500. The walls of the room, if painted, should be washed in a similar manner. If papered, the paper should be removed. The ceiling should be whitened or tinted. All washable materials should be boiled for an hour. Books and toys had better be burned, as there is no way of disinfecting these articles properly. The experiments of Koch in 1888 proved conclusively that sulphurous acid gas, in the manner in which it was usually employed, was useless and that this method of disinfection was misleading. It has been shown in the laboratory that various micro organisms exposed under a bell glass to the fumes of sulphurous acid gas for twenty four hours have been destroyed, yet this is no proof that sulphurous acid gas is an efficient disinfectant for apartments. The conditions in the rooms of a house are entirely different from those under a bell glass. It is impossible to make a room in a house airtight, and for this reason sulphurous acid gas cannot be considered a reliable disinfectant in these cases. For the purpose of investigating the true germicidal value of sulphurous acid gas disinfection, a few experiments were made by the writer. Six test tubes, contain ing each about 10 c.c. of the water from the tap, colored slightly with rosolic acid and plugged in the usual way, were exposed to the fumes of sulphurous acid gas for six hours in a room where there had been a case of diphtheria. The cotton plugs from three of the tubes were removed just before the room was closed and replaced as soon as the room was entered. It was found that the color of the rosolic acid was discharged by the sulphurous acid gas in all of them, proving that the gas bad penetrated into the interior of the tubes. Cultures on gelatin plates made from all these tubes showed a growth of the common organisms found in drinking water. The number of colonies, however, that developed in the gelatin plates was not so great as that which developed in the plates used for the control experiment. In the second experiment six test tubes one of which contained a pure culture of the diplitheria bacillus on cotton cloth; a second, containing a pure culture of the spirillum of Asiatic cholera prepared in a similar manner; a third, a culture of the diphtheria bacillus in bouillon ; a fourth tube, containing a culture in bouillon of the spirillum, of Asiatic cholera, of the diphtheria bacillus, and of the bacillus pyocyaneus ; a fifth tube, containing a pure culture of the diphtheria bacillus on blood serum, and a sixth tube, containing the Water from the tap were used. These tube, plugged in the usual way and the contents colored slightly with rosolic acid, were exposed to sulphurous acid gas for six hours in the presence of moisture. As in the previous experiment, the plugs were removed from three of the tubes. The color was found to be discharged from the rosolic acid in all of them. Cultures made from these tubes Were found to contain all the organisms with which the initial tubes had been inoculated, with one exception, that of the tube in which there were three organisms. In this tube the spirillum of Asiatic cholera was not found. The growth was not very abundant in the inoculation,,; made from these tubes. It therefore seems evident from this limited investigation that, while sulphurous acid gas may possibly inhibit the growth of pathogenic organisms, it certainly does not destroy them. Chlorin gas, when evolved in the presence of steam, is one of the most efficient disinfectants, but the objection to it is the fact that it ruins all metal with which it comes in contact. Fischer has proved by his experiments that if the spores of the anthrax bacillus were exposed in moist air to chlorin gas they were destroyed after an exposure for one hour. The disinfectant known as electrozone , which is made by the decomposition of sea water with a current of electricity, contains a large proportion of chlorin With a small quantity of iodin and bromin. Recent experiments prove that this agent possesses powerful antiseptic and germicidal properties. There can be no doubt regarding its deodorizing powers.

Steam under pressure is now considered to be the only proper method of disinfecting mattresses, wearing apparel, and carpets. It is important to take the precaution of removing all leather and horn buttons, as these materials Will Dot stand the high temperature. There are various forms of steam disinfecting apparatuses manufactured abroad, and those made in this country are modelled on the same plan. Geneste and Herscher of Paris manufacture a stationary and a movable apparatus. The stationary one consists of a large iron cylinder capable of sustaining a pressure of twenty pounds to the square inch. At each end of the cylinder, which is placed in a horizontal position, are cast iron heads moving on hinges and adapted with screw bolts, so that they can be tightly closed. A tight partition wall separates the ends, so that there can be no communication between the room where the infected articles are put in and that from which the disinfected articles are removed. At the bottom is a coil of closed steam pipes for the purpose of heating the interior of the cylinder; at the top is a set of perforated pipes for introducing steam. An appliance for exhausting the air to increase the penetrating power of the superheated steam is attached to the apparatus. The movable one, the prinicple of which is the same as that of the stationary, is mounted on wheels and weighs about as much as a fireengine. The steam is generated by a fire box at the lower part of the cylinder. Henneberg of Berlin manufactures a similar movable apparatus, which has some slight improvements over that of Geneste and Herscher. These movable disinfecting cylinders can be used with great advantage in sparselysettled districts, but are not adapted for use in a thickly settled locality. Numerous experiments show conclusively that a temperature of about 21~_ F. for one hour will destroy all micro organisms, and, therefore, where heat can be properly applied without injury to the articles, it is the very best method of disinfection. In disinfecting by heat in one of these steamcylinders it is important to raise the temperature to 250', which means a steam pressure of fifteen pounds to the square inch, for an hour, in order that the heat may penetrate into the interior of mattresses and rolls of blankets. The best method of disinfecting upholstered furniture is an open question. The only available method of accomplishing this end is by immersion in boiling naphtha for two or three hours. Although there are no reliable bacteriological experiments on this point, yet as most of the coal oil products are disinfectants of greater or less value, and as it has been definitely settled that the thermal death point of many organisms is about 160' F., it seems reasonable to suppose that this method of disinfection for these articles is of practical use. The vapor of formaldehyd, judging from the results of the experiments of Vaillard and Lemoine, is a germicide of some value. The apparatus required is inexpensive and its use not difficult. More extended experiments, however, are necessary before the efficacy of this mode of disinfection can be absolutely accepted.

Symptomatology. The period of incubation of diphtheria is from two to three days. The disease is ushered in by a slight chill and a general feeling of malaise. In children the onset in certain instances may commence with a slight convulsion. There is a feeling of pain and soreness in the throat; dysphagia is not a prominent symptom at the commencement of the attack. There is a peculiar dark red appearance of the mucous membrane of the mouth which is characteristic of the disease, and, although not always seen, yet it is sufficiently common to be classed as one of the symptoms. At the end of twelve to twenty four hours a small patch of membrane of a grayish or dirty white color appears. This membrane may extend very rapidly, so that in the course of twenty four hours the tonsils and uvula may be covered by it. Sometimes the membrane becomes gangrenous and there is an extremely disagreeable fetid odor from the patient. At this stage a profuse nasal discharge may appear; and if the membrane extends and the patient becomes septic, spots of ecchymosis appear on various parts of the body. These spots of ecchymosis are of very grave import. Few cases in which these symptoms appear recover. The difficulty of swallowing now increases; the patient is in a listless condition or may be delirious. Delirium of an active type is not a common symptom in diphtheria, although it sometimes occurs. An eruption resembling scarlet fever may appear in the later stages. Hemorrhages may occur from the nose and mouth. The temperature, as a rule, is not much elevated, but in certain instances, on the second or third day of the attack, may rise to 1040 F. The accompanying charts (Figs. 599, 600) give the temperature in diphtheria without antitoxin and with antitoxin. In some instances the temperature may be subnormal. A subnormal temperature is greater cause for anxiety than a moderately elevated one. The pulse is rapid and weak and does not always bear any relation to the temperature. Sometimes the pulse is very slow; and when this occurs it is an indication of the profound impression of the toxin of diphtheria upon the nervous centers. There is anorexia and, frequently, nausea and vomiting. Diarrhea is frequent, but it is not a constant symptom. In the laryngeal cases it is the exception rather than the rule that any membrane is visible in the mouth. There is marked stenosis of the larynx, characterized by a cyanotic hue of the face and by marked retraction just below the xiphoid cartilage. Supraclavicular retraction is also a prominent symptom, more marked in older children and young adults. The patient is restless, is constantly opening his mouth in the vain attempt to get air into the lungs. In adults retraction of the thoracic walls is not a very marked symptom. Attacks of dyspnea may occur very suddenly in the course of a mild attack of the disease. A peculiar harsh, brassy cough is a symptom of very frequent occurrence in laryngeal diphtheria. These attacks of suffocation are sometimes relieved by the expulsion of large pieces of membrane.

In the acute stage of diphtheria death is caused by either laryngeal stenosis or by the toxin generated from the growth of the bacilli. In the later stages of the disease or during convalescence a fatal issue is due to the action of the toxin on the nervous centers. Pneumonia and broncho pneumonia are very frequent complications in the course of diphtheria. A streptococcous infection, abscess of the cervical glands, and a purulent inflammation of the joints may occur. Inflammation of the middle ear not infrequently is observed. In the later stages or during apparent convalescence paralysis very frequently appears. Palatal paralysis is frequently seen, characterized by a nasal voice and by the passage of fluids through the nose during the act of swallowing. This form of paralysis may be so marked that there is inability to swallow a sufficient amount of food, and the patient is in danger of dying from inanition. Ocular paralysis also frequently occurs, characterized by inability to read, dilated pupil, and also in certain instances by double vision. There may also be a general paralysis, in which the patient lies in a listless state in bed, unable to raise his head or to move his arms and legs beyond a limited extent. There is sometimes a peripheral neuritis, in which the pain and discomfort are very marked. Paralysis of the pneumogastric nerve, characterized by obstinate vomiting and failure of the action of the heart, is a frequent cause of death during apparent convalescence from the disease.

Diagnosis. The discovery of the bacillus of diphtheria by Klebs, in 1883, and the further study of this organism by Loffler, have given us a ready method of diagnosis by the aid of bacteriology. Much has been said regarding laboratory diphtheria and clinical diphtheria: clinicians having claimed that, in certain cases where the membrane in the fauces had the characteristic appearance of a diphtheritic membrane, the bacteriologists failed to detect the specific organism of the disease. As a matter of fact, from personal study of something over 3000 cases of diphtheria, both clinically and bacteriologically, it seems to me that the failure to detect the organism has occurred so seldom that it does not invalidate the accuracy of a bacteriological diagnosis. If the cultures are taken properly, if the culture medium is in a suitable condition, and if the staining is done secundum artem, the failure to detect the organism very rarely occurs. A very great source of error is the fact that when taking the culture the swab or the platinum needle is rubbed over the surface of the membrane in' the very position where the organisms are most likely to die. The edge and, if possible, the under surface of the diphtheritic membrane are the proper places from which to take the cultures. It is also well to take a second culture from the secretions of the mouth. In nasal diphtheria where no membrane is visible, the profuse secretion from the nose is invariably found to be loaded with the bacilli. A second source of error is the use of an antiseptic gargle a short time before the culture is taken. Practical experience has shown that when this is done the bacilli of diphtheria are not, as a rule, found in the cultu re medium, although other organisms, such as cocci and streptococci, may be present.

The organism that causes diphtheria, not only in human beings but in the lower animals, is a small bacillus, straight or slightly curved, with rounded ends, having a diameter of 0. 5 to 0.8,u and from 2.5 to 3u in length (Fig. 601) ; or, in other words, the length of this organism is about one half that of the diameter of a red blood corpuscle. This organism requires a peculiar stain, which is known as Loffler's methylene blue, consisting of a saturated alcoholic solution of methylene blue (30 c.c.), and of a watery solution of caustic potash, I part to 10,00(;(100 c.c.). Hunt's differential stain is of great assistance in doubtful cases. This stain is composed of a watery solution of methylene blue, a 10 per cent., watery solution of tannic acid, and a dilute watery solution of methyl orange as a counter stain. When the bacillus of diphtheria is stained by this method the pole granules are brought out with great distinctness, while the body of the organism is of a light greenish yellow color. So far as is known, no other organism presents this peculiar appearance when stained in this way. The bacillus of diphtheria is an aerobic, non motile, non liquefying organism. It does not form spores, which has an important bearing on the subject of disinfection. Although this organism grows on all the usual culture media, the growth is more characteristic on Loffler's mixture, which is composed of 3 parts of blood serum and 1 part of bouillon containing I per cent. of peptone, 1 per cent. of grape sugar, and one half of I per cent., of sodium chlorid. On this culture medium, at the temperature of the blood, the growth is very abundant, so that at the end of twenty four hours small, round, elevated colonies of a gravish white color and dry app earance will be seen. In laryngeal cases of diphtheria where no membrane is seen, cultures from the mouth invariably give a negative result. If' the case requires operation, cultures from the intubation tube or from the tracheotomy tube, as a rule, show the presence of the bacillus. The fact that in these laryngeal cases a negative result is obtained, has led many to throw discredit upon this method of diagnosis; but a consideration of the anatomy of the parts must lead one to the conclusion that we should not expect to find the organism in these cases, for the false membrane is situated so far down in the larynx that it is impossible to reach it. Another point of interest that has been proved by clinical experience is the fact that these laryngeal cases, unless associated with nasal diphtheria, are not particularly infectious.

The statement has been made that diphtheria bacilli may be found in the throats of healthy individuals who have been exposed to diphtheria; and while this is true in certain instances, it is so rare that very little weight should be given to it. The result of the examination of the throats of thirty nurses on duty in the diphtheria wards of the South Department of the Boston City Hospital proved the presence of this organism in only one instance. The existence of an organism resembling the bacillus of diphtheria found in healthy throats, and known as the pseudo diphtheria bacillus, has been used as an argument against the accuracy of this method of diagnosis; but this organism is so seldom found that it is not a very important factor. It has also cultural peculiarities which assist in its differentiation from the true diphtheriabacillus. Abbott has made a bacteriological study of 53 cases of simple sore throat; and in only 4 of these was a bacillus found which resembled that of diphtheria. The examination of cultures from 130 non diphtheritic throats, made by the writer, showed that the existence of this bacillus was not sufficiently frequent to be an element of error in bacteriological diagnosis. In the cultures from these 130 throats, bacilli of many varieties were found; but in no instance was an organism seen that with care would be likely to be mistaken for the bacillus of diphtheria.

The bacilli of diphtheria may be present a long time after recovery, and when this occurs the individual must be considered a source of danger, unless it has been shown by repeated experiments on guinea pigs that the organism are non virulent. The length of time that the bacillus continues after the disappearance of the membrane varies in each case. Instances are reported in which positive cultures were obtained sixty days after the disappearance of the membrane. The organism remains much longer, as a rule, in nasal cases. The average length of time is about ten days, as proved by an analysis of 1972 cases treated at the South Department of the Boston City Hospital.

Prognosis. Diphtheria must be considered an extremely fatal disease, the percentage of mortality in severe epidemics being as high as 50. In Boston, from 1878 to 1894, the highest death rate of cases reported to the board of health in any one year was 35.7 per cent. ; the lowest death rate for any one year was 26.44 per cent., with an average of 30.7 per cent. As these figures are based on 24,813 cases, the fatality of the disease is evident. The prognosis, even in mild cases, must always be guarded. When there is extensive membrane, profuse nasal discharge, and marked septic odor, the prospect of recovery is very slight. A gangrenous membrane is cause for an unfavorable prognosis. The laryngeal cases that come to operation, in certain instances succumb to broncho pneumonia; in others, death is caused by extension of the membrane into the bronchi; the prognosis therefore, in these cases, must be doubtful. The paralysis that occurs as a late symptom, if the muscles of respiration are not affected, generally ends in recovery. Failure of the action of the heart, characterized by a slow pulse, is a very grave omen; few cases of this nature recover. Degeneration of the pneumogastric nerve, characterized by persistent vomiting, irregular respiration, and a slow and irregular pulse, renders death certain. Spots of ecchymosis are very unfavorable symptoms, and epistaxis is of the gravest import. Sepsis, both in the operative and non operative cases, is the forerunner of death. After apparent convalescence has commenced, the liability to failure of the action of the heart must be considered. Convalescence is always slow and tedious in the severer cases.

Treatment. As diphtheria is a depressing disease, alcoholic stimulation should be commenced at the outset. The quantity of alcohol that a young child will take with positive benefit in a severe attack is surprisingly large. Whiskey or brandy must be given. It is well to commence in severe cases, in a child from one to two years of age, with a dose of from one to two drams every four hours, watching carefully the effect on the pulse and on the general condition. Digitalis should also be administered in appropriate doses early in the disease. Strychnia may be given in the later stages if there are indications of commencing heart failure. When there is a great collection of mucus in the air passages, atropia sometimes proves to be of great benefit. In cases of collapse the use of nitro glycerin sometimes gives marked relief. Mercuric chlorid in small doses has been given apparently with advantage in a certain number of cases.

Antitoxin, however, is the most important agent in the treatment of diphtheria, and must be administered early in the disease. The healing serum has been in general use some three years, and the results obtained from it are as favorable to day as they were when the attention of medical men was first called to it. The animals that are to furnish antitoxin are rendered immune, so that the diphtheria toxin has no effect on them. The toxin is prepared by cultivating virulent diphtheria bacilli in bouillon for one month at a temperature of 37' C., or 98.5' F., so that the poison may accumulate. Before commencing to prepare the toxin the virulence of the diphtheria bacilli must be tested by its effect on guinea pigs. A procedure requiring less time has been advocated by MM. Roux and Yersin. This method consists in growing the cultures in a current of moist air. It must be borne in mind that in the preparation of antitoxin the bacilli of diphtheria are not used; but the toxin caused by their growth, the specific poison caused by them, is used. Toxin thus prepared should be of such virulence that one tenth of a cubic centimeter should kill a guinea pig weighing 500 grams in from twenty four to forty eight hours. Frankel first rendered guinea pigs immune to diphtheria by injecting pure cultures of the diphtheriabacillus which had been sterilized at 70' C. Since then Bebring has recommended a mixture of toxin and Gram's solution of potassic iodid.

Burger and Wasserman arrived at satisfactory results by growing a culture of the dipbtheria bacillus in a bouillon made from the thymus gland. This culture bad been exposed*to a temperature of from 65' to 70' C., during a quarter of an hour. The method which has given the best results is that used by Roux and Vaillard in their researches on tetanus. This consists of the addition of three parts of Gram's solution consisting of iodin one part, potassic iodid two parts, and water 300 parts to one part of the toxin. The injection is to be repeated after a few days, and either the dose of the mixture must be increased or the proportion of Gram's solution diminished. A little later the toxin can be given pure. It is sometimes necessary to omit the injection for a time if the animal is losing in weight.

Dogs have been rendered immune to diphtheria by many experimenters, among the number Bardach and Aronson. Sheep and goats are quite sensitive to the action of' the diphtheritic poison. The immunization of milkanimals, such as cows and goats, is of particular interest from the fact that the milk of these animals has a certain antitoxic power. Of all the animals capable of furnishing great quantities of the antidiphtheritic serum, the horse is the most easily rendered immune. He bears the toxin much better than any of the animals to which allusion has just been made. By injecting gradually increasing doses of the toxin at various intervals the horse, in two months and twenty days, is rendered immune that is, be can receive from 200 to 300 c.c., according to his weight, of toxin of definite strength without disturbance. The serum from this animal has a certain protective power, which must be determined by experiments on guinea pigs before it is ready for use.

The curative action of antitoxin has not been satisfactorily explained but it appears from numerous experiments that this agent does Dot destroy the toxin, but that its remedial power is due to stimulation or some other special action on the tissue cells. If, however, the cells have become so damaged by the action of the toxin of diphtheria that they Cannot respond to the stimulation of the antitoxin, the remedy fails to accomplish good. This is a powerful argument in favor of the early administration of the healing serum. The remedial power of antitoxin is also restricted to a certain degree by its inability to combat the streptococcous infection, brolichopneumonia, and other complications referable to secondary infection. In some of the experiments made for testing the action of antitoxin, diphtheria was caused in female guinea pigs by rubbing pure cultures of the diphtheriabacillus on the excoriated surface of the vulvae. In these cases the pigs recovered if the serum was injected before the inoculation, otherwise they died. A membrane was formed at the point of inoculation, but there was very little constitutional disturbance. After the second day the false membrane became detached and repair of the mucous surface commenced. In these experiments the protected animals received one five thousandth part of their weight of the serum. Other experiments were those in which guinea pigs were inoculated in the fauces with pure cultures of the diphtheriabacilli. Guinea pigs inoculated in this way died in three days if not protected by the serum.

In February of 1894, after the beneficial effects of antitoxin on animals had been proved, as the preceding brief resume shows, the treatment of diph¬theria by this method was commenced in the Children's Hospital in Paris.

During the years from 1890 to 1893, inclusive, in this hospital 3971 cases of diphtheria were treated, with a death rate of 51.71 per cent. From Feb¬ruary to July 24, 1894, 448 cases were treated by antitoxin, with a death¬ rate of 24 per cent., a diminution of more than one half. It should be said that all the cases treated by this method were extremely severe in their nature. It must also be borne in mind that in many of the cases there was in addition to the diphtheria infection a streptococcous infection which, as has been shown, has a nullifying effect on the benefit of the antitoxin. The effect on the local lesions in the throat was similar to that observed in the experi¬ments on guinea pigs.

It has been claimed by the opponents of antitoxin that diphtheria has of late years assumed a less virulent type, and that many cases are now recognized by a bacteriological examination which were not so classed a few years ago. Baginsky, director of the Emperor and Empress Frederick Children's Hospital of Berlin, states emphatically that it is untrue that since the introduction of the serum treatment diphtheria has assumed a less virulent type. On the other band, he says the most malignant forms have been treated by him successfully with the healing serum. He says for the six months ending June, 1896, the percentage of mortality (excluding moribund cases) was 8.22, as compared with a mortality of 40 to 50 per cent. a few years ago. Baginsky also states that between March 15, 1894, and March 15, 1895, the deathrate in his service in cases treated by antitoxin was 15.6 per cent., and that during the time when the supply of serum gave out in the months of August and September, in the same hospital, the death rate rose to 48.4 per cent. It has been noticed by many observers that during the warmer months diplitheria, as a rule, does not assume so virulent a type as during the colder months; and the fact, therefore, that in the former period, when antitoxin was not used, the death rate was nearly three times as great as when it was used, seems to be a sufficient answer to the statement that antitoxin statistics are unreliable because based on mild forms of the disease. Korte says that there was an increase from 33.1 per cent., when the serum was used to 53.8 per cent., when it was not used. Ganghofner noticed an increase from 12.7 per cent., with serum to 53.2 per cent., without. Heim found that the mortality rose to 65.6 per cent., without serum as compared with 22 per cent., with serum. In an epidemic at Trieste the fatality rose to 50 per cent., when the supply of serum failed, as compared with 18.7 per cent., when it was used. As these statistics are based upon cases occurring in the same epidemics, the argument that antitoxin statistics are unreliable because based upon the mild forms of diphtheria is untenable.

In the Boston City Hospital, from February, 1891, to February, 1894, when antitoxin was not used, there were 1062 cases of diphtheria treated, with 493 deaths, giving a percentage of 46. As this embraces a period of three years, the type of the disease might change considerably. In the South Department of the Boston City Hospital, for a period of thirteen months, from September, 1895, to October, 1896, there were 1972 cases treated with antitoxin, and of these 1706 were discharged well, 266 died, giving a percentage of mortality of 13.4. If the deaths of the 70 patients who were admitted in a moribund condition are eliminated, it would bring the deathrate down to 10.3 per cent.

Mackenzie gives the death rate in cases of laryngeal stenosis without operation as 90 per cent. Although these cases are not stated to be diphtheria, yet it is safe to conclude, in the light of our present knowledge, that Dearly all of them must have been diphtheria. Of 260 cases of diphtheria with marked laryngeal stenosis treated with antitoxin at the South Department of the Boston City Hospital, 60 were relieved of this symptom without operation; two died. The cause of death in one case was broncho pneumonia, and in the other cardiac failure. In addition to the use of antitoxin, some of these cases were placed under steam and others had calomel fumigation. While these measures relieved temporarily the urgency of the symptoms, the permanent relief was due to antitoxin, judging by the experience in pre antitoxin days. In cases of intubation, antitoxin has been of very great benefit. Waxham, of Chicago, in his monograph on intubation, states that of 150 cases collated by him, previous to the use of antitoxin, the percentage of recoveries was 27.33., the originator of intubation, reports in the Medical Record of October 29, 1887, 50 cases with 12 recoveries, giving a percentage of 24. As these cases occurred in private practice, it is reasonable to suppose that the operation was performed early, a condition that does not always occur in hospital practice, because patients are sent to a hospital as a last resort. In the Boston City Hospital, for the year ending January 31, 1895, there were 89 intubations and 74 deaths, giving a percentage of recoveries of 16.8. These cases did not have antitoxi n. in the South Department, for the thirteen months ending October, 1896, there were 200 intubations where antitoxin was administered, with a percentage of recoveries of 46.5. If the percentage of recoveries in cases occurring in private practice where antitoxin was not used is compared with that of hospital cases at the South Department where antitoxin was used, it will be seen that the percentage of recoveries in the hospital cases is considerably larger than that occurring in private practice. If hospital cases before the days of antitoxin are compared with hospital cases after the use of this agent, it will be seen that the percentage of recoveries has been increased from 16.8 to 46.5. In intubation cases the use of antitoxin has shortened the length of time that it is necessary to wear the tube.

The question of conferring immunity on individuals, who have been exposed to diphtheria, by injection of antitoxin, is a very interesting and important one. The results thus far obtained seem to prove that an attack of the disease may be prevented by the early administration of the healing serum. In an outbreak of diphtheria occurring in institutions, the immunization of all persons exposed to the disease should be strongly advocated. The time that immunity can be conferred is short, being about thirty days. A small dose, 200 to 300 units, is required.

Injurious Effects of Antitoxin. Eruptions of various kinds following the use of antitoxin have been observed. These eruptions can be classified as urticaria, erythema, a papular eruption, and an ecchymotic eruption, which must be distinguished from the spots of ecchymosis occurring as an early symptom in severe cases of diphtheria; a punctiform eruption resembling scarlet fever, and an eruption resembling that of measles. The first four eruptions are sufficiently characteristic Dot to present any very great difficulties in diagnosis; but the last two so closely resemble eruptions of scarlet fever and measles that the most careful examination is required to make a definite diagnosis, and in some instances it is absolutely impossible.

In the scarlatinal form of eruption, the absence of vomiting, a normal temperature, no hardness of the palms of the bands or the tips of' the fingers, the fact that the papilla of the tongue are not enlarged, and the absence of any eruption in the throat, are the cardinal points on which the differential diagnosis must be made. In the measles like eruption the diagnosis must be based upon its transient character; that there is no rise in temperature; that the eruption appears first on the extremities; that there is no coryza; that there is no cough; no eruption in the mouth; no eruption behind the ears. In a small number of cases joint pains, resembling articular rheumatism, have been noticed. These joint pains, although a source of considerable discomfort to the patient, have not been sufficient to cause any great amount of anxiety and have been followed by no serious results. In a very few instances abscesses have occurred after the injection of antitoxin ; but the number is so small that it is hardly worthy of consideration, being no greater than would follow a large number of subcutaneous injections of morphia. It has been stated that albuminuria is caused by the use of antitoxin, but the observers who have made these statements have lost sight of the fact that albuminuria very frequently occurs in the course of diphtheria; and they also have not appreciated the well recognized fact that the toxin of diphtheria may cause albuminuria, as is proved by the condition of the kidneys of guinea pigs that have died from injections of pure cultures of the diphtheria bacilli. Of the 1972 patients treated with antitoxin at, the South Department of the Boston City Hospital, 674, or 34.1 per cent., had albuminuria, which proves that antitoxin does not increase the frequency of albuminuria, as this is not as large a percentage as occurs in cases not treated with antitoxin. In 173 cases the urine was examined before and after the administration of antitoxin. Of these 173 cases, it was found that in 99 instances albumin was absent both before and after the administration of antitoxin, which was without doubt due to the fact that the healing serum was administered before the diphtheritic membrane bad increased sufficiently to generate toxin enough to cause albuminuria. In 33 cases the albumin was about the same, in 25 the albumin was diminished, which seems a sufficient answer to the claim that antitoxin causes albuminuria. In 16 cases the albumin was increased, but not to a sufficient extent to cause any special anxiety. Antitoxin has no influence on the later symptoms of diphtheria caused by the action of the toxin, such as paralysis, cardiac failure, and nerve degeneration, but it does have a marked effect in preventing the formation of toxin and the consequent appearance of these symptoms. In Pepper's "Theory and Practice of Medicine," published in 1 893, the percentage of post diphtheritic paralysis in a large number of cases is given as 40. In the Homerton Hospital, England, of 1071 cases treated without antitoxin, paralysis occurred 1,25 times, giving a percentage of 11.6. Of the 1972 cases treated with antitoxin at the South Department of the Boston City Hospital, paralysis occurred in about 115 instances, 5.8 per cent. The conclusion, therefore, that antitoxin does not cause paralysis, as has been asserted, is justifiable.

In conclusion, then, it can be confidently asserted that antitoxin is a remedial agent of great value in the treatment of diphtheria; that its use does not cause albuminuria ; that it does not predispose to paralysis, and that the eruptions and the joint pains that sometimes follow its administration are not of sufficient importance to preclude its use.

The dose of antitoxin has been variously stated by different observers. The quantity must depend upon the number of antitoxin units that the specimen used contains. As an initial dose, from 2000 to 3000 units, depending upon the age of the patient, should be given. If there is not a marked improvement in the appearance of the throat and in the general condition of the patient at the end of eight hours, a second dose should be given. If at the end of twenty four hours the membrane has not commenced to roll tip at the edges, if the swelling of the cervical glands is not diminished, if there is a profuse nasal discharge with a septic odor, a third dose should be given, and in certain cases a fourth, or even a fifth, dose may be required.

The method employed by Behring and Ehrlich in testing the strength is the one now in general use in Germany. In the Boston Medical and Surgical Journal of December 17, 1896, Behring's method of testing the serum is thus described:

“Diphtheria toxin is injected subcutaneously into a series of guinea pigs to determine accurately the smallest quantity of toxin which is fatal to the guinea pig. When this has been determined the toxin becomes the testtoxin. A given quantity of serum to be standardized is mixed with ten times the minimum fatal dose of the test toxin and injected subcutaneously into guinea pigs of nearly the same weight as those used in standardizing the toxin. If no local edema nor infiltration appears, if, in other words, the guinea pig is completely protected, the quantity of serum used contains onetenth of an antitoxin unit. This is best illustrated by an example the testtoxin has been standardized and found of such strength that 0.039 c.c. is the minimum fatal dose. The serum to be tested is diluted with sterile normal salt solution until 1 c.c. contains 0.0016 2/3 C.C. of serum. The serum and 0.39 c.c. of toxin are mixed and injected subcutaneously. If the guineapig remains permanently well and shows no edema at the place of injection, 0.0016 2/3 c.c. contains at least one tenth of an antitoxin unit. One c.c. would contain at least 60 units that is, enough serum to completely protect 600 guinea pigs from ten times the fatal dose of toxin. The antitoxic unit may thus be defined as being contained in ten times that quantity of any given serum which is required to neutralize ten times the minimum fatal dose of diphtheria toxin when mixed with the latter and injected subcutaneously into a guinea pig."

Prof. H. C. Ernst employs the following method in testing the antitoxin which be prepares. This method is described by him as follows:

"A normal toxin is one of such a strength that .1 c.c. injected subcutaneously in a guinea pig weighing 506 grams kills the animal in forty eight hours; in other words, kills 5000 times its weight of guinea pig. We call a normal antitoxin a serum of such a strength that .1 c.c. injected at the same time subcutaneously in a 500 gram guinea pig with I c.c. (ten times the fatal dose) of normal toxin produces no effect; in other words, protects 50,000 times its weight of guinea pig, and is, therefore, of a strength of I to 50,000. This is a serum that for practical purposes is marked “dose 10 c.c.," or approximately sufficient to protect 100 pounds. When we find the serum tested in the same way of a strength of 1 to 100,000 or over, we mark it “dose 5 c.c.," an amount approximately sufficient to protect the same weight."

Many places have been selected for the site of the injection the outer aspect of the thigh, the abdomen, the back, and the upper part of the thorax near the posterior axillary line. After trying these different places, experience has shown that the last mentioned situation is the most desirable, because here the tissues are lax, there is no danger of entering a vein, and the patient can lie on the back or on one side without bringing any pressure on the inoculated place. If an abscess forms there is no danger of burrowing of pus, as might be the case in the thigh and back. The technique of the injection is as follows: The parts are thoroughly sterilized by washing with a solution of corrosive sublimate; a portion of the skin is pinched up and the needle plunged deeply into the subcutaneous cellular tissue, the antitoxin is then slowly injected. The puncture made by the needle is sealed by sterilized gauze and collodion. It is very important that the needle and syringe should be carefully sterilized by boiling. It is advisable to pour the antitoxin through sterilized gauze into the barrel of the syringe, rather than to attempt to draw it through the needle.

There are many different kinds of syringes in the market. Williams's syringe, which has an asbestos packing and is made of glass, is the one in use at the hospital, and it has proved to be well adapted for its purpose.

Luer's syringe, which has a ground glass piston accurately fitted, is a very satisfactory instrument. Koch's syringe is a very good instrument to use.

In selecting a syringe, it is well to choose one that has the needle Connected with the barrel by rubber tubing. It makes very little difference what kind of a syringe is used if the different parts are made of materials that can be sterilized by heat without injury. A comparatively small needle should always be used. Figs. 602 and 603 represent the two syringes in general use.

In the treatment of moderate laryngeal stenosis occurring in diphtheria, recourse may be bad to the inhalation of steam. A tent can be made over the bed and the steam generated in the ordinary croup kettle. In hospitals a special apparatus for this purpose is connected with the steam supply. Medicated steam sometimes seems to afford relief. The following mixture, in the proportion of' one ounce to a pint of water, may be used with advantage in the croup kettle:

Apothecary. Metric.
R. Olei eucalypti, 3j 30
Acidi carbolici liq., 3j 30
Olei terebiDthinoe, 3Viij 240. M.

Only a moderate amount of steam is required. The debilitating effect of a continued steam bath is very great, and this is always to be avoided in the treatment of diphtheria. The air in the canopy must be simply saturated with steam, not oversaturated, as is frequently the case. The sublimation of calomel often gives relief. A small alcohol lamp, surrounded by wire gauze or perforated tin, with a pan on the top for the reception of the calomel, is the apparatus used. Five to ten grains of calornel are placed in the pan, and the quantity is repeated every thirty minutes for two or three times, depending on the urgency of the symptoms. Care must be taken, however, not to continue this treatment for too long a time, as there is danger of causing salivation. Small doses of the syrup of ipecac, in addition to the meastires just described, sometimes prove of benefit. Emesis, however, must not be caused.

Caustic applications to the throat have been advised, but their use is of doubtful advantage. The less the throat of a patient ill with diphtheria is irritated, the better. The experiments of Roux and Yersin show that the bacilli of diphtheria do not, as a rule, grow on sound mucous membrane, and, therefore, when the epithelium is removed by caustics and irritants, a fertile soil is prepared for the growth of these organisms. Irrigation with hot normal salt solution, or with a solution of mercuric chlorid, I part to 8000, or with a weak solution of chlorinated soda, every four hours, frequently gives much relief to the patient. This irrigation can be given by means 4 the fountain syringe, with the patient either in the horizontal or vertical position. In nasal diphtheria the douche is of great advantage. By the irrigation all the loose membrane is removed, contributing much to the relief of the patient.

When there is marked dysphagia, spraying the throat with a 2 to 4 per cent. solution of cocain, a short time before food and stimulants are administered, is often of marked benefit, enabling the patient to take his treatment with a certain degree of comfort.

Painting the throat with a mixture of salicylic acid, twenty grains to the ounce of glycerin, is sometimes of advantage. The application of hydrogendioxid is sometimes beneficial. If there is much membrane, a strong solution is required. The application should be made with a mop. The nose can be sprayed with weak solutions of one, two, or five volumes.

In order to cause the disappearance of the bacilli after the membrane has disappeared, many things have been tried, but the results have not been very satisfactory. Spraying the throat with lemon juice or with a 5 per cent. solution of antipyrin, or with a weak solution of mercuric chlorid, or with a ten volume solution of hydrogen dioxid, can be tried.

In laryngeal stenosis, characterized by great restlessness, a marked cyanotic hue, distinct clavicular and sternal retraction, operative interference is demanded. The choice lies between intubation and tracheotomy. O'Dwyer's tubes for intubation are in general use in this country. The apparatus consists of five tubes, suitable for children from one year to twelve years of age; the gag, the introducer, the extractor, and a scale indicating the tube to be used for a particular age. These tubes are plated with gold. The upper end of the tube has a head that rests on the ventricular bands and prevents the tube from slipping into the trachea; in the middle there is attached.

a fusiform enlargement by which the tube is retained in the larynx. On the right side of the head is a small hole for the reception of a loop of silk. This loop of silk is to prevent the swallowing of the tube, if the first attempt at intubation is not successful. Each tube is fitted with an obturator, which is screwed to the introducer. The introducer consists of a handle and a shank; on the handle is a button, by pushing which the jaws, at the end of the shank are pressed forward and the obturator disengaged from the tube. The extractor, which is curved, has at the distal. end jaws which are opened by pressing on the ]ever in the handle.

Fig. 606 shows a tube attached to the introducer ready for use, a detached tube, the extractor, scissors for cutting the silk, the gag, and the scale.

Intubation is performed in the following manner: The patient is wrapped firmly in a blanket, so that he cannot move his arms, and then placed in a horizontal position, with the head slightly raised. The mouth is held open by the gag, with its jaws resting on the molar teeth. Care must be taken not to have the cheek injured by the gag, and special care must be taken to prevent its slipping. The head must be steadied by the assistant who holds the gag. The operator takes the introducer in the right band, with the indexfinger around the hook on the under surface of the handle; the loop of silk passing over his little finger and his thumb resting on the button on the upper surface of the handle. The index finger of the left hand is then passed down to the epiglottis, which is hooked forward ; the tube is passed into the mouth, with the handle well down on the chest of the patient; when the epiglottis is reached by the point of the tube, the handle should be given an abrupt turn, so as to bring the tube into a vertical position. As soon as the tube is well in the larynx the button on the handle should be pushed forward, disengaging the obturator, which must now be removed, and the tube pushed into position by the index finger. The loop of silk is passed about the ear and the gag removed. If the tube is in the larynx, the patient will immediately commence to cough with a peculiar sound, which to be appreciated must be heard. If the breathing becomes easier; if the cyanotic hue disappears; if the retraction of the thoracic walls diminishes ; if the loop of silk does not shorten, one may rest assured that the tube is in the larynx. After becoming satisfied that the operation has been properly performed, the gag is inserted a second time, the index finger placed on the bead of the tube, and one strand of the silk loop cut so that it can be removed. Remember that the finger of the operator must be a continuation of the posterior wall of the larynx; remember to make the abrupt turn; remember that no force must be used. If the tube is in the esophagus, no cough will be heard; there will be no relief in the breathing; the silk loop will commence to shorten as the tube passes down the esophagus. In certain instances intubation does not give relief, and tracheotomy must be done. If the tube becomes clogged by membrane, as is sometimes the case, it must be immediately removed. The first steps of an extraction are similar to those of an introduction. The extractor is passed into the lumen of the tube and the lever on the handle pressed so as to open the jaws, and the tube extracted by a reverse of the movements in introduction. Sometimes there is considerable difficulty in extraction, but by patience and gentleness the end can be accomplished. If the child coughs up and swallows the tube, the accident may cause considerable annoyance to the physician, yet it is not of serious import, for experience has shown that the tube is passed by the rectum. in from twenty four to forty eight hours, without causing discomfort. No definite rule can be given regarding the length of time that the patient should wear the tube. It is well to remove it at the end of the third or fourth day, but it is frequently necessary to immediately re insert it. In some instances three or four extractions and introductions may be required. The most favorable cases are those in which the child coughs up the tube at the end of the third day and does not require re intubation.

The operation of tracheotomy is fully described in the article on Operations and in works on surgery.

In regard to the relative merits of tracheotomy and intubation, a few words maybe said. It seems to me that intubation, in the majority of cases, is the better operation: First, because there is comparative little shock; second, because there is no open wound to become infected; third, because the air in intubation enters the lungs through the natural channels, thereby diminishing the chance of broncho pneumonia; and, lastly, because recovery is much more rapid after intubation than after tracheotomy, there being no granulating wound to heal. In adult life, tracheotomy is, perhaps, the better operation. Bourdillat gives the following statistics of recoveries after tracheotomy, by years: Under two years, 3 per cent.; between two and two and one half years, 12 per cent. ; two and one half to three and one half, 17 per cent.; three and one half to four and one half, 30 per cent. ; four and one half to five and one half, 35 per cent.; over five years of age, 39.5 per cent.

Waxham, in his collation of 1072 cases of intubation, gives as the percentages of recoveries after intubation, by years, as follows : Under two years, 15.62 per cent.; between two and three years, 19.46 per cent.; between three and four years, 30 per cent.; between four and five years, 32.65 per cent.; between five and six years, 33.92 per cent. ; over six years, 43.33 per cent. It will be seen, therefore, that under two years of age the percentage of recoveries after intubation was five times as great as after tracheotomy ; and that in only one instance was the percentage of recoveries higher after tracheotomy than after intubation, and then the increase was very slight.

It has been claimed that an intubed child could not take sufficient nourishment, that he suffered from the lack of liquids, and to obviate this condition of things various measures have been suggested, such as rectal alimentation, the use of soft solids for food, and by what is known as the Casselberry method of feeding, which consists in placing the child on its back and lowering the head, so that the pharynx is on a lower plane than the larynx. When the child is placed in this position he can take a certain amount of food with comparative comfort. Nasal feeding, however, is by far the best method of introducing food into the stomach of an intubed child. It is not a painful procedure; it is not specially difficult to perform, and one has the satisfaction of knowing just bow much food, how much stimulation, and what drugs are introduced. After the second or third introduction of the tube, as a rule, the child does not struggle and does not exhibit any indication of discomfort. The apparatus in use at the hospital consists of a soft rubber catheter, in which is inserted a short glass tube, which in turn is attached to a rubber tube, and the rubber tube is connected with a glass funnel. The catheter having been well lubricated is slowly and carefully, without any force, passed through the anterior naris down into the esophagus. The funnel is elevated and about two ounces of water are poured into it, and then the requisite amount of milk ' stimulants, and whatever drug may be deemed advisable to administer, followed by an ounce or two of water. The catheter is then removed quickly but gently. If the catheter is removed slowly its passage may cause vomiting, therefore it is important to remove it quickly. The condition of intubed children fed in this way is very gratifying as compared with those fed in any other way. Nasal feeding is also of 'very great advantage in cases of postdiphtheritic palatal paralysis, and there is no doubt that lives have been saved by adopting this procedure when it was impossible for the child to take food in the natural way. Many cases might be cited in which death might from inanition or from pneumonia caused by the introduction of food into the air passages, if this method of feeding bad not been used.

In diphtheria of the eye, the chief reliance must be placed on antitoxin, which should be administered heroically. The pupil must be dilated with atropia. The eye should be irrigated every two hours with a 2 to 4 per cent., solution of boric acid. In some instances the following ointment has seemed to be of use:

Apothecary. Metric.
R. HYdr. iodid rub., gr. J .065
Cocainve muriatis, gr. iv .260
Atropim sulphatis, gr. iv .260
Petrolati, 3j 30. M.

A portion of this ointment the size of a small pea should be put in the eye every eight hours. The treatment of the later effects of diphtheria on the eye belongs rather to the province of the oculist than to that of the general practitioner. The action of antitoxin on the diphtheritic process in the eye is very marked, and the results following its use are very gratifying. The greatest attention should be given to keeping the eye clean. If only one eye is affected, the other must be protected with a watch glass. It must be borne in mind that the object of treatment is to prevent the extension of the membrane and to cause its early disappearance; therefore all irritation of the conjunctiva is to be avoided. A patch of membrane that in the throat would not be of importance, in the eye might cause blindness.

The administration of food in the treatment of diphtheria must receive careful attention. Milk is the best article of diet, and should be given in quantities as large as the patient can be induced to take. Soups and broths may also be given. Soft solids are frequently grateful to the patient. In the later stages of the disease, cod liver oil and iron should be given. Paralysis can be treated with strychnia, massage, and electricity. In the treatment of diphtheria, care must be taken Dot to exhaust the strength of the patient by over zealous attempts to induce him to take food. The practice of giving food and drugs to a patient ill with an exhausting disease, every ten or fifteen minutes, is productive of much barm,. and, therefore, cannot be too strongly censured.

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