usually small and feeble. Cerebral symptoms are infrequent.

In the pharyngeal type there is complaint of sore throat and difficulty in
swallowing. The pharynx and tonsils are inflamed and swoUen and upon
the latter there are yellowish spots which gradually enlarge, becoming grayish
in color, until by the third or foixrth day the tonsils are entirely covered and the
piUars of the fauces and the soft palate may be involved to such an extent
that the opening of the pharynx may be wholly occluded. The cervical
glands are swoUen. In the ordinary case the patient is not markedly poisoned
and the symptoms soon abate. In about a week or ten days the glandular
swellings have disappeared with the false membrane, leaving the pharynx
clean, the temperature falls and the patient is convalescent.

In nasal diphtheria the onset is marked by the usual constitutional mani-
festations and an increased nasal discharge which irritates and often exco-
riates the upper lip. The glands beneath the angle of the mandible are swoUen
and indiu-ated. This enlargement is characteristic and probably due to
the fact that the nasal mucosa is particularly rich in lymphatics. Many
cases of nasal diphtheria are of severe type with marked constitutional symp-
toms and antral, aiual or ocular complications are frequent. A peculiar
form is sometimes met in which constitutional manifestations are absent;
the nostrils are occluded by typical membranes in which the bacilli are present
but the infection is characterized by a benign course.

Laryngeal diphtheria or membranous croup is characterized by a laryngeal
cough at the onset and by the gradual development of obstruction. The
latter may, however, appear suddenly at night. The respiration is rapid



DIPHTHERIA. 8 1

and difficult, the expiration particularly being interfered with, the abdomen
and lower thorax are retracted in inspiration and the mucous membranes
and extremities become cyanotic from lack of oxygen. The patient becomes
restless and may fall into a semi-coma and die of asphyxia. In milder instances
the paroxysm may last but a short time and the patient will gradually become
quiet. The attack is, however, likely to be repeated during the following
night. At times relief will foUow the coughing up of the membrane, in part
or as a whole. The constitutional symptoms are often not marked but
when there is an accompanying pharyngeal membrane the opposite is usually
the case.

Membranous croup occurs in two varieties, the clinical appearances and
symptoms of which are so similar as to prevent their differentiation except
by bacteriological examination. Cultures alone will determine whether
the affection is due to the streptococcus or to the diphtheria bacillus.

Diphtheria in other parts is rather infrequent but the inflammation may
affect the conjunctiva, either primarily or by extension through the lacry-
mal duct, the skin, especially about the lips and nostrils and the external
auditory meatus by extension from the middle ear. The genitals may be
affected, whence the inflammation may spread to the surrounding skin and
diphtheritic inflammations may occur in open wounds which have been infected
by the bacillus.

The symptoms oj constitutional infection in mild cases are not marked.
In more severe instances, three or four days after the onset the patient's con-
dition becomes one of great weakness, the heart action is feeble and cerebral
symptoms are present. At this time there is great danger of death from
paralysis of the heart. In other cases the constitutional symptoms are prom-
inent from the beginning, the temperature is high and the evidence of
toxaemia pronounced. As a rule the constitutional symptoms are directly
proportional to the local involvement.

A marked leucocytosis is usually present in diphtheria even of mild type
and albuminuria occurs in nearly aU severe cases.

Complications and Sequelae. The slight albuminuria which is so
commonly seen is not to be attributed to nephritis but the appearance
of blood and epithelial casts and the occurrence of diminution of the
urine indicate that serious kidney involvement is present. Oedema is
less frequent than in scarlatina and while the nephritis of diphtheria
usually terminates in recovery it may cause death. Bronchitis and broncho-
pneumonia are important and serious complications. Pericarditis and
endocarditis are rare. The heart is often irregular and an apical systolic
murmur is present in a large majority of cases. Heart weakness, evidenced
by rapid and galloping rhythm and by sudden diminution in the pulse rate,
is a serious manifestation. The cardiac symptoms usually appear from the
6



82 THE INFECTIOUS DISEASES.

loth to the 2oth day of the disease but fatal acute dilatation may occur in
convalescence, even as late as the seventh week.

Minor complications such as nasal or pharyngeal haemorrhage, various
skin eruptions and jaundice are not uncommon.

Paralysis ig a most important sequel and is a result of neuritis due to the
toxins of the disease. It may appear as early as the seventh day or not until
convalescence and as frequently follows mild as severe cases. It occurs in
lo percent, to 20 percent, of cases and is more frequent in adults than in
children. The palate is most often affected and involvement of this struc-
ture is evidenced by nasal voice and the regiirgitation of food through the
nostrils. The phar}'nx is anaesthetic. Involvement of the muscles of deglu-
tition is also frequent and various ocular palsies are not rare and neuritis of
the extremities may occur resulting in permanent disability. Recovery
usually takes place from these paralyses within a few weeks. Multiple neuritis
may be observed which may rarely involve the innervation of the heart and
the respiratory muscles, in which event the patient's condition is dangerous.

The diagnosis can be assured only by bacteriological examination of the
false membrane; fortunately this is not a difficult procedure, and where there
is no health department affording facilities for laboratory diagnosis, it may
be carried out by the practitioner. For a description of the technique the
reader is referred to any good work upon clinical diagnosis.

The prognosis since the introduction of the antitoxin treatment has been
rendered vastly more favorable than previous to this event. By this remark-
able therapeutic advance the mortality from diphtheria has been reduced
from 30 percent, to 50 percent, to from 10 percent, to 15 percent. The prog-
nosis is excellent in the usual case. Complications and laryngeal involve-
ment render it less good. Sudden heart failure, paralyses and uraemia
may result fatally.

Prevention. Prophylaxis in diphtheria has been fiu-ther developed and
is more successful than in any other infectious disease save smallpox. The
following condensation of the rules concerning the disease laid down by the
New York Health Department covers the subject of prevention very
thoroughly.

If possible one person should take entire charge of the patient and no one
else except the physician should be allowed in the sick-room. The nurse
should hold no communication with the rest of the family, who should not
receive or make visits during the illness. Discharges from nose and mouth
must be received on cloths which should be immediately immersed in carbolic
acid solution (six ounces of pure carbolic acid added to one gallon of hot
water and diluted with an equal quantity of water). All handkerchiefs,
towels, bed linen, clothing, etc., that have come in contact with the patient,
after use must be at once immersed without removal from the room in the



DIPHTHERIA. 83

above solution. These should be soaked for two or three hours and then
boiled in water for one hour.

The greatest _ care should be taken in making applications to the throat
and nose lest the discharges be coughed into the face or upon the clothing of
the attendant. A pane of glass held between the patient and the physician
will effectually prevent this accident.

The hands of the attendant should always be disinfected by washing in the
carbolic solution and in soapsuds after making applications and before eating.

Siufaces of any kind soiled by discharges should be immediately flooded
with carbolic solution.

All utensils used by the patient must be kept for his use alone and not
removed from the room, but must be washed in the carbolic solution and in
hot soapsuds. After use the soapsuds should be thrown in the water-closet
and the vessel which contained it washed in the carbolic solution.

The sick-room should be thoroughly aired two or three times a day and
swept frequently after scattering wet sawdust or tea leaves on the floor to
prevent the dust from rising. After sweeping, the room should be dusted
with damp cloths. The sweepings should be burned and the cloths soaked
in the carbolic solution.

^Vhen the disease is recognized shortly after the beginning of the illness all
hangings and unnecessary furniture should be removed from the sick-room.

After recovery, the patient's body and hair should be washed with hot soap-
suds, he should be dressed in clean clothes, which have not been in the room
during the illness, and taken from the apartment.

The quarantine should last as long as the diphtheria bacilli are found upon
the mucous membranes; they may persist for six or eight weeks.

The nurse and physician should wear, while in the sick-room, a gown which
covers the clothing completely. This should be kept just outside the apart-
ment and sterilized directly after use. If the patient, while the throat is being
examined, should cough in the examiner's face, the latter should wash the
face and hair in soap and water followed by i to 1000 mercury bichloride
solution. The hands must always be sterilized upon leaving the sick-room.
The niurse should spray or gargle her throat several times a day with mild
antiseptic, such as Dobell's solution.

It is strongly advisable that the nurse and members of the family, if they
have been exposed, should receive an immunizing dose (100 units for a child
under the age of one month to 800 units for an adult) of antitoxin and at
the first sign of sore throat a full dose must be given. The effect of an
immunizing dose lasts about four weeks and at the close of this period a
second dose should be given if there is continued exposure.

After removal of the patient the room and its contents should be properly
disinfected and aired.



84 THE INFECTIOUS DISEASES.

Treatment. The patient should be immediately isolated, especially if
the disease is complicated by pneumonia, in an apartment which should be
kept cool (65° F, — 18.5° C.) and freely ventilated. If practicable, in hospitals
it is always better to assign each patient a separate room than to collect the
sufferers in a ward. From the onset of the disease until all possible danger
of heart failure is past the patient should be kept in bed. At the beginning
of the treatment the bowels should be freely opened by means of fractional
doses of calomel to be followed by a saline and regvilar daily movements
should be obtained throughout the coiirse of the disease.

The treatment of diphtheria by antitoxin is attended with such good results
and has so few disadvantages and dangers that it should always be employed.
All patients in whom the symptoms and clinical appearances resemble those
of diphtheria should receive the treatment without waiting 24 hours or more
to learn the result of a bacteriological examination. By enforcing this rule
we may give antitoxin in many cases in which it is unnecessary but it is better
to do this than to allow one patient who is suffering from true diphtheria to
wait even a few ho\irs.

The antitoxin of any reputable producer may be used and the technique
of its administration is simple. An ordinary hypodermatic syringe may be
used or the injection outfit provided by the maker of the serum. The needle
should be sterihzed and the skin of the selected site, which is usually the
thigh, buttock or side of the chest, bathed with soap and hot water, washed
with alcohol and i to 5000 mercury bichloride solution. The serum should
then be slowly injected, the needle withdrawn and the puncture covered
with a bit of sterile gauze held in place by adhesive plaster.

The quantity of the antitoxin administered depends upon the severity
of the infection and the age of the patient. After the first injection the dosage
should be regulated by the effect produced and is limited by this consideration
alone. The most concentrated serum obtainable should be used so that the
bulk of the dose should be as small as possible. In mild cases one dose of
2000 to 3000 units is often sufficient, a unit being the amount required to
neutralize the amount of diphtheria toxin necessary to kill 100 small guinea
pigs; 5000 units is a proper initial dose for a child of two years with a severe
infection. All cases with laryngeal involvement should receive a dose at least
as large. Late in the disease when the condition is profoundly toxic 10,000
units may be given and repeated until the condition is ameliorated. Too great
insistence cannot be laid upon the importance of giving large doses in severe
infections for it is possible by this means to save seemingly hopeless cases.
The treatment is harmless and amounts of over 100,000 units have been given.
The favorable action of the antitoxin is evidenced as a rule within 24 hours
and often within less time. The membrane ceases to spread and becomes
more soft and more easily detachable. The surrounding and underlying



DIPHTHERIA. 85

mucous membrane rapidly assumes a normal appearance. In nasal and
laryngeal diphtheria the amelioration of the local inflammation is quite as
evident. The glandular swellings diminish and at the same time the consti-
tutional symptoms clear, the temperature falling, the heart action becoming
stronger and the prostration less marked.

It is important to keep in mind the fact that the antitoxin in order to exert
its best effect must be given early. One should not wait for an assured bac-
teriological diagnosis but the treatment should be instituted as soon as the
patient is seen. The serum is impotent to check such complications as
septic infection, nephritis and broncho-pneumonia.

Unfavorable Effects of Antitoxin. Authentic cases of sudden death have
never been reported and the consensus of opinion is that the treatment is
harmless. Various skin eruptions, especially lu-ticaria may foUow injection
and cases of arthritis and abscess have been reported. The latter are not
often seen and considering the advantages of the antitoxin treatment are
wholly negligible.

Local treatment has become less important since the introduction of anti-
toxin but still holds a considerable place in the management of diphtheria.
The object sought is cleanliness rather than the destruction of the baciUi.
In many cases it is difl&cult of accomplishment owing to the objections of the
patient. If the child is prone to struggle it is better not to employ force, and
in such instances the local treatment may be omitted. The most approved
method is to irrigate the nose and pharynx with mild solutions such as normal
sodium chloride or weak boric acid as hot as the patient will bear, by means of a
fountain syringe or rubber hand syringe to which a soft rubber catheter is
attached. The child should lie on his side with the head slightly lower than
the rest of the body so that the irrigation can readily flow from the mouth
into a convenient receptacle. In severe cases such irrigations should be
given every two or three hours.

Nasal syringing is necessary in cases with nasal discharge and in patients
with pronounced symptoms and evident marked nasal involvement is abso-
lutely necessary. If there is epistaxis the irrigations should be temporarily
omitted and sprays of suprarenal extract, 10 percent, calcium chloride solution
or of weak alum solution may be employed.

In mild cases when practicable mild antiseptic alkaline sprays should be
used both upon the nose and pharynx. Dobell's solution or diluted liquor
antisepticus (U.S. P.) are applicable for this purpose.

Direct applications to the site of the inflammation are used less now than form-
erly but many physicians approve them. The patient should be warmly wrapped
and held by the nurse, the mouth being held open by a cork between the
teeth or by a mouth gag while the application is made by means of a cotton
swab or a brush. Various solutions may be employed, that originated by



86 THE INFECTIOUS DISEASES.

Loffler being one of the most efficient. It consists of lo parts of menthol,
26 parts of toluol, liquor ferri sesquichlorati 4 parts and absolute alcohol
60 parts. Other solutions which may be used are 10 percent, lactic acid;
one part of mercury bichloride to 1000 parts normal sodium chloride; mercury
bichloride one part, tartaric acid five parts, water 1000 parts; phenol three
parts, rectified oil of turpentine 40 parts, absolute alcohol 60 parts; hydrogen
dioxide solution, etc. Such applications may be made to the inflamed sur-
face ever}^ three to six hours.

Insufflations of various powders such as bismuth subgallate, thymol iodide
(aristol), nosophen, one part iodoform to five parts sodium bicarbonate may
be given, but the treatment can be carried out very satisfactorily without
them.

External apphcations to the throat in the form of poultices are not indi-
cated. Ice bags, however, may lessen both the pharyngeal inflammation and
the tendency to enlargement of the cervical and submaxillary glands. Sucking
bits of ice often makes the patient more comfortable and may influence the
pharyngeal inflammation. In glandular enlargement and tendency to cervical
suppuration inunctions of unguentum Crede and injections of antistrep-
tococcus serum are valuable since suppuration in diphtheria is considered
to be due to mixed infection with pyogenic micro-organisms.

In the early stages and especially in laryngeal diphtheria, steam inhalations
by means of a croup kettle, the spout of which is introduced under a tent of
blankets constructed over the child's crib, are indicated. The steam may be
that from plain water, lime water, 2 J percent, lactic acid solution, 3 percent,
phenol solution, one drachm of eucah^tol or benzoinol to a pint of water, etc.

In lar}-ngeal diphtheria with obstruction and pronounced dyspnoea emetics
should be given. Here syrup of ipecac may be administered in teaspoonful
doses to a child of three years every 15 to 30 minutes until emesis is induced,
or a teaspoonful of the following formula may be given in the same way.
I^ pulveris ipecacuanhae, gr. xxii ss (1.5); antimonii et potassii tartratis, gr. i
(0.065); syrupi scillEe, 5i (30.0); aquee destillatas, 5iv (15.0).

Lar}-ngeal obstruction which does not yield quickly to this form of treat-
ment necessitates immediate intubation or tracheotomy.

The internal administration of drugs with the hope of influencing the
course of the disease is considered by many authorities quite useless while
among the more conservative the old idea still prevails and drug medication
is prescribed as before the introduction of antitoxin. Mercury bichloride is
given to adults in doses of ^ig- to J^- ^^ ^ grain (0.0012 to 0.005) every two
hours with potassium chlorate and tincture of iron chloride in the hope of
causing the membrane to loosen. For children the dosage should be some-
what lower. Toxic effects are not likely to occur since digestive disturb-
ances usually appear before any harm is done. Calomel is also given with



DIPHTHERIA. 87

the same object in view, in fractional doses, ^ to ^ of a grain (o.oii to
0.008) every' hour, until free diarrhoea is induced.

The saturated solution of potassium chlorate was for long the classical
mouth wash in diphtheria and is still prescribed by some but it is in no way
preferable to the solutions previously suggested. Gargling with potassium
chlorate solution is inferior to irrigating and spraying, for it is almost impossible
to bring the gargle into contact with the seat of the inflammation if it is behind
the piUars of the fauces. Iron and quinine may be given through the course
of the disease in the hope of supporting the patient's strength.

Stimulation becomes necessary as soon as the toxaemia is evidenced by the
general condition and by tendency to heart weakness. In mild cases stimu-
lants may be unnecessary but alcohol will be required in most cases sooner or
later. The need of its exhibition is shown by marked constitutional symp-
toms and feebleness of the pulse. The dosage should be regulated by the
patient's condition and either brandy or whiskey, diluted with water, may be
given. Half a drachm (2.0) every three hours is a proper amount for a child
of five years. This quantity may be increased as necessary. Strychnine is
valuable and digitalis may be given in small doses if there is low arterial tension
combined with cardiac weakness. Sudden heart weakness necessitates the
administration of stimulants hypodermatically and here we may give camphor
dissolved in aether or in sterile oil. H}'podermatic injections of morphine
in appropriate doses are said to be our best means of combating the cardiac
paralysis which is so much to be dreaded in diphtheria.

When there is evidence of obstruction to respiration, due to excessive forma-
tion of membrane in the larynx, intubation or tracheotomy becomes neces-
sar}'. The former procedure possesses the following advantages: It is safe,
rapid and without danger, is free from shock, needs no anaesthesia, no wound
is made, the patients make no objection and the air taken into the lungs is
warmed and filtered by its passage through the upper air passages. Intuba-
tion relieves the mechanical obstruction and the indication for its performance
is dyspncea which necessitates relief. Cyanosis is not a safe guide. When
there is evident effort in respiration as shown by the action of the abdominal,
thoracic and cervical muscles, weak heart action and coldness of the extremi-
ties, constitutional depression and evidence of marked toxaemia, intubation
should be performed at once. It is far better to intubate too early than to
wait until too late. In a few instances the laryngeal membrane may be
pushed into the trachea by the introduction of the tube but if the latter is
withdrawn immediately the former will be coughed up; if this does not take
place tracheotomy must be done at once. The operation of intubation is not
difficult and a moderate amount of practice upon the cadaver or upon dogs
wiU render the physician proficient. 0'Dw>-er's original tube is best but while
he was accustomed to intubate with the patient in the erect position, the



88 THE mrECTious diseases.

horizontal is preferable especially if there is tendency to marked prostration
or cardiac weakness.

Diphtheritic paralysis should be treated by rest in bed and, if persistent,
by means of strychnine, electricity, massage and hydrotherapeutic measures.

During convalescence the patient should be kept in bed until all danger of
heart failure is past, this complication being prone to occur for some time
after the acuity of the disease is over.

The diet should be fluid and it is very important that the patient should
get sufiicient nourishment. If nursing, the child should not be allowed the
breast but should be fed upon milk withdrawn by means of the breast pump.
For older children dilute cow's milk, if necessary peptonized, should be the
chief food. If is often necessary, in order that the child shall receive plenty
of food especially in the later stages of the disease, when the appetite is insuffi-
cient and there is pain and difficulty in swallowing, to feed the patient by means
of the stomach or nasal tube. The latter is especially to be employed in
children who object to the former and in those who have been subjected to
intubation or tracheotomy. The food should be predigested in so far as is
possible. The operation is performed with the patient upon his back and
the stomach should be washed before each feeding. Medicines may also
be administered by means of the tube. Each feeding should be of considerable
size for of necessity the operation cannot be performed at frequent intervals.

The quarantine should be continued until cultures from the throat show
the presence of no diphtheria bacilli. The treatment of diphtheroid injections
(pseudo-diphtheria) is the same as for true diphtheria, save that antitoxin
is not indicated. Antistreptococcus serum may be given in its stead.