TREATMENT OF DIPHTHERIA. BY J. W. PEARCE, M. D. It is generally thought that the treatment of diphtheria is pretty well understood by the profession, and more strongly has this idea taken hold upon us since the discovery of the specific micro-organism and the institution of antitoxin in its treatment. I have nothing to say against antitoxin; I think it is good in its way. But antitoxin can not always be had, especially by physicians living in remote or rural districts, away from the great medical centers where the dazzling lights of medicine shine; and it is not always fresh even when obtained in the more favorably located sections, which is one of the most essential points in its use to insure success. Now, brother physician, picture yourself called to see a little patient suffering from diphtheria of a day's or more duration. What are you going to do? Give it that dose of antitoxin you have in your chest, which is not less than six months old, and calmly sit down and wait for the deadly disease to get in its work? Remember, you are miles and miles away from any place where fresh antitoxin can be secured, and there is no chance whatever of getting it. There is but one alternative. If you have pinned your whole faith to antitoxin, then you have nothing to do but give it and watch the little fellow die. If you have studied other remedies and other plans of treatment you will feel much relieved, and if the worse comes you will have the great satisfaction of knowing that you did all that could be done under the circumstances. Our forefathers in medicine, some of them, were very successful in treating diphtheria, and that was long before the days of antitoxin. They used a great deal of common sense and saved a great many of their patients. Now we use a great deal of theory and horse-serum and lose about as many patients. To briefly relate, this is the way I treat diphtheria, and I have never lost a case. If I can get perfectly fresh antitoxin I give it, but if it can not be had perfectly fresh I do not. Whether antitoxin is given or not, I give ecthol (Battle & Co.) in full doses appropriate for the age of the patient, every three hours, administered by the mouth. The entire fauces, larynx, and pharynx are sprayed with a mixture of ecthol and peroxide of hydrogen, three parts of the former to one of the latter, every fifteen to thirty minutes. Calomel in small doses is administered every hour until the bowels are thoroughly moved. Nourishing and supportive diet is given at short, regular intervals, and everything done to make the patient comfortable in the way of supplying fresh air, etc. I have been using this plan, modifying it to suit the needs of each individual case, for several years, and can not recommend it in too glowing terms to my fellow practitioners, knowing that it will give good results and entire satisfaction if it is carefully and effectively administered and carried out. Nothing can save a patient in articulo mortis, and it is needless to try this in such cases hoping to do something. A study of these cases will be interesting: Willie N., aged five years, healthy, robust child, of good family history. Was called to see him one morning. I found him with a high fever, constipated condition of bowels, nausea and vomiting, sore throat, etc. I made a careful examination of the throat, and covering the greater part of it was that grayish membrane characteristic of diphtheria. Microscopic examination of the exudate confirmed my diagnosis. When I informed the parents of the trouble they said there were several cases in the neighborhood. I prescribed as follows: Twenty drops of ecthol in small quantity of water every three hours, one-fifth grain tablets triturate of calomel every hour until the bowels moved freely, a solution of ecthol and peroxide of hydrogen (three to one) to be used as a spray in an atomizer every fifteen to thirty minutes, and a nourishing and stimulating diet was advised to be given at short, regular intervals, in small quantities. That evening when I called his temperature was slightly lower, but otherwise I could note no improvement. The next morning, however, there was a considerable improvement, the temperature being considerably lower than on the previous morning, when I first saw him, and he appeared very much brighter. From this time on he progressed to a rapid and uninterrupted recovery. Antitoxin was not administered in this case, as I could secure none that was fresh, but the outcome of the case was fully as good as though antitoxin had been administered. Bessie C., aged two and a half years, well-grown, plump little girl, of a good family history. Was called to see her one night about eleven o'clock, she having been taken ill the night previous. The family was not alarmed, though she had considerable fever all the day before I called, they thinking it caused by some slight digestive trouble due to some error in diet. I found her with a temperature of 103° F., constipated bowels, nausea and vomiting, sore throat, etc., and as there were several cases of diphtheria in the neighborhood I surmised this case to be diphtheria. On examination of the throat I discovered the characteristic grayishwhite exudate covering a large portion of the fauces, larynx, and pharynx, and subsequent examination of a smear by microscope demonstrated the Klebs-Loeffler bacillus, confirming my surmise. Having fresh antitoxin, I administered it and prescribed the following: Twelve drops of ecthol in small quantity of water every three hours, one-eighth grain of calomel in tablet triturate every hour until bowels were thoroughly evacuated, and throat to be sprayed with a solution of ecthol and peroxide of hydrogen (three to one) every twenty to thirty minutes. Next morning I thought there was a slight improvement, the temperature being lower than I anticipated. On the next evening I could note distinct improvement. She progressed nicely toward recovery, which was uneventful, being complete in a few days. Annie G., aged five and a half years, well nourished and healthy child, of good parentage. Was called to see her, whom I found to be suffering from all the initial symptoms indicative of an attack of diphtheria. There was considerable elevation of temperature, it being 102.5° F., nausea and vomiting. A careful examination of the throat revealed a small patch of exudate which was characteristic, situated on one side of pharynx, from which position it soon spread so as to almost cover the entire region of the throat. Microscopic examination revealed the specific bacillus, confirming my partial diagnosis. The treatment was as follows: Fifteen drops of ecthol were administered every three hours in a small quantity of water, one-fourth grain tablet of calomel was given every hour until the bowels acted freely, and a spray of ecthol and peroxide of hydrogen (three to one) used every fifteen minutes. No fresh antitoxin being obtainable, none was administered in this case. Twelve hours of steady treatment sufficed to show improvement, temperature being lower and the patient looking and stating that she was feeling better. In a short while all the membrane was expelled and disappeared, and she went on to an uneventful and complete recovery. In the three cases reported above it will be noticed that antitoxin was used in one and was not used in two. As I previously stated, if fresh antitoxin could be secured it was administed, but even then I did not depend upon it entirely, but always supplemented it with the use of ecthol. It will also be noticed in the three cases reported above that those which did not receive antitoxin seemed to do just as well as the one which did get it. I could notice not the slightest difference at the time of treatment, and do not belive that there was any. In a series of twenty-four cases which I have treated as above seven received antitoxin and seventeen did not. The seventeen that did not get it did as well as those that did, as far as I was able to tell. All twenty-four cases recovered, and I attribute most of the remedial effects to the ecthol, which was used in all cases throughout the entire attack. LA GRANGE, N. C. A MISLEADING GUNSHOT WOUND OF THE BRAIN, CAUSED FRACTURE OF SKULL. BY J. K. W. PIPER, M. D. In selecting the following cases for report I have been influenced not alone by the fact that they seem in some respects to be more than ordinarily interesting, or at least unusual, but by the fact that many most interesting cases that terminate otherwise than as we would wish are never reported, as we are, all of us, naturally more prone to report our successes than our failures, even though success in some interesting case may have been out of the question from the start. The first case is a misleading gunshot wound of the head. E. C., forty years of age, farmer, of good physique but of dissipated habits, received pistol-shot wound of the head. I saw him within a few minutes after receipt of the wound, at which time he was completely unconscious, not having moved after having fallen from effects of the wound. Skin cold and clammy, respiration slow and sighing (six or eight to the minute), pulse slow and weak (thirty to the minute), and pupils equally dilated. There was a wound of entrance made by a thirty-eight caliber bullet just behind the outer angle of the left eye, and one of exit behind the ear on same side. From both openings blood and macerated brain was oozing in considerable quantities. A temporary dressing was applied and he was removed to his home, a distance of two squares, put in a warm bed and surrounded by hot water bottles, stimulated with strychnine sulphate and nitro-glycerine, and his head shaved and prepared for an operation. * Read before the Southern Kentucky Medical Association, at Adairville, Ky., April 23, 1902. Two hours after receipt of wound his temperature per axilla was 96°, pulse 30, respiration 6 and very irregular, and pupils unequal; left dilated and right much contracted, and brain and blood still oozing from openings. He being unconscious, it was not deemed necessary to administer an anesthetic. A large flap was turned down, exposing part of squamous portion of temporal and mastoid. An opening three fourths of an inch in diameter and two and a half inches in length was found in squamous portion of temporal, extending from before backward, appearing as though the ball, after having entered the bone, kept its course therein and destroying, almost pulverizing, it to the above extent. A number, probably twenty, small pieces of bone were removed, some from a depth of three fourths of an inch in the brain, it being necessary to trephine wound at posterior angle of bone so as to be able to get at them. A rent of two inches in length was found in the dura mater, from which brain and clotted blood were oozing. Several small vessels were cut, but had about ceased to bleed. At the time, we were unable to find the track of the bullet or part thereof leading deeper into the brain. The wound was cleaned as thoroughly as possible with boracic acid and normal salt solution. It was impossible to draw the edges of the dura together so that they could be sutured, so a three-sixteenth inch perforated soft rubber tube and sterilized gauze was introduced for drainage, the flap closed lightly with silk sutures, and the whole covered with sterilized dressings. Almost as soon as the pressure caused by depressed bone, macerated brain, and clots were removed the patient seemed to show signs of improvement; the left arm and leg were moved more or less freely, and the right arm and leg, both of which seemed to be completely paralyzed before (responding to no irritation), were moved occasionally. While he gave no sign of consciousness during the cutting and turning down of the flap, or during the cleansing of the parts, he cried out and moved his limbs freely, especially the left arm and leg, during the introduction of the stitches. After the operation his pulse was 40, respiration 8, and temperature 97°. Pupils remained the same. For the following seven days he showed marked signs of improvement; temperature became normal, pulse and respiration slowly increased in number to 70 and 15 respectively; intelligence improved, so that he recognized the members of his family, and he notified his nurses when he wished to urinate, but his bowels seemed to act regularly without his knowledge. During this time his temperature |