Showing the Effect of Antitoxin on the Local Diphtheritic Process. The figures on the left show the gradual increase of the false membrane from the first to the thirty-sixth hour. ne figures on the right show the disappearance of the membrane during the next thirty-six hours as a result of the use of antitoxin.

or, if this cannot be done, a spray, from a glass atomizer, of the strength of 1:4 of water may be employed. The effect is often extraordinary. After a few applications the false membrane appears to exist only in disorganized shreds. If the nasal chambers become affected, a tepid solution of odinary salt (7:1000) should be used in a spray or by means of a fountain syringe. The child is placed with its hips on the lap of one nurse and its head on the lap between the knees of another, the dress of the nurse being protected by a rubber sheet, and the nasal cavities irrigated. The position of the child should be on its side, not on its back, and the face should be turned down sufficiently to allow the liquid, after entering the upper nostril, to flow out the lower one with ease, the child breathing through its mouth. The applications should be made as frequently as the membrane forms.

Antitoxin Treatment. This treatment excels all others in efficacy and usefulness, and should displace all other plans of treatment except the local applications. Of all the extraordinary advances made in pathology and therapeutics, the introduction and proof of the value of antitoxin in cases of diphtheria are perhaps most worthy of note. (For the study of Antitoxin itself, see Antitoxin, in Part III.)

There are several facts in connection with the use of the diphtheritic antitoxin which should be borne in mind. The syringe for injecting it should have a glass barrel in order that any foreign bodies or air-bubbles can be seen and removed before the injection is given. The packing of the piston should be made of asbestos or rubber, since it is practically impossible to sterilize leather or other packing; and the different parts of the syringe should be easily disjointed in order to permit thorough cleansing and sterilizing. Immediately before and after the use of the syringe the needle should be removed and the cap taken off so that the sterilizing fluid may readily enter the syringe and needle, and then they should be placed in warm water which is brought to the boiling-point. By this gradual heating breaking of the glass barrel is avoided. It is best to employ one of the syringes made for the purpose. The injection is to be given slowly into any part of the body which has loose subcutaneous tissues, such as the broad of the back, the side of the abdomen, or the outside of the thigh. The skin at the place of injection should be thoroughly sterilized beforehand, and after the injection the fluid should be allowed to diffuse itself and not be spread by rubbing.

At the present time some manufacturers of antitoxin put up their product in hermetically sealed bulbs, or in special containers from which the serum may be directly injected without the use of an extra syringe. The advantage of this plan is that the physician is saved the trouble of sterilizing a syringe and can use a fresh piece of apparatus for each injection. (See Figs. 109 and 110.)

The dose of antitoxin serum is to be judged by its known strength or power of conferring immunity and by the severity of the disease and the susceptibility of the patient. Not less than 4000 units should be

given as an initial dose and be repeated in twelve hours. The dose should be repeated every six or twelve hours in severe cases, and doubled in amount in very malignant cases or in those with deeply seated cervical induration or laryngeal or nasal diphtheria. Small doses are not required by young children. The fact that they succumb more quickly to the disease than older children makes a large dose necessary.

It has been urged against serums containing over 250 units per c.c. that their use is apt to be followed by untoward effects such as skin eruptions and local irritations. On the other hand, if the weaker serums are employed, such large amounts have to be given that very considerable swelling of the area in which the injection is given is produced, and, of course, valuable time is lost before the whole dose is

FIG. 109 shows an antitoxin container from which the antitoxin is expelled into the subcu taneous tissues by means of a rubber bulb. At the other end a sterile hypodermic needle is attached.

FIG. 110 represents another form of container shaped like a syringe. In it is a piston into which is screwed a rod when the antitoxin is to be used. At the other end is attached a needle for the injection after the cup is removed and the glass tip is broken.

absorbed; whereas if serums containing high immunizing power are employed, the small dose is quickly absorbed. In urgent cases of nasal or laryngeal diphtheria the stronger serums are indicated, whereas in the more moderate cases the lower grades of strength may be used.

Professional opinion the world over is strongly in favor of the use of antitoxin in diphtheria. So far there have been published an immense number of reports and statistics concerning its use, and it is a fact that the use of antitoxin is of the greatest value. Whereas the average death-rate without antitoxin varies from 25 to 65 per cent. according to the severity of the epidemic, with the use of antitoxin it falls as low as 16 or even 8 per cent.

The author cannot too strongly urge upon the reader the vital

importance of using antitoxic serum early and freely. The reports in which it has been condemned are imperfect and unreliable. It has been claimed by some persons that since the use of antitoxin more cases of complications or sequelæ are met with than ever before. The reason is manifest, viz., that before antitoxin was used all the very malignant cases died, whereas a large percentage of these are now saved, and suffer from lesions which if antitoxin had not been used would have been fatal. Every patient who apparently suffers from the disease should receive this remedy, so potent for good and so lacking in harmful qualities even when given to non-diphtheritic persons. The physician who can obtain the serum and does not use it is not doing the best thing for his patient.

Much depends upon the early use of the remedy, for after degenerative changes have taken place in the heart and kidneys the damage is done. Statistics show that in cases which receive the antitoxin on the first day the mortality is often only 3 to 5 per cent., whereas with each day of delay the percentage rises, so that when it is not given till the fourth day the mortality is as high as 40 per cent. As the use of antitoxin does no harm, it should be employed in all doubtful cases of diphtheria without waiting for a bacteriological diagnosis.

When the antitoxin is given, general improvement usually takes place in twelve to thirty-six hours, and the temperature falls. The spread of the membrane is arrested and its separation soon begins.

Although the use of antitoxin for immunizing purposes when persons have been exposed to infection has been resorted to, it is not practised by the general body of the profession to the extent that it should be. The use of 1000 normal antitoxin units will usually produce immunity for three or four weeks.

Full doses of antitoxin of the higher potencies sometimes give rise to pains in the joints or to an erythematous eruption, which are without danger and need not excite alarm.

The only new local application which promises much is that of Loeffler. He directs that the mucous membrane shall be carefully wiped off by a pledget of cotton, and after this is done that a second pledget dipped in the following solution shall be pressed against the diseased area for ten seconds at three-hour intervals: menthol 2 drachms (10 grammes) dissolved in 9 drachms (36 c.c.) of toluol, to which are added 1 drachm (4 c.c.) of liquor ferri chloridi and absolute alcohol 2 ounces (60 c.c.). This solution, if kept in a dark glass bottle, well stoppered, will keep for months. The author prefers to use peroxide of hydrogen in all cases, as it is efficacious and painless, whereas the application of Loeffler's solution is apt to be very painful.

The local use of iodine, phenol, and similar irritating and poisonous substances is not justifiable.

Great care as to the prevention of the disease is needful. All cases should be carefully isolated; children who have been exposed should be quarantined for fourteen days; persons in perfect health who have

been nursing such patients should also be quarantined, for in the secretions of the throat diphtheria bacilli may be carried by an apparently healthy nurse to another patient. The nurse and physician should therefore gargle with saline solutions and follow this by antiseptic mouth washes, using the greatest cleanliness as to the hair, hands, face, and clothing.

The maintenance of the patient's strength during an attack of diphtheria is of great importance. Simple, easily swallowed, and easily digested food should be freely given, and plenty of water provided to allay thirst and flush the kidneys of poisons. Milk, predigested or plain, is useful, as is also properly made beef-tea (see Feeding the Sick); soft eggs, etc., are to be given; and if swallowing is difficult because of soreness or paralysis, then we must feed by the use of the soft-rubber nasal tube, inserted through the nasal cavities into the pharynx after being well oiled with albolene. (See Gavage, Part III.) Such a method of feeding may be resorted to in cases of inability to swallow arising from paralysis and consequent regurgitation; in coughing which prevents swallowing, as in tracheotomy cases; and in the vomiting which sometimes follows swallowing, but often does not follow nasal feeding. It is best to use throat applications before giving the food, in order to avoid vomiting.

may

Feeding by the rectum may also be resorted to, and hypodermoclysis is not to be forgotten for the purpose of supplying fluid to the tissues. Tincture of the chloride of iron, quinine, and strychnine are of service to keep the kidneys active, to stimulate the heart and respiration, and to support the vital forces. The dose of the tincture of iron be as much as 2 minims (0.1) every hour to a child of four years. Steam set free in the air of the room is very useful as an adjuvant to local treatment, and the bronchitis-tent may be used in laryngeal cases. A method of using turpentine by inhalation was highly recommended by J. Lewis Smith. The following prescription is placed in water in the proportion of 2 tablespoonfuls (30.0) to a quart (960 c.c.), and this mixture is then placed on a gas or oil stove in a broad, open vessel and allowed to boil constantly. The air of the sick-room is soon laden with the vapor, which is not offensive. The prescription is as follows:

R-Phenol.,

Olei eucalypti

Ol. terebinthina

ǎá f3j (30.0).
f3 viij (240.0).—M.

S.-Use as directed. Label: Poison if taken internally.

In other cases there is no doubt that calomel by sublimation does great good. The child is placed in a bronchitis-tent and from 45 to 75 grains (3.0 to 5.0) of calomel are placed in a sublimator and gradually vaporized into the air the child breathes.

When the glands of the neck threaten to suppurate, ice-bags should be applied to the throat and pieces of ice held constantly in the mouth, while the tincture of iron is pushed in as full amounts as possible.