DIPHTHERIA.
Preventive treatment in time of epidemic consists in rigid isolation as in scarlatina, &c. The diphtheritic patient cannot be regarded as innocuous until after a period of at least three weeks, or as long as the bacilli can he found in the nasal discharge or Throat. The best prophy lactic in the case of these carriers consists in the use of insufflation of the nostrils by the Pasteur Institute Powdered Antimierobie Serum three or four times daily. The injection of a moderate dose of antitoxic serum (1,000 units) affords protection only for 3 or 4 weeks. The best results arc obtainable by using r c.c. of a Toxin antitoxin mixture or this plus 1,000 million sterilised bacilli. As the disease has a brief incubation period, a week's quarantine is sufficient for the isolation of suspected individuals who have been in contact with diphtheritic patients. By using the Schick test (the minimal lethal dose of toxin for a guinea-pig) the susceptibility of an individual is determined by the appearance of a local reaction within 48 hours at the seat of injection.
Treatment by Antitoxin, when once any membrane has become visible, must be instituted without a moment's unnecessary delay. Statistics demonstrate conclusively that the mortality of the disease increases with every fraction of a clay's delay, and even in the mildest case the physician cannot be held as blameless who postpones injection unnecessarily once the diagnosis has been arrived at. In most cases, even with a speck of false membrane visible upon the mucous membrane of the fames, the delay caused by waiting for an incubation of the bacillus from a swab of wool is unjustifiable.
The dose is not to he regulated by the bulk or volume of the antitoxic liquid or by the age of the patient. In early mild cases 2,000-5,000 units should be injected under the skin of the abdomen or into the substance of the vastus externus muscle, and repeated inside 24 hours if no visible change is apparent in the small patch of membrane. Cases only seen upon the third or fourth day require larger doses—viz., io,000 to 15,000 units—which should be repeated in half this amount in 12 hours after wards. No late case, no matter how apparently hopeless, should be de prived of the advantage of the antitoxin, even should its intravenous injection be demanded. The repetition of the injections will be required in all such cases every 12 hours. Intramuscular injection gives better results than the subcutaneous.
Should the membrane show no signs of disintegration or should it be extending it may be accepted as a limit that 25,000 units very rarely will be required, though double and even treble this amount has been given with success in grave and neglected cases. In all laryngeal or
tracheal cases the first dose should never be less than io,000 to is,000 units.
Under this treatment all early cases may confidently be expected to clear up rapidly, as the discharge speedily lessens, and the symptoms of general toxaemia and cardiac weakness are prevented, the mortality in uncomplicated faucial cases dealt with upon the first day of the disease being practically nil.
Rest in bed in a warm and well-ventilated room should be insisted upon from the first. In private practice the room itself must be carefully isolated from the rest of the house, and a sheet kept moist by a disinfectant should be fastened outside the door.
The should be kept in the horizontal position owing to the danger of cardiac weakness, and any necessary change from this posture should be effected slowly, especially in the early stages of the disease when there is much septic discharge, and in the convalescent stage when a more serious cardiac weakness is liable to follow from a paralysis of the heart.
The diet should be generous and sustaining, but must be administered in the liquid form. Peptonised milky foods of the consistence of gruel or cream are as a rule more easily swallowed than thin fluids; boiled milk with arrowroot in which an egg is well beaten up answers every purpose. Small quantities of beef juice or any good thick soup devoid of all greasi ness may be also given at short intervals. Many children take greedily a pap made by soaking a Naples or Marie biscuit in warm milk flavoured with weak tea. When swallowing is difficult or impossible rectal feeding must not be relied upon; it is always unsatisfactory in children. The best plan will be to feed through the nasal tube, and this will be imperative in intubation cases, and at a later stage in all cases where, owing to paraly sis, food constantly regurgitates through the nose. Obviously in the presence of continual vomiting rectal feeding must be tried; even the hypodermic use of saline solution may be indicated, and the writer has resorted to the inunction of cod-liver oil, which apparently saved life in two desperate examples of the disease in the paralytic stage, where both rectum and stomach were unavailable routes for the administration of food.