PROPHYLAXIS For efficient warfare against. the plague of diphtheria there a-re two plans: (1) the destruction of the bacilli; (2) the closing of the avenues by which the bacilli travel.
Of the highest importance is an accurate diagnosis and a knowledge of the possibilities of infection. Very few physicians have been suffi ciently schooled in bacteriologic methods or possess the necessary apparatus for culture experiments, so in the great majority of large cities there have been established central laboratories in which exam ination is made of the cultures sent by physicians from cases in which diphtheria is suspected. It is greatly to be desired that physicians should use these facilities frequently, that they should form the habil of inspecting the pharynx at erery visit to a sick child. With membrane, no matter how small, and especially with unilateral, purulent, chronic rhinitis: ac companied by fever, they should study or hare studied- for them the exudate or discharge. Until the report on the results of the investigation is re ceived the physician should regard every suspicious case as true diph theria. With such care he may be able to prevent much trouble, espe cially at. the beginning of an epidemic. The patient and nurse should by all means be isolated. Whether the antitoxin should be given immedi ately depends on the special circumstances. It is better to inject unneces sarily than too late! When the diagnosis is established, all the usual precautionary measures customary in other infectious diseases are to be strenuously enforced, forbidding visitors in the sick room. etc., and these measures should be maintained until complete disappearance of the local symptoms, in order to avoid a spread of the infection. For the same reason, the patient, if at all feasible, should remain in one room throughout the attack.
Because contagion may have occurred before the presence of the disease is established, all children in the immediate surroundings are to receive prophylactic injections of antitoxin. For this a dose of 200 units is sufficient, hut for children with other diseases such as measles, and for children under two years of age, it is better to inject from 600 to 1000 units.
These measures must be particularly enforced if the parents of the children come in contact in their occupations with many people, as is the case with teachers and salespeople, especially those connected with the handling of food supplies.
The physician may also be the carrier of infection. With certain precautions he may avoid receiving the infectious material, by the use of long rubber tubes on the stethoscope (with subsequent disinfection), and by standing behind the patient while inspecting the pharynx, looking down from above and thus avoiding the danger of having the patient cough in his face, and at the same time gaining a much better and deeper view of the pharynx (Fig. 93).
The immediate return of the convalescent to his family is allowed some days after the disappearance of the membrane. A separation until the bacilli have disappeared from the throat is not practically feasible, and moreover in view of their spreading to other mucous membranes where they linger much longer, it is useless. The raising of the quaran tine includes a cleansing bath for the patient and disinfection of the room with formaldehyde vapor.
Not until eight days after disappearance of the membrane in un complicated cases is the child to be allowed to return to school. A longer exclusion from school is superfluous because the intercourse, as it ordinarily exists among school children, is not specially adapted for the transmission of the disease. Greater care is necessary with children who return to such institutions as day-nurseries, because with these children "dirt-infections" are more frequent (Escherich, Feer).
The other children of the family must also be included in the exclu sion from attendance at school unless they were promptly and completely isolated from the sick one. with the added protection of immunization and provided that they show no signs at all suspicious of diphtheria.