When the diphtheritic exudation invades the trachea the danger is very serious ; but if the operation of tracheotomy be performed in time, and a marked retraction of the chest-wall indicates that the smaller tubes are free below the point of obstruction, and that air, if admitted, will be able to penetrate to the alveoli, recovery is far from impossible. After the oper ation, success depends chiefly upon the child's capability of taking and di gesting his food, and upon the lungs remaining free from pneumonia. If there is difficulty in administering nourishment, the child can be still fed through the stomach-tube ; but loss of appetite usually implies feeble di gestive power, and the prospect is not favourable. If pneumonia occur, the prognosis is gloomy.
After the end of the second or third week nervous symptoms may be expected. In these the prognosis is favourable. It only becomes serious when the lesion is widely diffused, when all the muscles of deglutition are affected so that swallowing becomes impossible, or when the diaphragm and respiratory muscles are attacked. No child, however, should be al lowed to die of starvation, for nourishment can always be administered at regular intervals through the stomach-tube passed through the nose.
Treatment.—Diphtheria is an infectious disease, and the ordinary pre cautions must therefore be taken against its spread. The sick room should be divested of carpets, rugs, curtains, and superfluous furniture ; and proper measures should be taken to disinfect all discharges from the patient before removal.
The child must be kept quiet in bed. It is well to place him in a tent bedstead and to envelop him in au atmosphere of steam impregnated with thymol, creasote, or other disinfectant. This may be most conveniently done by the use of the " croup kettle " designed by Mr. R. IV. Parker, on, the principle of Dr. Lee's " steam draught inhaler." Creasote or carbolic acid may be added to the water in the kettle in the proportion of twenty drops to the pint, or a saturated solution of thymol can be made use of. So many technical matters have to be attended to in the treatment of these cases that whatever be the age of the child the assistance of a skilled nurse is indispensable. Amateur nursing, seldom if ever satisfactory, is here a serious disadvantage to the patient, and introduces into the case an addi tional element of danger.
The treatment of the disease comprises general and local measures, and these are of about equal importance.
The general treatment consists in employing every means to support the strength of the child, so as to enable him to struggle successfully against the exhausting influence of the disorder. The patient should be supplied with food of a nourishing and digestible kind. Strong beef es sence, yolk' of egg, milk thickened with Chapman's entire wheat flour biked in an oven, pounded underdone meat made fluid with strong meat juice or meat essence, all these are very useful. Alcohol must not be for gotten, and will often have to be given in full doses. Old brandy or whiskey, with or without yolk of egg, should be given at the first sign of feebleness of the pulse. A child five years of age will take with benefit thirty drops of good brandy every two hours. In infants white wine whey given freely is very useful. In giving stimulants we must be guided by the state of the pulse, or in infants by the condition of the fontanelle. As long as the pulse is firm or the fontanelle little depressed, alcohol is not re quired, when the pulse gets soft and compressible, or the fontanelle sinks, stimulants must be given without delay. It some cases they will be re quired from the first.
In the selection of medicines preference should be given to such as do not cause depression. In diphtheria there is a tendency to failure of the heart's action ; and this tendency is likely to be favoured by the use of de pressing remedies, such as the salicylate of soda, which has been sometimes recommended. A simple febrifuge may be given while the temperature is high and the skin dry ; but directly the strength shows signs of failing, iron and quinine should be resorted to. The perchloride is perhaps as good a preparation as any other. Ten or fifteen drops of the tincture may be given with one grain of quinine every three hours to a child five years of age. Much larger doses of the drug are often recommended ; but young children vary greatly in their capacity for benefiting by chalybeate remedies, and in weakly subjects the stomach may be readily deranged by an excess of the medicine. Now it is of the first importance to maintain the digestive power, as incomparably the best tonic for a child is nourishing food.