The number of remedies recommended in diphtheria is immense. No other proof of its dangerous nature is needed. In the following I shall review those which I consider it worth while either to reject or to recommend.
Steam is used partly to soften the membranes, but principally to increase the secretion from the mucous membrane, and thereby throw off the superjacent membrane. This can be done to advantage only where there is a natural tendency to it; that is, where there are a great many muciparous follicles under a cylindrical or fimbriated epithelium. This is the condition on part of the pharynx, but not on the tonsils; and in a small portion of the larynx, in the trachea and bronchi, but not on the vocal cords. Wherever there is pavement epithelium on the normal surface, and where the membrane is imbedded into the tissue, steam can hardly be expected to do good. In the other cases it will. Thus, the locality of the diphtheritic process determines to a great extent whether steam is indicated or not. If it be used, the necessity of a full supply of atmospheric air must not be disregarded. Steam, with an overheated room and without pure air, is liable to be as injurious as steam in pure air is beneficial in a number of cases.
There can be no better proof for the necessity of individualizing, and the impossibility of treating all cases alike, than the fact that many will do well under steam treatment, and others are certainly injured by it. I have repeatedly had the joy of seeing children with croup become less cyanotic after their removal from an atmosphere of vapor, and I can readily see that pure atmospheric air would be more agreeable and wholesome to a child with stenosis of the larynx than an atmosphere laden with steam. Of course this remark does not apply to cases of pseudo-croup and bronchitis, which are generally benefited by a warm, moist atmosphere. Those, however, who deem it judicious to employ steam as a vehicle for carbolic acid, salicylic acid, chloride of sodium, chlorate of potassium, or lime, had best resort to the atomizer for applying these remedies. It can be used without trouble; most children are sufficiently intelligent to allow the spray to be directed upon the fauces and larynx every ten or fifteen minutes in case of necessity. When it is deemed advisable to administer steam, I warn against the use of gas stoves. They require a great deal more oxygen than an alcohol lamp, which ought to be preferred when a stove or slaking lime or hot iron or bricks immersed in water are not available.
Water may be made serviceable in different ways. Its effect on the skin, when taken in large quantities, under normal or abnormal circumstances, is a matter of daily experience. Copious perspiration is its immediate result. The very same effect is produced on the mucous membranes. In diphtheria, besides professional hydropathists, I know of but one46 who favors the plentiful use of water, 100-200 grammes (3-6 ounces) every hour or oftener, either by itself or mixed with an alcoholic beverage.
46 C. Rauchfuss, in C. Gerhardt's Handb. d. Kinderkr., iii. 2, 1878.
Severe inflammatory symptoms, such as redness of the throat, great pain, swelling of the glands, require cold applications, either an ice-bag or ice-cold cloths well pressed out and frequently changed. They must, however, be placed where they can do most good—in laryngeal diphtheria around the neck, in pharyngeal diphtheria with glandular swelling over the affected part. In the latter, therefore, the flannel cloth which covers the whole of the application must be tied over the head, and not behind. When ice-bags are used, care is to be taken lest they should be too large; if so, they will not affect the desired spot at all. Small pieces of ice frequently swallowed are greatly relished by the patient; water-ices in small quantities will render the same service; ice-cream, in half-teaspoon or teaspoon doses every five or ten minutes, adds to the necessary nutriment. When the fever is high and the surface hot, sponging with tepid or cold water, or water and alcohol, will mitigate both. For the cold bath or the cold partial pack (trunk and upper part of the thighs) the general indications hold good. As a rule, I favor the latter, for many cases have such a tendency to debility and collapse that sometimes the circulation of the surface of the body is badly interfered with by cold bathing. Therefore, a contraindication to cold bathing must be found at once in cold feet, either before or after a bath. When, unfortunately, the feet do not recover their normal temperature in a very short time, they ought to be warmed artificially, and the cold bath not repeated. In such cases the cold pack, however, is still indicated. A linen or cotton cloth, large enough to cover the trunk and half of the thighs, is dipped in cold water, well pressed out, and the body of the patient wrapped tightly in it. The arms remain outside; the whole body is then wrapped up in a blanket; the feet may be warmed meanwhile when necessary, and the cold pack repeated as often as required to reduce the temperature—viz. once every five minutes, every half hour, every hour.
The contraindications to the use of cold have in part been alluded to. Very young infants bear it but to a limited extent. The beginning of recovery contraindicates it, unless for some local cause; for instance, an inflamed gland. The extensive use of cold water or ice is also forbidden when there is no fever, where there is perhaps an abnormally low temperature, where we have to deal with the septic or gangrenous form of diphtheria, where the vitality is low and the mucous membranes pale or even cyanotic. In such cases, on the contrary, while unlimited internal stimulation is required, the hot bath, or hot pack and hot injections into the bowel, will be found beneficial.
Lime-water, glycerine, lactic acid, pepsin, neurin, papayotin, chinolin, and pilocarpine are all solvents of pseudo-membrane, but whether there is sufficient time and opportunity to produce a curative effect by every one of them is a question open for discussion. Of lime-water and glycerine I have employed a mixture of equal parts in considerably more than a hundred cases after the completion of tracheotomy, directing the remedy through an atomizer into and below the canula, but cannot say that the descent of the membrane into the trachea or bronchi was prevented by it. Lime-water may be used in the nose and throat as an injection, spray, or gargle, but its solvent effect is greatly diminished by the action of the carbonic acid of the breath on the lime. I have no doubt that if water alone was used with the same persistence as lime-water, its effects would be nearly the same. Still, what little effect the minute dose of lime (1:800) in the lime-water may have may just as well be utilized. What I object to is the omission of more powerful agents. If lime is to be used, slaking lime frequently in the presence of the patient is attended with vastly more benefit, inasmuch as by that proceeding a large amount of powdered lime is projected into the air of the room and the mouth and respiratory organs.
Lactic acid also, in from ten to twenty-five parts of water, has yielded no better results in my hands. Those cases of tracheotomy which I afterward treated with lactic acid spray terminated no better than such as were treated with lime-water and glycerine. Of the solvent effect of pepsin I have not been able to convince myself so as to recommend it. The accounts of neurin have not encouraged me to try it at all. Chinolin (tartrate) has been used locally by O. Seifert,47 Müller, and others. It is said to remove the membranes and relieve the fever. For a gargle it is dissolved in five hundred parts of water, or it is mixed with ten parts of water and alcohol each, and applied by means of a sponge. To relieve the burning sensation ice is swallowed afterward. The local applications of alcohol have the same drawback. There are but few patients who do not suffer intensely from its local contact.
47 Berl. klin. Woch., Nos. 36, 37, 1883.