Internally he orders from six to twelve drops of the solution in a half ounce of sweetened water, every hour, two, or three hours, according to the urgency of the case, and continuously.
The most convenient way of making Smith's solution is: Take two ounces of a saturated solution of potassium bromide in water; add to this, very slowly, in a bottle and with constant shaking, one ounce of bromine. It is better to add a part, and then let it stand a while before adding the rest; then fill up gradually, and with constant shaking with water, until it measures four ounces.
Ozone has been used as an anti-fermentative in inhalation during three or five minutes every hour or two, by Jochheim.
Boric (boracic) acid, in saturated (1:25) or milder solutions, has some antiseptic effect. It is mild, and not very injurious when swallowed by necessity or mistake. In diphtheritic conjunctivitis it is valued highly, and in nasal injections I have found it very useful. It is less repugnant than most other substances administered in that way.
Sodium benzoate cannot be relied on either as an anti-diphtheritic nor as an anti-febrile. The doses which were recommended were two scruples or a drachm daily for a child a year old.
Sulphur has been used locally. It gives rise to coughing and vomiting.
Cubebs have been given in incredible doses, two drachms of the powder to a child a year old. The drug disorders the stomach and kidneys.
Local Treatment.—The mechanical removal of the membranes is not permissible unless they are almost detached. It is best to avoid their being cast off, unless partly loosened membranes in the larynx or trachea afford an indication for an emetic. Scratching and eroding the mucous membrane of the neighborhood give rise to new deposits. Even after spontaneous elimination of a membrane a new one may be formed within a few hours.
To cauterize a diphtheritic membrane or infiltration I consider wrong, unless I shall be able to do so thoroughly and to limit the action of the caustic to the diseased surface. Therefore potassa or chromic acid cannot be utilized, because of the impossibility of limiting their effect. Nitrate of silver and mineral acids can be restricted in their effects, but these are not sufficiently thorough, particularly as but few patients will consent to have the remedy applied properly. When I do cauterize, I prefer a mixture of equal parts of carbolic acid and glycerine or the undiluted acid. The membrane crumbles and falls off in pieces. Force must never be used. Where it would be required in the case of obstinate children mild washes must be employed instead of the caustic. Besides, the internal medication detailed above meets every indication. When there is a slight swelling of the lymphatic glands, cold water or ice applications are usually all that is needed. The latter should be made according to general indications. The glandular and peri-glandular swellings are less the result of an actual filling up with foreign matter than of secondary irritation. Ice has a happy effect in such cases, both on internal administration, in the form of frequent small quantities of ice-water, ice-pills, ice cream, and iced medicaments, and also externally by ice-cold cloths or india-rubber bags filled with ice.
In general, the treatment of the swelled glands must be both based on its causes and adapted to the present condition. The adenitis and peri-adenitis is of secondary nature, the irritation being in the mouth, pharynx, and nares. In these localities is where the main treatment is required. The sooner the primary affection is removed or relieved or rendered innocuous, the better it is for the secondary complaint. Frequent doses of chlorate of potassium or sodium, or biborate of sodium in mild doses frequently repeated, according to the principles laid down in another part of this article, mouth-washes, gargles, nasal injections with water, salt water, or solutions of disinfecting substances, are not only indicated, but highly successful. When the case is recent, cold applications are required, but no washes. When it is of older date, stimulant embrocations are in order. Iodine ointments are absorbed but slowly; mercurial plasters do good in some cases; iodide of potassium dissolved in glycerine (1:3-4), frequently applied, iodine in oleic acid (1:8-12), iodoform in collodion or flexible collodion (1:12-15) applied twice daily, the latter frequently with very good result, are beneficial. Copious suppuration is very rare. Cases in which a free incision meets with an abscess ready to heal are very uncommon. But numerous small abscesses with gangrenous walls and pus mixed with a sero-sanguinolent or sero-purulent liquid, are more frequently found. In such cases a probe introduced into the lancet wound enters easily into the broken-down tissue in every direction, to a distance even of three to six centimetres, (several inches), according to the size of the tumefaction. I have seen fatal hemorrhages from such gangrenous destructions; therefore the treatment must be both timely and energetic. The incision must not be delayed too long. When the skin assumes a purplish hue or is simply discolored, it is time to incise and to apply concentrated or nearly concentrated carbolic acid to the interior, unless the neighborhood of very important blood-vessels or nerves yields a contraindication to concentrated applications. In that case a milder preparation is advisable, but the application should be repeated often, until the suppuration becomes more normal. Then mild disinfectant injections into what has now become a cavity will be found satisfactory, particularly when meanwhile the general condition of the patient has been improved.