A system of practical medicine. By American authors. Vol. 1

by Unknown

Treatment of Nasal Diphtheria.—Especially during the prevalence of an epidemic of diphtheria must we be careful not to allow a nasal catarrh to have its own way; we must likewise guard against considering the thin and flocculent discharge in infected cases as a mucous secretion. Whatever be the origin of nasal diphtheria, whether primary or the result of a similar affection in the throat, local treatment should at once be instituted, and if this be done the great majority of cases will terminate favorably. The danger in this form of disease consists in an excessive absorption of putrid substances and in the breathing of contaminated air. The interior of the nasal cavities must be thoroughly cleaned and disinfected. If this be commenced early, the original seat of the affection may be reached, and the disinfectant process will, as a rule, have good results. It is not necessary to select very energetic disinfectants; a solution of twelve to twenty-five centigrammes (two to four grains) of carbolic acid in thirty grammes (an ounce) of water is at once mild and effective, and hardly gives rise to more discomfort than lukewarm water. Nasal injections must be made very frequently, until each time the stream of fluid has a free exit through the other nostril or through the mouth. They must be made at least every hour, and even oftener if necessary; at the same time it is advisable to be careful that the fluid does not enter the Eustachian tube. This can be prevented, to a certain extent, by compelling the patient to keep the mouth open during the procedure. I have seldom seen evil or even disagreeable results from the administration of nasal injections in diphtheria. It is likely that the mucous membrane of the pharynx is swollen as far as the openings of the Eustachian tubes to such a degree as to render the entrance of fluids into the latter improbable. The hardness of hearing, which is of so frequent occurrence in the course of a severe catarrh or of a diphtheritic attack, seems to indicate that the mucous membrane of that part is in a state of swelling. An ordinary syringe will suffice. However, when administered by parents or nurses the blunt nozzle of an ear syringe is preferable. Occasionally here, as in local applications to the mouth and pharynx, the atomizer may be used to advantage, but the tube must be properly introduced into the nostrils. There are cases of nasal diphtheria, however, which are far more troublesome to manage than the foregoing would seem to indicate. I have seen cases in which the nasal cavities, from the anterior to the posterior nares, were filled and completely occluded by a dense, solid membranous mass. I was then compelled to bore a passage with a silver probe, to gradually introduce a larger-sized one, and then to apply the pure carbolic acid, in order to remove the densest and thickest masses, and finally was able to make injections; even in such cases I have had the gratification of being able to give a favorable prognosis. The dangerous secondary swelling of the glands will often subside after a steady employment of disinfectant injections for from twelve to twenty-four hours. It will be found that children frequently do not object to this method of treatment; I have even met with some who, after convincing themselves of the relief afforded thereby, asked for an injection. When we are about to bring each injection to a close it is well to press together the nasal cavities for an instant with the fingers. By this procedure the fluid is forced backward to the pharynx, and is swallowed or ejected through the mouth, and thus washes the pharynx and mouth at the same time. Frequently, however, this latter object is obtained with every injection; for, the palate being swelled, oedematous, and paretic, the fluid is not prevented from reaching the pharynx, even in the average case. In regard to the choice of a disinfecting agent, I have but a few words to say. I believe that no one of them has important qualifications above the others. I avoid those which stain or which produce firm coagula. For the latter reason I do not use the subsulphate and perchloride of iron; for the former, the permanganate of potassium. I employ, as a rule, carbolic acid in solution, of the strength above mentioned. Where there is but a slightly fetid odor I have frequently employed lime-water or water with glycerine, or a solution (1:100, 1:50) of chloride of sodium, or of bicarbonate of soda or of borax, or a saturated solution of boric acid. Disinfecting agents and antiseptics, whether carbolic acid, salicylic acid, or iron, are of no service when administered internally only, unless the seat and cause of the septic infection be attended to previously. Under the local employment of antiseptics, as described, or by simply washing out with water or salt water, most cases recover; without them, death will result. Of late, in many cases, the local applications, injections, etc. of the corrosive chloride of mercury in water (1:5000-10,000) has proved very effective. It has this advantage over carbolic acid, that the swallowing of the former is not so dangerous. This much, after all, my experience has assured me of, that there is a certain number of cases which terminate fatally; but it is likewise true that the mortality need not be excessively great. I cannot grant that it is hard to carry out the exact and apparently barbarous treatment necessary for a favorable result, for it is certainly more barbarous to sacrifice than to save life.

It is a positive fact that when children suffering from nasal diphtheria, with its peculiarly septic character, are permitted to sleep much—and they are apt to be drowsy under the influence of the poison—they will certainly die. To allow them to sleep is to allow them to die.

The first symptom of improvement is often a rapid diminution of the glandular swelling wherever it exists. It is not present in all cases, but chiefly in those in which a bloody serum was discharged in an early period of the disease. In these the blood-vessels appear to be very vulnerable, superficial, and apt to absorb; these are also the most dangerous cases, and require the greatest attention and care, and also prompt disinfection.

Treatment of Laryngeal Diphtheria.—The severest form of diphtheria is that located in the larynx, constituting membranous croup. Its general treatment, whether the disease has originated primarily in the larynx or trachea or has been communicated from the pharynx, does not differ from that laid down for diphtheria in general. Naturally the larynx calls for special treatment on account of the symptoms of suffocation which result from its stenosis. The main indication of removing viscid mucus or partly-detached membranes is best met by the administration of an emetic. Such is their only indication in my experience. The selection of the emetic, when indicated, is of great importance. Antimonials ought to be avoided because of their depressing and purgative effect. Ipecacuanha is but rarely effective. The sulphates of zinc and copper, and particularly the latter, deserve preference. Turpeth mineral acts promptly and satisfactorily. When no emesis can be obtained the prognosis is decidedly bad. Recourse must then be had to tracheotomy, the good results of which are however only too often delusive and transient.

When, after the operation, there is scarcely any relief, and particularly when the case takes a very rapid course, it is probably one of ascending croup which commenced in the trachea. Mechanical relief by pushing down a hen's feather or a bundle of them, and turning it about and twisting, must be tried. It is a much better instrument than pincers of all sorts and shapes. But what relief will be accomplished is but of very short duration. When fever sets in within a few hours it means very much more frequently pneumonia than diphtheritic fever. It is apt to be soon complicated by that disproportion between pulse and respiration so characteristic of inflammatory diseases. Then quinia in larger doses, 0.25 or 0.5 (grs. iv-viij) every two, four, eight hours, at the same time doses of sodium salicylate 0.25-0.40 (grs. iv-vj) every hour or two hours until the temperature goes down, and small doses of digitalis where the heart requires it, must be given at once. Procrastination is dangerous; the patients want careful watching; many of them die within two days after the operation.

Diphtheritic conjunctivitis requires great attention and permits of no loss of time. Cold applications to the affected eye must be made constantly. Pieces of linen or lint kept on ice (better than in ice-water) of little more than the size of the eye, must be changed every minute or two day and night. The danger to the cornea is so imminent that constant watchfulness is required. Boric acid in concentrated solution should be dropped into the eye once every hour. Care must be taken that the well eye shall not get infected; for that purpose it is best to cover it with lint and collodion, or with lint or cotton held in place by adhesive plaster.

Cutaneous diphtheria requires the destruction of the membrane or of the infected surface by carbolic acid, either concentrated or somewhat diluted with glycerine, or the application of the actual cautery. After that the use of ice or iced cloths, or diluted carbolic acid, is indicated. As soon as the surface is no longer diphtheritic the local and general treatment is to be continued on general principles.

Diphtheritic paralysis is invariably complicated by anæmia and debility, and the diet and medical treatment must be regulated accordingly. However, neither overfeeding nor a sameness of diet are to be permitted, for not rarely the muscular coat of the stomach suffers with the rest of the muscular tissue, and the secretion of gastric juice is very deficient in anæmic individuals. While, therefore, iron is indicated, we must not neglect to pay particular attention to nutrition and digestion, and to aid the latter with pepsin and moderate amounts of muriatic acid, well diluted. Quinia in small doses and stimulants are appropriate whenever there is no contraindication to their employment. The treatment of the paralysis itself will naturally depend on the diagnosis of the condition present in each individual case, which we have seen to differ considerably. This alone can explain why various modes of treatment, the electric current among others, after being recommended by some authors, are branded by others. Where we have to deal with those rare changes in the brain and spinal cord, the utmost care is necessary in order not to make the condition still worse; and in such cases there would be a contraindication to the use of the faradic current, though this would not hold true with regard to the use of the galvanic current in short sittings. Besides, central paralyses are by no means so frequent as peripheral ones. In most cases there is not the slightest elevation of temperature during the course of the paralytic phenomena. I lay great stress upon this point, for I am aware that many cases of central congestion and even of inflammation exhibit but very insignificant elevations of temperature. But, as the diagnosis will depend on a positive knowledge of whether there have been changes of temperature, I rely on the rectal temperature only, for many a myelitis runs its course with no greater elevation above the normal than one-half or one degree. In all cases in which the temperature is normal or subnormal, I do not hesitate for a moment to employ the faradic or the galvanic current. In addition to the internal administration of iron I advise by all means the employment of strychnia. When there is no necessity for haste, we may give moderate doses, gradually increasing them, and using iron in combination. When there is danger in delay, recourse ought to be had to subcutaneous injections of the sulphate of strychnia, once or twice daily. They are mainly indicated in paralysis of the muscles of deglutition and of respiration. Of course, where the former are affected it is necessary to nourish the patient artificially, partly perhaps by nutrient enemata, but principally by means of the stomach-tube. In using the latter it is unnecessary to introduce it into the stomach, as it only requires to be passed a few inches below the affected parts, when the oesophagus will usually be found able to undertake the further disposal of the food. In these cases strychnia should be injected subcutaneously in the neck, once or twice daily. In a similar manner it should be injected in the region of the chest, diaphragm, or neck in paralysis of the respiratory muscles or of the glottis. In paralysis of the muscles of accommodation (in which Scheby-Buch claims to have seen the process cut short by the use of the Calabar bean, considered as inert by Hassner) they may be given in the forehead or temples.

Frictions dry and alcoholic, hot bathing, friction with hot water, kneading of the affected parts, will be found beneficial and pleasant.