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Treatment of diphtheria
PUBLIC HEALTH.
1908.
TREATMENT OF D I P H T H E R I A . BY C. J. RUSSELL McLEAN, M.D., EDIN.,D.P.H., Medical Officerof Health, Doneaster Rural and Tickhill Urban Councils. DO not intend in this paper discussing the various methods of the treatment of diphtheria, b u t simply to describe those which I have found most satisfactory, both in hospital and private practice, Treatment may be considered under the three following heads given in the order of their importance :--I. Specific, II. General, III. Local. I. SPECIFIC TREATMENT.--I~y this I mean treatment by diphtheria antitoxin. To get the best or specific result, the sermn must be given in the earliest stage of the disease, if possible within twenty-four hours of the onset. Satisfactory results depend absolutely on this. In every case where diphtheria is diagnosed clinically, or even suspected, antitoxin should be given at once and freely. If acquainted with the simple technique, a bacteriological examination of a throat specimen may be preferably made, prior to giving antitoxin, b u t no delay should ever be permitted in waiting for the report of a specimen sent to laboratory. Administer the* serum at once. If, later on, a negative report is received, which does not always disprove diphtheria, no harm will have been done, whilst if it is positive, one has the comfortable feeling of having got in t h e "first b l o w " in the fight, as, according to DSnitz, the remedy is only useful in neutralizing the toxin, which is extra cellular and free in the circulation, and has little effect on that which is fixed in the body cells, and which has already done the damage. Hence, therefore, the benefit of early administration, as the multiplication of the bacilli and consequent manufacture of toxin is the more readily arrested. Dosage : In cases seen on the first day of . . . . second . . . . . . . third ,. . . . . fourth . . . . . . . fifth . . . .
the disease, .
.
,.
. .
. .
.
. . . . . . . . . .
2,000 units. 4,000
,,
6,000 8,000 10,000
,, ,, ,,
In severe eases, laryngeal, or nasal cases, or those with a very rapid pulse, of 140 or over, temperature not over 100 °, and a large amount of false membrane, the dose of serum should be 8,000 or 10,000 units, irrespective of the day of disease.
271
If an irregular tox~emia exists, as is common in nasal eases, it may be advisable to give one dose of 20 to 30 e.c. ()f Polyvalent antistreptococcus serum at the same time, though I have not a great deal of faith as regards its effect in such cases. If the pulse-rate fails, tile false membrane begins to separate, or shows no extension, and general symptoms abate within twelve to eighteen h o u r s - - a s is usual in cases of average severity treated with serum (luring the first or second day of the disease--no further dosage is necessary. If the pulse-rate does not fall, or rises, if exudation increases and general sympto~ns are not improved in twelve to eighteen hours, a further dose of antitoxin should be given of half the initial quantity. If the case continues to pursue an unfavourable course, further dosage may be tried, b u t my experience is that the remedy, as such, becomes of less value after the first, and almost useless after the second injection. Yet it should be tried. Cases treated for the first time on the fourth day of the disease, stand a much diminished chance of improvement with serum, whilst those treated on the fifth day are practically uninfluenced b y it. Small repeated doses of 300 to 500, or even 1,000 units, is a useless procedure, and trifling with the disease. Heroic doses of 20,000 to 50,000 units are, I am certain, unnecessary, and no more beneficial than the doses above mentioned. Such large quantities, in fact, may be actually harmful b y throwing too great a strain on the already overtaxed excretory organs. I do not think the maximmn dose should ever exceed 10,000 units, and i have not seen any specially good results from intravenous injection, though theoretically it might be expected, especially in severe eases only seen some days after the onset. Statistics in New York show, with small doses of antitoxin, a mortality of 21 per cent. with larger doses of 5,000 to 10,000 units one of 14 per Cent. Children should not have smaller doses of antitoxin than adults, but, on the eo~ltrary, usually require larger amounts, owing to their natural powers of resistance to t h e toxin being less than in older persons. The condition of the patient, together with the location and duration of the disease, should be the deciding factors as regards the dosage rather than the age of the patient. 2I
272
PUBLIC HEALTH.
Administration.--The serum may be injected under the skin between the shoulders, in the loose tissue, internal to the inner edge of the scapula, but I prefer either a spot some two or three inches below and to the left of the umbilicus, or one about two inches below it, either of those being easy to get at, and less likely to cause discomfort than in any othe~" part. The skin should be well washed and covered with wet boracic lint for half an hour or so prior to injecting, and the point of puncture immediately covered with a little wool and collodion. The needle should be plunged well under the skin to begin with, and gradually withdrawn as the liquid is slowly injected. It is scarcely worth while freezing the skin. The resistance to the entrance of the needle is thereby increased, and as finer needles can be quite well used, if the liquid is slowly injected, than those at first employed, the pain is very slight. If a large close of serum is to be given, it is advisable to give it in two injections at different parts of the body. The syringe and needle should be boiled immediately before use, making sure, also, that the needle is clear and the syringe in good working order. It is advisable to again boil the needle and syringe immediately after use. A blunt-ended needle should be used to fill the syringe, as by drawing up the serum with the sharp needle the fine point is soon destroyed by coming in contact with the bottom or sides of the vial. The vial of serum (which must be q u i t e clear) should not be opened until quite ready to use it, and any sermn remaining should be destroyed. T h e vim should not be re-sealed in order to keep it for another ease. Having myself suffered from the use of a dirty needle in the earliest days of the treatment, I would the more urgently press for strict measures of cleanliness in carrying out the process. Tracheo~omy.--Since the introduction Of antitoxin, laryngeal eases have lost much of their terrors, both as regards the mortality without operation and in those requiring traeheotomy. My limited experience of traeheotomy without antitoxin was, I am afraid, a very unsatisfactory one, but with it, the operation, unless in hopelessly delayed eases, is likely to be successful. Laryngeal eases now, as a rule, do well if treated early enough and with sufficient dosage of serum, and only seldom require operation. A word of warning is, however, necessary as regards eases in
Sl~TEm~mk
young children with a large amount of exudation in the lower part of the larynx, and which are doing well with antitoxin. I n these, the separation of the false membrane is usually more rapid than is the case in the faucial affection, the ciliated epithelial lining of the larynx permitting of separation of the membrane more readily and in larger pieces or casts than in the case of the fauces, where the epithelium is of the squamous, or flat, variety. If, therefore, the patient has difficulty in expelling the membrane by coughing, there may be a sudden onset of suffocation, necessitating immediate operation, just when the case was apparently pl:ogressing most favourably. Such cases may be actually put down as ones of sudden heart failure. It is wise, therefore, in laryngeal diphtheria to warn the nurse in charge and to have the necessary apparatus for operation ready. So far as m y limited experience goes, I m u c h prefer tracheotomy to intubation. Complieatlons.--Rashes of an erythematous or urticarial nature, lasting twenty-four to forty-eight hours, sometimes occur a few days after the administration of antitoxin, and are u s u a l l y ' a c c o m p a n i e d by intense itching, especially of the feet, and occasionally, though less frequently, followed by a form of arthritis. This is not usually severe nor very lasting, though a case has come under m y observation where joint pains have been more o r less constantly present for a period of over six y e a r s since the patient received antitoxin. Albumenuria occurs in a good many cases of diphtheria, but rarely passes to a definite nephritis. The administration of antitoxin, in m y opinion, somewhat increases the liability to this complication, but cases, as a rule, do well. As purer sere are obtained, these complications may become less frequent, though their absolute disappearance is unlikely, owing, it is said, to a natural peculiarity ia horses' blood serum, and quite apart from antitoxin. Paralysis is by some considered to be more prevalent after the use of antitoxin than formerly. I am not of this opinion. As the natural result of a reduced mortality from the disease due to antitoxin treatment, there are, of necessity, more cases which may subsequently develop this complication. So far as I have seen, the cases are not of a worse type than in pre-antitoxin days. Mortality.--If the serum treatment is begun during the first twenty-four hours of the
1908.
PUBLIC ItEALTH.
disease, the mortality will not exceed 1 to 2 per cent., or probably less. If begun within forty-eight hours of the onset, it should not be over 3 to 4: per cent. At the Metropolitan Asylums Board hospitals, where large numbers of eases in all stages and conditions are treated, the mortality has fallen from over 37 to just over 15 per cent. since the serum treatment was adopted. The general mortality at present is probably under 10 per cent.
Prophylaxis.---Individuals who are, or have recently been, in contact with a ease of diphtheria, especially if of a severe type, should at once be given a protective dose of 500 units of antitoxin, thereby anticipating, if not aetuMly preventing, an attack of the disease. Such protection only lasts about four weeks, and as the infection of a ease frequently persists longer than this period, it is advisable to repeat the dose not later than a month if the person is still in contact with the disease, or if the throat be not well by that time. As an example of this condition, I may mention the case of a nurse in a diphtheria ward, who, nnless she received a dose of serum every three or four weeks, was laid up with a mild attack of diphtheria. Suscel0tible contacts, and there are many such, should be so treated and strictly isolated under medical observation for some days. Convalescents and " carriers," who, though apparently quite well and have no local lesion, yet have the Bacillus d@h~heriee present in the throat or nose, should be kept isolated until three swab examinations are "negative." I~. GENERALTREATMENT.--This is important, and may be considered under three headings, viz: 1. Food; 2. Rest; 3. Medicinal. 1. Food.--.The diet must be of a nutritious, light and varied nature. Food should be given every two to two-and-a-half hours. In no case must the stomach be overloaded, nor should any article of food be enforced which is repugnant to the taste. Milk, as a rule, is acceptable, and may be given either raw, boiled or thickened with a cereal food as preferred. Curds and whey, made with unflavoured rennet and sweetened, is a nutritions food, and usually well taken by children. Eggs, as thin custard, or white of egg beaten, sweetened and a little water added, or milk if it agrees. These, with Liebig's extract, or broths and thin bread and butter, with plenty of weak tea, should form the basis of feeding during the acute stage of the disease, and may be supplemented with jellies, wheat-crystals (an excellent preparation), etc. Plasmon and Sanatogen are valuable additions, and refrigerants in the
273
way o1~ grapes and oranges are comforting, and should be allowed. Sweetened drinks should be avoided, but weak tea and h'equent sips of cold water are refreshing and useful, as is a little pure lemon juice for those who like it, but not taken with or immediately after milk. As convalescence becomes established more solid food may be allowed, such as minced chicken, sweetbread, tish, etc., and so on gradually to ordinary diet., including red meat. In some cases where vomiting occurs, rectal feeding is necessary. It is important for the welfare of the patient that abundance of fresh air be admitted to the room, taking care, of course, that no actual risk be run of giving the patient a chill, as such eases are very liable to develop pneumonia. 2. Rest.--Every case of diphtheria inchildren must be kept ill bed without pillows for at least two weeks, the only exception to this being in a few cases, where, from extreme laryngeal obstruction, there may be difficulty in breathing. If much objection is offered to the flat position, one pillow may have to be allowed, but in such cases the feet of the bed should be raised on blocks, in most cases there is no objection, and, if all goes well, one pillow may be allowed in the third week and two in the fourth, at the end of which period a back rest may be permitted for another week before leaving bed, making in all five weeks confinement to bed in uncomplicated cases. This may seem a long period, but, in my opinion, is not too long, and might with advantage be more generally carried out in the case of children in private~practice. In adults the position need not always be quite flat nor so long continued. The main points to observe are to see that only gradual resmnption of the erect posture is permitted, and to observe its effect on the heart daily. If there is evidence of any heart complication, the flat position in bed may be necessary for a further two to four weeks, and in any ease medical supervision should be kept up for six weeks from the onset, both for the sake of the patient and for the safety of others, as in probably five or six per cent. of eases infection may be retained for that period. Heart Complication. The condition of the heart should be carefully watched in diphtheria from the onset, but especially towards the end of the first week, when a possible vagus neuritis may become manifest ; and again from the end of the second week onwards, when actual muscle degeneration of the organ, due to toxmmia is likely to occur. It is in these cases that sudden exertion sometimes proves serious or fatal. An important sign to observe is vomiting,
~74
SI~P~'Em~~'~l~,
PUBLIC HEALTH.
which is frequently a warning of heart complication, a condition which is explained when we remember the intimate connection between the nerve supply of the heart and the stomach by the motor fibres of the vagus nerve. Accompanying signs of cardiac complication are, an irregular or galloping " ~ie t a c " r y t h y m of the heart, a murmur, usually systolic, reduplicated sounds, a low tension pulse, accompanied by a restless sighing condition of the patient, cold limbs, increasing prostration, pallor and dyspncea. Such eases are very often fatal, despite all treatment, which usually resolves itself into the giving of strychnine hypodermically, and keeping up the action by further injections, and giving by the mouth, in combination with strophanthus, also oxygen inhalation, hot saline solution per rectum, and rectal feeding, with warm applications to the limb, 3. Medicinal.--Little or no medicine is required in an ordinary ease of diphtheria, though in the early stages some citrate of potash or ammonia may be of some service in helping the elimination of waste products. Plenty of water to drink may, however, be quite as useful at this period. I do not recommend the giving of iron owing to the discomfort in the mouth and the anorexia which it induces. It has no influence on the disease in the acute stage, but during convalescence, in combination with arsenic and stryehnia, it is of service. Stimulants are beneficial in m a n y asthenie eases; in the form of champagne or good brandy, in the early stages, and old port wine, with or without bark, during convalescence. On the first sign of cardiac complication, small doses of stryehnia and strophanthus should be given. III. LOCAL TREATMENT.--If a sufficient dose of antitoxin has been given in the early stage of the disease, very tittle local treatment is required, beyond frequent flushing of the mouth and throat with a simple warm alkaline douche or spray, the best of which I think are either a solution of borax and bicarbonate of Soda in water and glycerine, or glycothymoline, to which a little more soda has been added. Either of these may be applied to the nostrils if desired. A weak spray of permanganate of potash may be used for the throat, and for adults listerine makes an excellent mouth wash and gargle. Alkaline solutions keep the mouth moist and comfortable and help to loosen the membrane. Strong or caustic applications should be avoided. I have never found any of them tend to arrest the disease, and they always cause discomfort or pain, and are dreaded by children. In the later stages of the disease, the ordinary astringent paints and gargles may be used with advantage.
THE
CONTROL SCHOOL
OF RINGWORM CHILDREN.
IN
BY H. MEREDITH RICHARDS, M.D. Medical Officer of Health, Croydon. (From the Annual Report on the Health of Croydon, 1907).
following table shows the number of T H Ecases of r i n g u o r m supervised by the Public Health Department during 1907 : - Total number outstanding January 7th., 1907 . . . . . . Scalp Body Total number reported during 1907 . . . . . . . . . . . . Scalp Body Total number freed during 1907 . . . . . . . . . . . . Scalp Body Total number outstanding January 6th, 1908 . . . . . . Scalp Body
41 21
63
310 176
486
549
245 177
422
422
106 21
127
127
It will be noted that the number of eases outstanding at the end of 1907 was in excess of the eases under treatment at the beginning of the year. This was to be expected, as one of the first results of municipal treatment was to increase the number of eases reported from the schools. It is very probable that there may be a further increase during the current year as a result of the recently-adopted scheme for the medical supervision of all sehoot children. I have received so many inquiries from other districts and from medical practitioners in the town as to the exact procedure adopted in Croydon, that at the risk of repetition I have incorporated the following summary of the work in this report : - (1) Children suffering from ringworm are reported to the medical officer by the teachers and attendance officers. (2) These and any other cases coming to the knowledge of the medical officer are excluded from school until released by him. (3) The notification is sent to the health visitor for the district, who visits the home and informs the parents that the child must either be treated by their own doctor or be brought to the town hall at certain fixed times, where free treatment can be obtained. At the same time, the health visitor obtains specimens of the diseased hair in order that the diagnosis may be verified at the laboratory if necessary. (4) Parents who elect private treatment are thereupon notified to the attendance officers,
1908.
TREATMENT OF D I P H T H E R I A . BY C. J. RUSSELL McLEAN, M.D., EDIN.,D.P.H., Medical Officerof Health, Doneaster Rural and Tickhill Urban Councils. DO not intend in this paper discussing the various methods of the treatment of diphtheria, b u t simply to describe those which I have found most satisfactory, both in hospital and private practice, Treatment may be considered under the three following heads given in the order of their importance :--I. Specific, II. General, III. Local. I. SPECIFIC TREATMENT.--I~y this I mean treatment by diphtheria antitoxin. To get the best or specific result, the sermn must be given in the earliest stage of the disease, if possible within twenty-four hours of the onset. Satisfactory results depend absolutely on this. In every case where diphtheria is diagnosed clinically, or even suspected, antitoxin should be given at once and freely. If acquainted with the simple technique, a bacteriological examination of a throat specimen may be preferably made, prior to giving antitoxin, b u t no delay should ever be permitted in waiting for the report of a specimen sent to laboratory. Administer the* serum at once. If, later on, a negative report is received, which does not always disprove diphtheria, no harm will have been done, whilst if it is positive, one has the comfortable feeling of having got in t h e "first b l o w " in the fight, as, according to DSnitz, the remedy is only useful in neutralizing the toxin, which is extra cellular and free in the circulation, and has little effect on that which is fixed in the body cells, and which has already done the damage. Hence, therefore, the benefit of early administration, as the multiplication of the bacilli and consequent manufacture of toxin is the more readily arrested. Dosage : In cases seen on the first day of . . . . second . . . . . . . third ,. . . . . fourth . . . . . . . fifth . . . .
the disease, .
.
,.
. .
. .
.
. . . . . . . . . .
2,000 units. 4,000
,,
6,000 8,000 10,000
,, ,, ,,
In severe eases, laryngeal, or nasal cases, or those with a very rapid pulse, of 140 or over, temperature not over 100 °, and a large amount of false membrane, the dose of serum should be 8,000 or 10,000 units, irrespective of the day of disease.
271
If an irregular tox~emia exists, as is common in nasal eases, it may be advisable to give one dose of 20 to 30 e.c. ()f Polyvalent antistreptococcus serum at the same time, though I have not a great deal of faith as regards its effect in such cases. If the pulse-rate fails, tile false membrane begins to separate, or shows no extension, and general symptoms abate within twelve to eighteen h o u r s - - a s is usual in cases of average severity treated with serum (luring the first or second day of the disease--no further dosage is necessary. If the pulse-rate does not fall, or rises, if exudation increases and general sympto~ns are not improved in twelve to eighteen hours, a further dose of antitoxin should be given of half the initial quantity. If the case continues to pursue an unfavourable course, further dosage may be tried, b u t my experience is that the remedy, as such, becomes of less value after the first, and almost useless after the second injection. Yet it should be tried. Cases treated for the first time on the fourth day of the disease, stand a much diminished chance of improvement with serum, whilst those treated on the fifth day are practically uninfluenced b y it. Small repeated doses of 300 to 500, or even 1,000 units, is a useless procedure, and trifling with the disease. Heroic doses of 20,000 to 50,000 units are, I am certain, unnecessary, and no more beneficial than the doses above mentioned. Such large quantities, in fact, may be actually harmful b y throwing too great a strain on the already overtaxed excretory organs. I do not think the maximmn dose should ever exceed 10,000 units, and i have not seen any specially good results from intravenous injection, though theoretically it might be expected, especially in severe eases only seen some days after the onset. Statistics in New York show, with small doses of antitoxin, a mortality of 21 per cent. with larger doses of 5,000 to 10,000 units one of 14 per Cent. Children should not have smaller doses of antitoxin than adults, but, on the eo~ltrary, usually require larger amounts, owing to their natural powers of resistance to t h e toxin being less than in older persons. The condition of the patient, together with the location and duration of the disease, should be the deciding factors as regards the dosage rather than the age of the patient. 2I
272
PUBLIC HEALTH.
Administration.--The serum may be injected under the skin between the shoulders, in the loose tissue, internal to the inner edge of the scapula, but I prefer either a spot some two or three inches below and to the left of the umbilicus, or one about two inches below it, either of those being easy to get at, and less likely to cause discomfort than in any othe~" part. The skin should be well washed and covered with wet boracic lint for half an hour or so prior to injecting, and the point of puncture immediately covered with a little wool and collodion. The needle should be plunged well under the skin to begin with, and gradually withdrawn as the liquid is slowly injected. It is scarcely worth while freezing the skin. The resistance to the entrance of the needle is thereby increased, and as finer needles can be quite well used, if the liquid is slowly injected, than those at first employed, the pain is very slight. If a large close of serum is to be given, it is advisable to give it in two injections at different parts of the body. The syringe and needle should be boiled immediately before use, making sure, also, that the needle is clear and the syringe in good working order. It is advisable to again boil the needle and syringe immediately after use. A blunt-ended needle should be used to fill the syringe, as by drawing up the serum with the sharp needle the fine point is soon destroyed by coming in contact with the bottom or sides of the vial. The vial of serum (which must be q u i t e clear) should not be opened until quite ready to use it, and any sermn remaining should be destroyed. T h e vim should not be re-sealed in order to keep it for another ease. Having myself suffered from the use of a dirty needle in the earliest days of the treatment, I would the more urgently press for strict measures of cleanliness in carrying out the process. Tracheo~omy.--Since the introduction Of antitoxin, laryngeal eases have lost much of their terrors, both as regards the mortality without operation and in those requiring traeheotomy. My limited experience of traeheotomy without antitoxin was, I am afraid, a very unsatisfactory one, but with it, the operation, unless in hopelessly delayed eases, is likely to be successful. Laryngeal eases now, as a rule, do well if treated early enough and with sufficient dosage of serum, and only seldom require operation. A word of warning is, however, necessary as regards eases in
Sl~TEm~mk
young children with a large amount of exudation in the lower part of the larynx, and which are doing well with antitoxin. I n these, the separation of the false membrane is usually more rapid than is the case in the faucial affection, the ciliated epithelial lining of the larynx permitting of separation of the membrane more readily and in larger pieces or casts than in the case of the fauces, where the epithelium is of the squamous, or flat, variety. If, therefore, the patient has difficulty in expelling the membrane by coughing, there may be a sudden onset of suffocation, necessitating immediate operation, just when the case was apparently pl:ogressing most favourably. Such cases may be actually put down as ones of sudden heart failure. It is wise, therefore, in laryngeal diphtheria to warn the nurse in charge and to have the necessary apparatus for operation ready. So far as m y limited experience goes, I m u c h prefer tracheotomy to intubation. Complieatlons.--Rashes of an erythematous or urticarial nature, lasting twenty-four to forty-eight hours, sometimes occur a few days after the administration of antitoxin, and are u s u a l l y ' a c c o m p a n i e d by intense itching, especially of the feet, and occasionally, though less frequently, followed by a form of arthritis. This is not usually severe nor very lasting, though a case has come under m y observation where joint pains have been more o r less constantly present for a period of over six y e a r s since the patient received antitoxin. Albumenuria occurs in a good many cases of diphtheria, but rarely passes to a definite nephritis. The administration of antitoxin, in m y opinion, somewhat increases the liability to this complication, but cases, as a rule, do well. As purer sere are obtained, these complications may become less frequent, though their absolute disappearance is unlikely, owing, it is said, to a natural peculiarity ia horses' blood serum, and quite apart from antitoxin. Paralysis is by some considered to be more prevalent after the use of antitoxin than formerly. I am not of this opinion. As the natural result of a reduced mortality from the disease due to antitoxin treatment, there are, of necessity, more cases which may subsequently develop this complication. So far as I have seen, the cases are not of a worse type than in pre-antitoxin days. Mortality.--If the serum treatment is begun during the first twenty-four hours of the
1908.
PUBLIC ItEALTH.
disease, the mortality will not exceed 1 to 2 per cent., or probably less. If begun within forty-eight hours of the onset, it should not be over 3 to 4: per cent. At the Metropolitan Asylums Board hospitals, where large numbers of eases in all stages and conditions are treated, the mortality has fallen from over 37 to just over 15 per cent. since the serum treatment was adopted. The general mortality at present is probably under 10 per cent.
Prophylaxis.---Individuals who are, or have recently been, in contact with a ease of diphtheria, especially if of a severe type, should at once be given a protective dose of 500 units of antitoxin, thereby anticipating, if not aetuMly preventing, an attack of the disease. Such protection only lasts about four weeks, and as the infection of a ease frequently persists longer than this period, it is advisable to repeat the dose not later than a month if the person is still in contact with the disease, or if the throat be not well by that time. As an example of this condition, I may mention the case of a nurse in a diphtheria ward, who, nnless she received a dose of serum every three or four weeks, was laid up with a mild attack of diphtheria. Suscel0tible contacts, and there are many such, should be so treated and strictly isolated under medical observation for some days. Convalescents and " carriers," who, though apparently quite well and have no local lesion, yet have the Bacillus d@h~heriee present in the throat or nose, should be kept isolated until three swab examinations are "negative." I~. GENERALTREATMENT.--This is important, and may be considered under three headings, viz: 1. Food; 2. Rest; 3. Medicinal. 1. Food.--.The diet must be of a nutritious, light and varied nature. Food should be given every two to two-and-a-half hours. In no case must the stomach be overloaded, nor should any article of food be enforced which is repugnant to the taste. Milk, as a rule, is acceptable, and may be given either raw, boiled or thickened with a cereal food as preferred. Curds and whey, made with unflavoured rennet and sweetened, is a nutritions food, and usually well taken by children. Eggs, as thin custard, or white of egg beaten, sweetened and a little water added, or milk if it agrees. These, with Liebig's extract, or broths and thin bread and butter, with plenty of weak tea, should form the basis of feeding during the acute stage of the disease, and may be supplemented with jellies, wheat-crystals (an excellent preparation), etc. Plasmon and Sanatogen are valuable additions, and refrigerants in the
273
way o1~ grapes and oranges are comforting, and should be allowed. Sweetened drinks should be avoided, but weak tea and h'equent sips of cold water are refreshing and useful, as is a little pure lemon juice for those who like it, but not taken with or immediately after milk. As convalescence becomes established more solid food may be allowed, such as minced chicken, sweetbread, tish, etc., and so on gradually to ordinary diet., including red meat. In some cases where vomiting occurs, rectal feeding is necessary. It is important for the welfare of the patient that abundance of fresh air be admitted to the room, taking care, of course, that no actual risk be run of giving the patient a chill, as such eases are very liable to develop pneumonia. 2. Rest.--Every case of diphtheria inchildren must be kept ill bed without pillows for at least two weeks, the only exception to this being in a few cases, where, from extreme laryngeal obstruction, there may be difficulty in breathing. If much objection is offered to the flat position, one pillow may have to be allowed, but in such cases the feet of the bed should be raised on blocks, in most cases there is no objection, and, if all goes well, one pillow may be allowed in the third week and two in the fourth, at the end of which period a back rest may be permitted for another week before leaving bed, making in all five weeks confinement to bed in uncomplicated cases. This may seem a long period, but, in my opinion, is not too long, and might with advantage be more generally carried out in the case of children in private~practice. In adults the position need not always be quite flat nor so long continued. The main points to observe are to see that only gradual resmnption of the erect posture is permitted, and to observe its effect on the heart daily. If there is evidence of any heart complication, the flat position in bed may be necessary for a further two to four weeks, and in any ease medical supervision should be kept up for six weeks from the onset, both for the sake of the patient and for the safety of others, as in probably five or six per cent. of eases infection may be retained for that period. Heart Complication. The condition of the heart should be carefully watched in diphtheria from the onset, but especially towards the end of the first week, when a possible vagus neuritis may become manifest ; and again from the end of the second week onwards, when actual muscle degeneration of the organ, due to toxmmia is likely to occur. It is in these cases that sudden exertion sometimes proves serious or fatal. An important sign to observe is vomiting,
~74
SI~P~'Em~~'~l~,
PUBLIC HEALTH.
which is frequently a warning of heart complication, a condition which is explained when we remember the intimate connection between the nerve supply of the heart and the stomach by the motor fibres of the vagus nerve. Accompanying signs of cardiac complication are, an irregular or galloping " ~ie t a c " r y t h y m of the heart, a murmur, usually systolic, reduplicated sounds, a low tension pulse, accompanied by a restless sighing condition of the patient, cold limbs, increasing prostration, pallor and dyspncea. Such eases are very often fatal, despite all treatment, which usually resolves itself into the giving of strychnine hypodermically, and keeping up the action by further injections, and giving by the mouth, in combination with strophanthus, also oxygen inhalation, hot saline solution per rectum, and rectal feeding, with warm applications to the limb, 3. Medicinal.--Little or no medicine is required in an ordinary ease of diphtheria, though in the early stages some citrate of potash or ammonia may be of some service in helping the elimination of waste products. Plenty of water to drink may, however, be quite as useful at this period. I do not recommend the giving of iron owing to the discomfort in the mouth and the anorexia which it induces. It has no influence on the disease in the acute stage, but during convalescence, in combination with arsenic and stryehnia, it is of service. Stimulants are beneficial in m a n y asthenie eases; in the form of champagne or good brandy, in the early stages, and old port wine, with or without bark, during convalescence. On the first sign of cardiac complication, small doses of stryehnia and strophanthus should be given. III. LOCAL TREATMENT.--If a sufficient dose of antitoxin has been given in the early stage of the disease, very tittle local treatment is required, beyond frequent flushing of the mouth and throat with a simple warm alkaline douche or spray, the best of which I think are either a solution of borax and bicarbonate of Soda in water and glycerine, or glycothymoline, to which a little more soda has been added. Either of these may be applied to the nostrils if desired. A weak spray of permanganate of potash may be used for the throat, and for adults listerine makes an excellent mouth wash and gargle. Alkaline solutions keep the mouth moist and comfortable and help to loosen the membrane. Strong or caustic applications should be avoided. I have never found any of them tend to arrest the disease, and they always cause discomfort or pain, and are dreaded by children. In the later stages of the disease, the ordinary astringent paints and gargles may be used with advantage.
THE
CONTROL SCHOOL
OF RINGWORM CHILDREN.
IN
BY H. MEREDITH RICHARDS, M.D. Medical Officer of Health, Croydon. (From the Annual Report on the Health of Croydon, 1907).
following table shows the number of T H Ecases of r i n g u o r m supervised by the Public Health Department during 1907 : - Total number outstanding January 7th., 1907 . . . . . . Scalp Body Total number reported during 1907 . . . . . . . . . . . . Scalp Body Total number freed during 1907 . . . . . . . . . . . . Scalp Body Total number outstanding January 6th, 1908 . . . . . . Scalp Body
41 21
63
310 176
486
549
245 177
422
422
106 21
127
127
It will be noted that the number of eases outstanding at the end of 1907 was in excess of the eases under treatment at the beginning of the year. This was to be expected, as one of the first results of municipal treatment was to increase the number of eases reported from the schools. It is very probable that there may be a further increase during the current year as a result of the recently-adopted scheme for the medical supervision of all sehoot children. I have received so many inquiries from other districts and from medical practitioners in the town as to the exact procedure adopted in Croydon, that at the risk of repetition I have incorporated the following summary of the work in this report : - (1) Children suffering from ringworm are reported to the medical officer by the teachers and attendance officers. (2) These and any other cases coming to the knowledge of the medical officer are excluded from school until released by him. (3) The notification is sent to the health visitor for the district, who visits the home and informs the parents that the child must either be treated by their own doctor or be brought to the town hall at certain fixed times, where free treatment can be obtained. At the same time, the health visitor obtains specimens of the diseased hair in order that the diagnosis may be verified at the laboratory if necessary. (4) Parents who elect private treatment are thereupon notified to the attendance officers,