IDA F. KITTREDGE, M.D., ST. LOUIS, MO.
This is an acute infectious disease caused by the Klebs-Loeffler bacillus. This disease is highly contagious, as this particular germ is very virile, and may live in a throat for months after a case has been pronounced well. It is usually contracted by direct contact, but may be contracted by instruments, hands, clothing, etc. Young children are much more susceptible than older ones, and succumb more readily to the disease, hence, the, necessity of strict prophylaxis.
Predisposing Causes.—Chronic catarrhal inflammations, adenoids, enlarged tonsils, cavities of carious teeth, will harbor bacilli, before and after an attack, and I have found whooping cough a predisposing cause for laryngeal diphtheria.
Pathology:—Epithelial cells of the mucous membrane are attacked, also heart muscles, lymph glands, nervous system, kidneys, liver and spleen. Fortunately, the diphtheria bacillus is not apt to invade deeply the subjacent structures, but is found in great number on the surface of the affected mucous membrane, and false membrane. Unfortunately, the diphtheritic toxins are very diffusible, readily entering the blood and lymphatic circulation, and through these channels the poison is conveyed through the entire system.
Symptoms:—In laryngeal diphtheria we do not have the clinical features found in diphtheria of the upper air passages above the larynx. The first signs of laryngeal invasion is hoarseness, croupy cough, and slight dyspnea. These symptoms steadily increase until laryngeal stenosis is present. We also have a rise of temperature, with quick rapid pulse, according to the severity of the case.
Treatment:—If there is any place in the practice of medicine where we have an indication for acids and iron, it is here. Echinacea is our sheet anchor for all septic conditions. Phytolacca is certainly indicated where you want an active glandular system. Aconite for the feeble, rapid pulse. Locally I like peroxide and listerine, one-half of each, dropping the peroxide as soon as the false membrane has disappeared. Antitoxin is used early, in good full doses. Use it while the lesion is practically local. If you wait until you have mixed infection, you need not hope for excellent results from antitoxin.
Intubation is an important means of relief—steaming with lime under a tent is an excellent aid. Brown iodide of lime, given early, persistently and frequently, has aided me in saving lives.
DR. ROSA GATES: I just want to add a word, and that is that we want to use a large dose of antitoxin. There is nothing equals it for diphtheria or croup.
DR. MUNDY: What do you call a full dose of antitoxin in the beginning?
DR. GATES: According to the age, never less than 4,000 units. Give a large dose and give it early, if you want to do any good.
DR. MUNDY: There seems to be considerable diversity of opinion upon the initial dose of antitoxin. So far as my personal experience goes, I am not such a strong advocate of antitoxin as some physicians. It might be that my first experiences were due to the idiosyncrasies of the patient, but they were not very happy. I practiced medicine before we had antitoxin, and had considerable experience with diphtheria with all its complications. In the last two years I have gone through an epidemic of diphtheria, with antitoxin, and have compared my results with former epidemics when I did not have antitoxin. Of course, I can only speak from memory, but they will be published in the transactions of the Ohio State Society. I also compared the results in the Willard Parker Hospital, in which many thousands of cases were treated, and I find that my figures, although a limited number of cases compared with the thousands in the Willard Parker Hospital, that my percentage is very close to that of the hospital. Physicians tell me that since the day of antitoxin, they lose no cases of laryngeal diphtheria. I think that is a mistake. My initial dose in a case of laryngeal diphtheria is 5,000, never less, usually 10,000, repeated in from six to eight hours if I see no improvement in the patient. My experience has been that I have never seen the membrane disappear in the few hours as many physicians claim with antitoxin. I have seen systemic changes, I have seen the pulse sink, the skin become moist, and respiration easier, but I have not seen that shedding off of the false membrane that so many men talk about.
When I use antitoxin I use other means also. You are not confined to the use of antitoxin. No disease gives me so many hours of restless sleep as laryngeal diphtheria, and I believe, too, that a false impression has been given the laity regarding the use of antitoxin that is having an unpleasant effect, because they hide the mild cases of diphtheria, which are the dangerous ones in the spreading of the disease.