THE TREATMENT OF DEPU- 
TE FIMA. 
Read in the Section on Diseases of Children at the Forty-fourth Annual 
Meeting of the American Medical Association. 
BY F. E. WAXHAIvf, M.D. 
DENVER, COLO. 
EMERITUS PROFESSOR OK LARYNGOLOGY AND RIIINOLOGY, COLLEGE OF 
PHYSICIAN'S AND SURGEONS OF CHICAGO. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAS MEDICAL ASSOCIATION 
DECEMBER 1, 1893. TILE TREATMENT OF DIPH- 
THERIA. 
Read In tlie Section on Diseases of Children at the Forty-fourth Annual 
Meeting of the American Medical Association. 
BY F. E. WAXHAM.M.D. 
DENVER, COLO. 
EMERITUS PROFESSOR OF LARYNGOLOGY AND RHINOLOGY, COLLEGE OF 
PHYSICIANS AND SURGEONS OF CHICAGO. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 
DECEMBER 2, 1893. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION, 
1893. THE TREATMENT OF DIPHTHERIA. 
It is to be hoped that in the not far distant future 
the inoculation treatment of diphtheria will super- 
sede or largely displace all other treatment. The 
researches in the field of bacteriology; the discovery 
of the Klebs-Loftier bacillus and the various experi- 
ments with ptomaines and anti-toxines are most 
assuring. Yet notwithstanding the fact that Bering 
and Ivitasato have clearly demonstrated that cul- 
tures, which will invariably kill susceptible animals 
in very small amounts, have their toxic properties 
entirely destroyed by the addition of the blood of 
an immune animal; and while the experiments upon 
animals have been such as to give us confidence in 
the future treatment of the disease by inoculation, 
yet for the present we must rety upon the well- 
tried methods of to-day. 
While mice inoculated with a virulent filtrate, neu- 
tralized by the addition of immune blood have 
remained immune to diphtheria for forty or fifty 
days, yet this method has not been employed with 
satisfaction in the human subject. There are still 
great difficulties to be overcome and much experi- 
mentation still to be done before this treatment can 
be applied to man. We ascribe all honor to the in- 
vestigators who have already accomplished so much 
and look to them with interest and hope for the fu- 
ture. 
I shall not occupy your time in discussing the 
preventive treatment, important as it is, for it would 
only be to reiterate principles that are perfectly 
familiar to all. 4 
In considering the treatment of this disease we 
may for brevity, confine our remarks to four head- 
ings: 1, nourishment; 2, stimulation; 3, internal 
medication, and 4, local antisepsis. 
In the treatment of this disease, nourishment is 
quite as important as medication, and the life of the 
patient often depends, not only upon alcohol, oxygen 
and the local use of antiseptics, but upon proper and 
abundant nourishment as well. On account of the 
energetic employment of various remedies, the im- 
portance of feeding is often overlooked. We some- 
times neglect to inquire explicitly in regard to the 
amount that is taken, and we frequently find that 
very little is given when we had supposed that the 
child had been receiving a sufficient amount. On 
account of the loss of appetite and the pain of swal- 
lowing, a patient often refuses all nourishment: and 
there is sometimes an insane repugnance for all food, 
which can not be overcome by ordinary means. In 
these cases we should at once resort to forced feed- 
ing. We should endeavor at frequent intervals to 
give some nourishment by the mouth, while pepton- 
ized food should be given by enema. If a patient 
absolutely refuses all nourishment by the mouth I 
would emphasize the importance of introducing a 
small gum elastic catheter into the stomach by way 
of the nasal cavities. 
After the introduction, a safety pin should be 
passed through the end of the catheter to prevent its 
slipping beyond reach. It may be allowed to remain 
as it gives rise to but little irritation, or it may be 
removed and re-introduced at each feeding. It, how- 
ever, should be removed two or three times daily 
and cleansed and the nasal cavities flushed with a 
warm alkalin antiseptic solution. Milk and stimu- 
lants in full quantities can be introduced through 
the catheter by means of a syringe, and I am con- 
vinced that many lives may be saved in this manner 
that would otherwise perish. 
There are those who oppose the idea of alcoholic 5 
stimulation in the treatment of this disease, but I 
believe it is the judgment of the profession generally 
that it is a very important remedy. While mild cases 
do not require its use, yet in severe or malignant cases 
it is imperatively demanded. It is a well-known 
fact that alcohol is one of the most potent destroyers 
of microorganisms in culture fluids. Its benefit in 
diphtheria is undoubtedly due to its antidotal action 
upon the ptomaines in the blood. In no other way 
can we explain the fact that alcoholism is not pro- 
duced, even when it is given in large quantities. 
When required, it should be given freely; at least 
one or two teaspoonfuls of whisky or brandy or its 
equivalent of alcohol, every hour or half hour, accord- 
ing to the urgency of the case. In severe or malig- 
nant cases, other stimulants must also be given, as 
strychnia, musk and ammonia. 
In regard to internal medication, there is one rem- 
edy that stands out preeminently above all others. 
While so-called specifics have come and gone, this 
one, the tincture of the chlorid of iron, has remained 
as one of our sheet anchors in the treatment of diph- 
theria. No one claims it to be a specific, yet it is a 
fact that red blood corpuscles increase amazingly 
under full doses of this agent, hence its usefulness 
as an internal remedy, while its local effect as an 
astringent and antiseptic increases its efficacy. It 
should be given in frequent and full doses; ten, fif- 
teen or twenty drops to young children, all that the 
stomach will tolerate, and it should be repeated 
every hour or half hour. Should it disturb the 
stomach, carbolic acid should be combined with it. 
There are other remedies, such as bichlorid of mer- 
cury, turpentine and chlorate of potash, that have been 
much used; but in very severe cases of pharyngeal 
diphtheria I believe they are too irritating to the 
kidneys and should be employed with caution. In 
laryngeal diphtheria, where the kidneys are not fre- 
quently involved, however, the bichlorid of mercury 
is the most useful remedy at our command. 6 
The local antiseptic treatment of diphtheria is of 
the utmost importance. It matters little what anti- 
septics are employed, providing they are thoroughly 
applied to the throat and nasal cavities. Carbolic 
acid, bichlorid of mercury, pyoktanin, chlorin 
and peroxid of hydrogen are agents that have fre- 
quently been employed with more or less success. 
The results, however, will depend, not so much upon 
the remedy selected, as upon the method employed. 
To spray the throat with the most effective antisep- 
tic, leaving the nasal cavities uncared for will only 
invite failure; while to use an antiseptic solution 
that does not thoroughly irrigate the whole nasal 
tract will be inefficient. 
The bichlorid of mercury is undoubtedly one of 
the most powerful germicides at our command, and 
in the strength of 1-4000 is not irritating. The per- 
oxid of hydrogen diluted to one part to four of water 
is also efficient, but its use should be followed by a 
warm alkalin douche. When the spray from a hand 
atomizer will reach the whole nasal tract it is to be 
preferred to the douche, as there is no danger of 
forcing the fluid into the middle ear. This accident 
which will occasionally result from the too forcible 
use of the douche is an unfortunate one. One of the 
most effective methods of treating the nasal cavities 
is by means of the soft rubber catheter, as first sug- 
gested by the President of this Section. This should 
be introduced along the floor of the nasal cavities 
until it reaches the post-nasal space when,by means of 
a small syringe, a warm, alkalin antiseptic solution 
can be gently introduced and the whole nasal tract 
thus thoroughly irrigated. The advantages over the 
atomizer are obvious for when the nasal cavities are 
obstructed the spray simply rebounds and the deeper 
parts remain untreated. I would advocate the early 
use of the douche in this manner in all cases of 
diphtheria where there is the slightest tendency to 
invasion of the nasal cavities. 
It seems proven beyond doubt that the disease 7 
is primarily a local one, and that the constitutional 
symptoms are the result of ptomaine poisoning ; this 
poison being produced by the bacilli which are found 
in countless numbers in the diphtheritic exudate. 
How necessary, then, that the local treatment should 
be most thorough and eflicient. To recapitulate: 
the indications in the treatment of diphtheria are to 
destroy, as far as possible, the bacilli by the thor- 
ough and early use of our most powerful germicides ; 
to support the system and prevent the disorganiza- 
tion of the blood by abundant nourishment, free 
stimulation and full and frequent doses of iron.