Etiology.--This disease has been epidemic, endemic, and sporadic. For the last twenty-five years it has gradually been declining in severity.

Children who are overfed, who have developed in the intestinal tract a state of decomposition or putrescence, running on for some time, and who have broken down their resistance, will develop a state of toxemia which will cause them to be susceptible to the prevailing influences, atmospheric and otherwise.

Children who are fed too frequently or fed improperly, and who are troubled with constipation and the passing of undigested food with the bowel movements, are made susceptible not only to diphtheria, but also to scarlet fever, measles, whooping-cough, etc. Indeed, it can be proved that normal, healthy children--children who have bowels that are regular, and who are not troubled with intestinal indigestion--cannot be made to take any of these diseases.

Symptoms.--The pharyngeal type starts very much as tonsilitis. There are symptoms of cold, and if these conditions develop, the throat becomes sensitive, painful, and swollen. Diphtheria is located on the tonsils and in the pharynx when these locations are inflamed.

Children usually complain of slight discomfort. If the parents look into the throat, they will see a little redness and swelling, and perhaps two or three white specks about the size of a wheat-grain. If the disease is light, these specks may coalesce, the inflammation will not extend very far down, and the child will complain of difficult swallowing for a few days; but within a week the throat will be well without any special treatment, except to inhibit eating.

Where the infection is intense, the temperature will run to 102° and 103°, the tonsils will become very much enlarged, and the diphtheritic membrane will form over these parts, sometimes extending pretty well up on the soft palate. In such cases swallowing is almost impossible. The disease may even extend into the nostrils. If such patients are fed, brain complications may develop, and the patients die in the course of ten days to two weeks. The glands in the neck become very much swollen, due to infection. The membrane that forms will at first have a grayish-white color, then change into a dirty gray or brown, sometimes a yellowish white; it is firmly adherent, and, if loosened and thrown off, leaves the surface completely denuded and decidedly irritated, but it is soon covered with another exudate.

True Croup or Laryngo-Tracheal Diphtheria

Where the larynx and trachea are involved, the symptoms at first are those of ordinary croup. Children will begin by coughing with a croupy sound. In the majority of cases they do not appear to be very ill; in fact, they win entertain and amuse themselves with their playthings and playmates, sometimes for two days; and again I have known cases to run on for three days, the cough becoming a little more croupy each afternoon and evening, but this symptom passing off more or less in the fore part of the night and the forenoon. Parents seldom are uneasy, because the croup is not severe; it does not affect the breathing very materially, and the child usually has an appetite, and will eat its regular meals where it is permitted to do so. If examined by the trained ear, there will be evidence of a deposit taking place in the bronchial tubes.

Years ago, when I was doing a general practice, it was my misfortune to meet with a great many of these cases. In those days it was not uncommon for me to be called to prescribe for a child with a slight attack of croup. All that the parents seemed to think would be necessary for me to do was to give the patient a little croup medicine, so insignificant were the symptoms. To strengthen this belief, when I called to make the examination, I would often find the child playing with other children. On looking into the throat, perhaps I would see a little redness of the pharynx. Then, on placing my ear between the shoulder-blades, I would hear a mucous rale, which not only diagnosed the case, but also prognosed it. I never knew a case to get well. Where this disease is located in the pharynx, and passes down only a very short distance into the trachea, sometimes the membrane is thrown off and the child recovers; but this is so rare that I have heard of only a few cases.

Many people will confuse diphtheritic croup, or diphtheria, with catarrhal croup. This is a very great mistake; for children should invariably recover from catarrhal croup, while in diphtheritic croup, or true croup, where the membrane extends, down to the bronchial tubes, the mortality is one hundred per cent.

Treatment.--The entire profession is enlisted on the side of antitoxin as the proper remedy. I have no faith in it, do not believe in the theory, hence have not recommended it--nor shall I. The claims that there has been a tremendous reduction in the amount of diphtheria, and especially in the mortality of the disease, because of the use of serum, I am not prepared to accept. Scarlet fever is just as formidable a disease, just as contagious, and just as dangerous to life as diphtheria has ever been. It keeps pace with diphtheria in growing less severe in type and in having fewer epidemics. Indeed, mortality statistics show that there is a larger percentage of fatal cases in diphtheria than in scarlet fever, and the profession does not claim to know anything at all about the specific cause of scarlet fever; so, until the subject is illuminated to my entire satisfaction, I shall use the decline in severity of scarlet fever to prove that there is nothing in the contention of the bacteriologists that diphtheria has been controlled by antitoxin. The severity of all so-called contagions has declined in the last twenty years, and so has murderous treatment.

The proper treatment is to wash out the bowels two or three times a day, when the child is first taken sick, using as large enemas as can be put into the bowels.

See that the child has nothing at all to eat. It should not be encouraged to drink, nor to swallow anything. It should be encouraged to wash its mouth and spit out rather than to swallow. Thirst must be controlled by small water enemas.

The child should be placed on its right side, leaning well forward, with its face rather down, so that the saliva will drain from the mouth on a cloth. These cloths should be burned. The child should not be allowed to lie in such a position that the secretion will run down the throat into the stomach.

A small towel may be wet in tepid salt water, pressed snugly against the throat, and held there by pinning a dry towel around the neck. The towel may be wet every three or four hours. No sprays or washes of any kind should be used. it is to be hoped that the old-fashioned gargling has passed into oblivion. Gargling, or spraying the throat, only aggravates the disease and encourages swallowing. The disease must be confined to the throat as much as possible, and the child must be allowed to lie in a position where everything will drain well out of the mouth. This is to prevent further infection. When the child is tired of lying on one side, it may be changed to the other side, but kept in the same position--lying on the side, inclining well forward, with either the left or right leg, whichever is uppermost, bent at a right angle with the body, so as to prevent the child from rolling over on its face.

If the temperature is above 103° F., the child should have a hot bath once or twice a day. After being in the hot water about five minutes, cold water may be added to reduce the temperature of the water from 100° to 60°. If the child's temperature is not above 102°, simply a warm bath morning and night is enough. When the child is showing great restlessness, it may have an extra bath, and the water may be extra warm to bring on relaxation and relief. The child should have its spine rubbed at least once a day before bedtime. This is to relieve any aching and tire. The rubbing should be very gentle, and should be continued until the child is quieted down and asleep. Children with this disease should be left as much alone as possible. Certainly there are to be no questions asked, and curious people should not be permitted in the room. Of course, where quarantine is thoroughly carried out, no one except the nurse will be permitted to see a sick child.

No feeding, nor swallowing even of water, is to be indulged in until the disease is thoroughly under control. No drugs are necessary.