It is well to regard vomiting in diphtheria as of serious import until it has been proved to be the contrary. It may be merely the result of injudicious feeding, of a bilious attack, or of some other trivial cause. It may also be, and too often is, an early symptom of fatal cardiac failure. Even if this is not the case, the strain of vomiting, be the cause ever so trivial, may be too much for the heart muscle, which seldom escapes some degree of deterioration. The rule, then, is first to treat the vomiting as a serious event, and secondly to speculate as to its cause. All food by the mouth must be stopped at once. After a few hours' interval, if the vomiting has not recurred, a cautious attempt may be made to give a little peptonized milk. If this is vomited it is best to resort to rectal feeding without further delay, as to persist in attempts to feed by the mouth will only make matters worse. Rectal feeding is at best unsatisfactory, but with care it may tide the patient over the dangerous period. The bowel must be first thoroughly emptied by a simple enema. The nutrient injection may, of course, vary in composition according to the views of the physician. I usually prescribe the yolk of an egg in 2 or 3 oz. of milk, the whole peptonized. To this 1/2-1 oz. of cream and a dessertspoonful of brandy are added. Occasionally instead of the egg a few drachms of some meat juice such as bovinine are given. Boyd has recently drawn attention to the value of dextrose in nutrient enemata. This supplies the deficiency in carbo-hydrates. His prescription for a good nutrient injection is, the yolks of two eggs, 450 grains pure dextrose and 7 grains common salt in about 10 fluid ounces of pancreatized milk. Commercial dextrose is unfortunately too irritating to the bowel.
The nutrient enema should not exceed 4 oz. for a child. Adults can retain much more, and Boyd considers there may be some advantage in giving a large quantity, as some of the material occasionally passes above the ileo-coecal valve. The syringes usually employed are not suitable for the purpose. It is better to use a funnel with a soft rubber tube and pour the fluid in very slowly. The administration of sufficient fluid is of great importance, as thirst is a most distressing symptom in these cases. A saline injection of 6-8 oz. in a child, or of 10-20 oz. in an adult is usually well retained, if given rectally one or two hours before each nutrient enema. The enemata may be given every four hours, or less frequently if the patient's strength appears to be well maintained. At least once in the twenty-four hours the lower bowel must be thoroughly cleansed by a large injection of hot saline, or of hot water with a very little soap. Occasional attempts at mouth feeding may be tried, iced brandy or iced champagne being often tolerated when nothing else will lie on the stomach.
When only the palate is affected the adult patient is usually able to swallow his food satisfactorily, without regurgitation through the nose, if he takes it sufficiently slowly. Children, even with slight degrees of palatal palsy, should never be allowed to feed themselves. They cannot, as a rule, be trusted to take sufficiently small quantities at a time, and should have their nourishment administered in teaspoonfuls by the nurse. Soft solids are often swallowed with less difficulty than fluids, and custard pudding and jellies are usually readily taken. In the more severe form of paralysis, affecting the pharyngeal muscles, which appears later in convalescence, nasal feeding must always be used. Even if the patient does not absolutely choke in attempting to swallow, particles of food are liable to reach the lungs and set up a septic pneumonia.
I must confess to preferring nasal feeding after both these operations. Children very often swallow perfectly after tracheotomy, but it is as well to run no risks. After intubation infants as a rule swallow well, but older children are often nervous, especially with fluids, and are liable to have fits of violent coughing. The Casselberry position, with the child's head and shoulders lower than the rest of the body, undoubtedly makes swallowing much easier; but children tolerate nasal feeding so well that there is little to be gained by using any other method. The food, of course, must be fluid and will consist chiefly of milk, custard and meat juices. After the canula or tube is removed the child may be fed in the normal manner.
In my opinion diphtheria, if of average severity, is depressing enough to make the moderate use of stimulants advisable. It is doubtless the case that many patients can survive even a sharp attack without the use of alcohol, but it is also true that it is often impossible to predict with any certainty in which individuals a sudden heart failure is likely to occur. This being so, I cannot resist the feeling that, should such a tendency to syncope appear quite suddenly, those patients who have had comparatively recently even a small dose of alcohol will be less likely to succumb than those who have not had a similar advantage. The value of free stimulation in cases which have shown signs of a failing heart from the onset of the disease is unquestionable, and was often very well seen in the days before serum treatment. Nowadays, perhaps, we are a little too apt to attribute every improvement to the use of antitoxin. Believing, then, that alcohol may be of great value, it is my custom to prescribe it systematically to all cases which we would have unhesitatingly classed as classical diphtheria in the days before bacteriological examination was the rule, that is to say, to both severe and moderate cases of diphtheria. Cases, on the other hand, the diagnosis of which depends more directly on the result of the culture, do not receive alcoholic stimulants as a routine. Whisky is probably the most satisfactory form in which to give alcohol, and very small doses are given, unless the heart shows signs of failing, the routine dose being often as small as 30 minims every 4 hours for a child of 4 or 5 years of age, and a drachm for older children or adults. This is usually continued for the first 10 days and, if the pulse is not quite satisfactory by that time, for a week or so longer. If there is any tendency to sickness brandy is preferable, and if signs of definite heart failure with vomiting appear, there is nothing better than champagne. During the convalescence of adults port or a good Burgundy in suitable quantities is occasionally very useful.