Symptoms

Diphtheria is an acute, infectious disease characterised by croupous inflammation of mucous membranes which particularly affects the pharynx and upper air passages. Clinically the disease presents fever of an irregular type, with great debility, and frequently albuminuria. Anaemia and rapid loss of flesh and strength are characteristic. The mortality is high, especially among children, whom the disease chiefly attacks, and death may result from toxaemia, sudden heart failure, obstruction to the entrance of air caused by accumulation of the diphtheritic membrane, the extension of the inflammation down the air passages, or exhaustion from inability to swallow food. Recovery is uniformly slow, and may be still further retarded by paralysis or other sequelae. Owing to the extent to which the throat is involved, with consequent difficulty in swallowing, and to the general weakness and prostration, there are few diseases in which greater care in regard to dietetic treatment becomes imperative. There is anorexia, and the sense of taste is lost; nausea is frequently present as well as constipation. The cervical lymphatic glands are more or less swollen and give rise to pain or soreness on opening the mouth.

Albumin may appear in the urine as early as the second day.

Dietetic Treatment

" Alimentation occupies the first place in the general treatment" (Trousseau). Throughout the active stage of the disease while the fever lasts, there is difficulty in swallowing. All food must be given in fluid form, of which milk is the best, or if, as sometimes happens, semisolid material is more easily swallowed, the food must be thickened with cream, gelatin, eggs, or farinaceous articles; or beef meal, Mellin's food, malted milk, etc., may be added for this purpose to other foods. The diet should consist chiefly of nutritious beef or chicken broth and beef tea, egg albumin, eggnog, milk, and milk punch. Plain vanilla ice cream is nutritious, and if not too sweet it is well borne, and is frequently very grateful to the inflamed throat. Simple farinaceous foods, such as arrowroot, thoroughly cooked rice, soft cream toast, and gruels, may be taken. Continued disgust for food is a very bad prognostic sign, and every effort must be made to counteract it by offering variety. When the child is unable to swallow on account of pain or accumulation of membrane in the throat, forced feeding with a nasal or stomach tube may be better than nutrient enemata.

Intubation And Tracheotomy

When intubation of the larynx has been performed the child sometimes experiences great trouble in swallowing without drawing food into the trachea. It is difficult to close the epiglottis with the tube in position, or to draw up the larynx beneath the root of the tongue to the extent which should occur in normal deglutition, and hence fluid food particularly is liable to trickle through the tube into the trachea, exciting violent dyspnoea and spasms of coughing. Semisolid food or solid food, such as junket, mush, or eggs, is more liable to glide over the instrument without being sucked in through it during inspiration. Patients usually require considerable nourishment to support their strength, so that the difficulties of feeding may be serious.

Very young infants, who are dependent upon a milk diet, can swallow best if laid upon the back across the nurse's lap with the head downward supported below her knees. While in this position the bottle is given. Regurgitation through the nose may occur, but that is of little moment compared with the accident of inhaling the milk through the tube into the lungs.

In older children, when proper precautions are taken in regard to the position of the head in swallowing and the avoidance of inspiration at the same time, these dangers may be reduced to a minimum, or they may be overcome by the passage of an oesophageal tube, though this irritates the throat and may spread the diphtheritic membrane along the oesophagus. Intelligent children can learn to swallow well with a little practice and care while wearing the intubation tube. Some even swallow easier than before its insertion by reason of the relief of dyspnoea, which always makes deglutition difficult. In other cases the tube may be temporarily removed, if the dyspnoea is not extreme, while the child takes nourishment; but this requires skilled attendance, and, as the patient must be very frequently fed, it possesses great disadvantages. As a rule, the longer the tube remains in position, the better the patient acquires facility in swallowing. In some cases it may be well to resort to rectal alimentation for a day or two to obviate the necessity of swallowing while the tube is worn.

The late Dr. O'Dwyer said: "Solids and semisolids, when there is an appetite for such food, and when the patients can be induced to take it, are swallowed much better than fluids, and do not enter the tube, as far as I am aware "; and he added that a bolus of food tends to press the epiglottis down over the tube, while fluid tends to raise it, or slip in under it, although he modified the head of the tube by giving it a concave surface to fit the epiglottis.

It should not be forgotten with very young children that a failure to take food may be due to loathing or nausea, and not to physical inability to swallow with the tube in situ. O'Dwyer wrote: "I always instruct children who are old enough to understand, to drink as rapidly as they can, and then cough to expel any fluid which may have entered the tube, instead of coughing after each deglutition, as they usually do." He discountenanced the theory that food may enter the tube and excite pneumonia by reaching the deeper portions of the lungs, and said: "I do not believe - and there is no evidence so far to prove - that any of the fluid entering the tube ever reaches the bronchi, for it is promptly expelled by coughing." He cited cases in support of this statement, one being that of a woman who wore the laryngeal tube for over ten months continuously, and enjoyed good health. He said that vomited food enters the tube even less often than swallowed food.