Paralysis and Ataxia Following Diphtheria Postdiphtheritic paralysis may affect the general nervous system, the eye, ear, throat, etc. Paralysis of the soft palate is not rare. A stationary palate, a na al voice, and food regurgitation through the nose are the characteristic symptoms. For this condition, as well as for the temporary locomotor ataxia which is occasionally observed, we require fresh air, baths, massage, the interrupted. current, and of a grain of strychnine, three times a day, by the mouth or under the skin. The antitoxine treatment has not made paralysis cases more frequent, nor does it appear to facilitate the recovery from such complications. A gradual paralysis of the respiratory muscles, including the diaphragm, as shown by a weak cry and rapid, superficial breathing, is a very serious condition to deal with, but may improve under stimulation. and artificial respiration. In addition to the general treatment just announced, the cold douche and artificial respiration may do good. Cardiac arrhythmia in the wake of infectious disease is not infrequent and is mostly due to myocardial involvement, for which rest, hygiene, and rational diet and stimulation are to be employed. Sudden death from heart paralysis gives no chance for treatment. In all cases of septic diphtheria, early and proper stimulation may prevent it. The anæmia which is known to follow in the wake of diphtheria and other infectious diseases demands tonics, such as fresh air and iron. Bronchopneumonia and lobar pneumonia, thrombosis of veins and arteries, and other remoter complications will come under observation, and will call for proper management. DIET.-Milk, Vichy, matzoon, kumyss, beef peptonoids, cornstarch, eggnog, custard, ice water, cream, farina, cocoa, eggs, raw meat, burnt flour soup, whiskey, California Tokay, coffee, tea, punch, iced champagne, pineapple juice, and tropon. The diet in diphtheria is of prime importance. The food should be nutritious and digestible. Forced feeding is proper in exceptional cases, but it is well to remember that children with febrile and septic disease have little desire for food, and that the stomach will resent all attempts at overfeeding. Somatose is soluble meat without taste or smell, and can be given with cocoa, milk, gruel, rice, etc. For rectal alimentation we inject a mixture of whiskey, egg yolk, beef peptonoids, and warm water or somatose in oil emulsion. test. Gavage will be indicated in exceptional cases. In regard to the question as to when it will be safe to send children who have had diphtheria back to school, we should judge by the culture Whenever this test cannot be employed we should wait at least three weeks from the disappearance of clinical symptoms, during which time the nasopharyngeal toilet should be diligently carried out. CROUP In practice we recognize (1) a croupy cough without stenosis; (2) a catarrhal or pseudocroup with dyspnoea, and (3) true croup, in which the stenosis is progressive and frequently necessitates operative interference. The croupy cough is common in children with adenoid vegetations, follicular pharyngitis, or large tonsils; it usually begins at night and yields to the mildest treatment. A cloth wrung out of cold water, around the neck, salt water dropped into the nostrils, and a hot drink are all that is necessary for the time being, with subsequent curettage or cauterization of the swollen follicles in the pharynx. Emetics are not indicated, although very popular with that class of parents who delight in goose grease and turpentine. As a type of pseudocroup with dyspnoea, the croup of measles is characteristic. Here we have to deal with catarrhal laryngitis or oedema of the glottis, which rarely goes on to complete stenosis; the treatment is the same as for "croupy cough." Only in extreme cases will local scarification of the oedematous tissues or intubation be necessary. Adrenalin chloride is capable of controlling oedema. It may be applied by means of a cotton applicator every hour. The so called true croup either is a primary membranous laryngitis or is secondary to diphtheria of the nasopharynx. In primary membranous croup the pharynx is pale and the temperature normal, and the onset is never sudden; hoarseness, aphonia, and stenosis come on gradually, whereas in pseudocroup the onset is generally sudden, the pharynx is usually congested, and there is fever. About 80 per cent of membranous croup cases are known to be cases of Klebs-Loeffler diphtheria; in about 20 per cent this bacillus has not been found. True croup should, therefore, be quarantined as diphtheria. The secondary croup with stenosis is due either to an extension of the membranes downward or to the swelling and oedema of the tissues adjoining a diphtheritic patch. Urgent laryngeal stenosis, secondary to various forms of nose and pharynx diphtheria, is, therefore, not necessarily membranous, but the treatment is practically the same in both instances. Treatment of Croup with Urgent Stenosis. Before the advent of antitoxine the best treatment for true croup, before operation, was with mercury or calomel, internally, by inunction, or by fumigation, and it is well known to experienced physicians that intubation and tracheotomy gave better results when mercury had been administered. Mercuric bichloride, gr., was given every hour for one or two days, or 20 grains of calomel were volatilized over a lamp, under an improvised tent, every three hours for from twenty-four to forty-eight hours. The spray and croup kettle have very little value, and emetics in any shape are productive of evil, as they sap the strength of the patient. Now that we have specific treatment, we shall not discuss in detail our former management of croup cases, because the best treatment of croup, before operation, can be mentioned in one word—antitoxine. Here, again, I refer the skeptic to the report of the American Pædiatric Society on laryngeal stenosis, which tells the whole story, reflecting, as it does, the experience of hundreds of physicians and sifting the evidence in a judicial manner. Briefly, the report says: Before the use of antitoxine 27 per cent of intubation patients recovered; now 73 per cent recover. Sixty per cent of stenosis cases do not require operation if antitoxine is used in time, and an early use of antitoxine will lower the mortality of intubation cases still more. In every case of acute progressive stenosis 2,000 to 3,000 units of diphtheria antitoxine should be administered at once, and the dose may be INTUBATION AND TRACHEOTOMY 183 repeated in from twelve to twenty-four hours, and so on, until relief is manifest. As soon as the stenosis becomes less urgent, and the cough somewhat loose, the main danger is over, and camphor, gr., or spir. ammoniæ, aromat., gtt. x, may be given as an expectorant and stimulant, four times a day. The same management should be resorted to in secondary stenosis following scarlet fever, measles, pertussis, nasopharyngeal diphtheria, or so called tonsillitis, together with the nasopharyngeal toilet, as before described. When antitoxine fails to check a progressive stenosis, the time for operative interference is close at hand. The proper time for the operation is a matter of experience; the physician should not wait until the patient is cyanosed and the pulse intermittent. INTUBATION AND TRACHEOTOMY Intubation is the art of introducing tubes into the larynx and removing them at the proper time. In combination with antitoxine, intubation is one of the greatest blessings at the disposal of the physician. Dr. J. O'Dwyer, of New York, is the inventor of our present method of tubing for The instruments he devised have been in general use since 1886, and although a number of modifications have been suggested, none has come to the writer's knowledge which is in any respect an improvement on those used in the original method, with the exception of Denhard's gag, which is universally used. Many of the modifications are useless or bad. The tubes now in use have a smooth coating of hard rubber, to prevent incrustation. The operation of intubation and extubation is not, in itself, difficult; but every one contemplating becoming a safe operator |
