1900 Journal of the American Medical Association (JAMA)  
severe and intubation was performed with immediate relief. One thousands units of antitoxin were administered. The tube was removed on the fourth day, dyspnea returning in a few hours, and reinserted six hours after extraction. It was again removed two days later and dyspnea did not return until four days after the second extraction, when intubation was again urgent, a piece of membrane being loosened as the tube was inserted. One thousand five hundred units of antitoxin were given and,
more » ... given and, although the tube was coughed out twice during the next four days, on extraction the breathing was good and the patient recovered. The conclusions from this case, confirmed by later experience, show that if the tube can not be removed at the end of four days an additional 1500 units of antitoxin should be given. The retained tube was evidently necessary on account of persisting membrane, showing the original dose of 1000 units insufficient for this case. The tube was worn ten days. Case 2.-A girl, aged 2 years and 9 months, was seen with Dr. Rodd, Feb. 2, 1897. A glance at the child was sufficient to show that the marked cyanosis and comatose condition promised a speedily fatal termination. A three-year tube was quickly .prepared and, with only a nervous woman as assistant, and no one to hold the head, an attempt was made to pass the tube, but the faulty position and large size of the tube made two efforts unsuccessful, and it was at once apparent that one more failure was certain to prove fatal. I exchanged the three-year tube for the one-year size, and at this juncture Dr. Rodd arrived. Our next effort was successful and no more inspiring or delightful sight can greet the eyes of the surgeon than this picture of returning life to the asphyxiated child. An hour later the one-year tube was coughed out, and a two-year replaced it. The case progressed favorably but reintubation was necessary on the fourth, sixth, eighth and tenth days. A loose piece of membrane was removed at one of these operations and 1000 units more given. The tube was finally removed on the seventeenth day, twelve intubations having been performed. A case which illustrates the possibility of saving life when the patients are moribund was seen with Dr. Geo. Bassett, May 25, 1897. A boy, aged 3 years and 5 months, had been ill with diphtheria involving the tonsils, pillars and larynx for some days and no physician in attendance. On entering the room it seemed that death was a question of only a few minutes. There was no radial pulse and the child was completely comatose. It luckily happened that a three-year tube prepared for another patient was ready for use, and as the tissues were completely relaxed it was quickly passed without disturbing the position of the child on the bed, and artificial respiration resorted to. The tube gave perfect relief and the patient was sent to the hospital for treatment, 1500 units of antitoxin having been given. On the fourth day the tube was extracted, but dyspnea returning next day a second operation was performed and 1000 units administered. He coughed out the tube 2y2 days later, and was discharged from the hospital fully recovered fifteen days after admission. From a study of these cases and general observations in the treatment of diphtheria, we can formulate a series of definite conclusions and rules of procedure which apply to all cases of laryngeal diphtheria. 1. Administer antitoxin early without waiting for a bacteriologic diagnosis. 2. Tonsillar exudate attended by a croupy cough or partial aphonia is an indication for a full dose of 1500-2000 units of antitoxin. 3. Antitoxin administered twelve hours or more prior to operative interference will reduce the mortality of intubated cases at least 50 per cent. 4. Immunize all exposed children of croup age. 5. Continuous steam inhalations are of great value in all cases. 6. Early operation is most strongly advocated. summary of one hundred cases. Number of operations, 100; recoveries, 69; deaths, 31; mortality under 3 years, 49 per cent.; mortality over 3 years, 19 per cent.; complicating measles, 8 cases, 5 deaths. Age of patients operated on: 1 to 2 years, 16, of whom 9 recovered, 56.25 per cent.; 2 to 3 years, 23, with 11 recoveries, 47 per cent.; 3 to 4 years, 20, of whom 16 recovered, 80 per cent.; 4 to 5 years, 15, of whom 12 recovered, 80 per cent.; 5 to 6 years, 11 cases, with 10 recoveries, 90.9 per cent.; 6 to 8 years, 10, of whom 7 recovered, 70 per cent.; 8 to 12 years, 5, of whom 4 recovered, 80 per cent.; number of doses of antitoxin, 160. The danger of opium as a remedy in infancy has only recently been recognized. Many physicians give the drug or its alkaloids without the slightest recognition of its possible injurious effects on the organism in the future. In a recent text-book, a statement is made that the action of opium is transient in infancy, and without danger except in large doses. The prominence of certain proprietary drugs, as soothing syrups for children, and the characteristic effects of opium, with the great injuries noted later, have brought out facts of the damage from these sources. In current literature little notice is taken of this danger, and yet a great variety of facts are constantly appearing, pointing out the disease and degeneration clearly traceable to this cause. In all probability the largest use of opium in infancy comes from its domestic application. The various tinctures and infusions are household remedies and, in many sections, the gum from the poppy is gathered and put away regularly as a household necessity. It is the most convenient and practical of all remedies in the obscure disturbances of childhood. No doubt, some physicians find it very useful and often give it thoughtlessly. The drug store files show how commonly it is used in infantile therapeutics, and often it is given in a routine way for a long time, particularly for neurotic and intestinal disorders. My purpose is to call renewed attention to this danger, and show some new facts from the clinical side, that are not uncommon and, no doubt, can be confirmed in the practice of many physicians. In adult life, opium and its alkaloids, in a general way, are marked excitants or depressants. Either one or the other is most prominent, and both always are in the same person. This is not dependent on the doses, although that is marked in many cases. One will have a long, early stage of stimulation and wakefulness, and
doi:10.1001/jama.1900.24610200018001f fatcat:cirbjohlofflzachi2fjnnnzqa