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Practically all the above complications occurred after faucial diphtheria, but it is interesting
to note that two cases of myocarditis and two of palatal paresis occurred after attacks of nasal
diphtheria.
The table shows the high incidence of myocarditis as a complication, thus confirming my
previous statement as to the severity of the cases admitted during the year.
In the last four annual reports there have appeared accounts of the treatment
at the North-Western hospital of laryngeal diphtheria by suction after peroral
endoscopy. There have been no striking developments in the method of treatment
during 1934, but minor improvements in technique continue to be made. The
results of the treatment are summarised below :—
Number 'scoped only 5
Number 'scoped and aspirated 25
Number in which aspiration probably obviated operation 4
Number in which aspiration required to be followed by
operation 11
Treatment
of laryngeal
diphtheria.
As in the past, intubation remains the operation of choice in laryngeal diphtheria
at the North-Western hospital, and of the 11 cases in which operation was performed
intubation was done in 9, and tracheotomy in 2. Of the intubations 5 were
performed by the direct method, i.e., by means of the laryngoscope, whilst in 4 the
indirect method formerly employed was carried out.
The data set forth below continue those of previous years, the general
diphtheria fatality rate being the percentage of all diphtheria deaths in 1934,
calculated on the total of diphtheria admissions for that year:—
Diphtheria excluding bacteriological diphtheria 712
Diphtheria fatality rate 4.63 per cent.
Laryngeal diphtheria 41
Operation cases 11
Cases requiring operation 27 per cent.
Deaths 3
Fatality of operation cases 27 per cent.
Details of the three fatal cases are as follows:—
(1) M.S., aged 11 months. Admitted with laryngeal diphtheria and contact of measles and
whooping-cough. Diagnosis of laryngeal diphtheria confirmed and aspiration and direct intubation
performed twice. Whooping-cough developed on the 8th day in hospital, and measles on
the 16th day, the child finally succumbing to bronchopneumonia on the 20th day.
(2) P.S., aged 4 years. Admitted with faucial and laryngeal diphtheria and aspiration
performed, but some time later owing to sudden complete obstruction immediate tracheotomy
was performed with relief. Acute meningitis due to hæm. influenzae developed on the 4th
day in hospital, and the child died of this complication on the 24th day.
(3) G.H., aged 1 year 8 months. Admitted with severe faucial and laryngeal diphtheria
on the 6th day of illness. Aspiration performed twice. Owing to the presence of toxic
myocarditis further repeated aspiration was considered inadvisable, and tracheotomy was
performed. Death from heart failure occurred 36 hours after admission.
During 1934, 5 cases of acute laryngeal obstruction due to other infections,
mainly streptococcal, were laryngoscoped. Also during the year one patient
developed chronic laryngeal stenosis following tracheotomy performed before admission
to hospital.
Since the ideal to be arrived at in the treatment of laryngeal diphtheria is the
avoidance of operation as far as possible, advantage was taken of the presence in
the hospital of an oxygen tent, kindly lent by Dr. E. P. Poulton for other purposes,
to make trial of its usefulness in the treatment of laryngeal diphtheria. In such a
tent atmospheres containing up to 40 or 50 per cent. of oxygen are available, and
it was considered that patients with the varying degrees of asphyxia encountered
in croup would derive benefit from respiration in such atmospheres. What is
believed to be a new departure in the treatment of this condition was thus initiated,
and of several patients one or two showed definite amelioration of symptoms. One
female patient aged 14 months, suffering from nasopharyngeal and laryngeal
diphtheria and bronchopneumonia, admitted to hospital in a state of collapse, presented
a remarkable degree of improvement in 24 hours and was removed from the
tent after 3 days to complete an uneventful convalescence.