Manual of Surgery Volume First: General Surgery. Sixth Edition.Thomson, Alexis
Science
Manual of Surgery Volume First: General Surgery. Sixth Edition.
Thomson, Alexis
Surgery
After the acute symptoms have passed off, various localised
paralyses may develop, affecting particularly the nerves of the palatal
and orbital muscles, less frequently the lower limbs.
#Diagnosis.#--The finding of the Klebs-Löffler bacillus is the only
conclusive evidence of the disease. The bacillus may be obtained by
swabbing the throat with a piece of aseptic--not antiseptic--cotton wool
or clean linen rag held in a pair of forceps, and rotated so as to
entangle portions of the false membrane or exudate. The swab thus
obtained is placed in a test-tube, previously sterilised by having had
some water boiled in it, and sent to a laboratory for investigation. To
identify the bacillus a piece of the membrane from the swab is rubbed on
a cover glass, dried, and stained with methylene blue or other basic
stain; or cultures may be made on agar or other suitable medium. When a
bacteriological examination is impossible, or when the clinical features
do not coincide with the results obtained, the patient should always be
treated on the assumption that he suffers from diphtheria. So much doubt
exists as to the real nature of membranous croup and its relationship to
true diphtheria, that when the diagnosis between the two is uncertain
the safest plan is to treat the case as one of diphtheria.
In children, diphtheria may occur on the vulva, vagina, prepuce, or
glans penis, and give rise to difficulty in diagnosis, which is only
cleared up by demonstration of the bacillus.
#Treatment.#--An attempt may be made to destroy or to counteract the
organisms by swabbing the throat with strong antiseptic solutions, such
as 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or by
spraying with peroxide of hydrogen.
The antitoxic serum is our sheet-anchor in the treatment of diphtheria,
and recourse should be had to its use as early as possible.
Difficulty of swallowing may be met by the use of a stomach tube passed
either through the mouth or nose. When this is impracticable, nutrient
enemata are called for.
In laryngeal diphtheria, the interference with respiration may call for
intubation of the larynx, or tracheotomy, but the antitoxin treatment
has greatly diminished the number of cases in which it becomes necessary
to have recourse to these measures.
Intubation consists in introducing through the mouth into the larynx a
tube which allows the patient to breathe freely during the period while
the membrane is becoming separated and thrown off. This is best done
with the apparatus of O'Dwyer; but when this instrument is not
available, a simple gum-elastic catheter with a terminal opening (as
suggested by Macewen and Annandale) may be employed.
When intubation is impracticable, the operation of tracheotomy is
called for if the patient's life is endangered by embarrassment of
respiration. Unless the patient is in hospital with skilled assistance
available, tracheotomy is the safer of the two procedures.
TETANUS
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