Laryngeal Diphtheria.—The disease may arise in the larynx, although, as a rule, it spreads thence from the pharynx. It first manifests itself by a short, dry, croupy cough, and hoarseness of the voice. The first difficulty in breathing usually takes place during the night, and once it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes stridulous or metallic or sibilant, and there is marked indrawing of the epigastrium and lower intercostal spaces. The hoarseness becomes more marked, the cough more severe, and the patient restless. The difficulty of breathing occurs in paroxysms, which gradually increase in frequency and severity, until at length the patient becomes asphyxiated. The duration of the disease varies from a few hours to four or five days.
After the acute sypmtoms 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.