the endometrium. Observe the irregular and wide distribution of the stroma nuclei
from oedema fluids. The irregular size and shape of the stroma nuclei is due to some
extent to the different positions at the time of section.
chyorome or dysmetic (figures 15, 17, 18,
19, 21, 22, 23) as is shown in the excellent
figures of Amann.
Hyperplasia of the vascular endothelia is
observed in the mitosis of the endothelial
cell lining the lymph and blood vessels.
The endethelial cell is elongated and pro-
jects toward the vascuar lumen. (Figures
23 and 24.)
The lymphocytes proliferate by the mito-
tic process. The mitosis of lymphocytes
may be observed in the blood vessels, lymph
vessels, glandular lumen, or intraglandular
stroma. (Figures 17, 18, iq, 20.)
The interglandular hyperplasia shows by
low power a great preponderation of inter-
glandular stroma over glandular structures,
â– and the glands appear compressed and
rarefied.
If there be a combination of glandular
hyperplasia and interglandular hyperplasia
it may be termed hyperplasia diffusa. Be-
sides associated with either glandular or in-
terglandular hyperplasia may be genuine
inflammation, whereby parts or segments
of glands, or portions of interglandular
stroma may be destroyed, coalesced, resi-
dues of part destructive endometritis. (Fig-
ure 21.)
Fig. 23 (J. A. Amann). Endothelial
mitosis. Interglandular endometrial stroma
in which lies a vessel lined with endothelial
cells of which one (e) is in a state of divi-
sion, mitosis. The mitotic endothelial cell
projects toward the vessel lumen, i. e., in
the direction of the least resistance.
E, mitotic endothelial cell.
5, vessel lumen,
2 and 4, bodies of stroma cells.
THE CHARLOTTE MEDICAL JOURNAL.
3, nuclei of stroma cells.
6, an endothelial cell in the resting state.
The stroma cells are in a state of hyper-
plasia.
(b) In muco-purulent secretion (chiefly
cervical endometrium) there is found round
celled infiltration, leucocytes infiltration,
both of which occur on an old floor or
Fig. 24 (J. A. Amann). Endothelial mitosis (e) and stroma cell mitosis (m).
In other words, the endothelial and stroma cells hyperplasia M, mitosis of a stratum
proprium mucosas cell. E, mitosis of endo thelial cell, i and S, endothelia in resting
stage. 2, vessel lumen; 3, 3, lymph spaces in the endometrium, where the accumulated
fluid forces the cells apart. 6, nuclei of stroma cells. The irregular distribution of
the nuclei is due to fluid pressure (lymphoe dema) and the difference in size and shape
is due to the position of nucleus at the time of section.
^^S- 25 (J. A. Amann). Oblique sec-
tion through a utricular gland. In contra-
distinction to a typical accumulation or
serial super-imposed layers of epithelia.
The transverse section of the nucleus be-
comes always smaller (c, a, b) in places
only the cell body without the nucleus is
met (a) other places only Ihe small point
of the nucleus is met (b) 3, free surface of
the surface epithelia. 4. nuclei of surface
epithelia; 2, basement membrane of utric-
ular gland.
through the glandular and surface epithelia.
Fig. 26 (J. A. Amann) represents a lym-
phocyte (L) in a diaster form within the
surface epithelia. i. nucleus of stroma cell
aud 2, body of surface epithelia, both quite
uniform ; 3, stroma cell nuclei. The dias-
ter formed lymphocyte lies at a higher level
than the ordinary nucleus, it being larger
than the nucleus is forced in the direction
of least resistance.
glandular hyperplasia, (c) In menorrha-
gia glandular hyperplasia, but especially
interglandular hyperplasia may be found.
The hsemorrhagic transudates called and
form the stroma apart and cleave the glan-
dular and surface epithelia from its stroma
in localized points. Besides blood is found
in the gland lumen.
In this essay I am indebted to the labors
of W. Nagel, C. Gebhart, and especially to
J. A. Amann for his excellent cuts.
THE CHARLOTTE MEDICAL JOURNAL.
451
Laryngeal Diphtheria.*
3y Dr. Eugene B. Glenn. Asheville, N. C.
In considering briefly the subject of laryn-
geal diphtheria, we will only mention diph-
theria in common when it is necessary to
make ourselves understood. I consider
laryngeal diphtheria one of the most if not
the most serious form of this disease, be-
cause not only do we have the toxic condi-
tion sufficiently present to produce death,
but the danger of suffocation due to the
formation of the pseudo-membrane cover-
ing the area of local inflammation.
The formation of this membrane in the
larynx and air passages below assumes more
the form which Virchow originally de-
scribed as croupous. Some observers claim
a dualty of membranous croup and this
form of diphtheria.
Pathologically it is difficult to establish
this theory between the two different in-
flammations, and it is almost impossible to
establish any dividing line between the two.
Our diagnosis at the present time seems to
depend upon the presence or absence of the
Klebs-Loeftler bacillus which is the specific
organism of diphtheria.
In 1894, 80 per cent, of the cases of mem-
branous croup reported to the Board of
Health in New York City, the diphtheria
bacillus was found. So far as we under-
stand, these processes differ in degree rather
than character and that the croupous deposit
is the stage of diphtheritic inflammation.
It is a difficult matter to decide why it is
that in a case of diphtheria the inflamma-
tion present in the pharynx should be diph-
theritic in character while in the larynx and
parts below, the inflammation should as-
sume the croupous type, unless we reason,
as has been suggested, that the anatomical
arrangement of the mucous membrane of
the larynx and trachea fail to favor the de-
velopment of diphtheria.
I believe that it has been clearly estab-
lished that the Loeffler bacillus of diphtheria
forms two different pathological conditions,
respectively, in the fauces and the pharynx.
But sometimes we find a pseudo-mem-
brane formed in the larynx without a diph-
theritic process which would seem to indi-
cate the fact that croupus laryngitis is a
disease distinct from true diphtheria, both
pathologically and clinically.
Pharyngeal diphtheria has a tendency to
extend towards the larynx, trachea and
bronchi, and sometimes in the nose. Ex-
tension to the larynx is indicated by hoarse-
t *Read before the Buncombe County Medical
I Society on March 19th, 1900.
ness or complete loss of voice, croupy cough,
dyspnea, noisy and stridulous breathing,
and if the inflammation extends to the
bronchi, the breathing becomes still more
embarrassed.
Diphtheria is undoubtedly produced by
the specific organism described by Klebs
and Loeffler, which, when it finds a favor-
able spot for its development, it produces
an inflammation of a diphtheritic type.
The organism does not enter the circulation
but the toxin produced by its growth and
multiplication does, and gives rise to the
constitutional symptoms of the disease.
Children under ten years of age consti-
tute the largest number of cases. It pre-
vails in all climates, in all seasons of the
year, but is more prevalent in the colder
portions of the temperate climates, dimin-
ishing in frequency as tropical climates are
approached. The disease is more prevalent
in the cold and damp months of Fall and
Spring. Defective hygienic surroundings,
or anytHng causing a lowered condition of
health, predisposes to the disease by weak-
ening the power of resistance of the sys-
tem. Enlarged and inflamed tonsils with
ragged surfaces cannot be over-estimated
as a marked predisposing factor in diph-
theria.
We find diphtheria occurring epidemi-
cally, endemically and sporadically, and
very frequently the epidemic form is seen
in great virulence in rural districts far re-
moved from sewerage system of large cities.
But in this case the source of infection is
found in some local cause, such as privy
vaults and cess pools which have been neg-
lected, and it has been conveyed long dis-
tances from communities where the condi-
tions favored the development of the dis-
ease. In the cities, besides cess pools, such
places as are permeated by foul air and
dampness, where sunlight is obscure, we
find a favorable source of infection of the
disease.
In any locality where stagnant filth, de-
caying animal or vegetable matter exists,
may also exist the origin of the contagion.
The germs may be conveyed in drinking
water, in milk where the water has been
used in cleansing the vessels and diluting
the milk, or it is found transmitted long
distances by railways, in baggage, letters,
clothing, or by the current of air in prevail-
ing winds.
A number of the lower animals, such as
cats, dogs, chickens, pigeons, sheep, cows,
etc., are frequently attacked by diphtheria,
and in that way may be instrumental in
spreading the disease. There is danger in
spreading the disease by patients who have
been discharged as well, as has been de-
THE CHARLOTTE MEDICAL JOURNAL.
monstrated by the finding of the Klebs-
Loeffler bacilli in the throats of these pa-
tients.
In a large majority of cases the deposit
occurs primarially on the tonsil from whence
the pseudo-membrane extends backwards
into the pharynx up on the soft palate,
faucial arch or up in the nose. But in diph-
theria the spread of the membrane is most
commonly toward the larynx and air pas-
sages below. The false membrane is formed
as a result of the lodging of the specific
germ on the mucous membrane where it
produces the disease and penetrates the
epithelial cells by an inflammatory process
characterized by dilatation of the blood ves-
sels, and the escape of leucocytes and trans-
udation of serum which undergo coagula-
tion later upon exposure to the air.
Together with the contraction of the
fibrinous bands and the excessive activity
of the process, a tissue necros's isproduced.
The pressure destroys the vitality of the
false membrane and a large portion of the
mucous membrane which separates in the
form of a slough followed by ; false mem-
brane or by resolutions. The period of in-
cubation varies according to the virulence
of the contagion from two to eight days.
In the outset of the disease there are
chilly sensations or well marked chills ; the
temperature is not much below 102 ; the
pulse somewhat feeble and somewhat
thready at this time. The throat symptoms
develop almost coincidentally, with pain on
swallowing, a sense of dryness and stifl'ness
and extreme tenderness of throat, and in
twenty-four hours by the swelling of the
cervical lymphatics.
The exudation sometimes begins as small
bluish white spots which in a few hours
change to a yellowish color. Within twenty-
four hours the membrane is complete and
stands out prominently above the mucous
membrane underneath. Sometimes in two
or three days the membrane shows evidence
of necrosis and a disposition to extend in
different directions associated with a muco-
purulent discharge.
The muco-purulent discharge constantly
bathes the parts as the necrotic process de-
velops. The inspired air dries the secretion
and dead tissues causing it to adhere, and
as a result forming additional annoyance to
the patient.
The secretion and necrosis cause the
breath to become fetid. The tongue which
was at first coated and slightly moist now
becomes dry, covered by a brownish look-
ing fur. If life is prolonged as long as
three or four days the membrane may be
expelled either as a partial or -complete cast
of the larynx and trachea, followed by the
reproduction of a new membrane or by
resolution.
When the tracheal membrane is expelled
there is little likelihood of a reformation if
the faucial exudation is progressing favor-
ably at the time. The development and
exfoliation of the diphtheritic membrane
covers a period of from five to seven days,
and the clinical history (providing death
does not occur as a result of the tracheal
exudation) in ordinary cases covers a period
of two weeks or more.
The gravest symptoms up to the third
day are those due to blood poisoning. The
blood poisoning is due to the septic absorp-
tion of the products of the different organ-
isms present.
The development of the false membrane
may begin in the larynx as early as the se-
cond or beginning of the third day and
rarely as late as the fifth day, which pre-
sents a more serious aspect of the disease at
this time.
This condition is marked first by hoarse-
ness, second by complete loss of voice and
is soon followed by dyspnoea. Dyspnoea is
recognized by cyanosis, abdominal and sub-
clavicular depression, etc., and other symp-
toms characteristic of laryngeal obstruction.
The re-occurrence of a febrile movement
suggests the occurrence of the membrane in
the larynx. A partial paresis of the respir-
atory muscles add no little to the symptoms
of stenosis of the larynx.
The malignant form of diphtheria is a
term that is applied to those cases where
the blood poisoning is profound and an
augmentation of all the symptoms of what
is known as a typical form of diphtheria.
The mild form of diphtheria is a term
that characterizes that form where a typical
diphtheritic membrane is produced in the
fauces associated with a slight febrile dis-
turbance, which shows the toxin in the
blood.
In this form the membrane shows no ten-
dency to spread beyond the tonsils and such
cases most always recover. If in the ma-
lignant form the patient survives three or
four days there is frequently an involvement
of the larynx producing laryngeal stenosis,
and as a rule the patient dies before the
dyspnoic symptoms can contribute to any
marked degree in the death of the patient,
therefore death results from toxemia rather
than the formation of a pseudo-membrane.
In considering laryngeal diphtheria there
is no points so important as a differentiation
between laryngeal diphtheria and croupous
laryngitis. In diphtheria the disease usually
begins in the tonsils and extends downward,
the exudation is cutaneous, often severe
pains on swallowing, swelling of sub-max-
THE CHARLOTTE MEDICAL JOURNAL,
453
ilary and lymphatic glands, can be traced
often to bad drainage, seldom much cough
and then only hoarse, both contagious and
infectious, often occurs in adults, often ex-
tends to the nares and other parts, septice-
m'a generally present, paralysis often fol-
lows, albuminuria frequent, death from
syncope common, often occurs in adults, a
constitutional disease, and the Klebs-Loef-
fler bacillus always present.
Croupous laryngitis or membranous croup
is a local disease, begins in the trachea and
extends up, exudation never cutaneous, sel-
dom occurs in adults, not contagious, mem-
brane does not extend to the nares, no symp-
tom of septicemia, no albuminuria, not fol-
lowed by paralysis, death due to suffocation
and seldom to syncope, not traceable to
bad drainage, no pain on swallowing, cough
always present, an asthenic disease and the
absence of the specific germ will aid in
making a differential diagnosis. A croupous
membrane is thin, glazed, shining and of a
white color, and easily separated from the
parts beneath. A diphtheritic membrane
is thick, of a velvety surface, soft, and of a
yellowish color and closely adherent to the
parts beneath. A croupous membrane re-
mains croupous, and when it is exfoliated a
cleanly aspect, healthy in color, is seen and
is never attended by a muco-purulent dis-
charge.
A diphtheritic membrane after the second
day, when necrosis occurs, has a bluish
black aspect with ragged edges associated
with a muco-purulent discharge and the
characteristic odor of necrosis. Any mem-
brane beginning on the tonsils and extend-
ing to the soft palate and uvula, is probably
diphtheria.
When the pseudo-membrane is stripped
off in diphtheria it leaves a raw, bleeding
surface, and with all these points of differ-
entiation we often find cases where it is im-
possible to make a positive diagnosis with-
out the aid of the microscope which enables
us to decide positively in all doubtful cases.
There is almost a universal rule that the
lymphatic tissues of thefaucial and pharyn-
geal tonsils present such a favorable nidus
for the germ that the primary origin of all
cases of diphtheria is to be traced through
the occurrence of a deposit in one of these
lymphoid masses.
The unfavorable prognosis of the disease
is universally known. The saddest memo-
ries of the healthiest and best developed
children who have fallen victims of the dis-
ease, are associated with the name "Diph-
theria." Where the process extends to the
larynx the symptoms of a severe consti-
tutional infection occurs, medical interfer-
ence has^ little or no power to prevent the
unfavorable termination of the disease.
In laryngeal diphtheria the tendency to
death in the main is due to development of
the membrane in the larynx, which results
in asphyxia. The highest percentage of
death-rate is seen in this form of diphtheria.
Age also plays an important part in form-
ing a prognosis. The younger the patient
the higher the mortality. .Since the^intro-
duction of antitoxin the rate of mortality in
diphtheria has been reduced.
Statistics show that the mortality is les-
sened in laryngeal diphtheria by intubation
and tracheotomy. Clinicians seem to have
demonstrated that by the u^e of antitoxin
early in the diphtheritic process, that the
extension of the diphtheritic process from
the fauces to the larynx can be checked,
and that fewer laryngeal obstructions occur
and that more patients recover from laryn-
geal diphtheria without an operation.
The diphtheria antitoxin has no effect on
the prognosis when mixed infection due to
other bacilli are present sufficiently great to
produce death.
Loeffler demonstrated first that micro-
organisms, such as the streptococcus and
staphylococcus pyogenes and other cocci
frequently found in a healthy throat, when
present in diphtheritic membranes in large
numbers, succeed in poisoning the system
by the formation of toxins and also in gain-
ing access to the circulation and invading
the interior organs, such as kidney, liver,
spleen, etc.
It should be borne in mind that even a
mild case may develop grave complications
at any time, as is sometimes the case when
the patient seems almost convalescent, sud-
denly dies from paralysis of the heart.
Local paralysis, pneumonia and kidney
complications may occur as sequelae and
precipitate a fatal issue in mild as well as
a severe case of diphtheria.
In the treatment of laryngeal diphtheria,
will only refer to some important points
which will afford an opportunity for any
who wish to discuss the treatment to give
us their experience in the treatment in
laryngeal diphtheria.
In the treatment of diphtheria we should
first as far as possible counteract and con-
trol the constitutional effect of the toxemia
and second destroy the infected quality of
the inflammatory process and limit its ex-
tension.
In using the anti-toxin we have no way
of determining the virulence and quantity
of the toxin or the susceptibility of the pa-
tient. Frequently it requires a great deal
more of the anti-toxic agent to neutralize
the effects of the toxin, Therefore in decid -
THE CHARLOTTE MEDICALfJOURNAL.
ing the proper amount to give we must be
guided by thie duration of the disease and its
locality and severity. We often have to re-
peat the injection of the anti-toxin vv^hen an
insufficient quantity is given at first. It
must be remembered that in laryngeal cases
it is necessary to give a large initial dose.
Patients given this treatment the first day
of the disease, before a mixed infection has
an opportunity to occur and before the toxin
has an opportunity to increase in quantity
sufficient to produce a profound prostration
in the patient, require less of the remedy
and have a better chance of recovery ; there-
fore in suspicious cases and croupous cases it
is better to give the anti-toxin at once with-
out waiting to determine whether the bacilli
are present or not.
Since the anti-toxin has no influence over
any other toxic condition except that pro-
duced by the Klebs-Loeffler bacillus, when
a timely in jection is given and
there is a failure to respond to the effects
of the anti-toxin, it indicates streptococcus
infection, bronchial pneumonia or some other
complication due to secondary infection.
In cases of laryngeal stenosis in a child
over two years old the dose of anti-toxin
should be from one hundred to two hundred
units the first injection, and repeated within
twenty-four hours at least if there is no im-
provement, and again the third dose may be
given if necessary after the same interval.
In severe cases in children under two years
of age and mild ones over that age, looo
units should be given and repeated as above
or within eighteen hours if necessary,
though a second dose is rarely required.
In favorable cases the injection is followed
in 48 hours by general improvement with a
fall of temperature. In most all favorable
cases the local diphtheritic infection is ar-
rested, the membrane separates rapidly or
gradually and convalescence rapidly ensues.
I believe it would be well to use the anti-
toxin for immunizing other members of the
family when there is danger of their taking
the disease. The quantity usually required
for immunization varies according to the
age of the patient, from 150 to 500 units of
the anti-toxin. The immunity usually lasts
three or four weeks.
Numerous antiseptics have been used in
the form of sprays, inhalations, and local
applications with good effects but none of
them are specifics. Internal medication
cons,ists of such remedies as will sustain the
vital forces and counteract as far as possible
the toxemia. Our main reliance is some
form of alcohol in the shape of whiskey or
brandy which acts as nearly a specific
against septic infection as any we can sug-
gest.
Its administration is governed by the
general condition of the patient which is
more closely evidenced by the pulse. Digi-
talis and strophanthus, singly or combined,
and carbonate of ammonia are often adminis-
tered to regulate the heart action. Mercury,
turpentine etc., are often used for the sup-
posed definite and specific action on the di-
sease. When a general tonic is necessary,
quinine is given the preference.
In laryngeal diphtheria, tracheotomy and
intubation have to be resorted to frequently.
But just when operative interference is in-
dicated, no definite directions can be given
other than these, when other remedies are
failing the laryngeal disease progressing,
intubation or tracheotomy should be done
at once because a large proportion of cases
can be saved by early surgical interference
before the vital forces are notably depressed
by blood poisoning or by defective oxygen-
ation.
When we stop to think how simple the
operation is and when slight danger to life
can be attributed to the operation itself, we
should not question the propriety of resort-
ing to it early in any laryngeal invasion.
As to whether one does an intubation or a
tracheotomy depends upon the age of the
patient and the extent of the invasion in the
air passages below.
Intubation sometimes promises the best
results in children under four years of age ;
tracheotomy promises better hope of saving
the patient after the age of five. When
there is any indication of the rapid.;invasion
of the trachea and air passages below, trach-
eotomy is preferabie.
Without discussing at length the various
considerations relative to the operations,
their comparative value is shown by the
latest statistics: tracheotomy, 27.14% intu-
bation, 27.2% recovered. These statistics
were taken without regard to the age of the
patient.
DISCUSSION.
Dr. Mili.ender. — One of the members
of the society a little while ago asked me to
tell him the function of the respondent. I
told him I was sure I could not do so. I
thought he was a sort of supernumerary.
And certainly he has no function to right
for Dr. Glenn has said everything on the
subject of Laryngeal Diphtheria there is to
be said.
But first in regard to the diagnosis, I am
glad Dr. Glenn takes the position that there
are two distinct diseases, producing in the
larynx a false membrane. It is of vital im-
portadce to differentiate at the very outset
between the two diseases. Laryngeal Diph-
theria and Croupous Laryngitis.
THE CHARLOTTE MEDICAL JOURNAL.