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James Meschter Anders.

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system and give rise to primary constitutional symptoms, the local
manifestations in the throat being secondary. I have met with a
single instance that would lend support to this view.

Predisposing Factors. — (1) Age. — This is the most important factor,
diphtheria being, in the main, a disease of childhood. Most cases occur
between the second and seventh years, while the receptivity diminishes
rapidly after the tenth year. Instances have, however, been observed
up to the fiftieth or even the sixtieth year. During the first year of
life also it is rare. (2) iSex. — This is without appreciable influence.
(3) Season. — Cases are more numerous in winter and spring than at other
seasons. (4) Climate. — Diphtheria is met Avith less freciuently in tropical



186 INFECTIOUS DISEASES.

than in temperate and cold climates. Humidity favors the propagation
of the diphtheria germ, and hence damp cellars also promote the spread
of the disease. (5) Unhygienic Conditionss. — Unfavorable sanitary sur-
roundings tend to lower vitality, thus increasing the susceptibility to the
specific virus. Most epidemic outbreaks have held more or less intimate
relationship T\-ith decomposing organic matter, defective drainage and
sewage, cesspools, etc., though it is to be especially remembered that the
disease often prevails in sparsely-settled rural districts.

Immunity. — A single attack does not confer perfect immunity.
Second and third attacks not infrequently occur in the same individual.

Symptoms. — Incubation. — The duration of this period is from two
to seven or ten days, and in a small percentage of the cases it may be
longer. In virulent epidemics and when the disease is produced experi-
mentally the incubation-stacre is short — from twelve hours to two or
three days. The iJrodromal indications of diphtheria are not strikingly
characteristic. They may either be acute in character or very mild ;
but usually the child will complain of feeling weary and indisposed to
play, of being chilly and cold, and of pain in the head, back, and limbs.
In young children the onset of diphtheria, as in other infectious diseases,
may be marked by convulsions. There is nothing in this early stage of
the disease to distincruish it from many of the other affections of children,
such as simple pharyngitis or tonsillitis. There may be some fever, not
very hio-h — an elevation of one or two degrrees at most. The child may
often complain of discomfort in swallowing, and on examination the fauces
will be found to be reddened, and in a short time the exudate will be
found on the tonsils or soft palate. This is the usual type of simple ton-
sillar diphtlieria.

Pharyngeal Diphtheria. — The symptoms are usually shiver of develop-
ment than in tonsillitis. The child is sluggish, looks heavy-eyed, languid,
and pale for several days. The fever may not rise above 101° or 102°
F. (38.8° C). On examining the throat, however, it is found to be
swollen and red, and if lividity is more pronounced than the swelling,
it suggests the true nature of the disease. The onemhrane begins on
the tonsils in the form of small patches of yellow exudate, scarcely
distinguishable from the thick, cheesy plugs of inspissated dead epi-
thelium and secretion which issue from the mouths of the follicles of
the tonsils during the course of acute or chronic tonsillitis. The mem-
brane spreads from the tonsils to the soft palate and half arches within
a few days, and it may also appear on the pharyngeal wall. During
this stage the throat may become much swollen and the tonsils greatly
enlarged, frequently meeting in the median line. The glands immedi-
ately beneath the angle of the lower jaw on one or usually both sides
become hard, painful, and slightly enlarged ; the swelling of these
glands is not usually great in mild forms, although their presence, in
association with the foregoing symptoms, is an infallible indication of
the disease. The child, as a rule, shows grave constitutional symptoms
for a few days, and loses its appetite. The temperature is not charac-
teristic, as a rule not being high, and the pulse is rapid and weak, being
out of proportion to the general indications of the disease. In mild
cases the symptoms abate by the end of the first week, and the pseudo-
membrane separates, leaving a red, inflamed surface behind. The child



DIPHTHERIA. 187

is prostrated for a number of weeks, and in about 20 per cent, of all
mild cases the toxic effects of the disease may show themselves in the
form of a neuritis, with its accompanying paralysis.

Variations in Manifestation. — Diphtheria may exhibit a number of
variations as regards the seat of attack and the severity of the poison-
ing. In some epidemics the Klebs-Loffler bacillus seems to be more
active and more numerous, or perhaps more virulent, than in others.
The severity of. the attack does not seem to depend on the amount of
the pseudo-membrane, but rather, according to Rotch, upon three fac-
tors : (1) the virulence of the bacteria ; (2) the local resistance ; and (3)
the general resistance. While false membrane is most frequently seen on
the tonsils, spreading gradually to the soft palate and uvula, the mucous
membrane of any part of the body (lips, tongue, conjunctivae, vulva, or
glans penis) may be the seat of the growth.

Malignant Diphtheria. — The symptoms are severe from the com-
mencement. There are one or at most two days of slight illness, and
then alarming symptoms manifest themselves, cardiac failure possibly
setting in without a specially severe local lesion. Vomiting and high
fever, resembling the onset of scarlet fever, may initiate the attack ;
and within a few hours we may find extensive SAvelling at the angles of
the jaws, with a feeling of stony hardness, a very offensive, bloody dis-
charge coming from the nostrils, accompanied with difficulty in opening
the mouth. If the throat is examined, there will be found extensive
swelling of the tonsils, even to meeting, the uvula and soft palate being
edematous and covered with much sloughy-looking membrane. The
temperature in severe cases soon reaches a point between 103° and
104° F. (40° C), while the heart-heats become exceedingly feeble. In a
day or two the cellulitis extends, the face becomes edematous, the skin
pits all over the face, neck, sternum, and chest-walls. The patient
soon becomes drowsy, cyanotic, and occasionally an erythematous rash
appears about the face, neck, and chest, while a purpuric rash is not in-
frequent in malignant cases. Death occurs in such cases within one
week from toxic poisoning. Malignant cases of diphtheria resemble
very closely malignant scarlet fever, though the pulse in scarlet fever
will be of assistance in the discrimination in the absence of the charac-
teristic rash.

Nasal Diphtheria. — In all severe cases of pharyngeal diphtheria the
inflammatory process is likely to extend to the nasal mucous membrane.
In some cases the nasal mucous membrane is found to be the first in-
volved, and it may spread to the tonsils, but in these cases the exudate
will be found to involve the back of the soft palate and pharynx as well.
In many cases of nasal diphtheria no membrane may be found during
life ; there may be only a purulent discharge with blood, the presence of
which in the nasal passage obstructs breathing, giving rise to a bubbling
sound, and rendering sleep troublesome and noisy. Many cases have
also been reported of formation of pseudo-membrane in the nose with
mild general symptoms (often insignificant), and from which bacilli
identical with diphtheria bacilli were obtained by culture, the bacilli often
persisting for months. Sometimes the cases have recurring mild attacks
of pseudo-membranous inflammation of the nose, while the bacilli may be
constantly present. It is probable that these cases may give rise to in-



188 INFECTIOUS DISEASES.

fections of like nature, and even of true diphtheria. In nasal diph-
theria the symptoms are quite as severe as in faucial diphtheria, and in
cases in which the soft palate, tonsils, and nasal mucous membrane are
involved the general symptoms, the depression, and also the albuminuria,
are well marked. In all cases of coryza with fever we should be guarded
as to opinion, especially if an epidemic of diphtheria is prevalent at the
time. The diphtheritic iniiammation may spread from the nose to the
conjunctivae, with the formation of a false membrane, and much purulent
discharge may escape from the eyes, the lids of which may be greatly
swollen. In this place it is well to remember that in measles we some-
times have a form of membranous exudation occurring on the nasal
mucous membrane and as a primary disease — " rhinitis fibrinosis " — which
is not always diphtheria. This disorder runs a favorable course, the
membrane being less adherent than in diphtheria. Ravenel has collected
77 cases, and in 33 out of 41 cases examined bacteriologically the Klebs-
Loffler bacillus was found. Constitutional symptoms were either slight
or wanting.

Wound-dipTitheria . — The bacillus will not live on normal skin, but
when the skin is cut or bruised, as after blistering or an eczematous
condition, and when a moist, raw surface is present, the bacillus freely
flourishes. Granulations also form a favorable soil. The diphtheritic
germs may be introduced into the system during an operation, such as an
excision of the tonsils, or even a vaginal examination ; and in new-born
infants the granulating surface left after sloughing of the cord may be-
come the seat of diphtheritic inflammation.

Laryngeal Diphtheria or Memhranous Group. — In many cases the
Klebs-Loffler bacillus produces its influence first on the mucous mem-
brane of the larynx, and in these cases the mucous membrane of the
nose and pharynx may never give evidence of a false membrane. In
laryngeal cases the first symptom is a cough of a harsh, metallic, ringing
character^ and never to be forgotten when once heard. The temperature
may be slightly above normal, or even, in many cases, normal. The
toxic absorption is slight, on account of the locality affected, and the
constitutional symptoms are usually mild. The local symptoms, however,
are very alarming, as they are the results of laryngeal obstruction, there
being marked dyspnea with retraction of the intercostal and supraclavic-
ular spaces, and later of the epigastrium and lower chest. These are
associated with an increasing cyanosis. The child is soon very restless,
is forced to sit up to breathe, and for the same reason bends forward with
its head thrown back. In these extreme cases, unless relief is soon gained,
the child dies of sufibcation. In many instances a slower form of sufl"oca-
tion may result from the extension of the membrane downward to the
bronchi.

Complications. — Local complications may be mentioned, as when
we have hemorrhage from the nose and throat in the more severe ulcera-
tive cases. Skin-rashes are not unusual, especially the diffuse erythema.
Sometimes urticaria will be noticed, and in severe forms purpura will
mark the skin.

Broncho-pneumonia is the most serious pulmonary complication of
diphtheria. It is not produced by the Klebs-Lofiler bacillus, but by
pyogenic cocci which have been taken in during respiration. Broncho-



DIPHTHERIA. 189

pneumonia is frequent, and most usually terminates laryngeal cases tliat
have been operated upon.

Albuminuria is really a part of the disease, and can scarcely be re-
garded as a complication. It is the most constant symptom, and is
almost as certain in establishing a diagnosis of true diphtheria as a bac-
teriologic examination. It is met with in both mild and severe cases,
and the greater the amount of albumin the more severe the case. When
acute nephritis complicates diphtheria it is usually not accompanied by
edema or anasarca.

Dysphagia may, by its constant existence throughout the disease, pro-
duce a profound impression on the general nutrition. Involvement of the
conjunctivce is a rare but grave complication.

Otitis media occurs frequently, and may be a troublesome complica-
tion as well as a sequel.

The most frequent sequelae are anemia, chronic naso-pharyngeal
catarrh, peripheral neuritis and its associated paralysis.

Anemia may so prolong convalescence that the child will frequently
be exposed to some intercurrent disorder. The chronic naso-pharyngeal
catarrh may be so marked as to offer a favorable ground for new diph-
theritic invasion. Neuritis and paralysis will not be noticed until the
third or fourth week, the paralysis usually being first seen when the child
attempts to swallow, and the food, especially if liquid, is regurgitated
through the nose. This is due to a paralysis of the muscles of the soft
palate, which will also be noticeable owing to a peculiar alteration of the
voice. The pai'alysis may take a general form, such as is seen in mul-
tiple neuritis, the lower extremities being affected and the knee-jerk
absent. It is frequently quite extensive ; it may extend to the external
ocular muscles and cause squint, to the ciliary muscles and cause dimness
of vision from unequal accommodation, or to the muscles of the trunk in
general, producing widespread paralysis. The child, unable to hold any-
thing, may stagger about as if intoxicated, so much so as to suggest the
existence of a cerebral tumor. The disturbance of vision and the ab-
sence of the patellar tendon reflex has in adults led to a mistaken diag-
nosis of locomotor ataxia. Loss of taste, deafness, and a disturbance of
sensation are not infrequent. Thus, paralysis is to diphtheria what
dropsy is to scarlet fever — a proof positive of the disease. To make one
step more, in many sudden deaths occurring in early diphtheria we must
recognize paralysis of the heart outside of all toxic influence, and the
fact that in cases of sudden death, which are by no means uncommon
during the disease, we have some sudden disturbance of the vagus brought
about by means of its cardiac branches.

The prognosis in all cases of post-diphtheritic paralysis is quite favor-
able. Myocardial weakness tends to supervene as a sequel. It is evi-
denced by the sudden accession of pallor, nausea, sometimes by vomit-
ing, and also by weak heart-sounds and a feeble, broken, irregular
pulse, etc.

Diagnosis. — The diagnosis of a pharyngeal diphtheria (the usual
typical form) is not difficult if an epidemic be prevailing. The false
membrane on the fauces and the presence of albumin in the urine give
us a practically certain diagnosis. The only unequivocal evidence of
the disease, however, is the finding of the Klebs-Loffler bacillus in the
membrane.



190 INFECTIOUS DISEASES.

DiflFerential Diagnosis. — Yrom follicular tonsillitis ^^e differentiate
diphtheria by the seat of the membrane, that of the former beino- in the
tonsils, while diphtheritic membrane is over the tonsils and over the soft
palate. Moreover, in follicular tonsillitis the fever is high, the onset is
sudden, and it is usually associated with gastric disturbance. Albu-
minuria is generally present in diphtheria, while it is present in follic-
ular tonsillitis in exceptional cases only. Moreover, mild cases may
not present albuminuria, or fail to show the presence of albumin until
later in the disease. The histories of the tAvo cases are quite different.
(For differential diagnosis between diphtheria and follicular tonsillitis,
see also Table, p. 718.) In many instances of so-called diphtheroid
lesions the membrane is formed only by streptococcus pyogenes {mem-
hranous angina), and these cases are sometimes of an intense grade.

Croupous or membranous angina may offer some difficulty; yet in
this disease there is no tendency to spread to the nasal mucous membrane
or to the larynx ; there is a diminished glandular enlargement; there is
no albumin, and the onset is more sudden.




Fig. 17.— 1, A tube of blood-serum ; 2, a sterilized cotton swab in test-tube.
Rub the swab gently but freely against tbe visible exudate, and without laying it down, after
withdrawing the cotton plug from the culture-tube, insert it into the latter, and rub that portion
which has touched the exudate gently but thoroughly over the surface of the blood-serum with-
out brealiing its surface. Now replace the swab in its own tube, plug both tubes, and place them
in tlie box provided by the health officials. This is to be sent to the bacteriologic expert. In
laryngeal diphtheria the swab is to be passed far back and rubbed freely against the mucous
membrane of the pharynx and tonsils.

Diphtheria frequently is associated with a rash, rendering it difficult
to distinguish the condition from sca^'let fever ; but in diphtheria the
rash is more truly an erythema, while in scarlet fever it consists of slightly
raised points between which there may be an erythematous condition.
The glandular swelling and sloughy condition of the throat, however,
closely resemble diphtheria, and a positive diagnosis without a bacteri-
ologic examination is often impossible. An immediate recognition of the
disease is often possible from a smear-preparation of the exudate from the
throat (see Fig. 17), the Klebs-Loffler bacilli being present in sufficient
numbers to be readily distinguished by the microscopist. Park, who has
had a rare experience with this affection, makes the following statement:
"• The examination by a competent bacteriologist of the bacterial growth
in the blood-serum tube, which has been properly inoculated and kept
fourteen hours at the body-temperature, can be thoroughly relied upon in
cases in which there is a visible membrane in the tnroat if the culture is
made during the period in which the membrane is forming, and no anti-
septic, especially no mercurial solution, has lately been applied. In cases
in which the disease is confined to the larynx or bronchi, surprisingly
accurate results can be obtained from cultures, and although, in a certain



DIPHTHERIA. 191

proportion of cases, no diphtheria bacilli will be found in the first, yet
they will be abundantly present in later cultures. We believe, therefore,
that absolute reliance for a diagnosis cannot be placed upon a single cul-
ture from the pharynx in purely laryngeal cases." When a bacteriologic
examination cannot be made the practitioner must regard as suspicious
all forms of throat-affections in children, and carry out measures of isola-
tion and disinfection. In this way alone can serious errors be avoided.
Mistakes do not usually occur in a more pronounced membranous sore
throat, but in the lighter types, many of which are in reality due to the
Klebs-Loffler bacillus (Osier).

Prognosis. — Diphtheria is at the same time the most prevalent and
most fatal of all the diseases with which the general practitioner has to
deal. The mortality is enormous (30 to 40 per cent.), though it differs
widely in different epidemics, and the most fatal variety is unquestion-
ably the laryngeal. In laryngeal diphtheria the mortality may be as
high as 75 per cent., and the younger the child the more unfavorable
the prognosis, the strong and healthy seeming to share the same fate as
the Aveakly. Of especially unfavorable prognosis are those cases that
show large quantities of albumin in the urine, general adenitis, cervical
glandular enlargement, excessive nasal discharge, a necrotic state of the
throat, vomiting, and partial or complete suppression of the urine. Al-
though the temperature in diphtheria is never very high, yet a sudden
fall of temperature to subnormal and an irregular pulse, or bradycardia,
are also a bad augury. Recovery from a severe attack in which there
are extreme depression and much albumin is unusual, especially in a
child under six years of age, though recovery takes place frequently in
what would be regarded as hopeless cases. The results of Morse's ex-
tensive observations are opposed to those of Bouchut and Dulinsay, who
claim that the degree of leukocytosis is of prognostic value (see p. 183).
The cases of neuritis invariably recover. A child who has had diph-
theria once is most likely to contract it again, and if he recovers is
liable to suffer from its effects for years.

The causes of death in diphtheria, in their order, are as follows:
membranous croup or laryngeal diphtheria ; septic infection, which
may be a sIoav death ; sudden heart-failure — paralysis of the heart ;
broncho-pneumonia, following tracheotomy or occurring during con-
valescence.

Treatment. — Prophylaxis. — The best preventive measures against
diphtheria are a clean nose and mouth. Insist upon a careful toilet of
the nose in all children. The slightest appearance of a coryza must be
overcome at once by the use of a mild antiseptic wash ; all accumulations
of crusts, dust, dried blood, etc. should be removed from the nose twice
daily, especially in children attending school or during the prevalence of
an epidemic. The child should be early taught to employ a small anti-
septic gargle as a daily routine, using a weak solution of hydrogen dioxid,
listerin, or even a mild dilution of alcohol. The teeth should be care-
fully cleaned daily, and all decaying teeth should be filled or removed.
If it is true, as one authority claims, that over two hundred different spe-
cies of bacteria find a happy home in the oral cavity, this fact should
make all parents attentive to the proper physiologic condition of the
mouths of their children.



192 INFECTIOUS DISEASES.

All cases of sore throat should be exarained for the Klebs-Lbffler bacil-
lus, and, if it is found, the individual should be isolated ; and all cases
of diphtheria should be kept isolated until the membrane has disap-
peared from the nose and throat. This is especially true in schools and
asylums. Moreover, the throats of all persons exposed to this disease,
and of those caring for diphtheritic patients, should be frequently ex-
amined for the Klebs-Loffler bacillus, and if it be found the person should
receive immunizing doses of antitoxin. The fact that the Klebs-Loffler
bacilli when found in healthy throats may not be active is no argument
against isolation, because it is well known that if the same germs were to
find such favorable soil as a broken or catarrhal membrane they would
rapidly develop. The seed being there, the soil only requires prepara-
tion for its reception.

An unrecognized feature in the prophylactic treatment of the disease
is seen in the uncertain period of convalescence. It frequently hap-
pens that long after all membrane has disappeared active bacilli may
still cling to the throat. This condition may continue from two to six
months, and even longer in deeply fissured tonsils ; and the disease may
be communicated by such throats in the act of kissing young children or
adults with sensitive throats or with a broken mucous membrane of the
mouth. For this reason the indiscriminate kissing of young children on
the lips should be interdicted by the physician.

Sufficient importance has not been been given to the milder cases of
diphtheria as to their isolation and disinfection, and this fact explains the
occurrence of many house-epidemics.

Treatment of the Attack. — The treatment falls very naturally under sev-
eral departments : (a) the hygienic measures to limit the difi"usion of the dis-
ease ; {b) the local management of the throat to destroy early the toxic
germs ; (c) medication to antagonize the eifect of the toxins, and event-
ually to overcome the complications and sequelae.

(a) Hygienic Treatment. — The patient should be in a room well ex-
posed to sunlight and fresh air, as diphtheritic germs grow well in poorly-
lighted and damp chambers. No stationary washstand should be allowed
in the room, and Goodhart well says that many cases seem to have their
origin in the proximity to foul-smelling drains. The physician should
never consent to be responsible for the recovery of a patient in a room in
which there is a washstand with its uncertain connection with the main
sewer. If possible, the patient should use two connecting rooms, one
during the day and the other at night, so that one while not in use may
be thoroughly aired and disinfected. Even in mild cases the patient
should be kept in bed throughout the attack, and in more severe cases
also for some time during convalescence. This is especially important
when there have been symptoms of cardiac depression during the acute
stage. The general comfort of the patient is enhanced by two daily
sponge baths of tepid salt-water or of alcohol and water.



Online LibraryJames Meschter AndersA text-book of the practice of medicine → online text (page 24 of 175)