=Definition.=—An acute, infectious disease, caused by the
Klebs-Loeffler bacillus, and characterized by a membranous exudation
on the mucous membrane of the fauces, larynx or nose, and by
constitutional symptoms. The presence of the Klebs-Loeffler bacillus
distinguishes true diphtheria from any other form of membranous
inflammation. The term diphtheroid is applied to all such forms as are
not due to the Klebs-Loeffler bacillus.
=Osteopathic Etiology= and =Pathology=.—The exciting cause is the
Klebs-Loeffler bacillus. The predisposing cause is obstruction to the
circulation of the pharynx and tonsils by subdislocations of upper
cervical vertebræ, and even the lower cervical and upper dorsal, and
severely contracted deep muscles of the neck. The stasis of blood
favors the growth of the bacillus.
Link[55] says: “The cause of nasal, pharyngeal or laryngeal diphtheria
is obstruction of the blood and lymph through the neck and the
obstruction occurs as a result of lesions in the cervical region,
affecting the cervical sympathetics, or lesions in the upper thoracic
region whence the vasomotor fibers arise. A derangement of the
vertebral articulation of the first rib is usually found. (This affects
the stellate ganglion and fibers of the sympathetic chain). These
lesions cause a condition of lowered vitality of the mucosa of the nose
and throat; the abnormal secretion favoring the rapid multiplication of
the Klebs-Loeffler bacillus—the exciting cause of the disease.”
Dr. Still believed that, among other lesions, contracting of tissues
involving the scaleni and disturbing the relations of the first
rib with the clavicle and vertebra are causative factors. The
constitutional symptoms are produced by the toxins generated by the
bacillus and absorbed from the diseased spots by the lymphatics
and blood-vessels. The bacillus is non-motile and does not usually
penetrate the mucosa, but remains very near the site of the local
changes although there are instances where it may enter the blood and
other tissues. The bacillus is very resistant and can maintain an
existence for months outside of the body. There is great variation in
the virulence of the Klebs-Loeffler bacillus; it has been found in
healthy throats, and sometimes the bacillus may exist in the throat
after an attack of diphtheria for months after all the membrane has
disappeared. It has also been found in cases of simple catarrhal angina
without membrane, and in simple tonsillitis Of the bacteria associated
with the bacillus of diphtheria, the streptococcus pyogenes is the most
common and probably the most active. The staphylococcus, micrococcus
lanceolatus and bacillus coli communis are also found.
The contagion is communicated, as a rule, through the air, by means of
fomites from the membranous exudate or discharges from the diphtheritic
patients, or during convalescence, from secretions of the nose and
throat. Infected milk may cause the disease. Most cases occur in
childhood, between the second and seventh year. The disease is most
prevalent in the cold autumn and spring months. It is most frequently
met with in temperate and cold climates. Defective drainage, catarrhal
conditions of the throat, enlarged tonsils, general weakness, and
feeble resisting power are predisposing factors. One attack does not
confer immunity from another, but rather predisposes to a second.
The =false membrane= is usually found on the tonsils, the pillars of
the fauces and the pharynx, and in fatal cases it may be extensive
and involve the uvula, the soft palate and the posterior nares, and
even the trachea and bronchi. At first this membrane is yellowish
white, but later may become gray; it is more or less adherent and
when torn off leaves a raw surface. The diphtheritic poison coming in
contact with the throat leads to, first, a necrosis or death of the
epithelial cells, especially the more superficial, and the leucocytes.
The second change is the hyaline transformation, and simultaneously
coagulation; hence the term coagulation-necrosis. The irritation
produced by the bacilli causes a migration of leucocytes and these are
destroyed and undergo hyaline transformation. This process proceeds
from without inward and is usually superficial, and the necrosis may
be extensive, involving the deeper tissues, causing ulceration and a
gangrenous condition of the parts. The erosion of the tonsils may be
so severe as to attack the carotid artery. The lymphatic glands are
considerably swollen. The spleen is commonly enlarged. The kidneys show
parenchymatous changes. The blood is dark and fluid. Fatty degeneration
of the heart is not infrequent. Sometimes fibrinous coagula are found
in the heart. Capillary bronchitis, catarrhal pneumonia and areas of
collapse are almost constantly found on examination of the lungs in
fatal cases. The =urine= is typically febrile with early albumin and
often tube casts and renal epithelium. The =blood= shows an excess
of red blood cells which may reach 7,500,000. Hemoglobin is slightly
reduced. There is considerable anemia during convalescence depending
upon severity of toxemia.
=Symptoms.=—The incubation period varies from one to ten days, usually
two or three days. According to the location, diphtheria may be divided
into pharyngeal, laryngeal and nasal forms.
In =Pharyngeal Diphtheria=, which is most common, there is first a
slight chill or chilliness, followed by fever and sore throat, both of
which increase rapidly. The throat is swollen and red and the patient
complains of difficult swallowing. The membrane begins on the tonsils
in the form of grayish-white patches; it then spreads from the tonsils
to the soft palate, sometimes covering the uvula. The cervical glands
are swollen and tender. The neck muscles are contracted and somewhat
difficult to relax. The temperature rises to 102 or 104 degrees F. The
pulse is rapid and feeble, ranging from 120 to 140. There is loss of
appetite. There is more or less prostration depending upon the gravity
of the constitutional symptoms. The average duration is from one to two
weeks.
=Laryngeal Diphtheria= (Membranous Croup) may be secondary to extension
from the fauces or it may be primary. At first there is slight
hoarseness and a harsh, metallic, ringing cough. These symptoms may
persist for a day or two, when the child suddenly becomes worse; there
is marked dyspnea and the lips and finger tips become livid. The child
soon becomes very restless. The temperature may be slightly above
normal and the pulse increased in frequency. In favorable cases the
dyspnea is not very marked and the child probably will have only one
or two paroxysms, when it will fall asleep and wake in the morning
feeling very comfortable. The next night, however, the attack may be
more pronounced. In extreme cases death may result from suffocation.
In some cases the suffocation is slower and results from extension of
the membrane downward into the bronchi. Dr. Still found same conditions
as in diphtheria, but also the hyoid is involved with the superior
laryngeal nerve. The sacral and lumbar nerves are also involved. He
always emphasized chilling of gluteal region as a cause for croup and
that heat should be applied at the inception of the disease.
=Nasal Diphtheria= is generally secondary, but it may be a primary
affection. In many cases no membrane is found; in others there may
be a pseudo-membrane formed in the nose, but there is absence of any
systemic disturbance. The Klebs-Loeffler bacillus is sometimes present
in these membranes. Nasal diphtheria may be a very grave disease—the
constitutional symptoms being great prostration, high fever, marked
glandular swelling, irritating and offensive discharges from the nose,
and epistaxis. Inflammation occasionally extends through the tear duct
to the conjunctiva.
A diphtheritic membrane may grow where the skin has been cut or
bruised, but the bacillus cannot live on normal skin. It nourishes on a
raw, moist surface and membranes have grown on the lips, tongue, vulva,
glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs
occasionally in the conjunctiva and the external auditory meatus.
It should be remembered that there are many atypical forms of
diphtheria. Bacteriological examination should always be made in
suspicious and puzzling cases.
The complications of diphtheria are nephritis, hemorrhages, rashes,
capillary bronchitis, pulmonary collapse, catarrhal pneumonia,
myocarditis, arthritis, otitis media, and paralysis.
=Diagnosis.=—The presence of the Klebs-Loeffler bacillus will at once
decide the diagnosis of diphtheria.
=Prognosis.=—The prognosis should always be guarded. The nasal and
laryngeal forms are always grave. The causes of death are involvement
of the larynx, septic infection, heart failure, bronchopneumonia during
convalescence, and rarely, uremia.
=Treatment.=—Hygienic and prophylactic measures are important. A room
should be selected that is ventilated and exposed to the sunlight. All
unnecessary articles of furniture should be removed. Great care must be
taken against the spread of the disease. Always isolate the patient and
disinfect everything that has come in contact with him. The greatest
danger lies in the spread of the disease during convalescence and in
the ambulatory form, when patients are about and coming in contact with
individuals, especially children with catarrhal conditions of the nose
and throat. The physician should be careful about disinfecting himself.
In view of the fact that many osteopaths have treated successfully
numerous cases of diphtheria and that the osteopathic treatment is
peculiarly indicated and effective, the probable requirement of
antitoxin (the use of which we do not feel called upon to discuss)
would be lessened. Relative to the antitoxin Osier says: “The principle
of action depends on the circumstance that the blood serum of an animal
rendered immune, when introduced into another animal, protects it
from infection with the diphtheria bacilli, and has also an important
curative influence upon diphtheria, whether artificially given to
animals, or spontaneously acquired by man.”
“The treatment of diphtheria by osteopathic methods is often a pleasure
rather than a trial because of the success which rewards us for our
efforts. There has been considerable discussion by the members of
our profession regarding the methods to be employed in successfully
overcoming this disease, and many have expressed the view that since
antitoxic serum is a physiological remedy, which naturally belongs
to all schools of healing, it should be employed by the osteopathic
physician in cases of diphtheria. I have no objections to the use of
the serum therapy by members of the profession who conscientiously feel
that they need it in their practice to secure the highest success.
However, I feel, on the other hand, that if they were well acquainted
with the technique of the methods * * * they would not feel it to their
advantage, from the standpoint of success, to use injections in a
single case.”—R. D. EMERY, Clinical Osteopathy.
The local treatment should be carefully, but vigorously, given. By
proper treatment of the throat the extension of the disease may be
prevented. The muscles about the throat, especially the deep ones,
should be thoroughly relaxed and the cervical vertebra; corrected if
displaced. The vasomotor nerves to the blood vessels of the affected
region require careful treatment at the superior cervical ganglion,
and the cervical lymphatics from the atlas to the first rib should be
closely watched. The nerves to control are the vagi, glosso-pharyngeal,
spinal accessory, and sympathetic nerves to the pharyngeal plexus,
and in cases of nasal diphtheria the fifth nerve has to be carefully
treated. An external treatment to the pharynx will have the greatest
effect on these nerves. An internal treatment to the nerves of the soft
palate will be of considerable service. The parts diseased should be
disinfected and kept as clean as possible. Bichloride of mercury (1 :
4000) used as a spray will be found satisfactory, although there are
several other disinfectants and germicides that may be used. Pellets
of ice in the mouth will be a comfort to the patient. Cold applied
externally will be found best for the adult; heat externally is better
for the child.
Every possible means should be used to prevent the disease from
spreading. One of the chief dangers of diphtheria is the spread of
the disease to the larynx, trachea and bronchi. When the disease has
extended to these parts it presents all the symptoms of =true croup=.
The deep cervical muscles should be thoroughly relaxed to aid in
relieving the passive hyperemia and with a view of disorganizing the
exudate. Attention should be given to the upper ribs, as interferences
with the vasomotor nerves of the mucous membrane of the trachea and
bronchial tubes usually occur. Direct treatment over the larynx and
local treatment through the mouth upon the soft palate will be of
aid. A thorough relaxation of all the dorsal muscles, even as low as
the tenth dorsal, should be given. Inhalations of slaked, freshly
burnt lime may be useful in loosening the exudation. In desperate
cases tracheotomy or intubation of the larynx should be performed.
Willard[56] says, relative to membranous croup: “It matters not whether
or not the laryngeal inflammation was immediately caused by a germ; it
would not, nor could not, have been produced by such had there not been
an unnatural condition of the circulation of and about the larynx.”
A constitutional treatment should always be given with a view of
preventing the spread of the disease from one organ to another and to
prevent complications. The heart’s action should be carefully watched
throughout the entire course of the disease. Treatment of the spinal
cord will guard against paralysis that sometimes follows the venous
hyperemia of the vascular linings and substance of the brain and spinal
cord. Pay particular attention to the upper dorsal region to prevent
possible heart involvement. Post-diphtheritic paralysis seldom if ever
occurs in cases that are treated osteopathically. This is a common
sequela and is present in from 10 percent to 30 per cent of cases,
appearing within three weeks of apparent recovery. Sometimes it is the
only result to show diphtheria was present. It seems to follow use of
antitoxin rather frequently. Attention to the splanchnics and to the
abdomen directly will tend to keep the stomach, liver, kidneys, and
intestines in a healthy state. The diet of the patient should consist
of liquid food—milk, broths, meat juice, raw eggs and barley water.
Let the patient drink freely of water. Treatment of the rectum may be
employed with benefit when the pharynx is greatly disturbed.
Various =sequelæ= and =complications= are best relieved or prevented,
according to Link, as follows: “First, limiting the production of
toxins by a most thorough relaxation of the muscles of the neck,
thereby favoring the unobstructed circulation of the blood and lymph;
second, by the correction of lesions which affect the vasomotor of
the head and neck; third, by spinal treatment affecting the vasomotor
to the areas involved; fourth, by increasing the activity of the
excretory organs, by treatment in the splanchnic and lumbar areas, that
the toxins may be more rapidly eliminated. In cases where laryngeal
stenosis is marked and suffocation is imminent, intubation should not
be delayed.” Post-diphtheritic paralysis usually yields to osteopathic
treatment. Apply treatment according to location.